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Classify the following medical document.
|
TITLE: CCU Progress Note
Chief Complaint:
24 Hour Events:
- No overnight events
- Comfortable on room air.
- Requesting to go home
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2124-3-9**] 07:11 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.9
C (98.4
Tcurrent: 36.8
C (98.2
HR: 75 (75 - 93) bpm
BP: 96/46(58) {84/44(55) - 103/58(69)} mmHg
RR: 22 (17 - 34) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Total In:
PO:
TF:
IVF:
Blood products:
Total out:
530 mL
295 mL
Urine:
530 mL
295 mL
NG:
Stool:
Drains:
Balance:
-530 mL
-295 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 98%
ABG: ///31/
Physical Examination
Gen: WDWN elderly male in NAD, appears younger than stated age.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP elevated to earlobe
CV: RR, 3/6 systolic murmur LUSB raditaing to carotids. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles to halfway B/L.
Speaking in full sentences.
Abd: Soft, NTND. No HSM or tenderness.
Ext: 2 pitting edema B/L.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Labs / Radiology
1.3 mg/dL
31 mEq/L
3.9 mEq/L
34 mg/dL
100 mEq/L
139 mEq/L
[image002.jpg]
[**2124-3-8**] 10:33 PM
Cr
1.3
TropT
0.02
Other labs: CK / CKMB / Troponin-T:31//0.02, Mg++:2.0 mg/dL
Assessment and Plan
The patient is a [**Age over 90 **] year-old male with a PMH of CAD, moderate AS, and
COPD admitted with acute onset dyspnea.
.
#. Acute on Chronic Systolic and Diastolic CHF - The patient presents
with acute onset dyspnea, similar to prior admissions, differential
diagnosis includes acute diastolic CHF vs COPD exacerbation. Patients
symptoms most likely secondary to CHF exacerbation given evidence of
volume overload on exam and CXR. BNP elevated though decreased from
prior. The patient has no evidence of CE elevation or new ischemic ECG
changes. He likley has episodes of transient ischemia leading to
acute-on-chronic diastolic dysfunction and pulmonary edema as described
prior. The patient also reports brief feeling of "chest spasm" relieved
with neb in ED, suggests possible component of reactive airway disease.
No wheezing on exam currently.
- Trend CE, negative x2 so far
- Continue lasix IV, goal 1L negative today
- Continue lisinopril and metoprolol
- Continue nebs PRN
- Hold on further abx/steroids for now. There appears to be a possible
RLL infiltrate that we will followup with PA and lateral chest xray.
.
#. Coronary Artery Disease - s/p BMS to OM2, D1, Left circumflex in
[**2122-11-16**] for unstable angina - pt has declined further attempts at
revascularization. No current acute ischemic changes on ECG
- Trend CE, negative x2 so far
- Continue ASA, metoprolol and lisinopril
- Goal HCT ~30 given history of ischemia
.
#. Moderate Aortic Stenosis - careful diuresis given increased preload
dependence
- BB and ACE-I as above
.
# Gout: On allopurinol. Started cholchicine at home dose as needed
#. COPD
Will start tiotropium for likely COPD. Outpatient PFTs
.
#. Chronic GI Bleeds - Pt has had GIB in past on plavix, monitor HCT
.
#. FEN - cardiac diet, replete lytes PRN
.
#. Access: PIV
.
#. PPx: heparin SC
.
#. Code: FULL
.
#. Dispo: Floor today
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2124-3-8**] 06:50 PM
Prophylaxis:
DVT: Heparin SQ
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
------ Protected Section ------
Cardiology Teaching Physician Note
On this day I saw, examined and was physically present with the
resident / fellow for the key portions of the services provided. I
agree with the above note and plans.
I would add the following remarks:
History
Nothing to add, agree with above
Physical Examination
Nothing to add, agree with above
Medical Decision Making
Nothing to add, agree with above
Total time spent on patient care: 30 minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 4646**] [**Name (NI) **] on:[**2124-3-11**]
08:28 ------
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2178-10-24**] Discharge Date: [**2178-10-30**]
Date of Birth: [**2135-7-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug-eluting stent placement in LAD
x 2
History of Present Illness:
Patient is a 43 year-old male with HTN, Family Hx of CAD, and
Tobacco use who had episode of persistent chest pain after work
2 days PTA. States sharp substernal chest pressure going from
throat to the esophagus. no radiation, no associated sob,
denies n/v/d. Pain constant never relieved and pt came to the
ED ~ 36 hours after the onset of pain.
.
In the [**Name (NI) **] pt noted to have ST elevations anterolaterally and
tachycardic, given IV lopressor and sent to cath lab.
.
On cath found to have proximal occlusion of LAD ->[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2, CI
1.86 -> IABP placed and pt transferred to CCU. Pain free post
cath. On admission to CCU pt had no complaints.
ROS: +some doe for months, denies pnd/orthopnea/syncope.
+Palpitations.
Past Medical History:
1. HTN
2. Anxiety
3. Psoriasis
Social History:
Smoker 15 pack year history. Lives in [**Location **], social etOH,
programmer at [**Hospital1 112**].
Family History:
Mother died of MI at 69, Father - CVA, 2 sisters with MI, DM, 2
brother with DM.
Physical Exam:
GEN: Middle aged man in NAD
HEENT: PERRL, MMM, JVP ~9cm at 30degrees.
CHEST: CTAB anteriorly and laterally.
CVR: RRR, nl s1, s2, no r/m/g
ABD: Soft, nt, nd
EXT: no edema, 2+ dp/pt pulses bilaterally. Groin site with
soft hematoma, arterial line in place.
Neuro: CNI-XII intact, A&O X 3.
Skin: bilateral white plaques on forarms consistent with
psoriasis.
Pertinent Results:
CBC: 15.3/44.2/331
Diff, N:79.6 L:15.0 M:4.5 E:0.5 Bas:0.5
Chemistry: 137/3.8/97/25/14/1.0/174
CK: 287 MB: 7 Trop-*T*: 2.43
PT: 13.2 PTT: 25.1 INR: 1.2
.
DATA:
ECG presentation: ST at 142, [**Apartment Address(1) 25947**],L, V1-V5. (V2-V4 >5mm).
ECG post cath: ST at 100, ST normalized in 1,l,v1. STE V2 2mm,
v3-V4 3mm.
Cath - CO 3.24, CI 1.83, PCW 21, RA 10, PA 32/17, RV 32/8.
LMCA - nl,
LAD occluded at its origin, diag with thrombus and stenosis at
its origin. dilation and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5303**]. residual 80% with normal
flow.
LCX - normal.
RCA - normal
.
ECHO
The left ventricular cavity size is top normal/borderline
dilated. There is
moderate regional left ventricular systolic dysfunction. Overall
left
ventricular systolic function is moderately depressed. Resting
regional wall
motion abnormalities include anteroseptal, anterior
hypokinesis/akinesis and
apical akinesis/dyskinesis. Right ventricular chamber size and
free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There
is no pericardial effusion. No apical thrombus seen (cannot
exclude).
.
CATH
Initial angiography showed a proximally occluded LAD.
We planned to recanalize the vessel. Eptifibatide was continued.
A 6
French XBLAD3.5 guide provided good support. The lesion was
crossed with
great difficulties using a Choice PT wire, which was then
exchanged for
a Prowater wire. Thrombectomy was performed using an Export
catheter.
The lesion was then pre-dilated with a 2.0 mm balloon at 8 atm.
Next,
two overlapping 3.0x3 mm and 3.0x28 mm Cypher DES were deployed
in the
mid and proximal LAD at 14 atm. Post-dilation was performed with
a
3.25x23 mm Highsail balloon at 16 atm. Angiography showed slow
flow in
D1, which was rescued with a 2.0 mm ACE balloon at 8 atm. Final
angiography showed no residual stenosis in the LAD, some
thrombus in D1
with an 80% resdual stenosis, no dissection and TIMI 3 flow in
both
vessels. The patient left the lab in stable condition.
* COMMENTS: 1. Selective coronary angiography in this right
dominant
patient revealed severe single vessel CAD. The RCA was
angiographically
normal. The Left Main and LCX were also both angiographically
normal.
The LAD was completely occluded at its origin. The D1 also had
thrombus and stenosis at its origin
2. Resting hemodynamics revealed mild RA pressure elevation of
10mmHG.
The pulmonary pressures were slightly elevated at 32/17 and the
PCWP was
moderately elevated to 21mmHG consistent with abnormal diastolic
function. The cardiac index was depressed at 1.83 l/min/m2.
3. Successful stenting of the LAD with two 3.0 mm Cypher
drug-eluting
stents, which were post-dilated to 3.25 mm.
4. Successful insertion of a 40 cc IABP with good diastolic
augmentation.
Brief Hospital Course:
Patient is a 43 year-old male with HTN, smoking history, Family
Hx of CAD who presented with anterolateral ST elevations and
found to have proximal occlusion of LAD in the cath lab. The
following issues were addressed during his hospital stay:
1. Cardiovascular
A. Coronary Artery Disease: Given complete proximal LAD
occlusion in cath lab, 2 DES were placed in the artery with
significant improvement in blood flow. Patient tolerated
procedure well. An intra-aortic balloon pump was also placed in
the cath lab with good diastolic augmentation. Patient received
integrillin drip for 18 hours post-cath. Also started on
ASA/Plavix/Statin/ACEI. BB was started prior to discharge, and
medications were titrated up as tolerated. Patient was evaluated
by Physical Therapy and cleared for discharge home with
recommendations for cardiac rehabilitation.
B. Pump: At cath, CO 3.24, CI 1.86. An IABP was placed at cath
for afterload reduction and better coronary perfusion. This was
discontinued the following day. LVEDP was 21 on cath, however
post-cath patient voided 450cc without any lasix. ECHO showed EF
35%, anterospetal, anterior hypokinesis/akinesis, apical
akinesis/dyskinesis, with no overt apical thrombus visualized.
Given apical akinesis, patient was started on Coumadin and
bridged with heparin until therapeutic INR was achieved.
C. Rhythm: Patient in sinus rhythm, with initial tachycardia of
multifactorial etiology: fever, acute coronary syndrome,
dehydration, and poor EF with compensatory tachycardia to
maintain cardiac output. Patient's HR began to decrease
gradually post-MI, with fever resolution and improved cardiac
function. No significant events were noted on telemetry.
Patient to follow-up with Electrophysiology in 1 month for ICD
placement evaluation.
2. FEVER
Patient developed fever of unclear etiology post-MI; UA, CXR
negative. 1 set blood cultures with gram positive cocci
clusters/pairs, coagulase negative, likley contaminant given
clinical picture. Other work-up was negative, and fever curve
trended down without antibiotic therapy. Impression was fever
secondary to acute myocardial infarction and cytokine release.
Patient was without evidence of leukocytosis, and was afebrile x
48h prior to discharge without Tylenol administration.
.
3. HTN
Patient initially with asymptomatic relative hypotension
initially, which resolved with cardiac revascularization and
gentle fluid boluses. Patient discharged on Toprol XL 50 and
Lisinopril 5, to follow-up in [**Hospital 191**] clinic for further control.
.
4. PSORIASIS
Patient with bilateral psoriatic plaques over arms, back, legs.
No acute issues as inpatient, to be followed as outpatient.
.
5. HEME
Blood bank contact[**Name (NI) **] team as patient with [**Name (NI) 25948**] antibody on
Type and Screen, usually seen in patients with history of
transfusion. Patient denies any history of blood product
transfusion. Labs not consistent with hemolysis; haptoglobin
350s, adjusted retic count WNL (LDH cannot be used as marker
given recent infarction)
Patient reportedly with sickle cell trait, nothing to work-up
further as inpatient.
.
6. Prophylaxis
Patient on heparin gtt while being bridged to Coumadin. Patient
ambulating, had BM while inpatient.
Medications on Admission:
Paxil 10mg qd.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*3*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*4*
4. Paroxetine HCl 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please have your INR checked; dose may be adjusted accordingly.
Disp:*30 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*6*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*6*
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO As directed by a
physician: [**Name10 (NameIs) **] is an extra prescription to be used pending any
changes in your Coumadin dosage. .
Disp:*60 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
Please have your INR drawn by VNA on Saturday and have results
called to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Hospital3 **] on [**11-2**] -
Monday A.M. -- [**Telephone/Fax (1) 250**] (INR does not need require f/u over
weekend)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary
1. Acute ST Elevation MI s/p 2 DES to LAD
Secondary
1. HTN
2. Hyperlipidemia
3. Tobacco use
Discharge Condition:
chest-pain free, hemodynamically stable, afebrile
Discharge Instructions:
1. Please take all medications as prescribed -- Aspirin and
Plavix MUST be taken daily.
2. Among your new medications, you have been started on
Coumadin. This requires frequent visits for lab draws. Please
make sure the results are sent to your PCP so that necessary
dose adjustments can be made.
3. Please make all follow-up appointments.
4. Please refrain from any strenuous activity including heavy
lifting for the next few weeks and until cleared by a
cardiologist.
5. Please stop smoking
6. You will need to begin cardiac rehabilitation in 1 month -
please arrange this with your PCP [**Name Initial (PRE) **]/or cardiologist.
Followup Instructions:
The following appointments have been schedule for you:
1. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-11-2**] 11:30 (To have your INR checked) -- [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) 895**], North Suite
2. Provider: [**Name10 (NameIs) 640**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2178-11-11**]
2:30
(To establish new PCP) - [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 895**]
3. Cardiology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2178-11-17**] 1:00, [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
4. Electrophysiology (evaluation for ICD placement). Dr. [**Last Name (STitle) **],
Friday, [**2184-12-3**]:00 AM. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 3971**]
Completed by:[**2178-11-2**]
|
Discharge summary
|
Classify the following medical document.
|
micu npn 1900-0700
patient received at 1900 from am shift. micu team had finished putting in r subclavian quad lumen. cxr showing that it was not in the correct position. dr [**Last Name (STitle) **] coming down to assist in rewiring line. cxr done and line ok per resident samone [**Doctor Last Name **]. r ij line pulled and i sent the tip for culture and switched over his lines to the new subclavian. within a half an hour dr [**Last Name (STitle) **] informed me that his line needed to be rewired again d/t incorrect positioning. i accessed his groin dialysis line fro propofol and the ambisone that he had begun to receive. dr. [**Last Name (STitle) **] and dr. [**Last Name (STitle) **] placed a new quad lumen in the r ij that has been confirmed by cxr to be in the correcr position. his line have been switched back over to this new line.
systenms review-
neuro- patient remains sedated on 30 mcg/kg/[**Last Name (STitle) 217**] of propofol. he opens eyes and awakens to voivem inconsistantly follows some simple commands, not able to get him to nod his head to yes/no q's though.
cv- vasopressin off ~12am with last line change, bp had been in the 120 sys map 70's range. within a half hour, the intern, dr [**Last Name (STitle) **], pulled the subclavian line and pt's bp began to fall to the mid 80 sys range maps 50-60. vasopressin restarted at previous dose of 0.04 u/[**Last Name (STitle) 217**]. also within this time. pt had previously not had any ectopy, he began to have 4-7 beat runs of vtach, which all spontaneously resoved. after the line was placed a chem 10 was sent off revealing a K of 2.9 and mg of 1.6. the pt received 40 meq kcl and 3 amps mg. am labs to be drawn shortlky will reflect this. hr 60-70's o/n, sbp remains 95-100 on vasopressin.
resp- remains on a/c .4 fio2 peep 10 750x14, occ breathing 1-2 breaths above, sats 98-100%, no abg's ordered this shift. suctioning tan thick sputum via ett q4-5 hrs.
gi/gu- tube feeds (deliver 2.0( continue at 30 cc/hr, to up rate to 40 at 6am, [**Last Name (STitle) **] to advance SLOWLY -- q12 hrs to goal of 50cc/hr. viokase begun to assist in absorbtion of tube feeds d/t pt's hx of pancreatic insufficiency. pt conts w/large amts of stool (1300cc) o/n to mushroom catheter, slightly ob+ this am. sm amts brown urine to foley.
endo- insulin gtt off xseveral hrs while access was an issue. [**Last Name (STitle) **] titrating blood sugars q1-2 hrs, currently at 0.5 u/hr bs in the 80;'s.
id- a febrile o/n. vasopressin back on ?volume depletion w/lg stool losses and dialysis x2 days in a row w/good fluid removal both days. vs. new sepsis s/p pulling line out.. conts on ambisone q24 hrs for yeast n blood cultures from [**2163-8-31**].
heme- conts to have [**Last Name (un) 374**] low platelets, hit+, now pt w/new lij, subclavian clots, pt written to begin on lipirudin for anticoagulation, held o/n d/t r dialysis line needing to be pulled tonight or more likely in the am..
skin- multiple issues,, see flowsheet for details. much improved rash from uremia of last week. now pt w/yeast to groin, back, arm pits.. treating w/miconizole powder.
[**Last Name (un) **] to support on vent until ms [**First Name (Titles) 7959**] [**Last Name (Titles) **] ready to begin weaning.. vasopressin for maps >60, attempt to turn off a
|
Nursing/other
|
Classify the following medical document.
|
Admission Date: [**2159-9-18**] Discharge Date: [**2159-9-20**]
Date of Birth: [**2084-12-10**] Sex: M
Service: MEDICINE
Allergies:
Enalapril
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p right carotid angiography and stenting
Major Surgical or Invasive Procedure:
Right carotid angiography and stenting
History of Present Illness:
74M hx of L ICA stenosis (s/p CEA [**2159-6-26**]), 80% R ICA stenosis,
CAD s/p CABG ([**2154**], anatomy unavailable), EF 60%, prior CVA (no
residual deficits), PAF (On Coumadin), HTN, HL, DMII, Moderate
to Severe PVD, that presents to CCU following right carotid
angiography and stenting.
.
The pt was referred to Dr. [**Last Name (STitle) **] on [**2159-4-28**] for evaluation of
PVD. The pt subsequently underwent stress nuclear perfusion (no
anginal symptoms or ischemic EKG changes). Non-Invasive vascular
studies revealed non-compressible vessels and moderate to
moderately severe peripheral vascular disease at rest based on
Doppler waveforms and PVR??????s. ABI??????s invalid due to non
compressibility of vessels. Given the pts known carotid bruits,
the pt underwent Carotid U/S that showed significant bilateral
carotid stenosis, L>R. Angiography ([**2159-6-25**]) revealed an 80%
stenosis of the [**Country **] (which supplies the left ACA) and a 99%
[**Doctor First Name 3098**] stenosis. Cerebral angiography further revealed patent
right ACA and MCA and patent left ACA and left MCA. He did have
a recent event when he was unable to move his left leg for a
couple of days, but slowly regained function.
.
Thus the pt underwent L CEA on [**2159-6-26**]. Of note during the
admission for ([**2159-6-25**] thru [**2159-6-28**]) the pt tolerated the
procedure well. On POD 1 he experienced a severe headache that
did resolve and was consistent with symptoms of reperfusion
postop. The pt was kept in the VICU overnight for observation.
The pt also experienced increased neck stiffness at that time.
The pt also had LE swelling US without DVT. Subsequent Carotid
U/S ([**2159-7-19**]) revealed stable R ICA stensosis 70-79%
(unchanged). Left side without residual stenosis at CEA site.
.
Upon further review of symptoms the pt reports + Occasional
dizziness, no prior syncope, occasional HA, Denies CP/SOB. No
sensory or motor defects. The pt also noted a history of "ill
defined feeling" in both legs with exercise that occasionaly
occurs with rest. The pt previously attributed this to prior SVG
harvest. He recalls that he might have had a stroke 10-15 years
ago (unclear) without any residual deficit. Prior to CABG, he
only had diaphoresis.
.
Further review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
.
In general, the patient tolerated the procedure well. He had a
vagal reaction during the procedure which required atropine.
His SBP then went up to the 200s requiring a nitro drip. Access
was first attempted in the right arm, but was unsuccessful.
Therefore a right femoral approach as used. He was transferred
to the CCU with an SBP of 100 off of the nitro drip for close
monitoring of his blood pressures with a goal SBP between 90 and
120. He had a headache after the procedure which resolved by
the time he was transferred to the CCU.
Past Medical History:
Paroxysmal atrial fibrillation
CAD s/p CABG in [**2154**] ([**Hospital1 112**])
Prior CVA
Bilateral carotid artery disease
Anemia
PVD
Hypertension
Diabetes c/b retinopathy and peripheral neuropathy
Cataracts s/p surgery
Thyroid nodule
Colon polyps s/p resection
Intermittent Lower back pain
Proteinuria
s/p right elbow fracture as a child
Arthritis
Social History:
Patient is married with two children
Lives with: Wife
Occupation: previously worked as a printer
ETOH: none
Family History:
No family history of premature CAD
Physical Exam:
VS: T=36.4 BP=91/44 HR=51 RR=14 O2 sat=100% RA
GENERAL: pleasant male in NAD. Alert and 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 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Left> right crackles at
the bases. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. RUE bandage is c/d/i.
RLE has some oozing at the cath site, no hematoma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Warm
and well perfused with normal capillary refill time. 1+ Left
and trace right lower leg edema.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP, PT [**Name (NI) **]
[**Name (NI) 2325**]: Carotid 2+ Femoral 2+ Popliteal 1+ DP, PT [**Name (NI) **]
Pertinent Results:
Cardiac Cath ([**9-18**])-
1. Access was initially obtained at the right brachial artery.
Due to
anatomic tortuosity, we changed our approach and obtained access
from
the right femoral artery.
2. Selective angiography of the right carotid artery showed an
80%
stenosis at the bifurcation of the ICA and ECA extending
distally into
the proximal segment of the ICA.
3. Successful PTA and placement of an 8.0x29mm self-expanding
Carotid
Wallstent were performed. The stent was post-dilated using a
5.0mm
balloon. (See PTA comments.)
4. The right common femoral arteriotomy was successfully closed
using a
Perclose Proglide device.
.
FINAL DIAGNOSIS:
1. Right carotid artery disease.
2. Successful placement of a stent in the CCA-ICA.
3. The primary operator for this procedure was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
The primary assistant was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
[**2159-9-19**] 06:40AM BLOOD WBC-8.1 RBC-2.95* Hgb-8.2* Hct-25.5*
MCV-87 MCH-27.7 MCHC-32.0 RDW-15.0 Plt Ct-220
[**2159-9-19**] 02:05PM BLOOD WBC-8.0 RBC-2.81* Hgb-8.0* Hct-24.5*
MCV-87 MCH-28.4 MCHC-32.5 RDW-14.3 Plt Ct-185
[**2159-9-18**] 09:00AM BLOOD PT-14.1* PTT-33.6 INR(PT)-1.2*
[**2159-9-19**] 06:40AM BLOOD PT-13.4 PTT-31.1 INR(PT)-1.1
[**2159-9-19**] 06:40AM BLOOD Glucose-58* UreaN-32* Creat-2.0* Na-134
K-4.3 Cl-100 HCO3-24 AnGap-14
[**2159-9-19**] 02:05PM BLOOD Glucose-215* UreaN-32* Creat-2.1* Na-130*
K-4.5 Cl-98 HCO3-23 AnGap-14
[**2159-9-19**] 02:05PM BLOOD Calcium-8.7 Phos-3.8 Mg-1.9
Brief Hospital Course:
74 y/o male with severe PVD, CABG in [**2154**], CVA with no residual
effect, and bilateral carotid artery disease s/p left CEA [**7-3**]
presenting for right carotid stenting.
.
# s/p RCA Stenting: Pt enrolled in [**Last Name (un) 81078**] study, underwent RCA
stenting. Patient had a vagal reaction during the procedure
which required atropine. His SBP then went up to the 200s
requiring a nitro drip. Otherwise he tolerated the procedure
well and was transferred to the CCU with an SBP of 100 off the
nitro drip. While in the CCU, our goal remained SBP 90-120.
Patient stayed in the 100s-120s. Neuro exam performed q1h for 2
hours, q2h for 2 checks, and then q6h after the procedure - all
were within normal limits. Post-cath check at 2:30PM showed
some R femoral oozing, but no hematoma or bruit. Patient's heart
rate was 40s-50s s/p procedure, asymptomatic. His beta blocker
was held in this setting; resumption will be addressed by his
PCP. [**Name10 (NameIs) **] will go home on [**Doctor Last Name **] of Hearts monitor to
continually monitor heart rate for 2 weeks. Patient's home dose
of ASA 325mg and Plavix 75mg continued after procedure.
Coumadin 5mg resumed after the procedure and lovenox
administered twice daily dosing until INR became therapeutic.
Patient will go home with 5 days of lovenox as bridge. INR will
be checked on [**9-24**].
.
# CORONARIES: previous CABG. Last stress-MIBI without concerning
ECG changes. Continued home ASA, Plavix, Statin, Beta-Blocker,
[**Last Name (un) **]. Patient denied any chest pain while in hospital. No EKG
changes noted.
.
# PUMP: Last EF 60%. Initially had elevated BP's post-procedure.
Trended down to SBP 100s-120s. Switched home atenolol 150mg
daily to metoprolol 75mg [**Hospital1 **] for rate control given slightly
increased creatinine. Upon discharge, BP was 110s-120s and HR
was 50s, 60s with ambulation. Patient stable.
.
# RHYTHM: Pt with hx of PAF, currently bradycardic sinus rhythm.
Continued to stay in bradycardic rhythm at HR 45-50s.
Discharged on [**Doctor Last Name **] of Hearts monitor for 2 weeks, as noted
above. Will transmit 2-3 times daily.
.
# DMII: Patient not on insulin as outpatient. HbA1C 7.3 ([**4-2**]).
Gave home dose of glipizide and then covered to Humalog SS while
in house. Held home metformin while in-hospital. Restarted
upon discharge.
.
# Anemia: Unclear etiology. There is a longstanding history
from prior records. Previous ferritin was normal. No
microcytosis. Mildly elevated creatinine. Hemoglobin
Electropheresis WNL (+FM hx for anemia). Hct baseline ranges
from 25-30. Ranged between 24.5-31.5 while in hospital.
Consider outpatient work-up.
.
Medications on Admission:
Aspirin 325mg daily
Plavix 75mg daily
Simvastatin 40mg Daily
Atenolol 150mg PO Daily
Irbesartan 300mg daily
Coumadin 2mg daily, 2 tablets as directed, last dose [**2159-9-13**]
Lovenox b.i.d. on [**2159-9-16**] and [**2159-9-17**]
Furosemide 40mg daily
Glipizide 10mg twice a day
Metformin 850mg three times a day
Iron-Docusate Sodium 150mg-100mg one tablet twice a day
Milk of Magnesia PRN
Foltx one tablet daily
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Iron with Stool Softener 150 (50)-100 mg Tablet Sustained
Release Sig: One (1) Tablet Sustained Release PO twice a day.
10. Foltx 2.5-25-2 mg Tablet Sig: One (1) Tablet PO once a day.
11. Enoxaparin 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous Q24H (every 24 hours) for 5 doses.
Disp:*5 syringes* Refills:*0*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM for 5 doses.
Disp:*5 Tablet(s)* Refills:*0*
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
start once your INR is between [**2-27**]. Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
right sided carotid stenosis s/p stent placement
.
Secondary diagnoses:
- s/p CABG
- HTN
- dyslipidemia
- PAF (On Coumadin)
- Prior CVA [**60**]-15 years ago (No residual defects)
- Bilateral carotid artery disease s/p left CEA [**2159-6-26**]
- Anemia (Unknown Etiology)
- PVD
- DMII c/b retinopathy and peripheral neuropathy
- Cataracts s/p surgery
- Thyroid nodule
- Colon polyps s/p resection
- Intermittent Lower Back Pain
- Proteinuria
- s/p right elbow fracture as a child
- Arthritis
Discharge Condition:
Good, vital signs stable, ambulatory
Discharge Instructions:
You were admitted to the hospital to undergo a carotid stent
placement to relieve a blockage in your carotid vessel. The
procedure went well however you developed a low heart rate
afterwards. Because of this you were admitted to the CCU for
close monitoring. While you were in the CCU, your heart rate
remained stable and you were asymptomatic. You will go home
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to continually monitor your heart
rate at home.
.
The following medication changes were made:
1. Stop your beta-blocker (atenolol 150mg).
2. Take lovenox 100mg daily for 5 days (day 1- [**9-20**]) or at least
until your Coumadin level (INR) is between [**2-27**].
3. Take Coumadin 5mg daily for 5 doses or until your INR is
between [**2-27**] and then you can go back to your home dose of
Coumadin 2mg daily.
4. You need to get your INR levels checked on [**9-22**] to monitor
your blood thinning levels.
.
Please follow-up with all of your outpatient medical
appointments listed below.
.
Please seek medical care if you experience any concerning
symptoms such as headache, dizziness, lightheadedness, decreased
muscle strength, chest pain, or increased shortness of breath.
Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below.
1. Follow-up with your [**Hospital 263**] clinic ([**Hospital1 **]-[**Location (un) **]) for INR check on
Saturday, [**9-22**] (If your INR is between [**2-27**] then you can stop
Lovenox, if it is below 2, continue with Lovenox).
2. Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2159-10-2**] 10:10
3. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2159-10-19**] 2:20
4. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**]
Date/Time:[**2159-11-7**] 11:15
Completed by:[**2159-9-20**]
|
Discharge summary
|
Classify the following medical document.
|
TITLE: [**Hospital Unit Name 10**] Resident Progress Note
Chief Complaint:
24 Hour Events:
- off neosynephrine, only on levophed
- checking daily LFTs and amylase/lipase as is s/p ERCP
- Echo results [**8-22**] showed hyperdynamic LV, EF >75%, mild LVH, no
focal wall motion abnormality
- CVP was 22 based on femoral line
- [**Hospital1 966**] accepted her for transfer
- Got CVVH in preparation for transfer and for afternoon K of 6.1,
decreased to 4.9 after CVVH
- [**Hospital1 966**] decided they don't have space for her until [**1-10**], but they did
tell us that she has antiphospholipid sydrome and she was started on
heparin gtt
Allergies:
Ace Inhibitors
Unknown;
Levaquin (Oral) (Levofloxacin)
Unknown;
Cephalosporins
Unknown;
Oxycodone
Unknown;
Percocet (Oral) (Oxycodone Hcl/Acetaminophen)
Unknown;
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2194-1-8**] 06:00 AM
Meropenem - [**2194-1-9**] 03:43 PM
Linezolid - [**2194-1-9**] 10:03 PM
Gentamicin - [**2194-1-10**] 06:31 AM
Infusions:
Fentanyl - 25 mcg/hour
Norepinephrine - 0.03 mcg/Kg/min
Midazolam (Versed) - 1 mg/hour
Heparin Sodium - 1,050 units/hour
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2194-1-9**] 03:42 PM
Pantoprazole (Protonix) - [**2194-1-9**] 04:24 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2194-1-10**] 07:26 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.7
C (98
Tcurrent: 36.5
C (97.7
HR: 75 (62 - 85) bpm
BP: 107/65(79) {91/54(66) - 117/78(89)} mmHg
RR: 19 (15 - 33) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 84.4 kg (admission): 74 kg
Height: 67 Inch
CVP: 24 (20 - 34)mmHg
Total In:
3,877 mL
312 mL
PO:
TF:
IVF:
3,737 mL
312 mL
Blood products:
Total out:
1,026 mL
104 mL
Urine:
NG:
500 mL
Stool:
Drains:
Balance:
2,851 mL
208 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 360 (360 - 360) mL
Vt (Spontaneous): 153 (153 - 153) mL
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 74
PIP: 22 cmH2O
Plateau: 22 cmH2O
Compliance: 21.2 cmH2O/mL
SpO2: 98%
ABG: 7.32/43/164/24/-3
Ve: 5.7 L/min
PaO2 / FiO2: 410
Physical Examination
GENERAL: cushingoid AAF, intubated and sedated
HEENT: b/l injected conjunctiva, b/l chemosis. No scleral icterus. MM
lubricated.
Neck: unable to assess JVP 2/2 habitus. tunneled line in place
CARDIAC: Regular tachycardia, 2/6 systolic murmur across precordium
LUNGS: coarse breath sounds, no crackles or wheezes
ABDOMEN: obese and surgically scarred abdomen. Minimal BS. NABS.
EXTREMITIES: cool, no edema, dopplerable dorsalis pedis/ posterior
tibial pulses. RUE old AV fistula without thrill/bruit
SKIN: No rashes/lesions, ecchymoses.
Labs / Radiology
105 K/uL
12.7 g/dL
126 mg/dL
5.0 mg/dL
24 mEq/L
4.9 mEq/L
37 mg/dL
109 mEq/L
147 mEq/L
41.7 %
8.4 K/uL
[image002.jpg]
[**2194-1-9**] 02:29 AM
[**2194-1-9**] 05:53 AM
[**2194-1-9**] 12:29 PM
[**2194-1-9**] 12:42 PM
[**2194-1-9**] 03:19 PM
[**2194-1-9**] 05:44 PM
[**2194-1-9**] 06:22 PM
[**2194-1-10**] 12:00 AM
[**2194-1-10**] 12:07 AM
[**2194-1-10**] 02:29 AM
WBC
8.3
8.4
Hct
41.5
41.7
Plt
110
105
Cr
6.5
6.7
5.0
5.0
TCO2
22
21
19
23
23
Glucose
198
144
119
126
Other labs: PT / PTT / INR:14.7/150.0/1.3, CK / CKMB /
Troponin-T:/8/0.45, ALT / AST:227/51, Alk Phos / T Bili:162/0.4,
Amylase / Lipase:53/32, Differential-Neuts:94.2 %, Lymph:3.6 %,
Mono:2.1 %, Eos:0.1 %, Lactic Acid:2.0 mmol/L, Albumin:3.3 g/dL,
LDH:212 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:5.9 mg/dL
Blood cultures 11/25 and [**1-9**] NGTD
Sputum [**1-8**]
GRAM STAIN (Final [**2194-1-8**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
RARE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
Assessment and Plan
49F with SLE on chronic steroids, ESRD on HD, ERCP earlier today for
choledocholithiasis, who presented with sepsis and pancreatitis.
.
#. Sepsis - probable biliary source but DDX includes line infection.
Has h/o multidrug resistant organisms at [**Hospital1 966**].
-- f/u blood cultures (and those from [**Hospital1 1504**] ER)
-- continue meropenem/getamicin/linezolid for broad coverage
-- prn fluid for CVP goal [**9-25**], will check femoral line CVP, will also
check delta pulse pressure
-- wean vasopressors for MAP > 65
-- continue stress dose steroids for now
-- f/u ERCP c/s recs
-- f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] c/s recs
-- will get echo to assess heart function with all these fluids, check
OSH records for any previous TTe
.
#. Resp Failure - Was intubated for airway protection, never dropped
saturations or demonstrated problems with oxygenation. She has evidence
of volume overload on CXR, will need aggressive IVF for sepsis and
pancreatitis management, so this will be a barrier to extubation in the
future.
-- wean FiO2 as tolerated, keep on AC for now
-- ultimately, volume management will be via HD/CVVH
-- send sputum cultures
-- fent/midaz for sedation
.
#. Pancreatitis s/p ERCP - no evidence of persistent obstruction or
free air on CT scan. However, pancreatic enzymes are elevated, and HCT
acutely elevated c/w pancreatitis.
-- aggressive IVF
-- NPO with bowel rest for now
-- pain control with IV fentanyl
-- trend LFTs and panc enzymes daily
-- ERCP to follow
.
#. ESRD
-- should be dialyzed today, will touch base with renal team
-- can likely do hemodialysis but if BP drops, may need CVVH
-- renally dose all medications
.
#. SLE
-- currently on stress dose steroids, replacing her home dose
-- continue Plaquenil 200mg daily
-- continue Bactrim SS daily for prophylaxis
.
# h/o PE - on despite ESRD [**3-18**] "coumadin resistence"
-- holding lovenox for now, will clarify coagulation needs by getting
OSH records
ICU Care
Nutrition: NPO for now given pancreatitis, but prefer early intiation
of TF's via OGT when possible, will obtain nutrition c/s
Glycemic Control: Added ISS
Lines:
Dialysis Catheter - [**2194-1-8**] 05:42 AM
Arterial Line - [**2194-1-8**] 06:33 AM
Multi Lumen - [**2194-1-8**] 03:18 PM
Prophylaxis:
DVT: Sc heparin/pneumoboots
Stress ulcer:
VAP:
Comments: Bowel regimen colace/senna
Communication: Comments:
Code status: Full code
Disposition: [**Hospital Unit Name 10**]
|
Physician
|
Classify the following medical document.
|
TITLE:
Chief Complaint: Hypoxia
HPI:
This is a 45 year old Armenian female transferred from the BMT service
with worsening hypoxia. She was in her usual state of health until mid
[**Month (only) 93**], she began to have fevers, chills, nightsweats. This was
accompanied by a non-productive cough, nasal congestion, and fevers to
104. She was seen at [**Hospital3 **] ED and was found to have a WBC of 115
with 7% blasts, 45% bands, 15% neutrophils, 5% lymphs, 3%
promyelocytes, 14% myelocytes with LDH 1661, uric acid 4.2, Hct 23.3,
plat 28,000. She had O2 sats in the 80s on RA and was given CTX and
levaquin. She had a BM biopsy at the time the results for which were
inconclusive and she was transferred to the [**Hospital1 1**] for possible
leukopharesis. She was started empirically on vancomycin, cefepime,
levofloxacin and tamiflu. She had a CT chest that showed diffuse
ground glass opacities with airspace opacification in RML and bilateral
bases, as well as central lymph node enlargement and splenomegaly. She
was started on hydroxyurea for her initial WBC 120,000 and her WBC has
improved today to 32,000. Bone marrow bx here suggestive of acute
myeloid leukemia, cytogenetics pending. Despite broad antibiotic
coverage, her O2 requirement began to increase and micafungin was added
empirically yesterday for fungal coverage. This afternoon MICU
evaluation was requested due to worsening hypoxia with O2 sat 90% on
50% FM. She was given lasix 10 mg IV with ~1.5L urine output. ABG
revealed respiratory alakalosis with concomittant metabolic alkalosis.
Bicarb gtt was discontinued to improve metabolic alkalosis. She was
noted to have a temperature of 104 and standing tylenol was ordered.
She underwent a repeat CT thorax that revealed worsening widespread
ground glass opacities in the lungs bilaterally, with airspace
opacities in the lung bases, right middle lobe, and lingula. Due to
lack of improvement in respiratory status, and also with plans to
initiate chemotherapy for presumed component of infiltrative leukemia
adding to worsening respiratory status, she was transferred to the
[**Hospital Unit Name 10**].
.
In the [**Hospital Unit Name 10**], she reports a productive cough with yellow sputum with
blood streaks. She reports that her breathing has been gradually worse
over the last few days.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2153-8-11**] 07:38 PM
Levofloxacin - [**2153-8-11**] 09:52 PM
Cefipime - [**2153-8-11**] 11:34 PM
Infusions:
Other ICU medications:
Other medications:
Medications at time of transfer:
Atrovent 1 neb Q6H
Albuterol 1 neb Q6H
Tylenol 650 mg Q6H
Allopurinol 300 daily
Micafungin 100 mg
Cefepime 2 gm Q8h
Vancomycin 1 gm Q12H
Levofloxacin 750 mg IV daily
Tamiflu 75 PO BID
Past medical history:
Family history:
Social History:
Rheumatic fever c/b arthralgias
Mother with history of breast cancer, father with history of throat
cancer.
She moved to US from [**Country 7525**] 7 years ago. Russian is her native
language. She also speaks English. Married. 2 sons, age 15 and 20,
works as a health aid. 25 pack year smoking history, quit 9 days ago.
Review of systems:
Flowsheet Data as of [**2153-8-12**] 12:07 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 39.2
C (102.6
Tcurrent: 37
C (98.6
HR: 99 (99 - 137) bpm
BP: 116/63(81) {116/63(81) - 122/67(84)} mmHg
RR: 24 (24 - 40) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Height: 62 Inch
CVP: 8 (8 - 12)mmHg
Total In:
1,060 mL
27 mL
PO:
TF:
IVF:
780 mL
15 mL
Blood products:
280 mL
13 mL
Total out:
1,410 mL
160 mL
Urine:
1,410 mL
160 mL
NG:
Stool:
Drains:
Balance:
-350 mL
-133 mL
Respiratory
O2 Delivery Device: Aerosol-cool
SpO2: 97%
ABG: 7.46/43/92.[**Numeric Identifier 641**]/24/5
PaO2 / FiO2: 93
Physical Examination
Vitals: T: 102.6 BP:122/60 P: 75 R: 38 O2: 92% 100% FM
General: Sleeping but arousable, shallow breathing, oriented x 3
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP ~12 cm, no LAD
Lungs: Diffuse crackles R>L
CV: Tachycardic, nl s1 s2, [**2-16**] non-radiating soft systolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Labs / Radiology
32 K/uL
6.8 g/dL
123 mg/dL
0.8 mg/dL
11 mg/dL
24 mEq/L
100 mEq/L
3.9 mEq/L
137 mEq/L
20.8 %
42.7 K/uL
[image002.jpg]
[**2150-1-12**]
2:33 A8/1/[**2153**] 07:48 PM
[**2150-1-16**]
10:20 P8/1/[**2153**] 10:21 PM
[**2150-1-17**]
1:20 P8/1/[**2153**] 11:35 PM
[**2150-1-18**]
11:50 P
[**2150-1-19**]
1:20 A
[**2150-1-20**]
7:20 P
1//11/006
1:23 P
[**2150-2-12**]
1:20 P
[**2150-2-12**]
11:20 P
[**2150-2-12**]
4:20 P
WBC
42.7
Hct
20.8
Plt
13
32
Cr
0.8
TC02
32
Glucose
123
Other labs: PT / PTT / INR:16.2/31.5/1.4, ALT / AST:34/25, Alk Phos / T
Bili:263/0.8, D-dimer:4687 ng/mL, Fibrinogen:541 mg/dL, Lactic Acid:1.2
mmol/L, Albumin:3.2 g/dL, LDH:559 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL,
PO4:3.5 mg/dL
Assessment and Plan
This is a 45 year old female presenting with new diagnosis of likely
AML now with worsening hypoxia, fever and diffuse interstitial
infiltrates on CT.
.
# Hypoxemic respiratory distress: Pt with underlying emphysema
compounding current picture. With interval progression of intersitial
pattern on CT scan and worsening O2 requirement. Differential includes
infectious etiologies (viral/bacterial including superimposing
nosocomial infection given that she is now day #4 of hospitalization).
Given progression despite broad spectrum coverage, infiltrative
leukemia is also on differential.
- Trial of diuresis with CVP goal < 10
- Check BNP, consider repeat ECHO if elevated
- Continue broad spectrum coverage including vanc, cefepime, levoflox,
micafungin and tamiflu.
- Will add empiric anaerobic coverage with flagyl given recent emesis
and worsening respiratory status
- Follow up culture data
- Frequent ABGs, trial of non-invasive ventilation if persistent O2
requirement/evidence of CO2 retention [**2-12**] fatigue
- Chemotherapy per oncology
- Nebs prn
.
# Fever: Currently meets SIRS criteria with temperature, HR, RR, and
WBC. Remains hemodynamically stable, cultures negative to date.
Clinical picture is compounded leukemia which may be responsible for
the above.
- f/u culture data
- Antibiotics as above
- Chemotherapy per oncology
- ATC tylenol for fever given tachycardia, increase in metabolic demand
.
# Leukemia: With likely AML, awaiting cytogentics. Plan to start
idarubacin and cytarabine tonight.
- Dexamethasone, idarubacin, cytarabine per heme onc
- TLS, DIC labs q6 hours
- Transfuse to hct >24, plt> 15K
- IVF with NS
.
# FEN: No IVF, replete electrolytes, regular diet
.
# Prophylaxis: p-boots
.
# Access: peripherals, RIJ, a-line
.
# Code: full
.
# Communication: Patient
.
# Disposition: pending above
.
ICU Care
Nutrition:NPO
Glycemic Control: n/a
Lines:
Multi Lumen - [**2153-8-11**] 05:46 PM
Arterial Line - [**2153-8-11**] 11:13 PM
Prophylaxis:
DVT: p-boots
Stress ulcer: n/a
VAP: n/a
Comments:
Communication: Comments:
Code status: Full code
Disposition: pending improvement
|
Physician
|
Classify the following medical document.
|
Mr. [**Known firstname 20**] [**Known lastname **] is a 86 yo man with h/o CAD s/p MI and CABG in [**2136**],
chronic AFib with V-pacing, chronic systolic CHF with EF 20%, multiple
recent admission to the CCU for ICD firing, readmitted from [**Hospital **]
rehab for left sided chest pain. He reports that he had severe left
sided chest pain, worse with inspiration and palpation. He denies any
dyspnea, nausea, vomiting, abdominal pain, diaphoresis, left arm or jaw
pain or any other complaints. He does not know if his ICD fired. Of
note he has been admitted numerous times recently for VT and ICD firing
due to sustained VT. During his recent admission from [**9-19**] -[**9-21**] he was
bolused with IV amiodarone twice for episodes of VT during the
admission. During that admission he continued to refuse VT ablation
and turning off ICD.
This admission pt again had VT and this time agreed to go for VT
ablation, dtr was on vacation and not reachable. Pt tolerated procedure
well, sheaths pulled last night at 8 PM, area of right groin is
slightly eccyhmotic in the inguinal area, and he also has bruises on
the ABD area. Distal pulses palpable.
Ventricular tachycardia, sustained
Assessment:
s/p ablation [**9-22**] remains, AV-paced w occasional to rare PVC
s noted. Hr
50-60earlier then MD [**First Name (Titles) 9311**] [**Last Name (Titles) 4129**] rate to 70 for improved cardiac
output. NO further runs of VT Post ablation. Lido off yesterday. Cont
on PO amiodarone. SBP 100-110 w map
s > 60 . PT does complain of off
and on Chest pain or burning and stomach upset. Team aware and they
believe pain to be R/T procedure and pt was given one percocet with
good effect. Pt, per family somewhat confused after percocet, because
he forgot that his niece was here earlier. However He can be difficult
to assess as he speaks mostly Russian and translating by family. Later
seemed more oriented, pt requested that I talk to the doctors at the
rehab, because he was not sleeping well there and maybe I could
get a sleeping pill ordered.
Action:
Monitored groin, site stable .
Response:
Remains hemodynamically stable post ablation
Plan:
Continue to follow.
Heart failure (CHF), Systolic, Chronic
Assessment:
Received lasix in lab yesterday and again this AM 120 mg IV.
Action:
Received lasix in lab and again this AM 120 mg IV.
Response:
Good diuresis after lasix putting out one liter so far today
Plan:
Cont per order, of note Mag was 6 this AM spoke to team we will redraw,
likely that
Level is due to labs being drawn from IV where Mag was running. We
will recheck at one thirty with next lab draw
Impaired Skin Integrity
Assessment:
Pt bruises easily, eccymotic areas on belly from Sub Cut heparin shots
and the area around procedure site ( right inguinal area, ) also bruise
on left wrist, ? old inflate on last admission , area 2x2 and pink.
Marked. Also left wrist bruise ? from A line attempt
Action:
All areas cleaned with soap and water, LOTA, marked
Response:
No advancement of bruises and areas skin remains intact
Plan:
Turn frequently lotion to all areas .
RISK for fall
Assessment:
Pt at times confused, language barrier, BKA , has not tried to get out
of bed today.
Action:
Exit alarm on, interpreter family members have reiterated that pt will
stay in bed and not get OOB without assistance, check on pt frequently,
offer water and toileting.
Response:
Pt did not try to get OOB today.
Plan:
Exit alarm on, interpreter family members have reiterated that pt will
stay in bed and not get OOB without assistance, check on pt frequently,
offer water and toileting.
Demographics
Attending MD:
[**Doctor Last Name **] [**Doctor Last Name 2562**] I.
Admit diagnosis:
VTACH
Code status:
DNR / DNI
Height:
Admission weight:
78 kg
Daily weight:
78.7 kg
Allergies/Reactions:
Morphine
Nausea/Vomiting
Mirtazapine
Unknown;
Ambien (Oral) (Zolpidem Tartrate)
nightmares;
Precautions:
PMH:
CV-PMH: Angina, Arrhythmias, CAD, MI, Pacemaker
Additional history: MI X2 (inferior and anteroseptal)
- CABG: LIMA to LAD, SVG to OM/PDA ([**Hospital1 609**] [**2136**])
- Afib w/o anticoag (fall risk)
- Sustained VTach in [**2146**] s/p admission
- PACING/ICD: BiV ICD ([**2122**]?). ICD generator changed to
[**Company 1994**] Concerto in [**2145**].
- legally blind secondary to glaucoma
- Hiatal hernia
- Hepatic cysts/hemangioma and lipoma in hepatic flexure
- s/p Lt BKA (WWII trauma [**2078**])
- BPH s/p suprapubic prostatectomy ([**2131**])
- s/p cholecystectomy ([**2110**])
- Chronic low back pain
- Osteoarthritis
- Positive PPD in past
- Depression and anxiety
**former oncology md-[**Country **].
Surgery / Procedure and date: s/p cabg
Latest Vital Signs and I/O
Non-invasive BP:
S:109
D:59
Temperature:
98.6
Arterial BP:
S:132
D:56
Respiratory rate:
21 insp/min
Heart Rate:
72 bpm
Heart rhythm:
AV Paced
O2 delivery device:
Nasal cannula
O2 saturation:
97% %
O2 flow:
2 L/min
FiO2 set:
24h total in:
956 mL
24h total out:
2,760 mL
Pertinent Lab Results:
Sodium:
133 mEq/L
[**2147-9-23**] 06:07 AM
Potassium:
4.5 mEq/L
[**2147-9-23**] 02:03 PM
Chloride:
100 mEq/L
[**2147-9-23**] 06:07 AM
CO2:
25 mEq/L
[**2147-9-23**] 06:07 AM
BUN:
18 mg/dL
[**2147-9-23**] 06:07 AM
Creatinine:
1.0 mg/dL
[**2147-9-23**] 06:07 AM
Glucose:
90 mg/dL
[**2147-9-23**] 06:07 AM
Hematocrit:
38.9 %
[**2147-9-23**] 06:07 AM
Finger Stick Glucose:
177
[**2147-9-23**] 04:30 PM
Valuables / Signature
Patient valuables: teeth in moth dentures- eye drops
Other valuables:
Clothes: Sent home with:
Wallet / Money:
No money / wallet
Cash / Credit cards sent home with:
Jewelry:
Transferred from: ccu
Transferred to: [**Hospital Ward Name **] 3
Date & time of Transfer:
|
Nursing
|
Classify the following medical document.
|
Admission Date: [**2137-9-11**] Discharge Date: [**2137-9-14**]
Date of Birth: [**2062-9-1**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Esophagoduodenoscopy with cauterization of duodenal ulcer
History of Present Illness:
75 year old man on ASA and Plavix for history of CVA, hx of
tobacco and EtOH abuse presented to his PCP with one week of
melena and increased stool output. He has had small dark
stools, epigastric discomfort, and decreased appetite for ~1
week. His stool output had increased from 1 BD /day to [**1-22**] then
several days PTA had constipation. He also endorsed LH, denied
N/V, CP/SOB. Later that night, lab called PCP that pt had hct
20. Pt was sent to [**Hospital1 18**] ED where he had negative NG lavage.
EGD showed an actively oozing duodenal ulcera in posterior bulb.
It was injected with epinephrine and cauterized. Upon arrival at
ED, his hematocrit was 19.3. He received 2 liters of NS and
total 6 units of PRBC with increased in hct to 33. He was
initially admitted to the MICU for observation overnight then
transferred to the floor with stable HCT.
Past Medical History:
CVA x 3 with blindness in right eye
Hypercholesterolemia
Heavy alcohol use
Social History:
Drinks 3-4 glasses of wine or beer per day and quit smoking 4
days ago. 60 pack year history. Lives with wife and is a retired
shoemaker who once worked in [**Country 651**]. Originally from Stuttgard.
Has one daughter.
Physical Exam:
T98.1 BP 123/76 (107-150/70-81) HR 80 (80-90) 16 98%RA
GEN WDWN elderly man, lying flat in bed, comfortable
HEENT [**Last Name (LF) 12476**], [**First Name3 (LF) 13775**], EOMI, 2+carotid, R bruit, JVP ~[**10-1**] @45' o/p
clear, MM dry
CV faint heart sounds, nl S1 + S2, no M/R/G noted
Pulm bibasilar crackles L>R, ~[**Date range (1) 23119**] from base
Abd +BS, mild distension, mild tenderness in hypogastrum, no
rebound
tenderness
EXT No edema, 2+DP
Neuro CN2-12 grossly intact
Pertinent Results:
[**2137-9-11**] 05:00AM
WBC-17.3* HCT-19.3* MCV-97 MCH-32.8* MCHC-33.9 RDW-17.2* PLT
COUNT-246
NEUTS-81.2* LYMPHS-13.6* MONOS-4.1 EOS-0.6 BASOS-0.5
[**2137-9-11**] 05:00AM CK(CPK)-77 CK-MB-3 cTropnT-<0.01
[**2137-9-11**] 07:18PM CK(CPK)-71 CK-MB-NotDone cTropnT-<0.01
[**2137-9-11**] 01:50PM HCT-21.7*
[**2137-9-11**] 07:18PM HCT-22.5*
[**2137-9-11**] 09:28PM HCT-23.4*
Brief Hospital Course:
1. Duodenal ulcer
After cauterization by EGD and transfusion of 6u PRBC, his hct
remained stable at 33 and he had no further episodes of melena
or frequent BM. Serology for H. pylori was positive and he was
started on clarithromycin and amoxicillin x 14 days in addition
to protonix [**Hospital1 **]. His ASA and plavix were discontinued and the
patient was asked to address with his primary care doctor when
he should begin taking these.
2. Anemia
Iron studies were consistent with iron deficiency anemia. He was
started on iron daily. In addition he was given B12, folate, and
MVI though these levels were normal, given his alcoholism.
3. EtOH use
He was placed on CIWA scale with Diazepam, which he did not
require. He was given MVI, thiamine, and folate as mentioned.
4. h/o CVA
He has had 3 strokes in the past, but per patient he had a
negative work up. He continued statin. While the ASA and plavix
were held, it is likely he needs to be placed back on these
medications for this significant CVA history; this will be
determined by his PCP as an outpatient.
Medications on Admission:
ASA 325 mg po qd
Plavix 75 mg po qd
Atorvastatin 10 mg po qd
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
Disp:*30 Cap(s)* Refills:*2*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO once
a day.
6. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
7. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcer
Upper gastrointestinal bleed
Blood loss anemia
Helicobacter Pylori infection
History of stroke x 3
Discharge Condition:
Stable
Discharge Instructions:
You have a duodenal ulcer. You are being given medicine to help
reduce your gastric secretions to allow this to heal. You have
also tested positive for H. Pylori, a bacteria that can
contribute to ulcers, and will need to take a course of
antibiotics to treat this. Call your doctor for any new blood in
your stool, diarrhea, dark black stools, lightheadedness, or
fatigue.
Followup Instructions:
Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**]
[**Telephone/Fax (1) 2936**], to make a follow up appointment within the next
1-2 weeks. He should discuss with you the risks and benefits of
restarting aspirin and plavix to prevent further strokes given
your ulcer and gastrointestinal bleeding.
|
Discharge summary
|
Classify the following medical document.
|
TSICU
HPI:
66F with hx of [**Hospital 1571**] transferred from [**Location (un) 78**] after having
worst HA of life at 4p while at church. She denied N/V, CP, SOB,
LOC. Was found to have SAH at OSH, Dilantin loaded and started on
Nimodipine. She was then transferred here for further evaluation.
Chief complaint:
SAH W/ ANEURYSM
PMHx:
HTN, GERD
Current medications:
1. 2. 3. 1000 mL NS 4. Acetaminophen 5. Acetaminophen-Caff-Butalbital
6. Bisacodyl 7. Calcium Gluconate
8. Docusate Sodium 9. HYDROmorphone (Dilaudid) 10. Heparin 11.
HydrALAzine 12. Insulin 13. Magnesium Sulfate
14. Metoprolol Tartrate 15. Neutra-Phos 16. Nimodipine 17. Omeprazole
18. Ondansetron 19. OxycoDONE (Immediate Release)
20. Oxycodone-Acetaminophen 21. Phenytoin 22. Pneumococcal Vac
Polyvalent 23. Potassium Chloride
24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush
27. Valsartan
24 Hour Events:
[**5-10**]: complaints of headache, dilaudid dose increased, recieved dose of
lopressor x1
Post operative day:
POD#4 - IR- Coiling x 3
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Hydralazine - [**2175-5-10**] 05:09 PM
Hydromorphone (Dilaudid) - [**2175-5-10**] 05:30 PM
Metoprolol - [**2175-5-10**] 05:40 PM
Heparin Sodium (Prophylaxis) - [**2175-5-10**] 08:17 PM
Other medications:
Flowsheet Data as of [**2175-5-11**] 05:56 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**77**] a.m.
Tmax: 37.9
C (100.3
T current: 37.5
C (99.5
HR: 81 (65 - 92) bpm
BP: 171/67(94) {141/40(60) - 209/90(116)} mmHg
RR: 17 (11 - 21) insp/min
SPO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 126 kg (admission): 125.9 kg
Height: 67 Inch
Total In:
1,400 mL
PO:
1,400 mL
Tube feeding:
IV Fluid:
Blood products:
Total out:
5,420 mL
450 mL
Urine:
5,420 mL
450 mL
NG:
Stool:
Drains:
Balance:
-4,020 mL
-450 mL
Respiratory support
O2 Delivery Device: None
SPO2: 95%
ABG: ///25/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: CTA bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Obese
Left Extremities: (Edema: Absent), (Temperature: Warm)
Right Extremities: (Edema: Absent), (Temperature: Warm)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
336 K/uL
11.8 g/dL
133 mg/dL
0.5 mg/dL
25 mEq/L
3.2 mEq/L
9 mg/dL
100 mEq/L
135 mEq/L
34.0 %
13.7 K/uL
[image002.jpg]
[**2175-5-6**] 11:57 PM
[**2175-5-7**] 02:00 AM
[**2175-5-8**] 01:37 AM
[**2175-5-9**] 02:13 AM
[**2175-5-9**] 02:07 PM
[**2175-5-10**] 01:49 AM
[**2175-5-11**] 03:40 AM
WBC
7.8
9.9
10.9
18.8
12.4
13.6
13.7
Hct
36.9
33.0
32.9
33.7
33.8
32.3
34.0
Plt
[**Telephone/Fax (3) 6029**]35
293
287
336
Creatinine
0.7
0.7
0.7
0.5
0.6
0.5
0.5
Troponin T
<0.01
Glucose
172
160
146
131
179
146
133
Other labs: PT / PTT / INR:12.6/23.2/1.1, CK / CK-MB / Troponin
T:32/2/<0.01, Differential-Neuts:82.8 %, Lymph:13.5 %, Mono:3.5 %,
Eos:0.0 %, Albumin:4.0 g/dL, Ca:8.3 mg/dL, Mg:2.2 mg/dL, PO4:2.1 mg/dL
Assessment and Plan
AEROBIC CAPACITY / ENDURANCE, IMPAIRED, BALANCE, IMPAIRED,
HYPERTENSION, BENIGN, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),
ANEURYSM, OTHER
Assessment and Plan: 66F with SAH s/p coiling of AComm aneurysm
Neurologic: Neuro checks Q: 2 hr, SAH, POD 2 s/p coiling. On dilantin
100 mg po tid. Low level, received additional bolus last pm, currently
8.9. Vasospasm prophylaxis with nimodipine. Repeat head CT unchanged.
Monitor for total 7 days in ICU
Pain:controlled with dilaudid prn, Fiorocet, oxycodone.
Cardiovascular: hx of HTN, goal SBP 100-200 per neurosurg. BP control
w/ hydralazine, metoprolol and nimodipine, otherwise allow to
autoregulate
Pulmonary: stable on 2L NC, encourage IS, PT consult to get pt OOB.
Gastrointestinal / Abdomen: regular diet. on bowel regimen colace,
dulcolax, senna prn.
Nutrition: Regular diet
Renal: Monitor UOP and Daily Cr
Hematology:HCT stable, check daily
Endocrine: RISS, BG<150
Infectious Disease: low grade Temp, wbc stable 13.7, we will monitor
fever curve no antibiotics for now
Lines / Tubes / Drains: PIV
Wounds: none
Imaging: none
Fluids: KVO
Consults: Neuro surgery
Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)
ICU Care
Nutrition: regular diet
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2175-5-8**] 12:39 PM
Prophylaxis:
DVT: Boots, SQ Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent: 21 minutes
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
58 yo man with with h/o ETOH abuse. Quit drinking on [**5-27**]. Had
some gait difficulty, slurred speech, confusion after that which
continued. Was to get MRI but it wasn't done. Went to [**Hospital3 **] for
vacation. Yesterday morning had very poor mental status - [**Hospital 3296**]
Hospital. Negative head CT. in ED BP 170/100, tach. labs sign for
plts in 90s, NH4 141. Intubated to protect airway. Got treated for
?meningitis, but no tap.
24 Hour Events:
INVASIVE VENTILATION - START [**2137-7-12**] 07:17 PM
actual start of veentilation in MICU6 was ~ 1830
Allergies:
Last dose of Antibiotics:
Vancomycin - [**2137-7-12**] 08:00 PM
Infusions:
Propofol - 30 mcg/Kg/min
Other ICU medications:
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2137-7-13**] 09:37 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.8
C (98.3
Tcurrent: 36.8
C (98.3
HR: 92 (69 - 95) bpm
BP: 153/80(98) {113/59(75) - 161/97(111)} mmHg
RR: 24 (10 - 24) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Height: 74 Inch
Total In:
1,039 mL
1,249 mL
PO:
TF:
IVF:
979 mL
1,219 mL
Blood products:
Total out:
1,240 mL
625 mL
Urine:
1,240 mL
625 mL
NG:
Stool:
Drains:
Balance:
-201 mL
624 mL
Respiratory support
Ventilator mode: CMV/ASSIST
Vt (Set): 600 (600 - 600) mL
RR (Set): 12
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 25
PIP: 16 cmH2O
Plateau: 11 cmH2O
SpO2: 100%
ABG: 7.44/37/160/25/
Ve: 12.2 L/min
PaO2 / FiO2: 400
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
11.4 g/dL
53 K/uL
131 mg/dL
1.0 mg/dL
25 mEq/L
3.3 mEq/L
14 mg/dL
113 mEq/L
142 mEq/L
31.7 %
5.9 K/uL
[image002.jpg]
[**2137-7-12**] 09:15 PM
[**2137-7-13**] 04:15 AM
WBC
5.6
5.9
Hct
33.1
31.7
Plt
57
53
Cr
1.0
1.0
TropT
0.02
Glucose
154
131
Other labs: PT / PTT / INR:16.7/37.6/1.5, CK / CKMB /
Troponin-T:449/7/0.02, ALT / AST:35/56, Alk Phos / T Bili:92/2.7,
Amylase / Lipase:45/61, Differential-Neuts:58.3 %, Lymph:31.6 %,
Mono:6.2 %, Eos:3.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.7 g/dL,
LDH:180 IU/L, Ca++:9.4 mg/dL, Mg++:1.7 mg/dL, PO4:3.6 mg/dL
Assessment and Plan
Delirium/poor MS: Most likely hepatic encephalopathy. Reported has
not drank since [**5-27**], so ETOH withdrawl unlikely. Continue with
lactulose.
doubt meningitis with two weeks of altered MS and no fever. Also
consider Wernicke's - tx with thiamine.
alchoholic hepatitis: discriminate score about 29. will ask
hepatology if they feel treatment is warranted.
respiratory failure: will try to extubate once stooling and MS better.
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2137-7-13**] 12:00 AM
16 Gauge - [**2137-7-13**] 12:00 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 40 minutes
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
TITLE:
Chief Complaint:
24 Hour Events:
Echo - Left ventricular cavity enlargement with extensive regional
systolic dysfunction c/w CAD (mid-LAD distribution, LVEF = 25-30). Mild
aortic regurgitation. Pulmonary artery systolic hypertension. Mild
mitral regurgitation. CT surgery, will likely get CABG Wed/[**Doctor First Name **], started
heparin gtt w/o bolus. Lipids at goal, A1C 5.4. Guiac pos stool. CXR
- ? R hilar mass, ordered CT chest. U/S -L ICA mod/severe stenosis
60-69% w/ interval progression; R no sign stenosis. Wound cons. Pend,
CK trending down, [**2116**]. Febrile o/n. BCx and UCx sent. Had episode of
hypxia/SOB, mild CP in HD, CXR unchanged, ECT STe in same leads as
STEMI. Given IV morphine, nebs, Nitro and back to HD.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Heparin Sodium - 1,200 units/hour
Other ICU medications:
Morphine Sulfate - [**2110-11-10**] 07:35 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2110-11-11**] 06:09 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 38.4
C (101.1
Tcurrent: 37.8
C (100.1
HR: 76 (63 - 104) bpm
BP: 97/47(58) {56/33(40) - 143/125(128)} mmHg
RR: 22 (13 - 35) insp/min
SpO2: 92%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 98.5 kg (admission): 100 kg
Height: 27 Inch
Total In:
927 mL
74 mL
PO:
660 mL
TF:
IVF:
267 mL
74 mL
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
927 mL
74 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 92%
ABG: ///31/
Physical Examination
GENERAL: Somnlent but otherwise well-appering man in NAD. Oriented to
person, month and year.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: Supple with no appreciable JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular line.
Distant heart sounds RR, normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Lower left-midline scar s/p
appendectomy per pt.
EXTREMITIES: No femoral bruits. L arm AV fistula, + palpable thrill
and audible bruit. R femoral area soft without ecchymosis or hematoma,
no bruits, 2+ femoral pulses bilaterally. 1+ DP and PT pulses
SKIN: Ulceration on L anterior skin with eschar and granulation tissue.
Chronic skin changes of bilateral lower extremities c/w statis
dermatitis.
Labs / Radiology
170 K/uL
10.2 g/dL
99 mg/dL
8.0 mg/dL
31 mEq/L
4.1 mEq/L
36 mg/dL
92 mEq/L
138 mEq/L
30.4 %
9.6 K/uL
[image002.jpg]
[**2110-11-9**] 05:42 PM
[**2110-11-10**] 02:30 AM
[**2110-11-10**] 01:53 PM
[**2110-11-11**] 03:53 AM
WBC
8.3
7.6
9.6
Hct
30.1
30.3
30.4
Plt
160
205
170
Cr
9.4
9.8
8.0
TropT
12.68
16.03
17.03
19.10
Glucose
102
181
99
Other labs: PT / PTT / INR:15.7/61.9/1.4, CK / CKMB /
Troponin-T:1216/50/19.10, ALT / AST:30/151, Alk Phos / T Bili:348/0.4,
Albumin:3.9 g/dL, LDH:849 IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:5.5
mg/dL
Assessment and Plan
64yo M with hx of ESRD on HD, CAD, hypercholesterolemia, CVA p/w chest
pain and STEMI, v. fib X 3 at OSH, resolved with shock, transferred
from OSH for cardiac cath, now s/p LAD BMS stent with 3v disease.
.
# CORONARIES: Pt with hx of CAD, p/w STEMI and cath showing 3v
disease, s/p BMS stent to LAD. Now chest pain free. ECG showed
anterior ischemic changes. Pt received [**Last Name (LF) **], [**First Name3 (LF) 119**], aggrastat at OSH.
- discuss with CT surgery regarding plans for CABG; if going to be done
this week, will start heparin for anticoagulation in the setting of a
BMS and will hold on [**First Name3 (LF) **]. If not done this week, will restart
[**First Name3 (LF) **].
- continue aspirin
- bblocker, statin
- check lipid panel, HBA1C, fasting glucose in AM
.
# PUMP: No prior echos to compare. Does not appear in heart failure
clinically.
- TTE
.
# RHYTHM: S/P v. fib X 3 at OSH with shock X 3. Has been in NSR since
with some non-sustained VT 6-9 beats on tele overnight. V fib
secondary to ischemia and now reperfusion.
- stop amiodarone today.
- continue to monitor on tele
.
# ESRD on HD: unclear origin of disease. Pt dialyzed M, W, F and last
dialysis was friday per patient. Pt received aggrastat which is
renally cleared and is likely having lasting effects on clotting time.
Sheath pulled and no evidence of bleeding or hematoma.
- pt to have dialysis today
- continue Sevelamer, Nephrocaps, Sensipar
- check platelet agglutination study today
.
# COPD: not contributing factor at this time and pt on no medications
- continue to monitor
.
# Weight Loss: Due to poor PO intake per daughter. [**Name (NI) **] etiologies
may be malignancy (lung, colon cancer), metabolic (hyperthyroidism).
TSH normal. CXR done this morning.
- guiac stool, pt will need outpatient colonscopy
- f/u CXR for lung cancer screening
.
# Left leg ulcer: appears chronic
- wound care consult
.
# Hx of CVA:
- continue [**Last Name (LF) 119**], [**First Name3 (LF) 124**] give [**First Name3 (LF) 120**] or heparin as per above
.
# FEN: cardiac, renal diet, replete lytes as needed
.
# Prophylaxis: no SC heparin for now given bleeding risk, PPI as per
home tx, bowel regimen
.
# Access: 2 PIV on right arm, fistula left arm
.
# Code Status: FULL, confirmed with patient and daughter
.
# Contact: Daughter [**First Name4 (NamePattern1) 532**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2967**]
.
# Dispo: call out to floor today
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2110-11-10**] 08:30 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
|
Physician
|
Classify the following medical document.
|
Chief Complaint:
24 Hour Events:
EKG - At [**2148-12-2**] 08:50 AM
History obtained from Medical records
Patient unable to provide history: Sedated
Allergies:
Ace Inhibitors
Cough;
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2148-12-2**] 02:00 PM
Vancomycin - [**2148-12-2**] 04:28 PM
Piperacillin - [**2148-12-3**] 06:00 AM
Infusions:
Fentanyl - 50 mcg/hour
Midazolam (Versed) - 1 mg/hour
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2148-12-2**] 02:00 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2148-12-3**] 08:09 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.6
C (99.6
Tcurrent: 37.5
C (99.5
HR: 93 (64 - 97) bpm
BP: 128/48(73) {86/37(54) - 171/57(90)} mmHg
RR: 20 (17 - 22) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 56.6 kg (admission): 56 kg
Total In:
4,082 mL
1,645 mL
PO:
TF:
IVF:
3,912 mL
1,645 mL
Blood products:
Total out:
1,307 mL
275 mL
Urine:
638 mL
275 mL
NG:
Stool:
Drains:
Balance:
2,775 mL
1,370 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST
Vt (Set): 400 (400 - 400) mL
Vt (Spontaneous): 165 (165 - 165) mL
PS : 0 cmH2O
RR (Set): 20
RR (Spontaneous): 9
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 13
PIP: 20 cmH2O
Plateau: 15 cmH2O
Compliance: 40 cmH2O/mL
SpO2: 100%
ABG: 7.34/52/127/25/1
Ve: 6.9 L/min
PaO2 / FiO2: 318
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)
Rub
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,
No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,
Tone: Not assessed
Labs / Radiology
155 K/uL
7.9 g/dL
67 mg/dL
2.9 mg/dL
25 mEq/L
4.6 mEq/L
46 mg/dL
110 mEq/L
144 mEq/L
23.0 %
10.4 K/uL
[image002.jpg]
[**2148-12-2**] 08:49 AM
[**2148-12-2**] 12:06 PM
[**2148-12-2**] 12:09 PM
[**2148-12-2**] 03:44 PM
[**2148-12-2**] 07:02 PM
[**2148-12-2**] 07:27 PM
[**2148-12-2**] 10:28 PM
[**2148-12-2**] 10:50 PM
[**2148-12-3**] 04:40 AM
[**2148-12-3**] 04:51 AM
WBC
10.4
Hct
29
25.0
27
23.0
Plt
155
Cr
3.2
3.0
2.8
2.8
2.9
TCO2
24
26
28
27
29
Glucose
146
73
159
137
67
Other labs: PT / PTT / INR:14.7/49.9/1.3, ALT / AST:164/102, Alk Phos /
T Bili:32/0.5, Amylase / Lipase:1485/68, Differential-Neuts:82.4 %,
Lymph:10.7 %, Mono:5.3 %, Eos:0.9 %, Lactic Acid:2.1 mmol/L,
Albumin:4.1 g/dL, LDH:254 IU/L, Ca++:9.2 mg/dL, Mg++:1.6 mg/dL, PO4:5.2
mg/dL
Assessment and Plan
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
PANCREATITIS, ACUTE
RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY
DISEASE)
HYPOTENSION (NOT SHOCK)
ICU Care
Nutrition:
Glycemic Control:
Lines:
Multi Lumen - [**2148-12-2**] 03:20 AM
Arterial Line - [**2148-12-2**] 03:20 AM
Dialysis Catheter - [**2148-12-2**] 05:32 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer:
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status:
Disposition:
|
Physician
|
Classify the following medical document.
|
TITLE:
Chief Complaint: 56 year old woman with metastatic breast cancer to
bone, lung and brain, presenting with worsening lower extremity edema,
found to be hypoxic and with new large right pleural effusion.
24 Hour Events:
THORACENTESIS - At [**2162-5-2**] 02:11 PM
Allergies:
Taxol (Intraven.) (Paclitaxel
Semi-Synthetic)
Anaphylaxis;
Last dose of Antibiotics:
Levofloxacin - [**2162-5-2**] 08:53 PM
Infusions:
Other ICU medications:
Pantoprazole (Protonix) - [**2162-5-2**] 08:28 AM
Morphine Sulfate - [**2162-5-2**] 05:52 PM
Heparin Sodium (Prophylaxis) - [**2162-5-2**] 10:28 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2162-5-3**] 07:39 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.6
C (97.9
Tcurrent: 35.7
C (96.2
HR: 95 (95 - 119) bpm
BP: 115/74(84) {115/54(84) - 154/94(104)} mmHg
RR: 15 (15 - 27) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Total In:
2,605 mL
76 mL
PO:
690 mL
TF:
IVF:
855 mL
76 mL
Blood products:
560 mL
Total out:
697 mL
245 mL
Urine:
697 mL
245 mL
NG:
Stool:
Drains:
Balance:
1,908 mL
-169 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 98%
ABG: ///24/
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
120 K/uL
8.7 g/dL
115 mg/dL
0.5 mg/dL
24 mEq/L
4.1 mEq/L
17 mg/dL
106 mEq/L
139 mEq/L
26.3 %
10.3 K/uL
[image002.jpg]
[**2162-5-2**] 09:41 AM
[**2162-5-3**] 05:02 AM
WBC
9.7
10.3
Hct
31.2
26.3
Plt
118
120
Cr
0.5
0.5
Glucose
88
115
Other labs: PT / PTT / INR:16.7/70.0/1.5, Differential-Neuts:86.0 %,
Band:6.0 %, Lymph:2.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.6 mmol/L,
Albumin:2.4 g/dL, LDH:830 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:2.3
mg/dL
Fluid analysis / Other labs: Pleural Fluid
Chemistry
Protein 2.4
Glucose 105
Creat: 0.4
LD(LDH): 428
Albumin: 1.7
Pleural Fluid
WBC 225
RBC 315
Poly 7
Lymph 37
Mono 7
EOs
Meso: 2
Macro: 43
Other: 4
Imaging: CTA
1. No definite evidence of pulmonary emboli.
2. Extensive lung masses and nodules involving both lungs, which
appears to
have increased when compared to prior exam. Some of these masses appear
to
encase the distal segmental pulmonary arteries.
3. Extensive ground-glass opacity and septal thickening. This could
represent
lymphangitic spread or edema.
4. Hypodense lesions in the liver concerning for metastasis and fluid
within
the perihepatic space.
5. Sclerotic lesions in the lower thoracic vertebral bodies with
compression
deformities.
6. Large left pleural effusion and small right pleural effusion.
LENI
IMPRESSION: No evidence of DVT.
The study and the report were reviewed by the staff radiologist.
Assessment and Plan
RASH
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**])
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**])
56 year old woman with metastatic breast cancer to bone, lung and
brain, presenting with worsening lower extremity edema, found to be
hypoxic and with new large right pleural effusion.
#. RESPIRATORY DISTRESS: Currently on 4L O2, at baseline is 100%RA. As
the pt has mets in lung and unclear history of sarciod it is difficult
to discern whether the pt has pneumonia as well. No fever, minimal
cough and nl WBC (although pt does have bands, and normal WBC may be
elevated in the setting of recent Avastin and possible
myelosuppression). Suspect effusion is most likely secondary to
malignancy.
-- Levaquin for CAP
-- S/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
-- Supplemental oxygen.
#. LOWER EXTREMITY EDEMA: Concerning for venous obstruction.
-- Final LENI
s negative for DVT
-- Consider imaging of abd/pelvis (CT v MRI)
-- Elevation of LE
-- F/u final echo
#. BREAST CANCER: No plans for inpatient therapy
#. BRAIN METASTASIS: CT stable, no significant change in cerebellar
lesions
#. URINARY TRACT INFECTION: Levaquin for now. X3d
-- F/U Culture
FEN: Regular diet
PPX:
-DVT ppx with SQ Heparin and Pneumoboots
-Bowel regimen
-Pain management with Tylenol
ACCESS: PIV's
CODE STATUS: full
-- Plan for family meeting today
DISPOSITION: transfer to OMED
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2162-5-2**] 02:48 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2120-8-28**] Discharge Date: [**2120-9-6**]
Date of Birth: [**2043-6-19**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins / Sulfa (Sulfonamides) / Iodine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Pt presented s/p fall w/bilaterall lower ext weakness
w/parasthesias and difficulty handeling secretions.
Major Surgical or Invasive Procedure:
Cervical stabilization anterior partial vertebrectomies
c4-5,c6-7 [**2120-8-30**]
Past Medical History:
Past Medical History:
diabetes type II
mild asthma
[**Doctor Last Name 3271**]-[**Doctor Last Name **] virus
lower extremity edema
newly diagnosed T3N1 poorly differentiated esophageal cancer
PAST SURGICAL HISTORY:
Significant for inguinal hernia repair in [**2082**] and status post
exploratory laparotomy in [**2098**] for abdominal pain at which they
performed an incidental cholecystectomy and appendectomy.
Social History:
He lives in [**Location (un) 3844**] where he has lived for the past 40
years with his partner. [**Name (NI) **] works as a cashier at a bookstore. He
smoked 50-pack year quitting 15 years ago. He does not drink any
alcohol. He has no children.
Family History:
His mother died at age of 87 from gastric cancer and his father
died at age of 70 from cirrhosis. He has a sister who is 81
years old and has no cancer. His brother is 66 and healthy.
Physical Exam:
NAD, A&Ox3
Echymosis bilateral orbits
PERRLA
RRR
Course BS bilat
Abdomen soft, NT/ND
Neuro: +[**12-23**] left bicep, +[**1-20**] left tricep, [**2-20**] bilateral hand
grips, [**1-20**] right bicep and tricep, [**12-22**] DTR LUE, [**11-21**] LUE, 0/4
Bilat LE, bilat downgoing toes, sensation intact but describes
as "pins and needles sensation" on bilateral UE.
Pertinent Results:
[**2120-8-28**] 12:20AM GLUCOSE-95 UREA N-9 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-30 ANION GAP-10
[**2120-8-28**] 12:20AM WBC-3.7*# RBC-3.68* HGB-11.5* HCT-35.2*
MCV-96# MCH-31.4 MCHC-32.8 RDW-21.2*
[**2120-8-28**] 12:20AM NEUTS-64.2 LYMPHS-29.5 MONOS-5.9 EOS-0.3
BASOS-0.1
[**2120-8-28**] 12:20AM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-3+
[**2120-8-28**] 12:20AM PLT COUNT-148*
[**2120-8-28**] 12:20AM PT-13.5* PTT-26.5 INR(PT)-1.2
[**2120-8-28**] 12:20AM BLOOD WBC-3.7*# RBC-3.68* Hgb-11.5* Hct-35.2*
MCV-96# MCH-31.4 MCHC-32.8 RDW-21.2* Plt Ct-148*
[**2120-8-28**] 12:20AM BLOOD Neuts-64.2 Lymphs-29.5 Monos-5.9 Eos-0.3
Baso-0.1
[**2120-8-28**] 12:20AM BLOOD PT-13.5* PTT-26.5 INR(PT)-1.2
[**2120-8-28**] 12:20AM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-138 K-4.0
Cl-102 HCO3-30 AnGap-10
Brief Hospital Course:
[**2120-8-28**]: Admited to TSICU after transfer from NEH on steroid
gtt. Made NPO for spinal intervention. Admited TSICU for
increased secretions.
[**2120-8-29**]: OR delayed secondary to increased secretions
[**2120-8-30**]: OR for Anterior fusion from C4-C7. Anterior partial
vertebrectomy of C5, C6, C7. Anterior discectomies C4-5, C5-6,
C6-7 Anterior instrumentation C4-C7. Structural allograft.
Stable postoperatively. Right groin line placed after failed
attempt on right subclavian w/small right apical pneumothorax.
Episode of hypotension w/position change requiring neosynephrine
and fluid boluses.
[**2120-8-31**]: Hematocrit drop from 33 to 26. Transfused.
[**2120-9-1**]: OR for: Total laminectomy of C3, C4, C5, C6. Fusion
C4-C7. Autograft.
Excision of soft tissue mass in the posterior cervical region.
On CPAP/PS post op w/occasional desats and increased secretions.
[**2120-9-2**]: Sputum returns w/gram neg rods w/levofloxacin
started. Attempted placement of dobhoff tube unsuccesfully.
[**2120-9-3**]: Patient extubated sucessfully.
[**2120-9-4**]: Patient failed swallow study w/frank aspiration.
Feeding tube by IR.
[**2120-9-5**]: Tube feeds started after placement of feeding tube by
IR. A-Line removed, femoral line removed w/mild hemorrhage
(approx 200cc blood loss) stopped w/direct pressure. Hct and
coags normal. Droping urine output responsive to fluid boluses.
RADIOLOGY Final Report
CT RECONSTRUCTION [**2120-8-28**] 4:02 AM
CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION
Reason: eval for [**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with fall and head trauma, ? C-spine injury
REASON FOR THIS EXAMINATION:
eval for fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Fall and head trauma and C-spine injury on outside
CT and MRI, evaluate fracture.
COMPARISON: None available at the time of dictation.
TECHNIQUE: Axial MDCT images were obtained through the cervical
spine without intravenous contrast. Additional coronal and
sagittal reformations are provided.
CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The
cervical spine is imaged from C1 through T3. There is a
minimally displaced fracture through the spinous process of C4
extending to the posterior arch of C4. Minimally displaced
fractures of the tips of the spinous processes of C5. Mildly
displaced fracture of the spinous process of C7.
There is malalignment of the component vertebrae at C4-5, with
grade 1 retrolisthesis of C4 on C5 and with marked widening of
the intervertebral disc space anteriorly. There is additional
widening of the intervertebral disc space anteriorly at C6-7.
There is marked narrowing of the spinal canal at C4-5 due to
retrolisthesis of C4 on C5 and angulation of the spine at this
level.
The prevertebral soft tissues are widened diffusely. In
addition, there is a suggestion of hyperdensity within the
widened intervertebral disc spaces at C4-5 and C6-7 as well as
within the prevertebral soft tissues, possibly representing
hematoma.
There is an additional questionable linear lucency within the
anterior inferior aspect of the C2 vertebra on the sagittal
views only without clear correlate on the axial views, finding
that could represent artifact Vs. a nondisplaced fracture.
The visualized portions of the lung apices appear unremarkable.
IMPRESSION:
1. Fractures of the spinous processes at C4, C5, and C7.
2. Cervical spine malalignment of C4-5 and C6-7, with
retrolisthesis and intervertebral disc space widening at C4-5
and disc space widening at C6-7, and spinal stenosis. The
findings are highly suggestive of ligamentous injury at these
locations. MRI should be considered for assessment of the spinal
cord as well as soft tissues.
3. Marked expansion of the prevertebral soft tissues consistent
with hematoma and edema.
4. Questionable artifact Vs. nondisplaced fracture of the
anterior inferior corner of C2 vertebra, seen on the sagittal
reconstructions only.
Results were discussed with the orthopedic resident at the time
of interpretation (4:45 a.m.).
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8913**] R.M. SUN
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 21104**]
Approved: WED [**2120-8-28**] 8:58 AM
Medications on Admission:
Actose 30 QD, Glucophage 250 QD, Methadone
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Albuterol Sulfate 0.083 % Solution Sig: [**11-19**] Inhalation Q4H
(every 4 hours).
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO PRN (as
needed) as needed for Mg<2.
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
6. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO PRN
(as needed) as needed for K<4.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO ONCE (once) for 1 doses.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
Scale Injection ASDIR (AS DIRECTED).
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
13. Magnesium Sulfate 50 % Solution Sig: One (1) Injection ONCE
(once) for 1 doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Cervical subluxation C4-5
Central cord syndrome
Discharge Condition:
good
Discharge Instructions:
keep collar on when out of bed. Keep incision clean and dry.
Daily dressing changes to surgical incisions.
Physical Therapy:
Activity: Bedrest with bed position
Pneumatic boots
Cervical collar: At all times
may elevate HOB
No heavy lifting (no lifting>10lbs)
Treatments Frequency:
Site: ant/post cervical
Type: Surgical
Dressing: Gauze - dry
Change dressing: qd
Site: Healing incision to ant, neck
Description: Incision
Care: dry sterile dressing
Followup Instructions:
10 days from date of discharge with Dr [**Last Name (STitle) 363**] [**Telephone/Fax (1) 3573**]
Completed by:[**2120-9-6**]
|
Discharge summary
|
Classify the following medical document.
|
Chief Complaint: Acute respiratory failure, pneumonia
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
PICC LINE - START [**2105-12-10**] 10:15 AM
MULTI LUMEN - STOP [**2105-12-10**] 04:05 PM
Trial of diuresis yesterday
Hypotensive SBP - 60's overnight, given 250 cc IV NS and increased neo
with BP increase to 90's.
Upper airway secretions reduced with scopolamine patch
Patient unable to provide history: Sedated, intubated
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2105-12-11**] 07:55 AM
Vancomycin - [**2105-12-11**] 07:55 AM
Infusions:
Phenylephrine - 1.2 mcg/Kg/min
Midazolam (Versed) - 2 mg/hour
Fentanyl - 50 mcg/hour
Other ICU medications:
Furosemide (Lasix) - [**2105-12-10**] 12:12 PM
Famotidine (Pepcid) - [**2105-12-10**] 08:45 PM
Heparin Sodium (Prophylaxis) - [**2105-12-11**] 07:55 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Pain: No pain / appears comfortable
Flowsheet Data as of [**2105-12-11**] 10:13 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.4
C (99.3
Tcurrent: 36.8
C (98.2
HR: 69 (63 - 80) bpm
BP: 104/46(66) {76/37(51) - 160/64(96)} mmHg
RR: 18 (13 - 22) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Height: 62 Inch
Total In:
3,082 mL
1,484 mL
PO:
TF:
1,148 mL
352 mL
IVF:
1,534 mL
982 mL
Blood products:
Total out:
1,420 mL
490 mL
Urine:
1,420 mL
490 mL
NG:
Stool:
Drains:
Balance:
1,662 mL
994 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Set): 450 (450 - 450) mL
Vt (Spontaneous): 365 (365 - 450) mL
PS : 10 cmH2O
RR (Set): 8
RR (Spontaneous): 31
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 81
PIP: 15 cmH2O
Plateau: 17 cmH2O
SpO2: 98%
ABG: 7.37/44/96.[**Numeric Identifier 7**]/23/0
Ve: 12.1 L/min
PaO2 / FiO2: 242
Physical Examination
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Breath Sounds: Rhonchorous: bilaterally )
Abdominal: Soft, Bowel sounds present
Extremities: Right: 1+, Left: 1+
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
9.7 g/dL
421 K/uL
125 mg/dL
0.6 mg/dL
23 mEq/L
3.8 mEq/L
16 mg/dL
104 mEq/L
137 mEq/L
28.0 %
25.0 K/uL
[image002.jpg]
[**2105-12-8**] 04:50 AM
[**2105-12-8**] 12:46 PM
[**2105-12-8**] 08:33 PM
[**2105-12-9**] 03:29 AM
[**2105-12-9**] 03:48 AM
[**2105-12-9**] 02:28 PM
[**2105-12-9**] 08:34 PM
[**2105-12-10**] 01:56 AM
[**2105-12-11**] 03:56 AM
[**2105-12-11**] 06:15 AM
WBC
27.6
23.3
25.0
Hct
30.3
30.0
27.6
28.0
Plt
[**Telephone/Fax (3) 2259**]
Cr
0.6
0.6
0.5
0.5
0.6
TCO2
21
23
22
26
Glucose
[**Telephone/Fax (3) 2260**]38
125
Other labs: PT / PTT / INR:16.9/41.3/1.5, CK / CKMB /
Troponin-T:228/7/0.06, D-dimer:1665 ng/mL, Lactic Acid:1.7 mmol/L,
Ca++:7.3 mg/dL, Mg++:1.7 mg/dL, PO4:2.9 mg/dL
Microbiology: C. Diff negative x 1
Assessment and Plan
ACUTE HYPOXIC RESPIRATORY FAILURE secondary to pneumonia. Secretions
are unchanged, thick tan. Concerning that WBC going back up. Having
diarrhea, sending stool for C. Diff. CXR suggests possible pleural
effusion, concerned for complicated parapneumonic effusion vs.
empyema. Will obtain CT chest today. Repeat sputum gram stain, C+S,
blood and urine cultures. Continue vanco/zosyn.
ATRIAL FIBRILLATION (AFIB): Remains in SR on amiodarone.
HYPOTENSION secondary to hypovolemia in setting of diuresis. Improved
with fluids albeit also required increased neo, now being weaned back
down.
ICU Care
Nutrition:
Comments: Tube feeds at goal.
Glycemic Control:
Lines:
Arterial Line - [**2105-12-8**] 07:00 AM
20 Gauge - [**2105-12-8**] 07:00 AM
PICC Line - [**2105-12-10**] 10:15 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Need for restraints reviewed
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 55 minutes
Patient is critically ill
------ Protected Section ------
CT chest shows dense consolidation on the left, mulitlobar involvement,
areas of external compression with obstruction of bronchus vs.
endobronchial obstruction. Bronched through ETT with the pulmonary
fellow, moderate amounts of purulent secretions, suctioned for mucus
plugs. Edematous ariways thorughout with external compression.
Washings sent for gram stain, C+S. Chest CT also shows pleural
efffusion. If elevated WBC persists, will need to tap.
------ Protected Section Addendum Entered By:[**Name (NI) 2140**] [**Last Name (NamePattern1) 2141**], MD
on:[**2105-12-11**] 18:29 ------
|
Physician
|
Classify the following medical document.
|
TITLE:
Chief Complaint:
24 Hour Events:
Extubated yesterday, required racemic epi for upper airway sounds,
briefly without gag reflex following extubation. T max of 100.1. Amio
400 TID started. Tele: 3 short runs of NSVT.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Bactrim (SMX/TMP) - [**2121-11-18**] 09:30 PM
Infusions:
Heparin Sodium - 1,350 units/hour
Amiodarone - 0.5 mg/min
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2121-11-20**] 07:44 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.8
C (100.1
Tcurrent: 37.3
C (99.2
HR: 64 (59 - 83) bpm
BP: 98/45(65) {93/45(65) - 146/98(328)} mmHg
RR: 18 (14 - 31) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 107 kg (admission): 104.5 kg
Height: 65 Inch
Total In:
1,308 mL
401 mL
PO:
270 mL
200 mL
TF:
IVF:
978 mL
201 mL
Blood products:
Total out:
3,270 mL
920 mL
Urine:
3,270 mL
920 mL
NG:
Stool:
Drains:
Balance:
-1,962 mL
-519 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Set): 550 (550 - 550) mL
Vt (Spontaneous): 473 (325 - 552) mL
PS : 5 cmH2O
RR (Set): 14
RR (Spontaneous): 23
PEEP: 5 cmH2O
FiO2: 50%
PIP: 11 cmH2O
SpO2: 96%
ABG: 7.41/32/89.[**Numeric Identifier 433**]/28/-2
Ve: 10.8 L/min
PaO2 / FiO2: 178
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
202 K/uL
12.5 g/dL
120 mg/dL
0.6 mg/dL
28 mEq/L
4.2 mEq/L
7 mg/dL
102 mEq/L
139 mEq/L
35.0 %
8.1 K/uL
[image002.jpg]
[**2121-11-17**] 05:08 PM
[**2121-11-17**] 06:54 PM
[**2121-11-18**] 05:15 AM
[**2121-11-18**] 05:26 AM
[**2121-11-18**] 09:37 PM
[**2121-11-19**] 02:28 AM
[**2121-11-19**] 04:55 AM
[**2121-11-19**] 11:00 AM
[**2121-11-19**] 02:48 PM
[**2121-11-20**] 05:40 AM
WBC
11.4
9.8
8.1
Hct
37.7
38.0
35.0
Plt
249
223
202
Cr
0.7
0.7
0.6
TCO2
30
30
31
26
30
31
21
Glucose
126
111
120
Other labs: PT / PTT / INR:13.1/60.2/1.1, Lactic Acid:0.8 mmol/L,
Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL
Assessment and Plan
URINARY TRACT INFECTION (UTI)
VENTRICULAR TACHYCARDIA, NON-SUSTAINED (NSVT)
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)
WITH ACUTE EXACERBATION
ICU Care
Nutrition:
Glycemic Control:
Lines:
Arterial Line - [**2121-11-17**] 05:00 PM
20 Gauge - [**2121-11-19**] 07:00 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2135-7-30**] Discharge Date: [**2135-8-6**]
Date of Birth: [**2082-12-21**] Sex: M
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: Patient is a 52-year-old man
with a history of HIV, now viral counts are undetectable, and
350 CD4 count who presents with bloody diarrhea three times
over a 24 hour period. Patient has felt dizzy on the day
prior to admission and collapsed on the way to the bathroom.
Patient lost consciousness for an unknown period of time.
Patient stated that after this and after walking to his
apartment, he collapsed again. Patient visited [**Hospital1 778**] office
where he regularly gets his medical care. He was seen in the
afternoon and told he was dehydrated and sent home. That
same night, when the patient was at home and was on the way
to the bathroom, he had collapsed again. Patient has had
black tarry diarrhea and some episodes of bright red blood
per rectum in medium to large amounts. Patient denied having
fevers or chills. There was no change in his urine color.
There was no nausea, vomiting or abdominal pain. Patient did
not ingest any unusual food and has no recent history of
travel. Patient denied taking over the counter medications
including aspirin, Motrin and others. Patient's colonoscopy
nine months ago was negative. Patient had colonoscopy as a
screening test due to his family history of colon cancer.
PAST MEDICAL HISTORY: CMV retinitis, PCP, [**Name10 (NameIs) 10619**] sarcoma,
all HIV related, neuropathy, depression and hypertension.
SOCIAL HISTORY: No tobacco, alcohol or drug use.
MEDICATIONS ON ADMISSION: Zestril, Lipitor, Wellbutrin,
amitriptyline and HIV medications were: Zerit 20 mg po
b.i.d., lamivudine 150 mg po b.i.d. and Sustiva 600 mg po
q.h.s.
ALLERGIES: To sulfa. Patient becomes anaphylactic.
PHYSICAL EXAMINATION: Revealed a 52-year-old man in no acute
distress, appearing comfortable, sitting in a hospital bed.
Vital signs on admission were 97. Heart rate 82.
Respiratory rate 19. Blood pressure 104/54 and 100% on room
air. Head, eyes, ears, nose and throat exam revealed no
lymphadenopathy, no jugular venous distention. Oropharynx
was clear with no blood in the oral cavity. Dentition was
normal. Lungs were clear to auscultation bilaterally. No
crackles. Heart: Regular rate and rhythm, no murmurs, rubs
or gallops, S1, S2 normal. Abdomen: Soft, nontender,
nondistended, positive bowel sounds, it was grossly guaiac
positive. There was blood evident on the rectal exam.
Extremities were within normal limits. There was no
cyanosis, clubbing or edema. There was no costovertebral
angle tenderness. Skin revealed no rashes and neurological
exam was nonfocal. Strength was [**5-7**] in upper and lower
extremities and sensation was grossly intact.
LABS ON ADMISSION: White blood cells were 12.4, hematocrit
22.6, platelets 212,000. Sodium 138, potassium 4.8, chloride
102, bicarbonate 22, BUN 40, creatinine 1.0, glucose 126.
His urinalysis was negative. His electrocardiogram showed
diffuse T wave flattening in I, III and aVF leads, as well as
biphasic T waves in V4 through V6. There was no findings
suggestive of acute ischemia.
HOSPITAL COURSE: During the course of his hospitalization,
Mr. [**Known lastname 10620**] has had some active bleeding and has required
a transfusion of a total of 11 units of packed red blood
cells over the course of his hospitalization. He has
undergone extensive work-up which has been unrevealing. His
tests included: Esophagogastroduodenoscopy, colonoscopy,
enteroscopy, small bowel follow through and tagged red blood
cells scan. All of these tests, again, were negative. The
patient was maintained on intravenous Protonix and was
aggressively resuscitated with fluids in addition to packed
red blood cells as mentioned. The patient was also
transferred to the Medical Intensive Care Unit for a period
of two days during his hospitalization. Over the course of
the last 72 hours, patient's hematocrit has remained stable.
Therefore, patient will be discharged home today. He will
live with his friend for two weeks. Therefore, patient will
be monitored if he has any recurrent episodes of collapse.
No follow-up with Gastroenterologist has been recommended by
the Gastrointestinal Service. The patient, however, will
follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9625**]. Per
Gastrointestinal Service, if the patient rebleeds, immediate
CT angiogram would be recommended.
HIV. During the hospital course patient was continued on his
regular outpatient HIV management.
Depression: Patient also continued on his outpatient
management consisting of Wellbutrin and amitriptyline.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10621**], M.D. [**MD Number(1) 10622**]
Dictated By:[**Last Name (NamePattern4) 10623**]
MEDQUIST36
D: [**2135-8-9**] 20:02
T: [**2135-8-9**] 20:02
JOB#: [**Job Number 10624**]
|
Discharge summary
|
Classify the following medical document.
|
Admission Date: [**2120-8-16**] Discharge Date: [**2120-8-20**]
Date of Birth: [**2067-7-3**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline / Clarithromycin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2120-8-16**] with DES to LAD.
History of Present Illness:
The patient is a 53 yo man with h/o HTN and gout, who presented
with acute onset chest pain. The patient states that he was in
his normal state of health until approximately 8 PM last night,
when he developed acute onset chest pain in the setting of
moving a mattress. The patient states that the pain was [**9-16**],
"pressure," located substernally and radiating to his left
shoulder and back. He had associated diaphoresis. His wife,
who was a RN in [**Country 532**], convinced him to come to the ED, where
he presented at approximately 1:30 am.
In the ED, the patient's VS were T 97.9, BP 126/87, P 82, R 20,
O2 97% on RA. A Code STEMI was called, and the patient was
taken emergently to the cath lab at 3 am. He was given ASA 325
mg, O2, NTG SL, Plavix 600 mg, Morphine, and he was started on a
heparin gtt.
In the cath lab, the patient was found to have a 100% occlusion
of the proximal LAD. A thrombectomy was performed, and a DES
was placed in the LAD. He was then admitted to the CCU for
further observation.
On arrival to the floor, the patient states that he is no longer
experiencing chest pain. He has stomach pain which began
shortly after the procedure, but he states that this is markedly
different from the pain which brought him into the hospital.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
GERD
IBS
PUD with negative H.pylori
h/o NASH
B12 deficiency
Vitamin D deficiency
Nephrolithiasis
Gout
Seasonal allergies
s/p cholecystectomy in [**2113**]
Social History:
The patient is married and lives with his wife. [**Name (NI) **] currently
drives a taxi for a living and has one son who lives in the
[**Name (NI) 86**] area. Son is alive and well, w/ active lifestyle.
-Tobacco history: The patient previously smoked for 30 years and
quit in [**2106**]
-ETOH: Only on holidays
-Illicit drugs: None.
Family History:
The patient's mother passed away from pancreatic cancer. His
father died when the patient was 10 in [**Country 532**]. No known family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
VS: T 98.8, BP 114/70, HR 91, RR 18, O2 sat 94% on 4L
GENERAL: Middle aged man, pleasant, anxious and emotional, in
NAD. Oriented x 3
HEENT: PERRL, EOMI, Oropharynx clear and without exudate.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Femoral catheter site
c/d/i.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2120-8-16**] 02:30AM
WBC-14.2 Hct-45.1 Plt Ct-217
Neuts-80.9* Lymphs-15.6* Monos-2.9 Eos-0.2 Baso-0.4
COAGs: PT-14.3* PTT-99.4* INR(PT)-1.2*
144 | 105 | 18 /114
4.1 | 20 | 1.4 \
Calcium-9.3 Phos-4.5 Mg-1.8
LFT's: ALT-72* AST-91* LD(LDH)-352* CK(CPK)-755* AlkPhos-93
TotBili-0.5
Cardiac Enzymes
[**2120-8-16**] 02:30AM CK 755 CKMB 32 MBindex 4.2 cTropnT-0.31*
[**2120-8-16**] 10:00AM CK-MB-189* MB INDX-2.9 cTropnT-13.33*
CK(CPK)-6439*
[**2120-8-16**] 03:05PM CK-MB-107* MB INDX-2.2 cTropnT-8.67*
CK(CPK)-4791*
[**2120-8-16**] 07:00PM CK-MB-74* MB INDX-1.8 CK(CPK)-4013*
[**2120-8-16**] 12:05PM BLOOD Type-ART pO2-66* pCO2-31* pH-7.50*
[**2120-8-16**] 12:05PM BLOOD Lactate-1.8
PERTINENT LABS/STUDIES:
EKG ([**8-16**]): NSR at 77 bpm. Q waves in V1-V5. 3mm ST elevation
in V2-V4. No R wave progression in precordial leads.
ETT ([**2115-5-8**]): The patient exercised for 6.5 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
protocol and was stopped for fatigue. Fair functional capacity.
The patient was asymptomatic throughout. The rhythm was sinus
with no ectopy. No significant ST segment changes. Appropriate
hemodynamic response to imposed demands. IMPRESSION: No
objective evidence of myocardial ischemia by EKG or anginal
symptoms at the achieved level of work. 1) Normal myocardial
perfusion. 2) Normal left ventricular cavity size and systolic
function
CARDIAC CATH:
- LAD: 100% occlusion with thrombus, now s/p thrombectomy and
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] placement
- LCx: 30% diffuse mid
- RCA: 30% mid
HEMODYNAMICS:
RA 11 (mean), RV: 49/11, PCWP: 25, PA: 42/23,
LABORATORY DATA:
Troponin: 0.31
CK 755, MB 32, MBI 4.2
BMP: Na 144, K 4.1, Cl 105, HCO3 20, BUN 18, Cr 1.4 (baseline
1.2-1.3), Glucose 109
CBC: WBC 14.2, Hct 45.1, Plt 217
PT 14.3, PTT 99.4, INR 1.2
Cholesterol Panel ([**5-16**]): Total cholesterol 191, Triglycerides
235, HDL 37, LDL 107
ECHO [**2120-8-16**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate to severe regional left ventricular systolic
dysfunction with akinesis of the anterior wall, septum and the
apex. The remaining segments exhibit compensatory hypERkinesis
(LVEF = 30%). There is spontaneous echo contrast at the LV apex,
but no formed thrombus at this time. Moderate to severe left
ventricular systolic dysfunction, c/w proximal LAD infarction.
No significant valvular disease. Mild pulmonary hypertension.
Findings discussed with Dr. [**Last Name (STitle) **] at 11a on the day of the
study.
DISCHARGE LABS:
[**2120-8-20**] 05:40AM BLOOD WBC-10.0 RBC-4.12* Hgb-13.0* Hct-37.4*
MCV-91 MCH-31.5 MCHC-34.6 RDW-14.4 Plt Ct-242
[**2120-8-20**] 05:40AM BLOOD PT-14.9* PTT-30.3 INR(PT)-1.3*
[**2120-8-20**] 05:40AM BLOOD Glucose-94 UreaN-22* Creat-1.4* Na-142
K-4.5 Cl-106 HCO3-23 AnGap-18
Brief Hospital Course:
# STEMI: The patient was found to have ST elevations in V2-V4,
and elevated cardiac biomarkers on admission (Troponin: 0.31 CK
755, MB 32, MBI 4.2). Code STEMI was called and patient was
taken to the cath lab. There patient was found to have a 100%
occlusion and thrombus of the proximal LAD, underwent
thrombectomy and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]. EKG showed improvement of ST
elevations, and chest pain resolved. The patient was started on
ASA 325 mg daily, Plavix 75 mg daily. Integrilin gtt was
continued for total duration of 18 hours. Metoprolol was started
and uptitrated gradually to 50 mg TID as tolerated. Captopril
was initially started, but was held when creatinine became
elevated in the setting of IV contrast for CT (see below). It
was restarted when creatinine returned to baseline on [**2120-8-18**].
Of note, patient has a history of erectile dysfunction on ACEi.
Home Diovan was held.
The patient had a previous history of fatty liver on Tricor.
Baseline LFTs were normal and it was decided that statin would
be started and LFT's monitored carefully. Home Prilosec was
changed to Ranitidine [**Hospital1 **] in the setting of starting Plavix.
TTE done in the morning following cath showed moderate to severe
left ventricular systolic dysfunction, c/w proximal LAD
infarction. No significant valvular disease. Mild pulmonary
hypertension. There was spontaneous echo contrast at the LV
apex, but no formed thrombus at this time.
That morning ([**2120-8-16**]), patient c/o headache, epigastric pain,
appeared diaphoretic. Repeat EKGs showed no significant change
from post-cath EKG. Patient received Tylenol, morphine and pain
improved. Given apical akinesis and pooling of blood seen on
TTE, there was concern for embolization to intestinal
vasculature.
CTA of the abdomen showed no SMA/[**Female First Name (un) 899**] thrombus or GI bleed.
Patient received Mucomyst and hydration prior to CTA.
In the setting of poor LV dysfunction/apical stasis and high
risk for thrombus/emboli, patient was started on heparin gtt,
with goal 60-80. Coumadin was started [**2120-8-17**]. Patient had no
further chest or epigastric pain during hospital course. Cardiac
biomarkers trended down, and patient remained hemodynamicaly
stable. He was discharged on Metoprolol, Aspirin, Plavix,
Atorvastatin and Lisinopril. For his anticoagulation, he was
discharged on Lovenox SC injection and Warfarin with plan to
have INR checked 3 days post-discharge and discontinue Lovenox
as able.
# Congestive Heart Failure: Acute systolic and diastolic CHF.
The patient had elevated RVEDP on cardiac catheterization (24).
TTE (see above) showed LVEF 30% with apical akinesis. The
patient received Lasix prn.
#. Hyperlipidemia: The patient has a history of hyperlipidemia,
though he reportedly developed NASH in the setting of TriCor. He
was started on 80 mg atorvastatin during admission since he is
now post-STEMI. Baseline LFTs were normal, and LFT's should be
monitored carefully as an outpatient.
# Acute Kidney Injury: Patient's creatinine bumped from baseline
1.2 to 1.7 after receiving contrast both in the cath lab and for
CTA, despite pre-treatment with mucomyst and IVF. Medications
were renally dosed and ACEi was held. Creatinine trended down to
baseline and captopril restarted on [**2120-8-18**].
#. Gout: Patient had no evidence of acute gout flare-up, he was
continued home Allopurinol, but the dose was decreased to 150 mg
daily given creatinine clearance.
#. GERD: The patient was taking Omeprazole for his GERD at
home. This was changed to Ranitidine in the setting of Plavix
use.
Medications on Admission:
Amlodipine 5 mg daily
Hydrochlorothiazide 25 mg daily - Stopped
Atenolol 50 mg daily - Stopped
Diovan 160 mg daily - Stopped
Allopurinol 300 mg daily
Prilosec 40 mg daily
Clobetasol 0.05% ointment [**Hospital1 **]
Vitamin B12 1000 mcg injections monthly
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take every day for one year.
Disp:*30 Tablet(s)* Refills:*11*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash.
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
Please check PT/INR on Thursday [**2120-8-20**] and call results to Dr.
[**Last Name (STitle) **].
8. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day: Take until INR > 2.0.
Disp:*6 syringes* Refills:*2*
9. Warfarin 2 mg Tablet Sig: 3.5 Tablets PO once a day.
Disp:*105 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction with Apical Akinesis
Hyperlipidemia
Hypertension
Acute Systolic Congestive Heart Failure
Discharge Condition:
Improved. Vital signs have been stable, patient ambulating
without issues.
Discharge Instructions:
-You were admitted with sudden onset chest pain and diagnosed as
having a heart attack. You were taken to the cardiac
catheterization lab where a blood vessel supplying the heart was
found to be blocked. The blockage was cleared and a stent placed
in the vessel to keep it open. Since coming to the Cardiac unit,
you have been started and continued on medications to maximize
your heart function and recovery.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> START Warfarin 7 mg daily for prevention of blood clots.
You will need regular INR checks at the coumadin clinic at [**Company 191**].
--> START Lovenox injections twice daily in place of the heparin
drip to prevent blood clots. Stop taking Lovenox when your INR
is greater than 2.0.
--> START full-strength aspirin 325 mg daily to keep the stent
open
--> START Plavix 75mg daily. It is important that you continue
this medication (at least for a year) as it keeps the new stent
in your heart clear. Do not stop taking Plavix unless Dr. [**Last Name (STitle) **]
tells you to.
--> START Atorvastatin 80mg daily for your cholesterol
--> START Toprol XL 150mg daily for your blood pressure.
--> START Lasix (Furosemide) 10 mg daily to prevent fluid
buildup
-->STOP your atenolol 50mg daily.
-->STOP your Amlodipine 5mg daily.
--> START Ranitidine 150mg twice a day for your GERD/reflux. It
is important that you do not resume your Prilosec (omeprazole);
Prilosec and other proton pump inhibitors have been found to
decrease the effectiveness of Plavix on keeping stents clear
--> CONTINUE your Allopurinol 300mg daily, Clobetasol Propionate
0.05% Ointment twice daily, Vitamin B12 injections.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools. You should weigh yourself every
morning and call your PCP if your weight increases by more than
3 lbs within one day on 6 pounds within 3 days. Also try to
adhere to a low salt (2 gram), low fat diet.
Followup Instructions:
Primary Care:
[**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2120-8-22**] 2:30
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Phone: [**Telephone/Fax (1) 62**]. Date/time: [**10-8**] at
2:40pm.
Dermatology:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2120-9-13**]
11:15
Rheumatology:
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2120-9-18**]
2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
Discharge summary
|
Classify the following medical document.
|
Chief Complaint:
24 Hour Events:
BLOOD CULTURED - At [**2119-6-27**] 12:26 AM
FEVER - 102.8
F - [**2119-6-27**] 12:24 AM
- Conjugated hyperbilirubinemia
- Vitamin K 5mg PO x1
- ID - Continue antibiotics, continue surveillance cultures. Persistent
fevers not concerning at this point. If continues, consider CT chest to
reassess for abscess.
- Pulmonary - Cautious fluid resuscitation, no plan for bronchoscopy
- [**Doctor First Name **], ANCA pending
- 2:00PM - LFTs, hyperbilirubinemia, platelet count, coagulopathy,
fibrinogen, FDP stable
- Levophed stopped at 2:30pm, restarted at 6:00pm
- 6pm: 7.36/34/83, Lactate 1.3
- No new culture data (as of 10:30pm)
- 12am: Spiked to 102.8 (rectal); hypertensive, and Levophed was
weaned; blood cultures sent; blood pressure slowly came down, MAPs
remained over 55
Allergies:
Morphine
Unknown;
Amlodipine
Unknown;
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2119-6-24**] 02:00 PM
Levofloxacin - [**2119-6-26**] 04:21 PM
Nafcillin - [**2119-6-27**] 04:00 AM
Infusions:
Fentanyl - 100 mcg/hour
Midazolam (Versed) - 4 mg/hour
Norepinephrine - 0.06 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2119-6-26**] 08:00 AM
Heparin Sodium (Prophylaxis) - [**2119-6-27**] 12:00 AM
Other medications:
Changes to medical and family history:
None
Review of systems is unchanged from admission except as noted below
Review of systems:
Intubated, sedated
Flowsheet Data as of [**2119-6-27**] 06:34 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 39.3
C (102.8
Tcurrent: 38.2
C (100.8
HR: 86 (71 - 105) bpm
BP: 109/51(70) {82/44(55) - 134/63(84)} mmHg
RR: 22 (16 - 24) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Height: 72 Inch
CVP: 11 (9 - 13)mmHg
Total In:
4,733 mL
777 mL
PO:
TF:
350 mL
223 mL
IVF:
3,914 mL
425 mL
Blood products:
Total out:
1,310 mL
260 mL
Urine:
1,310 mL
260 mL
NG:
Stool:
Drains:
Balance:
3,423 mL
517 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST
Vt (Set): 500 (500 - 500) mL
RR (Set): 20
RR (Spontaneous): 5
PEEP: 8 cmH2O
FiO2: 50%
RSBI: 58
PIP: 16 cmH2O
Plateau: 17 cmH2O
Compliance: 55.6 cmH2O/mL
SpO2: 96%
ABG: 7.36/36/116/18/-4
Ve: 10.9 L/min
PaO2 / FiO2: 232
Physical Examination
Labs / Radiology
294 K/uL
10.5 g/dL
119 mg/dL
2.5 mg/dL
18 mEq/L
3.6 mEq/L
40 mg/dL
110 mEq/L
139 mEq/L
32.3 %
9.8 K/uL
[image002.jpg]
[**2119-6-25**] 04:51 AM
[**2119-6-25**] 03:52 PM
[**2119-6-25**] 06:39 PM
[**2119-6-25**] 08:48 PM
[**2119-6-26**] 04:24 AM
[**2119-6-26**] 05:32 AM
[**2119-6-26**] 02:37 PM
[**2119-6-26**] 06:05 PM
[**2119-6-27**] 05:25 AM
[**2119-6-27**] 05:39 AM
WBC
10.2
9.8
Hct
33.1
35.0
32.3
Plt
[**Telephone/Fax (3) 6197**]
Cr
2.0
2.1
2.5
TCO2
25
19
19
20
20
21
Glucose
106
112
119
Other labs: PT / PTT / INR:24.7/36.0/2.4, CK / CKMB /
Troponin-T:339/6/0.51, ALT / AST:59/106, Alk Phos / T Bili:59/4.7,
Differential-Neuts:70.0 %, Band:1.0 %, Lymph:14.0 %, Mono:13.0 %,
Eos:0.0 %, Fibrinogen:620 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:2.6
g/dL, LDH:366 IU/L, Ca++:6.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL
Assessment and Plan
82M with hypertension, essential tremor admitted with NSTEMI, now with
MSSA pneumonia complicated by sepsis, enlarging right sided infiltrate
1. Hypoxic respiratory failure: Tolerated pressure support briefly
yesterday. Now currently on assist control. Large A-a gradient by blood
gas. Patient with component of respiratory alkalosis, although this may
be compensatory given metabolic acidosis.
- Pneumonia treatment as below
- Vent parameters per ARDSnet protocol
- Pulmonary recs
2. Pneumonia/sepsis: MSSA pneumonia. Patient with persistent fevers,
although lower grade. ID involved.
- Discuss with ID
given persistent fevers, should we expand
coverage for anaerobes?
- Continue Nafcillin for total 3 week course through [**2119-7-11**]
(start date [**6-21**], Vancomycin initiation date) and levofloxacin for
total 8 day course ([**2119-6-24**] through [**2119-7-2**])
- Follow culture data
- Maintain CVP 8-12, MAP>60; if falls below this, bolus IVF
(LR given non-anion gap metabolic acidosis potentially secondary to
NS); wean Levophed as tolerated
- CIS
3. Coagulopathy: INR elevated to 2.4, confirmed on recheck.
Differential includes DIC (FDP 10-40, although elevated fibrinogen and
PTT normal), shock liver (LFTs improved since admission). Could also be
nutritional deficiency.
- Vitamin K PO x1
- Recheck coags, FDP, fibrinogen this afternoon
4. s/p NSTEMI: Cath showed clean coronaries, NSTEMI possibly caused by
thrombus that had since resolved with medical therapy. Likely demand
ischemia in the setting of pneumonia.
- Continue ASA
- Hold beta-blocker in the setting of sepsis
- Hold Plavix at this time given concern for PAH (very low
likelihood)
- Continue statin
5. PUMP: TTE with newly depressed EF 35-40% with inferolateral and
apical hypokinesis
- Beta-blocker on hold as above
- Would benefit from ACE inhibitor once over acute illness
- Hold Plavix and heparin given mention of potential PAH,
although this is unlikely; will likely restart heparin in next 1-2 days
given concern for thrombus formation at site of hypokinesis
6. ACUTE RENAL FAILURE: Baseline 1.0. Creatinine slowly trending up,
likely prerenal given sepsis.
- Renally dose meds
ICU Care
Nutrition:
Nutren Pulmonary (Full) - [**2119-6-27**] 12:00 AM 40 mL/hour
Glycemic Control:
Lines:
20 Gauge - [**2119-6-24**] 10:14 PM
Arterial Line - [**2119-6-24**] 11:29 PM
Multi Lumen - [**2119-6-25**] 02:49 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
|
Physician
|
Classify the following medical document.
|
55 y.o. male with PMHx of DM, HTN, CAD s/p IMI with 3 stents to RCA and
recently diagnosed RCC who was transferred from [**Hospital3 **]for
ongoing work-up of acute renal failure and change in mental status.
.
Patient was admitted to [**Hospital3 **]Hospital on [**2165-4-16**] for chest
and abdominal pain. He ruled out for an MI with cardiac biomarkers and
was felt to be constipated (on CT) due to chronic narcotic use for
lower back pain and right hip pain (awaiting hip replacement). His
constipation was treated aggressively with medications and disimpaction
with minimal effect. On day 4 of his hospitalization, he was febrile to
104 with a leukocytosis to 14 and was pan-cultured while Vancomycin and
Zosyn were started empirically with specific concern for a PIV
infection suggested by surrounding erythema and edema. Blood cultures
later grew GPCs in [**2-23**] bottles and chronic foot ulcers were swabbed and
reportedly grew staph aureus with pending sensitivities. Zosyn was thus
discontinued. In the setting of infection, patient became delirious,
noted to be attempting to grab things from the air and talking to
people in the room. Of note, patient was continued on narcotics,
reportedly at the wife's insistence given concern for narcotic
withdrawal. Neurology was consulted and recommended a head CT which was
unremarkable, leaving them to conclude that the mental status was
toxic/metabolic in the setting of infection and narcotic use. He was
started on Ceftriaxone 2 grams daily for CNS coverage though no LP was
performed. On day 5, patient was noted to develop acute renal failure
with a creatinine of 3, up from 1.3 and was also anuric. CKs were
checked to evaluate renal failure from rhabdomyolysis and were not
likely contributing at a level of 361. He was transferred [**4-21**] to [**Hospital1 1**]
for concern of his renal failure progressing to the point of needing
HD, since [**Hospital3 6341**] no HD facilities.
.
Upon arrival, patient was noted to vomit and had reportedly vomited en
route to [**Hospital1 1**]. He additionally started experiencing low-amplitude,
rhythmic clonus of his hands and legs, became transiently hypoxic and
was not verbally responsive. There was concern for seizing and patient
was urgently intubated to protect his airway. Discussion with the
patient's wife, [**Name8 (MD) **] RN, revealed that the patient has never had a
seizure disorder and does not drink alcohol. Additionally, he had a CT
scan with contrast at [**Hospital1 49**] 3 days prior to his admission to [**Hospital 6342**]as a part of his RCC work-up and the wife expressed concern for
contrast-induced nephropathy. Patient was then ordered for a stat head
CT given the mental status and neurology was consulted for further
assistance with management. LP [**4-23**] + for meningitis, TEE neg for
vegetation.
Meningitis, bacterial
Assessment:
Pt O X 1, following commands with encouragement. Speech normal, but
saying random words. MAE, PEARL @ 3mm/brisk bilat. [**Month/Day (2) 6643**] restless.
Pt had rec
d Haldol 2mg IM overnight for yelling/verbal abuse with good
results. VSS with HR 71-87SR with occas PVC
s, BP 152/51-165/56.
Low-grade temp persists, presently 99.6ax. Lung snds clear, diminished
in bases with non-productive cough. O2 sat 93-96% on 4l NC with RR
21-26 and regular.
Action:
Soft wrist restraints remain in place bilat for pt safety. Pt freq
reoriented. Pt rec
d Vancomycin with HD.
Response:
MS [**Month/Day (2) **] to slowly improve.
Plan:
[**Month/Day (2) **] freq orientation, monitoring for change in MS. [**First Name (Titles) **] [**Last Name (Titles) 6636**] tx.
Follow-up cx results.
Renal failure, acute (Acute renal failure, ARF)
Assessment:
AM BUN/creat 54/5.8. Pt had rec
d Lasix 120mg X 1 yesterday with 1
liter diuresis resulting. Urine yellow/clear, draining @ 20-45ml/hr.
LOS fluid balance +4.8liters.
Action:
Pt rec
d HD today, removing 3liters over 4hrs.
Response:
HD tolerated well, no change in BP.
Plan:
[**Last Name (Titles) **] to monitor fluid balance, BUN/creat.
Impaired Skin Integrity
Assessment:
Pt has 3 dry ulcers on L foot. Two ulcers on bottom of foot
(2cmX2cmX3cm deep, and 1cmX1cm), and there is a small ulcer on top of
foot (3cmX1cm). Pt had amputated toes and the foot is very dry.
Podiatry dresses ulcers with WTD dsgs daily. Also, coccyx is red, yeast
infection around coccyx/periarea.
Action:
Pt repositioned Q2hrs. Miconazole powder to yeasty areas. Foot dsg
changed/reinforced as it comes off with pt
s restlessness.
Response:
No change.
Plan:
[**Last Name (Titles) **] present WTD dsg, podiatry to follow.
Hyperglycemia
Assessment:
FSG 218, 255.
Action:
Pt [**Last Name (Titles) **] to receive TF @ goal via NGT with no residuals. Abd soft/obese
with + BS. Flexiseal draining mod amts brown loose stool. Pt rec
Insulin per sliding scale and fixed dose.
Response:
FSG @ 1600 247. Pt rec
d 8units Humalog per sliding scale.
Plan:
Tighten sliding scale, as FSG consistently in 200
s. [**Last Name (Titles) **] Q4hr
fingersticks to check glucose.
Pain control (acute pain, chronic pain)
Assessment:
Pt denied pain in am but is poor historian at the moment. [**Name2 (NI) 6643**]
groaning, trying to reposition self in bed. Pt with PMH R hip pain. At
one point yelling for
Dr [**First Name (STitle) 1071**]
, saying he needed
$50 worth of MS
Contin
Action:
Pt with Lidocaine patch on R hip, 37.5mcg patch Fentanyl. He also rec
PRN Fentnayl 50mcg IVP @ 1500.
Response:
Pt states pain ins
@ 1600.
Plan:
[**First Name (STitle) **] to freq reposition pt. Pain meds per above, with PRN Fentanyl IVP.
|
Nursing
|
Classify the following medical document.
|
[**2156-2-6**] 5:37 PM
IVC GRAM/FILTER Clip # [**0-0-**]
Reason: High clinical suspicion PEpersitent hypoxia of sudden onsetP
Contrast: OPTIRAY Amt: 40
********************************* CPT Codes ********************************
* [**Numeric Identifier 1623**] INTERUP IVC [**Numeric Identifier 1624**] INTRO CATH SVC/IVC *
* -51 MULTI-PROCEDURE SAME DAY [**Numeric Identifier 1625**] PERC PLCMT IVC FILTER *
* [**Numeric Identifier 3895**] IVC GRAM C1769 GUID WIRES INCL INF *
* C1880 VENA CAVA FILTER *
****************************************************************************
______________________________________________________________________________
[**Hospital 4**] MEDICAL CONDITION:
67 year old man with
REASON FOR THIS EXAMINATION:
High clinical suspicion PEpersitent hypoxia of sudden onsetPt cannot be
anticoagulated secondary to head bleedWOuld require filter in PE present
______________________________________________________________________________
FINAL REPORT
HISTORY: 67 y/o man with intracranial injury and hypoxia.
RADIOLOGISTS: The procedure was performed by Drs. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and [**First Name4 (NamePattern1) 134**] [**Last Name (NamePattern1) 135**],
with the attending radiologist Dr. [**First Name (STitle) 135**] being present during the entire
procedure.
PROCEDURE AND FINDINGS: The risks and benefits were explained to the
patient's family and consent was obtained.
The patient was placed supine on the angiographic table and the right groin
was prepped and draped in sterile fashion. Under local anesthesia using 1%
Lidocaine, the right common femoral vein was accessed with a 19 gauge needle
and 0.035 [**Last Name (un) 414**] wire was advanced into the inferior vena cava. The needle
was exchanged for a 4 FR Omniflush catheter with its tip just above the IVC
bifurcation. Inferior vena cavogram was performed with injection of nonionic
contrast diluted to half which demonstrated patent bilateral common iliac
veins and IVC with no filling defect or anomalies visualized. Both renal vein
openings were identified bilaterally. The catheter was removed and the venous
entry site was dilated over a .035 wire with increasing sized dilators
sequentially. A 15 FR long sheath was advanced over the wire into the upper
inferior vena cava. Then, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16915**] filter was deployed with tip at the
level of bilateral renal vein openings. The final X-ray demonstrated the
filter is in proper position. The sheath was removed and local hemostasis was
achieved by manual compression.
The patient tolerated the procedure well with no complications.
IMPRESSION: Successful placement of a infrarenal [**Location (un) 16915**] IVC filter.
Patent inferior vena cava. Reflux into the left common iliac vein compatible
with increased right atrial pressure.
(Over)
[**2156-2-6**] 5:37 PM
IVC GRAM/FILTER Clip # [**0-0-**]
Reason: High clinical suspicion PEpersitent hypoxia of sudden onsetP
Contrast: OPTIRAY Amt: 40
______________________________________________________________________________
FINAL REPORT
(Cont)
|
Radiology
|
Classify the following medical document.
|
65 yo M without medical history presenting for evaluation of shortness
of breath, nausea and vomiting. 5-6 days prior to admission he
developed paroxysmal cough. He obtained Tessalon Perles and an
antibiotic from a local allergist. Over the weekend, he developed
prominent GI symptoms w/ persistent nausea, forced dry heaves/wretching
and some vomiting. He noted shortness of breath and came to the ED for
evaluation on [**7-21**]. CXR demonstrated RUL PNA w/ LLL nodular density
and he was dc
d on Levofloxacin, Albuterol and Prednisone. He went home
but his GI symptoms progressed and returned to the ED.
Hospital course complicated by H1N1 diagnosis, ARDS- placed on
Rotoprone bed on [**7-24**]- tolerating 3.15hrs of being prone and 45 min
being supine. CRRT started [**7-24**]. Transitioned to HD. Pt had been in
Afib- cardioverted on [**7-24**] back to NSR. Now aflutter/ST-NSR. + C-Diff
colitis tx vanco via NGT
[**8-1**] noted diffuse drug rash which does not appear any worse.
Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, [**Doctor Last Name 11**])
Influenza A+ HINI
Assessment:
Received pt off both fent/versed gtts. Had been dc
d right before
shift change at 1830. Pt had been started on methadone [**8-1**] to help
transition off fent/vers. Did require bolus dose of each x 1 overnight
for tachypnea up to 40
s and apparent resp distress with increased
WOB. Bolus effective. At other times, pt becomes tachypneic, high
minute volumes and high pressures but then settles back out on own
without intervention. Vent mode PSV 7/5 60% RR 18-38 TV >400. Sats
90-96% transient episodes Desats with turning; however, does do well
with max rotation on triadyne. Lungs dimished throughout, slight
rhonchi to bases. None to scant tan secretion. HR 85-110
s, NSR-ST
with pac
s and pvc
s. MAPS>60. Responsive to verbal and painful
stimulation as evidenced by opening eyes. Noted to have movement in
upper ext
s-not purposeful at this time. Moves left arm > right. Does
not follow any commands. No movement from LE
s. Grimaces with pain
and opens eyes. Illiciting strong cough. Opens eyes spont with
vigorous stimulation not tracking surroundings pupils 2mm equal react
brisk. T max 102.5. WBC 8.9 (up from 7.6) , +diffuse drug rash.
S/p HD on [**8-2**] with 3.2 L off (did transiently drop bp during HD and
required getting a little fluid back but still total of 3.2 off) Peep
weaned from 12 to 7 yesterday. Sats 90-95%.
Action:
methadone dose cut in half as ordered by MD. Seraquel dose PRN if
needed. Peep weaned from 12 to 8 on days and weaned from 8 to 7 this
shift. VBG done as pt without aline. Tylenol given. PO abx as
ordered.
Response:
Maintaining sats with peep wean with exception of turn/stimulation in
which case placed on 100% o2 suction. Cont to spike temps. No culture
growth to date.
Plan:
Wean Peep as tol
Cont sedation with methadone.
Plan fent/versed bolus PRN
Cont PO vanco x 14 days.
Renal failure, acute (Acute renal failure, ARF)
Assessment:
Anuric u/o tol 7cc this shift. Foley dc
d yesterday due to persistent
fevers. BUN/Creat 62/9.0 (from 66/9.8). Received HD with Fluid
removal 3.2L transient hypotension.
Action:
Urine spec sent tor easoniphils.
Response:
unchanged.
Plan:
Straight cath q12hrs.
HD for ARF and fluid removal; next HD Monday
C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)
Assessment:
Flexiseal in place.
Action:
PO vanco x 14 day course (to end [**8-11**])
Response:
cont with loose stool per flexiseal
Plan:
[**Month (only) 51**] decrease po dose of vanco
** Spouse [**Name (NI) **] visited at bedside and phoned for updates; with good
understanding of pt
s status and plan of care. Will be in today to
visit.
|
Nursing
|
Classify the following medical document.
|
Admission Date: [**2144-7-1**] Discharge Date: [**2144-7-6**]
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / aspirin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 88 year old woman with a history of aortic
valvular repair/replacement, DM2, HTN, vertigo here s/p
unwitnessed fall with head injury and loss of consciousness. She
has no memory of the event or antecedent symptoms and appears
emotionally distressed by the event; she answered most questions
regarding the event with "I don't know." She has a posterior
headache with some abdominal upse, but no vomiting, visual
disturbances, or lethargy/ inability to stay awake. She denies
any other neurologic symptoms. She was found on imaging to have
small bifrontal SAH and small subcentimeter R frontal SDH.
Past Medical History:
Aortic valve repair/replacement (not known, [**12/2143**])
HTN
HL
DM2
Vertigo
?Arrhythmia
Social History:
No tobacco, ETOH, or illicits endorsed.
Family History:
NC
Physical Exam:
VS HR: 82 BP: 108/73
General: Awake, NAD, lying in bed comfortably.
Head: NC, superficial bleeding on posterior occiput, no scleral
icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Extremities: Warm, well perfused
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented x name, month, birth
date, place. Does not recall the event. Attention easily
attained
and maintained. Follows two step commands, midline and
appendicular. Language fluent with intact repetition and verbal
comprehension.
Normal prosody. No paraphasic errors. No dysarthria. No neglect.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to
confrontation. Funduscopy shows crisp disc margins, no
papilledema.
[III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to
light touch bilaterally.
[VII] No facial asymmetry. [VIII] Hearing intact to finger rub
bilaterally.
[IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength
5/5 bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
tremor
or asterixis.
=[Delt] [Bic] [Tri] [ExD] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally.
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response silent bilaterally.
- Coordination - No dysmetria with finger/foot mirrored
movements.
- Gait - Not safe to assess.
Pertinent Results:
CT C-Spine [**7-1**]
IMPRESSION: No acute fracture or dislocation of the cervical
spine.
CT Head [**7-1**]
1. Bilateral subarachnoid hemorrhage.
2. 4-mm right frontal subdural hematoma without midline shift.
CT Abd/pelvis
No acute visceral injury in the abdomen or pelvis.
Mild anterolithesis of L4 over L5 of indeterinate age, but may
be
degenerative. Multi-level adjacent degenerative changes seen.
Cholelithiasis without CT findings of acute cholecystitis.
Apparent urinary bladder wall thickening, could relate to
underdistention, but recommend correlation with urine analysis.
CT head [**7-2**]
1. Thin right subdural hematoma, re-distributed posteriorly,
though unchanged in size with no significant mass effect.
2. Unchanged bifrontal subarachnoid hemorrhage.
3. Small focus of likely hemorrhagic contusion in the right
frontal region
inferiorly, which appears new from one day prior.
4. Newly noted layering of blood products within the occipital
horns of the lateral ventricles, likely reflecting
re-distribution. No hydrocephalus.
[**2144-7-3**] 08:40AM BLOOD TSH-5.7*
[**2144-7-4**] 02:35PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
Blood-MOD Nitrite-NEG Protein-30 Glucose-300 Ketone-10
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM RBC-42* WBC-11*
Bacteri-NONE Yeast-NONE Epi-<1
Brief Hospital Course:
Patient preented to [**Hospital1 18**] ER on [**7-1**] for eval after having a
witnessed syncopal episode in which she struck her head.
Imaging revealed a right frontal SDH and bifrontal contsuions.
She was on coumadin prior to admit so she was reversed with
vitamin K, factor 9, and FFP and admitted to the ICU for further
observation. She remained stable voernight in the ICU into [**7-2**]
and on the morning her INR was 1.5 for which she recieved a
single dose of Vitamin K PO in addition to her normal dosing,
she was also started on Dilantin for antiseizure prophylaxis.
She underwent a repeate head CT which showed normal evolution of
her bifrontal contusions as well as a new small amount of blood
in her occpital horns most likely due to redistribution of
blood. She was deemed fit for transfer to the floor and a
medicine consult was called to aid in a syncopal workup. A
follow-up INR was done which was 1.3 and after he tranfer to the
floor the medicine team saw her. They felt that she did not
require a TTE as she had one recently and given her lack of
symptoms pointing to a recurrent aortic stenosis as a culprit
they did not feel a new echo was warranted. She remained stable
on the floor on [**7-2**] and then in the evenign had a few episodes
of emesis which did not initially respond to zofran so phenergan
was added with good efect. On the morning of [**7-3**] medicine gave
further recs including orthostatic vital signs, medication
changes including adding evening lantus dosing for blood sugar
management, and IV fluids. She remained stable into the evening
of [**7-3**] with goals of mobilizing her and encouraging PO intake.
On [**7-4**] the patient was noted to be sundowning and to be
delerious. The medicine team made further recommendations in
regards to medications to avoid and started her on ceftriaxone
for a suspected UTI. A TSH was checked and was 5.6.
On [**7-5**] the patient was neurologically stable. Orthostatic VS's
were checked again and negative. The medicine team signed off
suggesting cefpodox for the UTI treatment x 10 days.
On [**7-6**] she was screened for rehab facilities. Her urine culture
resulted in no growth therefore her antibiotics were
discontinued. Now, DOD she is set for d/c to rehab and will
followup accordingly.
Medications on Admission:
Warfarin 10 on Thursday/Sunday and 7.5 other days, Metoprolol 25
[**Hospital1 **], Pravastatin 20, Ranitidine 150 [**Hospital1 **], Glargine (unknown
dose), Lispro (unknown dose), Meclizine PRN
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. insulin glargine 100 unit/mL Solution Subcutaneous
7. insulin lispro Subcutaneous
8. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for dizzy.
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Right Subdural Hematoma
Bifrontal contusions
Syncope
Urinary tract infection
hyperglycemia
Elevated TSH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
ACCORDING TO YOUR CARDIOLOGIST YOU NO LONGER NEED TO TAKE
COUMADIN
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
- You are on dilantin and we recommend that you continue for
until your scheduled follow-up with Neurosurgery. This will
need to be monitored with blood work from your PCP or rehab
center.
?????? CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
?????? You should follow up with your PCP upon discharge. It has been
recommended that you get a repeat TSH in [**3-25**] weeks.
Completed by:[**2144-7-6**]
|
Discharge summary
|
Classify the following medical document.
|
SICU
HPI:
70yo M w/ persistent abd pain, poor po intake, w/ gallstone
pancreatitis, complicated by abdominal compartment syndrome following
ERCP, ARDS, septic vasodilatory shock, Cdiff, and ARF. Now with
necrotizing pancreatitis s/p drain placement and multiple
necrosectomies.
.
SURGERIES:
ex lap ([**7-3**], [**7-3**])
partial abd closure ([**7-8**])
abd closure, GJ placement ([**7-13**])
vaccuum dressing ([**7-19**])
trach ([**7-24**])
vicryl closure ([**7-29**])
I&D retroperitoneal abscess ([**8-18**])
Minimally-invasive pancreatic necrosectomy ([**8-22**], [**8-28**], [**9-4**])
.
MICRO:
[**2113-7-3**]: Sputum: RARE YEAST
[**2113-7-8**] Sputcx: yeast w/ aspergillus
[**2113-7-8**] peritoneal: yeast 2+, [**Female First Name (un) **]
[**2113-7-11**] BAL: yeast, aspergillus
Cdiff: +
[**2113-7-19**] BALx2- prelim aspergillus
[**2113-7-25**] stool - guaic + [**2113-7-31**]
[**2113-7-25**] sputum: E.coli+yeast
[**2113-7-27**] Blood - GRAM POSITIVE COCCUS(COCCI)IN PAIRS AND CLUSTERS
[**2113-7-28**] BAL- Pan-S pseudomonas, cipro-R e.coli
[**2113-7-31**] sputum: pseudomonas + ecoli
[**2113-8-10**] cdiff neg x 3
[**2113-8-12**] blood cx P
[**2113-8-13**] pancreatic fluid culture: Pseudomanas and [**Female First Name (un) **] albicans
[**2113-9-4**]:[**Female First Name (un) 1354**]. Variable rods and gram positive cocci in chains and
clusters.
[**2113-9-5**] cdiff neg
[**2113-9-7**] BCx=coag neg staph and UCx Neg, L flank drainage - pseudomonas,
cipro and pip [**Last Name (un) 270**].
[**2113-9-7**] Wound Cx pseudomonas/ cipro-sensitive
[**2113-9-7**] Sputum +Pseudomonas and rare GNR
[**2113-9-9**] SputumCx: 4+(>10 per 1000X FIELD): GNR; 1+ Budding Yeast
[**2113-9-10**] UrineCx no growth
[**2113-9-11**] SputumCx: 4+ GNR, 2+ yeast
[**2113-9-12**] Picc Cath tip
IMAGING:
[**2113-7-1**]: RUQ US: limited study, gallbladder wall thickening, nl CBD, no
stones
[**2113-7-1**]: OSH CT abd/pelvis: thickened GB with stone in neck, can not
assess CBD, marked pancreatitis
[**2113-7-2**]: TTE and TEE ([**2113-7-2**]) showing hypovolemia, no wall motion
abnormalities.
[**2113-7-14**]: VUS: Non-obstructive clot in the left lower internal jugular
vein.
[**2113-7-14**]: Non-obstructive clot in the left lower internal jugular vein
[**2113-7-17**]: Liver U/S Cholelithiasis. Gallbladder wall thickening not
significantly changed. Small pericholecystic same as CT ([**2113-7-1**]). No
definite evidence cholecystitis.
[**2113-7-19**]: CT head/torso extensive pancreatic necrosis. No focal abscess.
Mild chronic sinusitis. R lobe PNA
[**2113-8-12**]: CT Torso necrotizing pancreatitis per [**Doctor First Name 213**] read
[**2113-8-21**]: Thrombosis L >RIJ, neither completely occluded. Complete
thrombosis R basilic vein which neither compresses nor augments.
[**2113-9-6**]: KUB paucity of abdominal gas. Residual barium throughout small
bowel, colon,rectum
[**2113-9-7**] CT abd: Interval decrease peripancreatic collection. Ascites,
unchanged. Small bilateral pleural effusions, atelectasis.
[**2113-9-8**]: CXR stable bibasilar atelectasis, effusions
[**2113-9-10**]: KUB = Contrast is seen in the transverse and descending colon.
hazy opacity projecting above the transverse colon ?extrav.
[**2113-9-10**] IJ Ultrasound = Small non-occlusive thrombosis in the distal
left IJ, smaller in size from prior. No new DVT.
[**2113-9-11**] CXR Moderate right pleural effusion, small left pleural effusion
and mild-to-moderate bibasilar atelectasis unchanged. Mediastinal
vascular congestion slightly improved.
[**2113-9-11**] KUB Contrast in transverse and descending colon
[**2113-9-12**] Renal US no hydronephrosis, stones or masses, arterial flow
documented bilaterally, limited exam cannot r/o R renal artery
stenosis, L kidney Doppler waveforms demonstrate good upstrokes however
lack of diastolic flow in the intraparenchymal arteries may be due to
technical limitations
[**2113-9-12**] KUB p
[**2113-9-12**] CXR p
.
EVENTS:
[**2113-7-2**]: ERCP, aspiration mid-procedure so intubated. Unsuccessful
ERCP, difficulty passing NG tube. Excessive air causing compartment
syndrome of abdomen. Taken to OR for Abd compartment syndrome from air
insufflation.
[**2113-7-3**]: Ex-lap, enterotomy for abd decompression. Due to worsening
[**Last Name (un) **] distension, hemodynamic instabilty the [**Last Name (un) **] wound was extended in
the ICU by the surgical team and packed. .
[**2113-7-8**]: to OR for washout + dressing change + partial closure, ABD
still open
[**2113-7-8**] Sputcx: yeast w/ aspergillus
[**2113-7-12**]: cdiff+, started po vanco, flagyl, dc vanco, zosyn.
[**2113-7-13**]: closed in OR
[**2113-7-17**]: Upper GI bleed, S/P Upper GI scope by GI and clipping of
bleeding vessel. Likely Dieulafoy's lesion.
[**2113-7-19**]: Head to pelvis CT - pancreatic necrosis, no evidence of large
hematoma or abscess. Developed hemoptysis w/ increased Gtube output ->
GI scoped - lots of debris in stomach, no evidence acute bleeding. TEE
- showing low svr state, hypovolemia, empty hyperdynamic ventricles.
Bronch showing erythematous trachea, bal for clot, thick secretions, no
plugs. Increasing abd distention with increased bladder pressures (28)
- OR for decompressive laporatomy. Vanco and zosyn for PNA.
[**2113-7-24**]: washout of abd wound and trach in OR
[**2113-7-28**]: Worsening infiltrates on CXR, bronch showing purulent fluid.
BAL sent. GPC to R SVC CVL. E.coli in sputum (pan-sensi). Lines
replaced w/ tips cultured. Vanco, zosyn, cipro added. Flagyl also added
for empiric C.diff. OR for closure w/ mesh. Trach with cuff leak, not
changed in OR.
[**2113-9-4**]: to OR for repeat necrosectomy, started levophed gtt, on CMV.
Left flank drain O/P bloody.
[**2113-9-5**]: 2 units PRBC, G/J changed in IR (tube was leaking), trach
collar trial
[**2113-9-6**]: Out of bed to chair, tube feeds re-started at 10 but bilious
vomiting several hours later, KUB ruled out obstruction, TF re-started
again
[**2113-9-7**]: TM trialx7h, CT A/P with PO unchanged per surgery, methadone 10
[**Hospital1 7**], started lopressor. T spike 101.6 ON--panCx and CXR.
[**2113-9-8**]: Bowel contents draining from wound around pancreatic drain. Pt
made NPO, TPN started. V/C/F started empirically.
[**2113-9-9**]: SputumCx 4+ GNR, 1+ yeast. Pancreatic drain dressing?
[**2113-9-10**]: Zosyn for ?pseudomonas, resent ET aspirate per ID as they did
not trust initial sputum/contam. KUB=+contrast still. Surgery wants
wet-dry [**Hospital1 7**] dressings, res and att aware of local breakdown [**2-6**]
fistula. IJ thrombi largely resolved on U/S. heparin gtt d/c'd.
[**2113-9-11**]: VAC change, Cr increasing to 3.3, Renal Reconsulted.
[**2113-9-12**]: New CVL, PICC pulled and sent for culture, A line placed. Abg
with 7.08 PCo2 81 HCO3 26 Lactate 1.2. Methadone held and placed on
rate - repeat gas 2 hrs later 7.08/81/153/23.
Assessment: 70M w/ gallstone pancreatitis s/p failed ERCP and abdominal
compartment syndrome([**2113-7-2**]) c/b vasodilatory SIRS shock w/subsequent
decompressive exploratory laparotomy ([**2113-7-3**]) w/ persistent open
abdomen, expansion of wound ([**2113-7-3**]) bleeding Dieulafoy's s/p clipping
([**2113-7-17**]) ARF, s/p episode ARDS and c.diff, s/p abd closure and repeat
decompressive ex lap ([**2113-7-19**]), now trached ([**2113-7-24**]), Partial closure
with mesh ([**2113-7-29**]) and wound Vac ([**2113-8-1**]). Repeatedly febrile, repeat
abd CT shows air in pancreas. now s/p drainage of pancreatic collection
by IR ([**2113-8-13**]) upsizing of drain ([**2113-8-18**]), laproscopic minimally
invasive pancreatic necrosectomy ([**2113-8-22**], [**2113-8-28**], [**2113-9-4**]).
.
PLAN:
Neuro: Methadone careful titration. Tylenol, Fentanyl prn pain.
CVS: Lopressor 5 IV Q6h as BP tolerates
Pulm: Follow CXRs. Changed to CMV for hypercabia.
GI: Significant drainage around pancreatic drain w. skin breakdown,
decreased since TF stopped. No drainage of perihep/gutter since not
loculated/acute. Per primary team low threshold for CT abdomen. KUB [**9-12**]
+ barium sigmoid. Small bowel follow through on hold. [**Doctor First Name **] wound care
plan is wet-dry [**Hospital1 7**] (too large for ostomy and aware of breakdown).
Renal: ARF, Cr 3.0 wtih FENA suggestive of primary renal etiology.
Renal Ultrasound limited Bl flow norm.
FEN: TF stopped [**2113-9-8**], TPN started (1.25g/kg prot; total [**Numeric Identifier **]). TPN +
LR IVF = 150. HyperP, hypoCa. No TPN phos. Corrected calcium normal.
Heme: Off heparin gtt for cleared neck U/S, on SCH. *PT REQUIRES ~8HRS
NOTICE FOR ANY BLOOD PRODUCTS [**2-6**] UNUSUAL ABS.
Endo: 20units regular in TPN. RISS.(normal [**Last Name (un) **] stim test [**2113-8-14**]). PTH
22
ID: V/C/Z for sensitive Pseudomonas+ pancreatic drainage. [**2113-9-7**]
BCx=coag neg staph and UCx Neg, L flank drainage - pseudomonas, cipro
and pip [**Last Name (un) 270**]. F/u PICC tip. Consider fungal coverage.
Wounds: Abdomen wound vac (changed [**9-11**]). Left flank wound around panc
tube. Wet->dry [**Hospital1 7**] per [**Doctor First Name 213**] att/res.
Prophylaxis: SCDs, H2B, SQH
Consults: West 2, ID, PT/OT, renal.
Code: Full
Disposition: SICU
Chief complaint:
Necrotizing pancreatitis
PMHx:
asthma, HTN, basal cell CA
Current medications:
Acetaminophen prn, Albuterol prn, Bisacodyl, Colace, Epoetin, Fentanyl
prn, Haloperidol prn, RISS, atrovent prn, Lorazepam prn, Protonix,
Elecrolyte SS, metoprolol 37.5mg po bid, methadone holding
24 Hour Events:
New CVL, PICC pulled and sent for culture, A line placed. Abg with 7.08
PCo2 81 HCO3 26 Lactate 1.2. Methadone held and placed on rate - repeat
gas 2 hrs later 7.08/81/153/23.
Post operative day:
POD#72 - ex lap for compartment syndrome. 2 drains to wall suction.
exam otherwise unchanged from previous.
POD#67 - s/p abdominal partial closure and dressing change
POD#61 - abdominal wound closure; insertion of g-j tube
POD#56 - ex lap
POD#51 - trach and abd washout
POD#46 - ex-lap and mesh closure of abdomen
POD#26 - Replacement of pancreatic drain for abscess including
irrigation port
POD#22 - laparoscopic pancreatic necrosectomy
POD#9 - washout of peripancreatic space.
Allergies:
Aspirin
Unknown;
Sulfa (Sulfonamide Antibiotics)
Rash;
Last dose of Antibiotics:
Vancomycin - [**2113-9-10**] 04:00 PM
Ciprofloxacin - [**2113-9-12**] 06:12 PM
Piperacillin/Tazobactam (Zosyn) - [**2113-9-12**] 11:45 PM
Infusions:
Other ICU medications:
Methadone Hydrochloride - [**2113-9-12**] 10:08 AM
Heparin Sodium (Prophylaxis) - [**2113-9-12**] 10:05 PM
Metoprolol - [**2113-9-12**] 10:05 PM
Fentanyl - [**2113-9-12**] 11:45 PM
Other medications:
Flowsheet Data as of [**2113-9-13**] 01:08 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**16**] a.m.
Tmax: 36.9
C (98.5
T current: 36.9
C (98.5
HR: 82 (71 - 96) bpm
BP: 118/59(78) {116/55(75) - 133/66(87)} mmHg
RR: 20 (12 - 25) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 90.7 kg (admission): 108.3 kg
Height: 64 Inch
CVP: 14 (7 - 14) mmHg
Total In:
6,570 mL
238 mL
PO:
Tube feeding:
IV Fluid:
4,770 mL
166 mL
Blood products:
Total out:
2,974 mL
30 mL
Urine:
494 mL
30 mL
NG:
800 mL
Stool:
Drains:
1,680 mL
Balance:
3,596 mL
208 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 312 (312 - 412) mL
PS : 0 cmH2O
RR (Set): 18
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 43
PIP: 31 cmH2O
Plateau: 24 cmH2O
SPO2: 100%
ABG: 7.26/50/153/22/-4
Ve: 10.5 L/min
PaO2 / FiO2: 383
Physical Examination
Labs / Radiology
337 K/uL
8.1 g/dL
143 mg/dL
3.9 mg/dL
22 mEq/L
3.8 mEq/L
85 mg/dL
104 mEq/L
135 mEq/L
28.8 %
13.6 K/uL
[image002.jpg]
[**2113-9-7**] 03:18 AM
[**2113-9-8**] 04:25 AM
[**2113-9-9**] 03:00 AM
[**2113-9-10**] 03:09 AM
[**2113-9-11**] 03:00 AM
[**2113-9-11**] 05:25 PM
[**2113-9-12**] 02:25 AM
[**2113-9-12**] 07:20 PM
[**2113-9-12**] 08:12 PM
[**2113-9-12**] 10:04 PM
WBC
7.6
8.2
7.8
11.7
13.3
13.6
Hct
28.4
28.6
28.7
29.7
29.6
28.8
Plt
[**Telephone/Fax (3) **]94
358
337
Creatinine
2.0
2.0
2.1
2.2
2.9
3.3
3.5
3.9
TCO2
26
23
Glucose
237
143
93
159
146
133
174
143
Other labs: PT / PTT / INR:19.7/117.8/1.8, CK / CK-MB / Troponin
T:57/5/0.38, ALT / AST:[**10-20**], Alk-Phos / T bili:86/0.9, Amylase /
Lipase:51/16, Differential-Neuts:72.0 %, Band:6.0 %, Lymph:11.0 %,
Mono:5.0 %, Eos:1.0 %, Fibrinogen:738 mg/dL, Lactic Acid:1.2 mmol/L,
Albumin:1.7 g/dL, LDH:151 IU/L, Ca:9.0 mg/dL, Mg:1.9 mg/dL, PO4:6.0
mg/dL
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 11**]), AIRWAY, INABILITY TO PROTECT
(RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), [**Last Name 12**]
PROBLEM - ENTER DESCRIPTION IN COMMENTS, IMPAIRED SKIN INTEGRITY, RENAL
FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), VASCULAR DEVICE INFECTION
(NOT CENTRAL OR ARTERIAL LINE, INCLUDING GRAFT, FISTULA), SHOCK,
SEPTIC, ELECTROLYTE & FLUID DISORDER, OTHER, ANXIETY, .H/O DIARRHEA,
PANCREATIC PSEUDOCYST, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,
GAIT, IMPAIRED, KNOWLEDGE, IMPAIRED, TRANSFERS, IMPAIRED, ALTERATION IN
NUTRITION, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), .H/O FEVER
(HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), PAIN CONTROL
(ACUTE PAIN, CHRONIC PAIN)
Assessment and Plan: Neuro: Methadone careful titration. Tylenol,
Fentanyl prn pain.
CVS: Lopressor 5 IV Q6h as BP tolerates
Pulm: Follow CXRs. Changed to CMV for hypercabia.
GI: Significant drainage around pancreatic drain w. skin breakdown,
decreased since TF stopped. No drainage of perihep/gutter since not
loculated/acute. Per primary team low threshold for CT abdomen. KUB [**9-12**]
+ barium sigmoid. Small bowel follow through on hold. [**Doctor First Name **] wound care
plan is wet-dry [**Hospital1 7**] (too large for ostomy and aware of breakdown).
Renal: ARF, Cr 3.0 wtih FENA suggestive of primary renal etiology.
Renal Ultrasound limited Bl flow norm.
FEN: TF stopped [**2113-9-8**], TPN started (1.25g/kg prot; total [**Numeric Identifier **]). TPN +
LR IVF = 150. HyperP, hypoCa. No TPN phos. Corrected calcium normal.
Heme: Off heparin gtt for cleared neck U/S, on SCH. *PT REQUIRES ~8HRS
NOTICE FOR ANY BLOOD PRODUCTS [**2-6**] UNUSUAL ABS.
Endo: 20units regular in TPN. RISS.(normal [**Last Name (un) **] stim test [**2113-8-14**]). PTH
22
ID: V/C/Z for sensitive Pseudomonas+ pancreatic drainage. [**2113-9-7**]
BCx=coag neg staph and UCx Neg, L flank drainage - pseudomonas, cipro
and pip [**Last Name (un) 270**]. F/u PICC tip. Consider fungal coverage.
Wounds: Abdomen wound vac (changed [**9-11**]). Left flank wound around panc
tube. Wet->dry [**Hospital1 7**] per [**Doctor First Name 213**] att/res.
Neurologic:
Cardiovascular: Beta-blocker
Pulmonary: (Ventilator mode: CMV), PS trial
Gastrointestinal / Abdomen:
Nutrition: TPN
Renal: Foley, Poor UOP, RUS with normal renal artery flow bilaterally,
Rising Creatinine
Hematology:
Endocrine: RISS
Infectious Disease: Check cultures
Lines / Tubes / Drains: Foley, Trach, Surgical drains (hemovac, JP)
Wounds: Wound vacuum
Imaging: KUB today
Fluids: LR
Consults: General surgery, ID dept, Nephrology
Billing Diagnosis: Pancreatitis, Acute renal failure
ICU Care
Nutrition:
TPN w/ Lipids - [**2113-9-12**] 09:51 PM 75 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
18 Gauge - [**2113-9-8**] 04:19 PM
Multi Lumen - [**2113-9-12**] 03:43 PM
Arterial Line - [**2113-9-12**] 08:45 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
Total time spent:
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
Chief Complaint: septic shock
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
42 y/o F w/CVID, Hep C cirrhosis, adm with C.diff sepsis.
24 Hour Events:
-head CT yest normal
-abd CT with ascites, edematous bowel but no pneumatosis
-tube feeds held due to worsening abd distention
-lactate normal
History obtained from Medical records
Patient unable to provide history: Sedated
Allergies:
Aspirin
rectal bleeding
Penicillins
Rash; Hives;
Sulfonamides
aseptic menigi
Biaxin (Oral) (Clarithromycin)
Diarrhea;
Levaquin (Oral) (Levofloxacin)
Rash;
Cefzil (Oral) (Cefprozil)
Rash;
Motrin (Oral) (Ibuprofen)
aseptic meningi
Erythromycin Base
Rash;
Last dose of Antibiotics:
Vancomycin - [**2189-3-19**] 06:33 AM
Metronidazole - [**2189-3-19**] 08:25 AM
Infusions:
Other ICU medications:
Hydromorphone (Dilaudid) - [**2189-3-18**] 03:57 PM
Dextrose 50% - [**2189-3-19**] 06:33 AM
Pantoprazole (Protonix) - [**2189-3-19**] 08:00 AM
Other medications:
vanco po, peridex, sodium chloride nasal spray, protonix, reglan,
insulin sliding scale, flagyl
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-3-19**] 10:22 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.6
C (97.8
Tcurrent: 36.2
C (97.1
HR: 94 (84 - 99) bpm
BP: 94/34(48) {85/30(46) - 114/51(64)} mmHg
RR: 23 (9 - 31) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 59.9 kg (admission): 64 kg
Height: 64 Inch
CVP: 14 (8 - 16)mmHg
Bladder pressure: 18 (18 - 18) mmHg
Total In:
2,881 mL
839 mL
PO:
TF:
453 mL
IVF:
806 mL
311 mL
Blood products:
Total out:
2,290 mL
535 mL
Urine:
2,290 mL
535 mL
NG:
Stool:
Drains:
Balance:
591 mL
305 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 350 (350 - 350) mL
Vt (Spontaneous): 113 (113 - 113) mL
RR (Set): 18
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
RSBI Deferred: RR >35
PIP: 11 cmH2O
SpO2: 96%
Ve: 10.8 L/min
Physical Examination
General Appearance: opens eyes to voice but doesn't follow commands
Eyes / Conjunctiva: icteric
Head, Ears, Nose, Throat: Normocephalic, trach in place
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous: diffusely), tachypneic
Abdominal: Distended, doesn't appear tender but limited exam given
mental status
Extremities: Right: 3+, Left: 3+
Skin: Not assessed, Jaundice
Neurologic: No(t) Follows simple commands, Responds to: Verbal stimuli,
Movement: No spontaneous movement, Tone: Not assessed
Labs / Radiology
9.0 g/dL
228 K/uL
42 mg/dL
2.0 mg/dL
22 mEq/L
3.8 mEq/L
125 mg/dL
103 mEq/L
137 mEq/L
25.7 %
34.2 K/uL
[image002.jpg]
[**2189-3-15**] 04:21 AM
[**2189-3-15**] 05:01 PM
[**2189-3-16**] 03:43 AM
[**2189-3-16**] 03:16 PM
[**2189-3-17**] 04:53 AM
[**2189-3-17**] 03:37 PM
[**2189-3-18**] 05:00 AM
[**2189-3-18**] 07:43 AM
[**2189-3-18**] 05:17 PM
[**2189-3-19**] 05:40 AM
WBC
15.9
14.7
17.6
15.3
19.7
22.3
34.2
Hct
23.7
20.9
24.6
22.1
24.7
25.4
25.7
Plt
257
211
234
[**Telephone/Fax (3) 5338**]
228
Cr
1.8
1.2
1.5
2.6
1.5
1.6
1.6
2.0
2.0
TCO2
23
Glucose
76
60
50
66
199
186
185
163
42
Other labs: PT / PTT / INR:31.7/76.7/3.3, Differential-Neuts:87.0 %,
Band:2.0 %, Lymph:4.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6342 ng/mL,
Fibrinogen:260 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.6 g/dL, LDH:339
IU/L, Ca++:8.7 mg/dL, Mg++:2.7 mg/dL, PO4:4.4 mg/dL
Imaging: CXR: diffuse multifocal infiltrates, R hemidiaphragm more
clear today than yesterday
Microbiology: Sputum yest: abundant PMNs, no organisms on gram stain
Blood cx pending
Urine cx pending
Assessment and Plan
42 y/o F with multiple medical problems, critically ill for the past
month, now with worsening tachypnea, leukocytosis, abdominal
distention.
# Likely sepsis: Most likely source is abdomen given her physical exam
findings. No clear cause elucidated on abd CT yesterday but didn't
have contrast so wasn't a great study.
-add back antibiotics today (vanc/[**Last Name (un) **])
-repeat cx
-paracentesis
-check bladder pressure pre- and post-paracentesis - concern for abd
compartment syndrome; she certainly has intra abdominal hypertension
and would see if her BP and renal perfusion improves with paracentesis
-check LFTs, pancreatic enzymes
# Resp failure: Due to ARDS, likely component of volume overload.
Would hold on diuresis given what appears to be evolving sepsis.
# [**Last Name (un) **]: Unclear etiology, likely combination of ATN vs AIN. Will
follow. Creatinine was improving with diuresis suggesting some
improvement of her stroke volume with decreased R sided filling
pressures, but at this point would hold on diuresis as above. Could
also have worsening creatinine from vascular effects of high abdominal
pressures.
# Coagulopathy: Likely due to underlying liver disease and chronic
illness. No evidence of DIC.
ICU Care
Nutrition:
TPN w/ Lipids - [**2189-3-18**] 07:35 PM 50 mL/hour
Glycemic Control: Insulin in TPN, Comments: Decrease insulin in TPN
Lines:
PICC Line - [**2189-3-4**] 03:00 PM
Multi Lumen - [**2189-3-10**] 03:35 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition :ICU
Total time spent: 35 minutes
Patient is critically ill
------ Protected Section ------
I saw and examined this pt, and was present with the ICU team for the
key portions of services provided. I agree with Dr. [**First Name (STitle) **]
s note as
outlined above, and would add: Abd and Head CT negative yesterday. Pt
remains less responsive with worsening renal function (despite holding
of diuretics) and worsening leukocytosis.
Remain concerned for sepsis with abdomen the most likely source- back
on Vanco/Merepenem while we await pan-cultures. Bladder pressures
somewhat high (18-19) and will proceed with paracentesis today.
Pt is critically ill. Total time spent: 40 minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 1174**] [**Last Name (NamePattern1) **], MD
on:[**2189-3-19**] 14:30 ------
|
Physician
|
Classify the following medical document.
|
TITLE: MICU Progress Note
Chief Complaint:
24 Hour Events:
Pt remained intubated. Spoke w/ son who says that goal is for family
meeting on Tuesday at [**Hospital3 **] where family will discuss goals of
care with [**Hospital3 **] staff. Indicated that they may move towards do
not hospitalize, CMO. Did well on SBT but remained intubated through
the day for concern of need for re-intubation. Transfused 1 unit PRBCs.
INR reversed w/ Vitamin K. Hct stable throughout the day. CT scan abd
obtained for concern of RP bleed, did not show evidence of RP bleed,
but did show anasarca, pleural effusions.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefipime - [**2190-3-20**] 03:14 PM
Metronidazole - [**2190-3-21**] 04:06 PM
Vancomycin - [**2190-3-21**] 08:00 PM
Meropenem - [**2190-3-22**] 04:05 AM
Infusions:
Propofol - 15 mcg/Kg/min
Norepinephrine - 0.03 mcg/Kg/min
Other ICU medications:
Lansoprazole (Prevacid) - [**2190-3-21**] 08:07 AM
Furosemide (Lasix) - [**2190-3-22**] 02:41 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2190-3-22**] 06:57 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**91**] AM
Tmax: 37.1
C (98.8
Tcurrent: 37.1
C (98.8
HR: 81 (68 - 89) bpm
BP: 98/39(53) {87/25(41) - 161/71(90)} mmHg
RR: 24 (13 - 27) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
2,956 mL
552 mL
PO:
TF:
IVF:
1,707 mL
522 mL
Blood products:
639 mL
Total out:
795 mL
215 mL
Urine:
795 mL
215 mL
NG:
Stool:
Drains:
Balance:
2,161 mL
337 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 499 (317 - 499) mL
PS : 5 cmH2O
RR (Spontaneous): 24
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 80
PIP: 11 cmH2O
SpO2: 100%
ABG: 7.37/38/66/20/-2
Ve: 11.9 L/min
PaO2 / FiO2: 165
Physical Examination
GEN: Intubated and sedated
HEENT: NC/AT.
PULM: Bilateral inspiratory rhonchi, left greater than right. Decreased
breath sounds right base.
CVS: RRR with normal S1+S2
ABD: Hypoactive BS, soft, non-distended.
Neurologic: sedated
Labs / Radiology
208 K/uL
9.1 g/dL
100 mg/dL
1.5 mg/dL
20 mEq/L
3.6 mEq/L
58 mg/dL
117 mEq/L
145 mEq/L
28.4 %
10.6 K/uL
[image002.jpg]
[**2190-3-20**] 05:30 PM
[**2190-3-20**] 08:56 PM
[**2190-3-20**] 10:15 PM
[**2190-3-20**] 10:41 PM
[**2190-3-21**] 02:28 AM
[**2190-3-21**] 12:40 PM
[**2190-3-21**] 03:50 PM
[**2190-3-21**] 05:50 PM
[**2190-3-21**] 11:19 PM
[**2190-3-22**] 02:24 AM
WBC
11.4
10.6
Hct
26.1
24.3
26.5
26.7
28.1
28.4
Plt
255
208
Cr
1.4
1.4
1.5
1.5
TropT
1.38
1.39
1.28
1.26
1.28
TCO2
18
20
23
Glucose
135
92
111
100
Other labs: PT / PTT / INR:20.0/36.6/1.8, CK / CKMB /
Troponin-T:132/22/1.28, Differential-Neuts:84.3 %, Lymph:10.4 %,
Mono:3.5 %, Eos:1.7 %, Lactic Acid:1.7 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0
mg/dL, PO4:3.8 mg/dL
CT Abdomen/Pelvis without Contrast:
1. No definite evidence of retroperitoneal bleeding.
2. Hyperdense fluid within the sigmoid colon. Correlation with
Hemoccult is
recommended to exclude blood within the colon. Alternately, this may
represent oral contrast. Correlation with clinical history is
recommended.
3. Large bilateral pleural effusions, slightly increased when compared
to
prior exam.
4. Vascular calcifications.
5. Diffuse anasarca.
Assessment and Plan
78 y/o M with multiple medical problems including healthcare associated
pneumonia, chronic aspiration, afib on coumadin, CVAs, and CAD who
presents with hypoxia, consistent with pulmonary edema.
# Acute hypercarbic respiratory failure: CXR with increased volume and
patient did not improve with Bipap in the ED. Now intubated with
improved ventilation on ABG. BNP greater than assay is markedly
consistent with CHF. Put out well in the ED. Anticoagulated, so PE
seems less likely. Mucous plugging seems like a likely component as
well. Already on HAP treatment, and schedule to complete course today.
Worsening leukocytosis and fever concerning for possible resistant
organism.
- Continue Ventilation now and talk with family about possible
extubation (family meeting scheduled for Tuesday)
- Pressure support trial on 0/0
- Continuing [**Last Name (un) 350**]/Vanco/Flagyl
would have DC
d today, but will keep
him on these for now
- Repeat TTE
# Hypotension: pt. intermittently hypotensive with diuresis, continues
on levophed
- consider CVL
- attempt to wean pressor
# Pneumonia: Initially the pt was on vanc/pip-tazo for HCAP on
admission on [**3-11**]. Piperacillin-tazobactam was changed to cefepime on
[**3-13**]. Metronidazole was added on [**3-13**] due to persistent fevers.
- broaden as above
- follow cultures
- repeat sputum
# Hypernatremia: [**Month (only) 8**] be do to poor po intake, but patient total body
overloaded. 2.5 L deficit at this time. Do not want to fluid bolus
given CHF as above. Na 145 this AM. FWD about 2L
- Continue FW flushes through tube 250cc x4
# NSTEMI: Troponin elevated but flat CK, could be consistent with
resolving infarct on last admission. EKG with signs of demand in
lateral leads. Troponin now trending down
- cycle enzymes to peak
- asa 325 mg daily
- high dose statin
- Betablocker with holding parameters
- hold ace-i in setting of acute CHF
# Afib: Sinus tachycardia has resolved, was previously in Afib in ED.
Pt has been on anticoagulation for afib but Hct trending down.
- restart coumadin
- Rate control as above
- Repeat EKG this morning
# Anemia: HCT appears stable after transfusion of 1 unit pRBCs.
- continue PPI
- T and S
- Maintain 2 PIVs , PICC
# Dm: ISS
# Dementia: Continue mirtazapine
# FEN: Gentle D5 IVF, replete electrolytes, NPO for now
# Prophylaxis: restart coumadin, PPI
# Access: peripheral
PICC Line - [**2190-3-20**] 01:45 PM
18 Gauge - [**2190-3-20**] 01:45 PM
# Communication: has two daughters and son; [**Doctor Last Name **] is HCP, work
no: [**Telephone/Fax (1) 12228**]. Email: [**Company 12171**]. [**Doctor First Name 792**], daughter
[**Telephone/Fax (1) 12035**].
# Code: Full (discussed with HCP)
# Disposition: ICU pending clinical improvement
I
ICU Care
Nutrition:
Glycemic Control:
Lines:
PICC Line - [**2190-3-20**] 01:45 PM
18 Gauge - [**2190-3-20**] 01:45 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:
|
Physician
|
Classify the following medical document.
|
Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
PEEP weaned to 8. FiO2 down to 40%. Was 9L neg on CVVH. CVVH taken off
this am. Switched insulin to TPN. Off vasopressin.
Allergies:
Aspirin
rectal bleeding
Penicillins
Rash; Hives;
Sulfonamides
aseptic menigi
Biaxin (Oral) (Clarithromycin)
Diarrhea;
Levaquin (Oral) (Levofloxacin)
Rash;
Cefzil (Oral) (Cefprozil)
Rash;
Motrin (Oral) (Ibuprofen)
aseptic meningi
Erythromycin Base
Rash;
Last dose of Antibiotics:
Vancomycin - [**2189-2-24**] 09:00 AM
Meropenem - [**2189-2-24**] 06:00 PM
Metronidazole - [**2189-2-26**] 06:03 AM
Infusions:
Insulin - Regular - 5 units/hour
Fentanyl - 275 mcg/hour
Midazolam (Versed) - 8 mg/hour
Other ICU medications:
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-2-26**] 11:35 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.2
C (99
Tcurrent: 36.3
C (97.4
HR: 102 (74 - 103) bpm
BP: 109/44(64) {109/43(64) - 139/63(89)} mmHg
RR: 25 (24 - 48) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Height: 64 Inch
CVP: 13 (-5 - 13)mmHg
Total In:
9,720 mL
3,929 mL
PO:
TF:
IVF:
8,259 mL
3,210 mL
Blood products:
Total out:
19,098 mL
6,714 mL
Urine:
691 mL
198 mL
NG:
200 mL
Stool:
Drains:
Balance:
-9,378 mL
-2,785 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: PCV+Assist
RR (Set): 24
RR (Spontaneous): 0
PEEP: 8 cmH2O
FiO2: 40%
RSBI Deferred: Hemodynamic Instability
PIP: 33 cmH2O
Plateau: 27 cmH2O
SpO2: 100%
ABG: 7.46/34/110/21/0
Ve: 9.6 L/min
PaO2 / FiO2: 275
Physical Examination
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
diffuse, Wheezes : diffuse)
Abdominal: Soft, Distended, Tender: diffuse
Extremities: Right: 3+, Left: 3+
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,
Tone: Not assessed
Labs / Radiology
11.2 g/dL
144 K/uL
209
0.4 mg/dL
21 mEq/L
4.5 mEq/L
17 mg/dL
106 mEq/L
137 mEq/L
32.8 %
11.5 K/uL
[image002.jpg]
[**2189-2-25**] 09:55 AM
[**2189-2-25**] 03:38 PM
[**2189-2-25**] 03:54 PM
[**2189-2-25**] 10:17 PM
[**2189-2-25**] 10:21 PM
[**2189-2-26**] 04:43 AM
[**2189-2-26**] 04:54 AM
[**2189-2-26**] 06:00 AM
[**2189-2-26**] 09:00 AM
[**2189-2-26**] 11:00 AM
WBC
11.5
Hct
32.8
Plt
144
Cr
0.4
0.4
TCO2
25
28
26
25
Glucose
124
146
137
96
173
186
196
209
Other labs: PT / PTT / INR:20.9/41.3/2.0, ALT / AST:45/96, Alk Phos / T
Bili:140/16.8, Amylase / Lipase:[**10-30**], Differential-Neuts:68.0 %,
Band:4.0 %, Lymph:14.0 %, Mono:11.0 %, Eos:0.0 %, D-dimer:6342 ng/mL,
Fibrinogen:202 mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.8 g/dL, LDH:445
IU/L, Ca++:9.3 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL
Assessment and Plan
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, [**Doctor Last Name 76**])
RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)
1. C. Diff sepsis: Cont. po vanco/pr vanco/ IV flagyl
-off pressors
-IVIG weekly, due tomorrow possibly
-trophic TF at 10/h if CT OK
-CT abd without contrast today to rule out free air
2. ARDS: Decrease PEEP to 5 and 0.4, could try PS if she starts over
breathing
-fentanyl [**Month (only) 453**] to 200, versed 4 today, turn off briefly for daily wake
up
-trach tomorrow
3. ARF: CVVH off
-I/O goal neg
-follow uop
-renal recs
4. DIC: Resolved
5. DM1, on TPN with insulin, SSI
6. Leukocytosis: pancx
7. Cirrhosis: LFts improved
-liver following
8. Pull L SCL today if enough access
ICU Care
Nutrition:
TPN without Lipids - [**2189-2-25**] 10:17 PM 62.5 mL/hour
Glycemic Control: Insulin in TPN
Lines:
Multi Lumen - [**2189-2-13**] 12:05 AM
Dialysis Catheter - [**2189-2-17**] 07:22 PM
PICC Line - [**2189-2-20**] 09:27 AM
Arterial Line - [**2189-2-24**] 09:29 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Need for restraints reviewed
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition :ICU
Total time spent:
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2138-9-29**] Discharge Date: [**2138-10-4**]
Date of Birth: [**2138-9-29**] Sex: M
Service: NB
[**Known lastname **] [**Known lastname 61773**] [**Known lastname 60891**] was born at 36-4/7 weeks gestation
by spontaneous vaginal delivery after induction for pregnancy
induced hypertension. This mother is a 36-year-old gravida 2,
para 1, now 2 woman. Her prenatal screens are blood type O+,
antibody negative, rubella immune, RPR nonreactive, hepatitis
surface antigen negative and Group B strep unknown. Rupture
of membranes occurred six hours prior to delivery. The mother
did receive intrapartum antibiotics for GBS prophylaxis. The
infant emerged with decreased respiratory effort requiring
bag and mask ventilation, his Apgar's were 6 at one minute
and 8 at five minutes. Of note is that the infant also had a
true knot in his umbilical cord. The birth weight was 3395
grams, the birth length 19-1/2 cm. And the head circumference
was 34.5 cm.
PHYSICAL EXAMINATION: On admission revealed a full term non-
dysmorphic infant anterior fontanel open and flat, bruised
faced due to rapid second phase of labor. Positive bilateral
red reflex, intact palate, mild subcostal retractions,
positive grunting, breath sounds were equal. Heart was
regular rate and rhythm. No murmur. Abdomen soft, nontender,
nondistended. Extremities well perfused, stable hips, spine
intact, bilateral descended testes and age appropriate tone
and reflexes.
NICU COURSE BY SYSTEMS: He continued to have respiratory
distress after admission to the NICU requiring nasopharyngeal
continuous positive airway pressure. He weaned from that to
nasal cannula oxygen on day of life #2 and then to room air
also later on day of life #2 where he has remained. He
continues to breath comfortably. Lung sounds are clear and
equal. He has had no apnea or bradycardia.
Cardiovascular status: He has remained normotensive
throughout his NICU stay. His heart has regular rate and
rhythm and no murmur.
Fluid, electrolyte and nutrition status: At the time of
discharge his weight is 3,175 grams. Enteral feeds were begun
on day of life #2 and advanced without difficulty to full
volume feeding by day of life #4. At the time of discharge he
is breast feeding or taking 20 calorie per ounce formula on
an ad lib schedule. He has remained U-glycemic throughout his
NICU stay.
Gastrointestinal status: He was treated with phototherapy
from day of life 3 until day of life 4. His peak bilirubin on
day of life 3 was total 15.5, direct 0.4. A rebound Bili is
pending.
Hematology: The infant has never received any blood product
transfusions during his NICU stay. His hematocrit at the time
of admission was 50.3. The infant is blood type O+, direct
Coombs' negative.
Infectious Disease: Ampicillin and gentamicin was started at
the time of admission for sepsis risk factors. The
antibiotics were discontinued after 48 hours and the blood
cultures were negative and the infant was clinically well.
Sensory
Audiology: Hearing screening was performed with automated
auditory brain stem responses and the infant passed in both
ears.
Psychosocial: The parents have been very involved in the
infants care throughout his NICU stay.
Genitourinary: A circumcision is planned prior to discharge.
The infant is discharged in good condition.
He is discharged home with his parents.
His primary pediatric care provider will be Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7363**] of
[**Location (un) 1439**], MA.
RECOMMENDATIONS AFTER DISCHARGE: Feeding: Formula, breast
feeding with appropriate support as needed.
The infant is discharged on no medications.
A State newborn screen was sent on [**2138-10-2**].
The infant has not yet received his first hepatitis B
vaccine.
Recommended immunizations:
1. Synagis RSV prophylaxis to be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following
three criteria: Born at less then 32 weeks. Born between
32 and 35 weeks with two of the following: Day care
during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings or with chronic lung disease.
2. Influenza immunization is recommended annually in the
Fall for all infants once they reach 6 months of age.
Before this and for the first 24 months of the childs
life immunization against influenza is recommended for
household contacts and out of home caregivers.
FOLLOW UP: Includes follow-up with his primary pediatric
care provider and lactation support as needed.
DISCHARGE DIAGNOSIS:
1. Prematurity at 36-4/7 weeks.
2. Status post transitional respiratory distress.
3. Sepsis ruled out.
4. Status post hyperbilirubinemia of prematurity.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 56577**]
MEDQUIST36
D: [**2138-10-4**] 06:26:40
T: [**2138-10-4**] 08:31:29
Job#: [**Job Number 62998**]
|
Discharge summary
|
Classify the following medical document.
|
48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware
removal course c/b post-op resp failure, asp pna, and L lung collapse,
arf,, a-fib / flutter, and etoh withdrawal, extubated [**8-22**]
Hypernatremia (high sodium)
Assessment:
Sodium level =142 this am
Action:
Pt given 250cc
s free water boluses via ngt as ordered and electrolytes
checked as ordered
Response:
Sodium level on the decline
Plan:
Continue to check lytes as ordered and adjust free water boluses as
needed
Arousal, Attention, and Cognition, Impaired
Assessment:
Pt experienced etoh withdrawal post op requiring large amts of iv
valium. Pt
s girlfriend very supportive to pt but questioning all
sedatives given to pt. states that pt is not to receive any haldol
because
it drops hr
. pt is avbel to state his name, name of the
hospital and street name but then becomes extremely agitated stating he
s getting out of here and going home. Pt has self d/c
d the condom
cath and once foley cath was reinserted he also disconnected the
foley. Pt becomes verbally abusive using foul language and then falls
off to sleep
Action:
Safe environment maintained. Bed alarm activated and bed locked and in
low position. All rails up to prevent pt from climbing oob. Pt offered
emotional support and told frequently the plan of care and that pt is
not safe or ready to go home.
Response:
Episodes of agitation continue but pt has not received any valium since
Monday. Pt
s girlfriend at times able to quiet pt down.
Plan:
Continue to reorient pt to plan of care and treatment plan. Maintain
safe pt environment and avoid medicating with haldol. Allow [**Doctor First Name 7312**] to
remain at bedside when possible to help quiet pt and support him
Alteration in Nutrition
Assessment:
Pt s/p extubation on [**8-22**] with altered ms and s/p 3 failed
extubations. Immedicately following extubation pt with impaired gag
reflex. Failed 1^st speech and swallow study and was scheduled to have
video speech and swallow study today but because of pt
s body habitus
study could not be done. Bedside eval done at bedside. After 1 st
failed study pt had ngt placed via left nare and tube fdgs were
started. Na today=142. pt passed 2 lg brown softs tools that were heme
neg.
Action:
Bedside speech and swallow study done. Tube fdgs of replete with fiber
continue at pt
s goal rate of 80cc
s/hr. electrolytes followed as
ordered. [**Name (NI) 7413**] pt was receiving 250cc
s free water boluses via ngt q
4 hrs but that was dropped down to 100cc
s q 4hrs b/cause na level is
on the decline
Response:
Tolerated bedside speech and swallow study without any evidence of
aspiration.
Plan:
Po diet: nectar thick liqs and moist puree consistencies. 1:1
supervision. Alternate bites with sips. Continue tube fdgs as primary
means of nutrition,hydration and meds. Please wait to remove tube fdgs
until pt is seen again by speech and swallow consult team. Maintain
aspiratipn precautions.
Refer to social workers progress note from [**8-29**] regarding conversations
with pt
s [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 7312**]
Demographics
Attending MD:
[**Doctor Last Name **] [**Doctor First Name 5409**]
Admit diagnosis:
RIGHT HIP OA/SDA
Code status:
Full code
Height:
72 Inch
Admission weight:
118 kg
Daily weight:
126 kg
Allergies/Reactions:
No Known Drug Allergies
Precautions:
PMH: ETOH, Smoker
CV-PMH: Hypertension
Additional history: Pt. is s/p FALL from roof in [**2178**] >>> severe right
femur fracture. Pt. developed avascular and osteo necrosis of femur
head, and chronic pain of right hip/groin, revised today.
Surgery / Procedure and date: '[**78**] IM nailing s/p femur fracture
Latest Vital Signs and I/O
Non-invasive BP:
S:181
D:78
Temperature:
98.6
Arterial BP:
S:145
D:72
Respiratory rate:
22 insp/min
Heart Rate:
84 bpm
Heart rhythm:
SR (Sinus Rhythm)
O2 delivery device:
None
O2 saturation:
96% %
O2 flow:
10 L/min
FiO2 set:
35% %
24h total in:
2,639 mL
24h total out:
1,700 mL
Pertinent Lab Results:
Sodium:
142 mEq/L
[**2182-8-29**] 04:24 AM
Potassium:
3.5 mEq/L
[**2182-8-29**] 04:24 AM
Chloride:
109 mEq/L
[**2182-8-29**] 04:24 AM
CO2:
28 mEq/L
[**2182-8-29**] 04:24 AM
BUN:
21 mg/dL
[**2182-8-29**] 04:24 AM
Creatinine:
0.8 mg/dL
[**2182-8-29**] 04:24 AM
Glucose:
143 mg/dL
[**2182-8-29**] 04:24 AM
Hematocrit:
28.1 %
[**2182-8-29**] 04:24 AM
Valuables / Signature
Patient valuables: transferred with pt
[**Name (NI) 19**] valuables: cell phone
Clothes: Sent home with:
Wallet / Money:
No money / wallet
Cash / Credit cards sent home with:
Jewelry: none
Transferred from: [**Hospital Ward Name **] 402
Transferred to: 1164
Date & time of Transfer: [**2182-8-29**] 1815
|
Nursing
|
Classify the following medical document.
|
CVICU
HPI:
53 y.o. M POD # 7 from CABGx1(SVG to PLB)/AVR (porcine), complicated
by respiratory failure (significant smoking history) and pneumonia. In
addition, post-op EtOH withdrawal.
Chief complaint:
PMHx:
PMH: Biscuspid AV with AS and AI, Sleep apnea (Did not tolerate CPAP),
HTN, Hyperlipidemia, LE claudication, Seasonal allergies, GERD
Hx of left forearm, right collar bone fractures without [**Doctor First Name 213**].
Cervical disc disease, on Percocet, Anxiety Age 6 MVA with head injury
H/o Pericarditis early [**2141**], s/pTonsillectomy, s/p neck lymph node
removal
[**Last Name (un) **]: Atenolol 50', Lipitor 20', Nexium 40', Fluoxetine 40', HCTZ 25',
Lisinopril 5', Oxybutynin Chloride 10', Percocet 5mg-325mg 1.5 in
afternoon, Aspirin 81', MVI
Tobacco +
ETOH + 4-5 beers a day
Current medications:
24 Hour Events:
URINE CULTURE - At [**2161-10-28**] 12:48 PM
ARTERIAL LINE - STOP [**2161-10-28**] 06:02 PM
EKG - At [**2161-10-28**] 09:00 PM
Post operative day:
POD#8 - avr & cabg x1
Allergies:
Shellfish Derived
Nausea/Vomiting
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2161-10-27**] 04:03 AM
Ciprofloxacin - [**2161-10-29**] 11:14 AM
Infusions:
Other ICU medications:
Other medications:
Flowsheet Data as of [**2161-10-29**] 11:34 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**63**] a.m.
Tmax: 36.2
C (97.2
T current: 35.9
C (96.7
HR: 75 (65 - 86) bpm
BP: 100/57(67) {93/54(65) - 121/70(82)} mmHg
RR: 19 (16 - 30) insp/min
SPO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 96.3 kg (admission): 102 kg
Height: 68 Inch
Total In:
2,435 mL
870 mL
PO:
1,640 mL
620 mL
Tube feeding:
IV Fluid:
695 mL
250 mL
Blood products:
Total out:
1,010 mL
200 mL
Urine:
1,010 mL
200 mL
NG:
Stool:
Drains:
Balance:
1,425 mL
670 mL
Respiratory support
O2 Delivery Device: None
SPO2: 97%
ABG: ///28/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)
Diastolic)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Bowel sounds present
Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
530 K/uL
10.3 g/dL
195 mg/dL
0.5 mg/dL
28 mEq/L
3.7 mEq/L
19 mg/dL
100 mEq/L
135 mEq/L
29.9 %
16.7 K/uL
[image002.jpg]
[**2161-10-26**] 06:00 PM
[**2161-10-26**] 08:53 PM
[**2161-10-27**] 03:45 AM
[**2161-10-27**] 03:51 AM
[**2161-10-27**] 07:38 AM
[**2161-10-27**] 09:56 PM
[**2161-10-28**] 03:35 AM
[**2161-10-28**] 11:00 AM
[**2161-10-28**] 05:49 PM
[**2161-10-29**] 02:28 AM
WBC
11.5
15.3
16.7
Hct
27.9
31.5
29.9
Plt
335
455
530
Creatinine
0.8
0.6
0.6
0.5
TCO2
37
32
33
Glucose
103
114
131
102
128
130
110
195
Other labs: PT / PTT / INR:13.7/26.7/1.2, ALT / AST:33/59, Alk-Phos / T
bili:109/1.7, Amylase / Lipase:63/52, Differential-Neuts:90.0 %,
Lymph:7.9 %, Mono:1.3 %, Eos:0.6 %, Fibrinogen:352 mg/dL, Lactic
Acid:1.6 mmol/L, Albumin:3.1 g/dL, LDH:708 IU/L, Ca:9.1 mg/dL, Mg:2.4
mg/dL, PO4:4.4 mg/dL
Assessment and Plan
ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES), VALVE
REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), HYPOXEMIA, CORONARY ARTERY
BYPASS GRAFT (CABG)
Assessment and Plan: 53 y.o. M POD # 7 from CABGx1(SVG to PLB)/AVR
(porcine), complicated by respiratory failure (significant smoking
history) and pneumonia. In addition, post-op EtOH withdrawal.
Neurologic: Neuro checks Q: 4 hr, Pain controlled, MS slightly
improved. Off midaz gtt. Valium 5 mg [**Hospital1 **], methadone 10 mg [**Hospital1 **] with much
improvement. In addition, clonidine patch and oral PO until tomorrow.
Welbutrine started for smoking craving. Still disoriented, but slightly
better
Cardiovascular: Aspirin, Beta-blocker, Statins, HD stable
Pulmonary: IS, OOB --> walking. Not compliant with IS
Gastrointestinal / Abdomen: BM yesterday and today. On bowel regimen
Nutrition: Regular diet
Renal: Adequate UO
Hematology: Serial Hct, Stable anemia. Monitor for now
Endocrine: RISS, BG well controlled. Keep < 150
Infectious Disease: Check cultures, H flue in sputum and enterobacter.
On cipro. Follow sensitivities. WBC continue to increase. CXR today
Lines / Tubes / Drains:
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: CT surgery
Billing Diagnosis: Post-op complication
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2161-10-26**] 06:14 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status:
Disposition: ICU
Total time spent: 20 minutes
|
Physician
|
Classify the following medical document.
|
Unit No: [**Numeric Identifier 67488**]
Admission Date: [**2156-8-16**]
Discharge Date: [**2156-8-23**]
Date of Birth: [**2082-9-9**]
Sex: M
Service: GU
CHIEF COMPLAINT: Bladder cancer.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 67489**] is a 73-year-old
man with known bladder cancer diagnosed on [**2156-7-15**]. He
is here for a cystectomy and stoma scheduled for [**2156-8-17**].
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS: Atenolol.
PAST MEDICAL HISTORY: Prostate cancer, radical resection of
the prostate in [**2148**], severe gunshot wound to the abdomen, 3
to 4 exploratory laparoscopies for pus and adhesions
secondary to these gunshot wounds. The gunshot wounds were a
result of injuries in hunting accidents.
PAST SURGICAL HISTORY: RRP [**2148**], abdominal ex-laps.
FAMILY HISTORY: There is a questionable history of prostate
cancer in his father.
SOCIAL HISTORY: He quit smoking 30 years ago and prior to
that smoked one pack per day for 20 years.
INPATIENT MEDICATIONS:
1. Acetaminophen.
2. Atenolol 25 mg PO once daily.
3. Diphenhydramine 25 PO q6 hours.
4. Dolasetron mesylate.
5. Docusate sodium.
6. Famotidine 20 b.i.d.
7. Oxycodone-acetaminophen 1 to 2 tablets PO q.4 to 6 hours.
8. Phenaseptic throat spray.
9. Sarna lotion.
PHYSICAL EXAMINATION: Temperature Max. 97.6, heart rate 46,
BP 154/80, respiratory rate 18, oxygen saturations 99% on
room air. Chest clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: With
urostomy in place and stents draining into urostomy. No
erythema or exudate or other sign of infection. Abdomen is
nontender, nondistended, and soft. Extremities warm and well
perfused. No clubbing, cyanosis or edema.
BRIEF HOSPITAL COURSE: Mr. [**Known lastname 67489**] was admitted on [**2156-8-16**]. His preoperative labs were all within normal limits. He
was typed and crossed for 4 units of blood.
On [**8-17**], postoperative day 1, he did well and was kept in
the SICU overnight for monitoring. He was also started on
Ancef and clindamycin for a total of 3 doses.
On postoperative day 2, Dr. [**Last Name (STitle) 9125**] discussed the results of
the surgery with him. Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], oncology, and Dr.
[**First Name11 (Name Pattern1) 11312**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 656**], radiation oncology, were consulted.
On postoperative day 3, the NG tube and the JP drain were
discontinued secondary to little output. The patient
tolerated PO intakes very well and was ambulating very well
and was tolerating oral pain medications with Percocet.
On hospital day 5, CT scan for staging was obtained. The CT
scan showed a moderate bilateral hydronephrosis, hydroureter
and on one side the stent located on the left within the
ureter and the other stent was located in the ileal conduit.
The patient continued to drain and complained of no pain or
dysuria or discomfort in the area of the stent and therefore
they were left as is. The patient was discharged home the
following day with Percocet for pain as well as Colace to
soften his stools. He was also given a witch [**Female First Name (un) **] type of
cream for his hemorrhoids.
A followup appointment with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] has been
arranged. The patient was instructed to call Dr.[**Name (NI) 15380**]
office to confirm that appointment and also a followup
appointment with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 365**] was made. The patient was
given instructions and was discharged in good condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13269**]
Dictated By:[**Name8 (MD) 560**]
MEDQUIST36
D: [**2156-8-24**] 03:49:52
T: [**2156-8-24**] 08:12:45
Job#: [**Job Number 67490**]
|
Discharge summary
|
Classify the following medical document.
|
Admission Date: [**2165-8-19**] Discharge Date: [**2165-8-24**]
Date of Birth: [**2088-8-5**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Briefly, this is a 74-year-old
male with a past medical history of hypertension and type 2
diabetes who felt chest discomfort and increasing pounding in
his chest.
He went to the hospital and was found to have had a
myocardial infarction. He was taken to the catheterization
laboratory which was positive for multivessel disease.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Hypertension.
2. Diabetes.
3. Transient ischemic attacks.
4. Bilateral carotid disease.
MEDICATIONS ON ADMISSION: His medications on admission were
Glucotrol, glyburide, Zestril, Zocor, aspirin, and Timolol.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, he was afebrile. His vital signs were stable.
His pupils were equal, round, and reactive to light. His
extraocular muscles were intact. His neck was supple with no
jugular venous distention, and no bruits. His chest
examination revealed he had small crackles at the bases;
otherwise, lungs were clear to auscultation bilaterally. His
heart was regular in rate and rhythm with no murmurs, rubs,
or gallops. His abdomen was soft, nontender, and
nondistended. Bowel sounds were present. His extremities
were warm and well perfused with just trace edema.
HOSPITAL COURSE: The patient was taken to the operating
room on [**2165-8-20**] where a coronary artery bypass
graft times three was performed; left internal mammary artery
to the left anterior descending artery, saphenous vein graft
to RPL, saphenous vein graft to right posterior descending
artery.
The patient was transferred to the Postanesthesia Care Unit
postoperatively, where he was slowly weaned from his
ventilator and extubated. He had labile blood pressures
which responded to volume; but otherwise he continued to do
well. He diet was advanced, and he was started on beta
blocker at that time. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Diabetes consultation was
obtained at that time to help control his blood pressures.
He continued to have labile blood pressures; however, he
continued to improve with aggressive fluid management. The
patient was transferred to the floor postoperatively where he
did well. Physical Therapy was consulted to assess his
ambulation, and they felt at that time he would do quite well
at home. It was planned by the family that he would have to
come stay with him 24 hours a day. A cane was given to
assist him in his walking; however, home Physical Therapy was
also planned in order to help him to increase his ability to
ambulate.
Postoperatively, his chest tubes were removed. His Foley
catheter was removed, and his wires were removed, and he did
well. Aggressive pulmonary toilet and diuresis was
continued. The patient's blood sugars also improved with
better control.
DISCHARGE DISPOSITION: The patient continued to improve, and
on postoperative day four, he was discharged to home in
stable condition.
MEDICATIONS ON DISCHARGE: (His discharge medications
included)
1. Lopressor 25 mg p.o. b.i.d.
2. Lipitor 10 mg p.o. q.d.
3. Timolol 0.25% one drop b.i.d. to effected eye.
4. Glipizide-XL 10 mg p.o. q.d.
5. Percocet one to two tablets p.o. q.4h. as needed.
6. Enteric-coated aspirin 325 mg p.o. q.d.
7. Zantac 150 mg p.o. b.i.d.
8. Colace 100 mg p.o. b.i.d.
9. Potassium chloride 20 mEq p.o. b.i.d.
10. Lasix 20 mg p.o. b.i.d.
DISCHARGE DIAGNOSES: (The patient's discharge diagnoses
included)
1. Coronary artery disease; status post coronary artery
bypass graft.
2. Hypertension.
3. Diabetes.
4. Glaucoma.
5. Transient ischemic attacks.
6. Bilateral carotid disease.
DISCHARGE STATUS: The patient was discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE FOLLOWUP: The patient was instructed to follow up
with Dr. [**Last Name (STitle) 1537**] in four to six weeks, and with his primary care
physician in one to two weeks, and with Cardiology in two to
four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2165-8-23**] 21:19
T: [**2165-8-29**] 09:00
JOB#: [**Job Number **]
|
Discharge summary
|
Classify the following medical document.
|
34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p
Bakri balloon placement now admitted to [**Hospital Unit Name 4**] for closer
monitoring.
BRIEF HISTORY :
34yo G8P6 admitted with vaginal bleeding. The patient was diagnosed
with non-viable pregnancy in [**Month (only) 2877**] with bleeding off and on since
then. Last week she went into her OB for a check up and was still
having uterine bleeding with a positive HCG. Her OB said she needed a
D+C but she wanted to wait until after passover to have this done and
since she was having only minimal bleeding it was agreed that she could
wait. However, overnight she had heavier bleeding including clots from
her vagina. She tried to stay at home to manage it but this morning her
husband convinced her to come to the OB/GYN.
.
In the OB/GYN triage unit she started passing large clots in toilet
this am and then, while the OB/GYN resident was standing with her, she
syncopized but didnt hit anything. Therefore she was taken back to the
OR for urgent D+C. D+C didnt show retained products but continued to
bleed afterward to the point that they were thinking of doing emergent
hysterectomy (lost 2 liters). At that point she then got a foley
balloon placed in uterus to tamponade (Bakri balloon). This was
attached to a urimeter to monitor bleeding - will see it in bag or on
her pad. Hct on admission was 29, intra op it was 20, received 3units
pRBCs in OR and near end of case was 28. INR 1.3 intraop. Fibrinopgen
190. Has 2 pivs in place. Actiev T+S and aline. VSS currently. Cramping
from uterus and LH after dilaudid but otherwise not symptomatic.
.
Also a type one diabetic but took it off when she got here but initial
FSBS was 300 - received 10units reg insulin in OR and now written for a
drip.
.
She was transferred to the [**Hospital Unit Name 4**] for monitoring overnight.
Uterine bleeding
Assessment:
s/p D &C and Bakri balloon placement [**4-27**] following LOC and 2L blood
loss. Pt with small amt of output from balloon. Dark red in color. 15
CC TODAY. No other signs of bleeding. Morning crit 21. MINIMAL
BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Bakri balloon defalted
at 11:00 with no bleeding noted. Fully removed at 13:30 by ob and few
small dark [**Doctor Last Name **] clots noted with removal. Pt oob to chair 30 min
after balloon out with 1 3-4 cm brown/pink clot. 1 pad with pink brown
serous drainage thus far noted. Minimal dizziness, bp 98/64.. hr up to
100 from 80
2 with standing. Recovered bp and pulse upon sitting
Action:
Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced
Response:
Pt A&O x 3 and appropriate. No s/s of sever bleeding noted.
Hemodynamically stable.
Plan:
Cont to monitor for s/s bleeding. Will start po intake if no bleeding
3-4 hr after balloon removed at 1700.
Diabetes Mellitus (DM), Type I
Assessment:
Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100
throughout night. Since 0700 glucone in 90-84 range.
Action:
Insulin gtt stopped at 13:30 and started on sub cutaneous humalog
insulin pump per pt own device . dose is .45 units/hr SC. Blood
glucose q 3-4 hr.
Response:
Ongoing. Good glucose control but pt is po. 2 PIV lines if needs
glucose rescue.
Plan:
Plan to start feeding pt if no bleeding occurs and will not need [**Doctor First Name 91**]
transfer to OB floor and prob discharge in am if no further bleeding.
Educate pt to diet intake for iron and volume for low crit.
Hypotension (not Shock)
Assessment:
UOP down at 0500-0600. bp 83/60 . pt c/o slight dizziness .
Action:
1000 cc ns bolus over 1 hr given
Response:
Bp 95-110 sys withmap > 60. hr 80
s nsr. Slight tachy to 100 with
exertion of OOB. Urine output this shift thus far is 1200 cc. minimal
dizziness with standing. Improving crit
Plan:
Conts to monitor. Send to ob floor
|
Nursing
|
Classify the following medical document.
|
Chief Complaint: subdural hematoma, respiratory failure
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
82 y/o M w/afib, s/p AVR, diastolic CHF, admitted with subdural
hematoma s/p fall now s/p craniotomy and evacuation, with persistent
respiratory failure.
24 Hour Events:
FEVER - 102.2
F - [**2135-9-27**] 12:00 AM
Became hypoxic to the 90s last night and peep was increased to 10. CXR
with worsening RLL infiltrate. Antibiotics broadened to cover
hospital-acquired organisms.
[**Name8 (MD) 54**] RN, left arm and left leg shook for a couple of seconds both
yesterday and this morning.
Allergies:
Procainamide
Arthralgia/Arth
Morphine
Confusion/Delir
Last dose of Antibiotics:
Cefipime - [**2135-9-27**] 04:00 AM
Infusions:
Other ICU medications:
Fentanyl - [**2135-9-27**] 04:00 AM
Famotidine (Pepcid) - [**2135-9-27**] 08:00 AM
Other medications:
D5NS at 125 cc/hr, peridex, multivitamin, folate, colace, atrovent,
dilantin, finasteride, atorvastatin, flomax, allopurinol, insulin
sliding scale, hydral, lopressor 25 [**Hospital1 **], amiodarone 200 [**Hospital1 **],
levothyroxine 75 mcg daily, imdur 20 [**Hospital1 **], vancomycin, tylenol prn,
fentanyl prn
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2135-9-27**] 09:44 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 39
C (102.2
Tcurrent: 38.3
C (101
HR: 60 (55 - 61) bpm
BP: 125/57(77) {107/46(63) - 158/70(96)} mmHg
RR: 17 (16 - 30) insp/min
SpO2: 98%
Heart rhythm: AV Paced
Wgt (current): 94.7 kg (admission): 68 kg
Height: 70 Inch
Total In:
2,137 mL
1,480 mL
PO:
TF:
1,440 mL
IVF:
347 mL
790 mL
Blood products:
Total out:
1,695 mL
465 mL
Urine:
1,695 mL
465 mL
NG:
Stool:
Drains:
Balance:
442 mL
1,015 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 600) mL
RR (Set): 12
RR (Spontaneous): 25
PEEP: 8 cmH2O
FiO2: 50%
RSBI Deferred: PEEP > 10
PIP: 25 cmH2O
Plateau: 22 cmH2O
SpO2: 98%
ABG: 7.52/36/87
Ve: 10.9 L/min
PaO2 / FiO2: 282
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: left pupil remains greater than right but both
reactive
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube
Cardiovascular: (S1: Normal), (Murmur: Systolic), Mechanical S2, II/VI
HSM at apex
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Warm
Neurologic: Responds to: Unresponsive, Movement: Non -purposeful, Tone:
Not assessed
Labs / Radiology
9.0 g/dL
163 K/uL
200 mg/dL
2.1 mg/dL
27 mEq/L
3.3 mEq/L
52 mg/dL
122 mEq/L
157 mEq/L
26.9 %
8.5 K/uL
[image002.jpg]
[**2135-9-25**] 09:06 AM
[**2135-9-25**] 05:30 PM
[**2135-9-26**] 04:20 AM
[**2135-9-26**] 04:35 AM
[**2135-9-26**] 06:09 PM
[**2135-9-26**] 10:27 PM
[**2135-9-27**] 01:44 AM
[**2135-9-27**] 02:38 AM
[**2135-9-27**] 03:01 AM
[**2135-9-27**] 07:44 AM
WBC
7.8
6.0
7.0
8.5
Hct
23.2
20.9
27.2
26.8
26.9
Plt
120
126
136
163
Cr
2.3
2.2
2.1
TCO2
29
29
29
30
30
Glucose
195
246
200
Other labs: PT / PTT / INR:25.9/53.7/2.6, CK / CKMB /
Troponin-T:154/13/0.07, ALT / AST:134/102, Alk Phos / T Bili:179/1.2,
Fibrinogen:300 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:2.9 g/dL, LDH:407
IU/L, Ca++:8.6 mg/dL, Mg++:2.6 mg/dL, PO4:1.2 mg/dL
Fluid analysis / Other labs: LFTs decreased slightly from yesterday
Reticulocyte count 0.6%
Hapto 110
FDP 10-40
Iron 39
TIBC 186
Ferritin 616
TG 84
Folate, B12 normal
Imaging: CXR today with worsened RLL infiltrate
Microbiology: Sputum [**9-26**]: 3+ GPC in prs and clusters
Blood cx [**9-26**] pending
Assessment and Plan
A/P: 82 y/o M w/afib, s/p AVR, diastolic CHF, admitted with bilateral
subdural hematoma and intraparenchymal bleed s/p fall now one week s/p
evacuation, course complicated by reintubation.
1. Respiratory failure: Persistent hypoxemia requiring increased peep,
with worsening infiltrate on CXR. Likely due to VAP.
- treating with vanco and cefepime
- has a respiratory alkalosis which is likely due to his CNS process -
decreased tidal volume but still has a high Ve
- extubation limited by mental status and hypoxemia
2. Subdural hematoma: s/p craniotomy and evacuation. Head CTs have
been stable despite what effectively is systemic anticoagulation
(elevated INR and PTT). Now with ? of seizure activity.
- continue dilantin
- discuss seizures with neurosurgery; dilantin dose appears to be
therapeutic
- discuss prognosis with neurosurgery
3. Diastolic CHF: s/p multiple admissions for this in past. Appears
relatively euvolemic and pulmonary infiltrates likely
pneumonia/aspiration as opposed to CHF.
- cont metoprolol
4. s/p AVR: Not on anticoagulation due to subdural, but PT & PTT both
elevated today. Continue to hold anticoagulation for now.
5. Coagulopathy: Both INR and PTT are elevated, despite having been
given multiple units of FFP during his hospital course. DIC panel
negative with normal fibrinogen and FDP. Held SQ heparin although
unlikely that he is systemically absorbing this.
- DIC panel negative
- restart SQ heparin
6. Anemia: Hct now stable. Anemia labs c/w ACD, has hx of abnl bone
marrow biopsy. Hemolysis labs negative.
- check Hct [**Hospital1 **]
- guaiac stools
7. CKD: baseline creatinine is 2.3-2.8. currently 2.2. BUN higher than
baseline, likely due to diuresis, now trending down.
- renally dose meds
8. Hypertension: Given bleed, goal SBP <160
- increase hydralazine to 37.5 mg TID
- Imdur 20 [**Hospital1 **]
- metoprolol 25mg [**Hospital1 7**]
9. Atrial fibrillation: Amiodarone 200 [**Hospital1 7**]
10. Hypothyroidism: On levothyroxine.
11. Altered mental status: Is unresponsive off of sedation. Likely
due to subdural with contributions from hypernatremia, uremia, and
infection. As above, will discuss with neurosurgery to assess trend of
his exam over hospital course.
- ? need for EEG given question of seizure activity this morning
12. Hyperlipidemia: continue statin
13. Hypernatremia: has been trending up, likely contributing to mental
status. Will start on D5W (was inadvertently on D5NS overnight.)
- free water boluses 300q4
14. Elevated LFTs: Now slightly improved. Unclear etiology; no clear
medications that should be causing this other than amiodarone but has
been on this for quite some time and statin.
- RUQ u/s
- hepatitis serologies
- d/c statin
ICU Care
Nutrition:
Comments: tube feeds
Glycemic Control: Blood sugar well controlled
Lines:
Arterial Line - [**2135-9-19**] 10:14 AM
20 Gauge - [**2135-9-25**] 04:30 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Comments:
Code status: DNR (do not resuscitate)
Disposition :ICU
Total time spent:
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
TITLE: Physician Resident Progress Note
Chief Complaint:
24 Hour Events:
-started meropenem and discontinued ceftriaxone
-consulted EP, will check ICD tomorrow
-6 p.m., noted to be more hypoxemic, blood gas 7.50/37/50
-gave Lasix and placed on non-rebreather without improvement
-7 p.m. intubated for hypoxemic respiratory failure
-8 p.m. A-line placed
-febrile, pan-cultured
-9 p.m. bolused 500 cc NS for SBP 70s
-10 p.m. started levophed for SBP 70s
-11 p.m. bolused additional 500 cc NS for SBP 70s
-2 a.m. ET tube advanced 2 cm.
-4 a.m. bolused with 500 cc NS for low urine output
Allergies:
Penicillins
Hives; Rash;
Ambien (Oral) (Zolpidem Tartrate)
Lightheadedness
Last dose of Antibiotics:
Cefipime - [**2141-3-3**] 08:15 PM
Azithromycin - [**2141-3-4**] 09:30 AM
Ceftriaxone - [**2141-3-4**] 03:00 PM
Vancomycin - [**2141-3-4**] 11:16 PM
Meropenem - [**2141-3-5**] 12:44 AM
Infusions:
Midazolam (Versed) - 2 mg/hour
Fentanyl - 50 mcg/hour
Norepinephrine - 0.08 mcg/Kg/min
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2141-3-5**] 05:58 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**42**] AM
Tmax: 38.2
C (100.7
Tcurrent: 37.8
C (100
HR: 60 (60 - 103) bpm
BP: 76/47(53) {76/47(53) - 124/83(96)} mmHg
RR: 22 (16 - 25) insp/min
SpO2: 97%
Heart rhythm: V Paced
Wgt (current): 104 kg (admission): 105 kg
Height: 72 Inch
Total In:
2,049 mL
712 mL
PO:
560 mL
TF:
IVF:
1,489 mL
712 mL
Blood products:
Total out:
1,610 mL
145 mL
Urine:
1,610 mL
145 mL
NG:
Stool:
Drains:
Balance:
439 mL
567 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 0 (0 - 0) mL
RR (Set): 22
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 70%
RSBI Deferred: FiO2 > 60%, Hemodynamic Instability
PIP: 20 cmH2O
Plateau: 15 cmH2O
Compliance: 51.5 cmH2O/mL
SpO2: 97%
ABG: 7.42/44/117/27/3
Ve: 10.7 L/min
PaO2 / FiO2: 167
Physical Examination
GENERAL: Alert; Oriented x3. Uncomfortable; fidgety. Diaphoretic.
High-flow O2 mask on.
HEENT: NC/AT.
NECK: Supple. Unable to appreciate JVP.
CARDIAC: Difficult to hear over breath sounds; No m/r/g appreciated.
LUNGS: Resp slightly labored; bilateral crackles and coarse breath
sounds.
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral hernia
present.
EXTREMITIES: No significant LE edema noted. No calf pain.
Labs / Radiology
172 K/uL
10.6 g/dL
134 mg/dL
0.9 mg/dL
27 mEq/L
3.7 mEq/L
29 mg/dL
105 mEq/L
139 mEq/L
31.5 %
7.5 K/uL
[image002.jpg]
[**2141-3-3**] 05:38 PM
[**2141-3-3**] 08:15 PM
[**2141-3-4**] 04:30 AM
[**2141-3-4**] 10:00 AM
[**2141-3-4**] 03:08 PM
[**2141-3-4**] 06:29 PM
[**2141-3-4**] 09:17 PM
[**2141-3-4**] 11:16 PM
[**2141-3-5**] 04:44 AM
[**2141-3-5**] 04:55 AM
WBC
7.4
7.5
Hct
33.9
31.5
Plt
174
172
Cr
1.2
1.1
0.9
TropT
<0.01
<0.01
<0.01
TCO2
28
30
30
27
26
30
Glucose
134
131
140
134
Other labs: PT / PTT / INR:24.2/34.4/2.3, CK / CKMB /
Troponin-T:374/4/<0.01, Lactic Acid:0.9 mmol/L, Ca++:7.7 mg/dL,
Mg++:2.1 mg/dL, PO4:2.1 mg/dL
Assessment and Plan
71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in '[**26**],
paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD
implantation, who presented to the ED with a chief complaint of
dyspnea, initially thought to be due to CHF exacerbation but now
suspicious for pneumonia.
.
# Dyspnea: Overnight, the patient had recurrent of dyspnea. Repeat CXR
showed a more clear left-sided infiltrate. Also, of note, pt had fevers
overnight. This presentation now more consistent with pneumonia, with a
possible superimposed CHF component. Pt given
vanc/cefepime/levofloxacin yesterday evening.
- vanc/cefepime/azithromycin for broad coverage for pneumonia at this
point
- attempt to get sputum cultures
- restarting Lasix 60 mg PO daily to prevent CHF exacerbation on top of
PNA
- continue metoprolol 12.5 mg daily, per home med list
.
# CORONARIES: Pt has a history of an anterior wall MI in [**2126**]. Pt
denies any current chest pain, and the first 2 sets of CE's was
negative. Of note, the patient did report some chest pressure
previously, but this has since resolved.
- will continue to rule out MI with 3 sets of CE's
- continue to monitor for any chest pain
.
# RHYTHM: Pt with a history of a.fib, for which he is on coumadin. His
INR is currently therapeutic at 2.3 on presentation. Telemetry
currently showing v-paced rhythm.
- continue coumadin, with goal INR of [**1-25**]
- need to closely monitor INR, as it may change with pt on abx
.
# Hypertension: Normotensive at this time.
- continue metoprolol tartrate
- lasix as above
.
# Hypothyroidism:
- continue levothyroxine 50 mcg daily
.
# Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.
Pt currently near his baseline.
- continue iron supplementation
- continue to trend hct
- bowel regimen with colace/senna
.
# ID: Per o/p ID notes, the patient is on chornic cefpodoxime for
ongoing suppression after high-grade viridans streptococcal bacteremia
in the setting of pacer/defibrillator wires and to continue intended
life-long suppression for suspected Klebsiella pneumoniae lead
endocarditis during a prior bacteremia.
- holding cefpodoxime while on broad spectrum abx as above
- touch base with outpt ID doc
.
# S/p Whipple:
- continue pancreatic enzyme repletion
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2141-3-5**] 12:58 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2195-12-8**] Discharge Date: [**2195-12-16**]
Date of Birth: [**2143-6-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
intubation [**Date range (3) 63639**]
right internal jugular central venous line [**Date range (3) 63640**]
History of Present Illness:
MR. [**Known lastname 10794**] is a 52 year-old man with NICM ([**10/2195**]-LVEF 20% and
1+ MR), and type 1 diabetes mellitus who presented to ED with
SOB. Patient reports running out of lasix 4 days PTA. He further
described cough, SOB, orthopnea and slightly worse LE edema 2
days PTA. And presented to the ED on [**12-7**] with worsened SOB at
rest.
In the ED, initial vitals 130/91 139 36 99% CPAP. His exam
notable for 2 sentence dyspnea, crackles to BL mid-lung fields.
Labs notable for WBC count of 11.3 w/ 85% PMNs, HCT 32.1, BNP
2361, creatinine 0.9, trop 0.02. ABG: 7.43 pCO2 34 pO2 324 on
BiPap. CXR with diffuse bilateral airspace opacities initally
though to be asymetric pulmonary edema. The patient was started
on nitro gtt and given lasix 80IV. He was then admitted to the
CCU.
In the CCU, he was continued on lasix IV in the CCU and achieved
1L liter length of stay fluid balance without significant
improvement in respirtory status. A CTA Chest was performed that
identified bilateral parenchymal opacities consistent with
multifocal PNA and inconsistent with pulmonary edema. The
patient was started on Cefepime, Azithromycin, Vancomycin and
Bactrim. The patient was febrile to 101.2 on [**12-9**] and the
decision was then made to transfer the patient to the MIUC.
Vitals on transfer were 100.0 103 82/51 96% 6L NC.
Past Medical History:
1. CARDIAC RISK FACTORS: Type I Diabetes, Hyperlipidemia, HTN
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
- Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 20%, LVD 6.4
cm, mild RV dilation, borderline function, 1+ MR)
- hepatitis C antibody positive
- MRSA pneumonia (requiring trach)
- COPD
- Substance abuse (cocaine)
- Tobacco abuse
- schizophrenia
Social History:
- history of multiple incarcerations (>6 months in [**2193**])
- lives with sister
- walks w/ cane due to right sided foot drop
- Tobacco history: current smoker, 1 cig per day
- ETOH: denies
- Illicit drugs: crack cocaine three days ago
Family History:
- Father: pacemaker, deceased
Physical Exam:
ADMISSION EXAM:
VS: 115/81 119 22 92% 4L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Frequent
yawns.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Poor dentition
NECK: Supple with JVP of 7 cm.
CARDIAC: tachycardia, normal S1, S2. No m/r/g. No thrills,
lifts. 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. No abdominial 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+
Neuro: strength 5/5 bilaterally UE and LE except R foot: [**2-21**]
strength in dorsiflexion. CN II-XII intact.
DISCHARGE EXAM:
VS: Tm 98 / Tc 98, BP (105-130)/(65-85), HR 75 (75-95), RR 18,
POx 97%RA FS glucose 172-300
GENERAL: NAD. Oriented to self, hospital name, year, month.
CARDIAC: S1 and S2, no murmur.
LUNGS: Clear to auscultation throughout all fields bilaterally
NEURO: chronic right-sided foot drop; gait stable with cane
Pertinent Results:
ADMISSION LABS
[**2195-12-8**] 02:35AM BLOOD WBC-11.3* RBC-3.95* Hgb-10.4* Hct-32.1*
MCV-81* MCH-26.5* MCHC-32.5 RDW-13.7 Plt Ct-286
[**2195-12-8**] 02:35AM BLOOD Neuts-85.6* Lymphs-9.5* Monos-3.4 Eos-1.2
Baso-0.4
[**2195-12-9**] 04:15AM BLOOD PT-13.8* PTT-38.7* INR(PT)-1.3*
[**2195-12-8**] 01:58AM BLOOD Glucose-256* UreaN-8 Creat-0.9 Na-139
K-3.3 Cl-105 HCO3-20* AnGap-17
[**2195-12-8**] 01:58AM BLOOD ALT-20 AST-27 LD(LDH)-299* CK(CPK)-249
AlkPhos-54 TotBili-0.2
[**2195-12-8**] 01:58AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.4*
[**2195-12-8**] 02:37AM BLOOD Type-ART pO2-324* pCO2-34* pH-7.43
calTCO2-23 Base XS-0
PERTINENT LABS
[**2195-12-12**] 08:36PM BLOOD calTIBC-203* Ferritn-679* TRF-156*
[**2195-12-14**] 08:49PM BLOOD TSH-3.2
[**2195-12-9**] 04:15AM BLOOD HIV Ab-NEGATIVE
[**2195-12-8**] 02:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
MICRO DATA
[**2195-12-8**] 02:45AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2195-12-8**] 02:45AM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2195-12-8**] 02:45AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
[**2195-12-8**] 02:45AM URINE CastHy-1*
[**2195-12-8**] 02:45AM URINE Mucous-RARE
[**2195-12-9**] 8:30 am BLOOD CULTURE x2
**FINAL REPORT [**2195-12-15**]**
Blood Culture, Routine (Final [**2195-12-15**]): NO GROWTH.
[**2195-12-9**] 6:55 pm BRONCHOALVEOLAR LAVAGE LEFT UPPER BAL.
GRAM STAIN (Final [**2195-12-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2195-12-11**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final [**2195-12-16**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2195-12-9**]):
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
NO FUNGAL ELEMENTS SEEN TEST REQUESTED PER DR.[**Known lastname **] [**Known firstname **]
[**2195-12-10**].
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2195-12-10**]):
SPECIMEN COMBINED.
PLEASE REFER TO SPECIMEN #337-2463B [**2195-12-9**].
PATIENT CREDITED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2195-12-10**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2195-12-14**]):
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
[**2195-12-9**] 6:55 pm Rapid Respiratory Viral Screen & Culture
BAL.
**FINAL REPORT [**2195-12-12**]**
Respiratory Viral Culture (Final [**2195-12-12**]):
No respiratory viruses isolated.
[**2195-12-10**] 5:58 am URINE Source: Catheter.
**FINAL REPORT [**2195-12-11**]**
URINE CULTURE (Final [**2195-12-11**]): NO GROWTH.
[**2195-12-9**] 10:05PM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-Negative
[**2195-12-9**] 10:05PM BLOOD B-GLUCAN-Negative
Brief Hospital Course:
Mr. [**Known lastname 10794**] is a 52y/o gentleman with nonischemic cardiomyopathy
who presented from home with progressively worsening shortness
of breath for two days and was found to be in hypoxic
respiratory distress due to multifocal PNA. He was intubated,
stabilized in the MICU with antibiotics, and was transitioned to
the medical floor where he was weaned to room air and was
discharged home.
ACTIVE ISSUES
#. Acute respiratory failure: due to multifocal PNA.
He was intubated and at first his presentation was concerning
for CHF exacerbation. Was initially admitted to the Cardiac ICU
and was diuresed, but when he spiked a fever and became
tachycardic in the setting of leukocytosis as well, a CTA was
performed which ruled out PE but showed multifocal PNA so
diuresis was stopped and he was started on antibiotics and
transferred to the MICU for further management (see below).
#. Multifocal pneumonia: Clinically resolved by discharge.
He has a history of MRSA pneumonia requiring tracheostomy during
prior admission to OSH in summer [**2194**]. Here, he was started on
Vanc/Cefepime/Cipro/Azithro as well as Bactrim given concern for
potential PCP (he has been in prison and has a h/o IVDU). His
HIV test was negative. PPD was placed and was negative.
Bronchoscopy was done and he was ruled out for TB and PCP so his
[**Name9 (PRE) **] were changed to Vanc/Cefepime/Cipro. Was extubated without
complication. Was transitioned to the medical floor where he
remained afebrile, hemodynamically stable, with leukocytosis
resolved. He was weaned to room air and ambulated without
desaturating. He completed an 8 day regimen ([**Date range (3) 63640**])
and was discharged home.
#. Non-ischemic cardiomyopathy: euvolemic.
LVEF 20%, mild RV dilation, 1+ MR. As discussed above, he was
initially diuresed due to concern for CHF exacerbation, but he
was euvolemic. He was transitioned back to his home dose of
lasix 40mg PO daily. He was also continued on his home ACE
inhibitor and beta-blocker.
#. Elevated troponin: possibly represented demand ischemia.
Troponin was mildly elevated with peak of 0.05 which was thought
to be related to demand from his persistent tachycardia. He
ruled out for MI with declining troponins. No EKG changes.
#. Acute kidney injury: likely prerenal; resolved.
Creatinine baseline is 0.9 but peaked at 2 on [**11-19**]. Was
likely [**1-21**] to spesis and over-diuresis. Also, possibly related
to brief Rx with treatment-dose Bactrim. His Cr then trended
down and was back to baseline at 0.9 upon discharge.
#. DM2: stable at the time of discharge.
He was initially continued on glargine and ISS. On [**12-10**] he
required insulin drip for FS persistently in the 400s despite SC
insulin, but this quickly resolved. He was discharged on his
home dose of medications and will follow up with his PCP.
#. Schizophrenia/Depression: with depressed mood/affect and
hallucinations this admission.
After he was stabilized and extubated, he was noted to respond
to questions with single-word answers, with flat affect and poor
eye contact. CT head was negative. However, after a visit from
his sister and sister's boyfriend, he tearfully admitted that he
had been lonely and felt that nobody was visiting him
(especially since he had been in the ICU on [**Holiday **]). After
this, he was alert/interactive and was fully conversant. He
admitted that while he was in the ICU he saw a tiger in his
room. It is unclear if this was related to intubation/sedation
or his untreated schizophrenia. No further hallucinations. At
the time of discharge, he denied SI/HI and desired follow-up
with a mental health provider so an appointment was made for
him.
#. Substance abuse: UTox positive for cocaine.
He was counseled on the importance of abstinence from drugs.
INACTIVE ISSUES
#. Hyperlipidemia: stable.
He was continued on home Atorvastatin.
#. COPD: stable.
He was continued on home Albuterol, Ipratropium.
TRANSITIONAL ISSUES
#. Emergency Contact: [**Name (NI) 4944**] ([**Telephone/Fax (1) 63641**])
#. Code Status: Full Code
Medications on Admission:
- lasix 40 daily
- metoprolol succinate 100mg daily
- lisinopril 5mg daily
- lipitor 20mg daily
- aspirin 81mg daily
- seroquel 25m QHS
- insulin 40u lantus QHS, 12u novolug AM
- atrovent 250/50 [**Hospital1 **]
- ipratropium Q6 PRN SOB
- albuterol PRN SOB
- doxepin 20mg QHS (not taking)
Discharge Medications:
1. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime: please use 1/2 dose if not eating well;
call your doctor for any blood sugars less than 80.
8. Novolog 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous every morning: please use 1/2 dose if not eating
well; call your doctor for any blood sugars less than 80.
9. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
10. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: 1-2 puffs Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
multifocal pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You presented with shortness of breath and cough, and were
admitted to the ICU where you required intubation (breathing
tube) for pneumonia. You were treated with antibiotics and were
able to be extubated and transferred to the medical floor to
complete your antibiotics. Now you are stable for discharge
home with Primary Care follow-up.
While you were here, you were depressed and had a hallucination.
You did not feel that you were a harm to yourself or others.
We made you an appointment with a mental health provider (please
see appointment below).
We did not make any changes to your medications.
Followup Instructions:
PRIMARY CARE
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: WEDNESDAY [**2195-12-23**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63642**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
PSYCHIATRY/SOCIAL WORK
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: THURSDAY [**2196-1-7**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 63643**], LICSW [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
Discharge summary
|
Classify the following medical document.
|
Chief Complaint: Hypotension, suspected pneumonia
HPI:
Mrs. [**Known lastname 10048**] is a 71 year old female with past medical history of
congestive heart failure, back pain, psychotic depression, and GERD who
presented from her nursing home with fevers and change in mental
status. Per report from ED and review of paperwork, at baseline she is
alert and oriented, though has some paranoia. Today her nursing
facility noted an acute change in mental status with hallucinations,
accompanied by a fever to 101. She was also noted to be hypoxic with
oxygen saturation of 88% on room air, improved on 2L nasal cannula. She
was brought to the [**Hospital1 19**] ED.
.
In the ED, initial vital signs were: temperature of 100.6, blood
pressure of 114/54, heart rate of 72, oxygen saturation of 95% on room
air. Patient was given 1 gram of vancomycin of which 500 mg was
received, 750 mg of levofloxacin, and 4.5 grams of Zosyn. She also
received 650 mg of Tylenol. She was given about 3500 mL of IVF for
borderline low blood pressure with systolic ranging 85-101. A chest
x-ray was notable for bilateral patchy opacities, retro-cardiac air
bronchograms, and mild cardiomegaly. An ABG was obtained which
demonstrated: 7.32/53/98/29.
.
Upon arrival to the ICU, she reports that she feels "lousy all over."
She states her breathing is "okay" as long as she is not turned on her
side or laying flat. She reports chronic back pain. She is oriented to
self and place. She reports that she thought she was coming down with a
cold, as everyone at her rehab has had cough and congestion.
Allergies:
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Home medications:
- Lidoderm 5% patch
- Levothyroxine 25 mcg
- Prilosec 20 mg
- Cymbalta 60 mg
- Colace 100 mg [**Hospital1 7**]
- Labetalol 200 mg [**Hospital1 7**]
- Oxycontin 30 mg [**Hospital1 7**]
- Senna 1 tablet [**Hospital1 7**]
- Diazepam 5 mg Q6H PRN
- Oxycodone 10 mg Q6H PRN
- Multivitamin daily
- Lyrica 50 mg daily 9 AM for two weeks, plan to increase to 50 mg [**Hospital1 7**]
on [**2121-8-27**]
- Robitussin 10 mL Q4H PRN
Past medical history:
Family history:
Social History:
- Congestive heart failure
- GERD
- Psychotic depression
- Infrarenal abdominal aortic aneurysm
- Degenerative joint disease/osteoarthritis
- Hypothyroidism
- Thyroid cancer
- Osteoporosis
- ICU stay with intubation (further details unknown) at [**Hospital3 4050**] [**2119**]
- Status-post Ceasarin section
- Status-post cystectomy
- Status-post cholecystectomy
- Status-post hysterectomy
- Lower back pain with surgery, discetomy in [**5-/2121**]
Unable to obtain.
Patient lives at [**Hospital 1833**] Rehabilitation and Nursing Center. She is a
former nursing health aide. She has four sons. She states her husband
died from sepsis. She smoked, however quit 30 years ago. She denies any
alcohol use.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or gain.
Denies headache, rhinorrhea or congestion. Denied cough. Denied chest
pain or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or bladder
habits. No dysuria. Denied arthralgias or myalgias.
Flowsheet Data as of [**2121-8-21**] 12:02 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 35.4
C (95.7
Tcurrent: 35.4
C (95.7
HR: 73 (68 - 73) bpm
BP: 129/99(106) {99/39(55) - 133/99(112)} mmHg
RR: 22 (12 - 22) insp/min
SpO2: 93%
Heart rhythm: SR (Sinus Rhythm)
Height: 61 Inch
Total In:
70 mL
PO:
70 mL
TF:
IVF:
Blood products:
Total out:
100 mL
0 mL
Urine:
100 mL
NG:
Stool:
Drains:
Balance:
-30 mL
0 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 93%
Physical Examination
Vitals: T: 95.7 BP: 126/57 P: 74 R: 20 O2: 96% on 4L
General: Oriented to self, place--"[**Location (un) 23**], [**Hospital1 19**]," month, and year. No
acute distress; unable to articulate whether her husband is alive or
dead, however answers some questions appropriate. Awake and alert. No
accessory muscle use.
HEENT: Sclera anicteric, oropharynx clear with very dry mucous
membranes, PERRL
Neck: supple, JVP difficult to assess, no LAD
Lungs: Decreased breath sounds over the right side, left side with
rales up 1/2 of the lung field, no dullness to percussion on the left
side, some at the base on right, no wheezes, + ronchi and transmitted
upper airway noise throughout.
CV: Regular rate and rhythm, normal S1 + S2, with systolic murmur, no
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, bilateral trace edema, no
asymetry, no cyanosis
Labs / Radiology
[image002.jpg]
Micro:
Blood cultures x2 from ED pending
.
Images:
Chest x-ray: bilateral basilar infiltrate versus edema, slightly
enlarged cardiac silhouette, blunting of left heart border
.
EKG:
Sinus, rate of 78, poor baseline, normal intervals and axis, late R
wave progression. No prior available for comparison.
Assessment and Plan
Mrs. [**Known lastname 10048**] is a 71 year old female with past medical history of
congestive heart failure, GERD, back pain, and psychotic depression who
presents with fevers, altered mental status, hypoxia, and hypotension.
.
#) Fevers, leukocytosis: Picture is most consistent with infectious
etiology. Most likely is pneumonia given chest x-ray findings, hypoxia,
and history of cough. Other potential source would be urinary tract
given mildly positive urine analysis with WBC and trace positive
leukesterase. No convincing story for GI source. Given question of
change in mental status, must also consider CNS infection, though this
appears less likely given hypoxia and cough, and improvement after
fluid resuscitation in ED.
- Continue broad coverage antibiotics: Vancomycin/Zosyn for hospital
acquired pneoumonia (given she lives in health care facility), and
levofloxacin to double cover gram negative pathogens as well as
atypicals. Will consider narrowing coverage pending culture data.
- Will send urinary legionella, sputum culture
- Urine culture
- Rapid respiratory panel, droplet precautions
- Repeat CXR in AM
.
#) Altered mental status: Currently appears to be at baseline, per
report from nursing facility. Suspect this was in the setting of fever,
hypoxia.
- Will continue to monitor respiratory status closely, should further
mental status changes ensue, would consider head CT and/or lumbar
puncture
.
#) Hypotension: Given above picture of fever and now relative
hypothermia, leukocytosis, initial tachycardia, and tachypnea, patient
fits criteria for SIRS/sepsis, given hypotension with possible end
organ damage given elevated creatinine (baseline unknown). Currently BP
improved after 3-4 liters of IVF. No known history of steroid use to
suggest adrenal insufficiency, no evidence of ischemia on EKG.
- Continue to monitor respiratory status closely, bolus for MAP >65 as
permitted given history of CHF
- Consider placement of CVL to obtain CVP, pressors if necessary
- Antibiotics as discussed above
.
#) Hypoxia: Suspect secondary to infectious process as well as possible
degree of CHF given CXR, however improvement in her symptoms after IVF
would argue against this. Currently doing well on 4 L NC. Given
bilateral infiltrates, must also be mindful of ARDS, though cannot
entirely be sure this is not secondary to fluids.
- BNP
- Repeat CXR in AM
.
#) History of CHF: Unknown what her systolic and diastolic function
are, currently feels better after IVF. As noted above, CXR could be
consistent with CHF, though seems less likely in setting of
leukocytosis and improvement in symptoms with hydration.
- Added on BNP
- Will attempt to get records from her PCP regarding status of her
systolic and diastolic function
- Will continue cautious IVF resuscitation given unknown cardiac
function
.
#) Psycotic depression: Patient is followed by Dr. [**First Name5 (NamePattern1) 461**]
[**Last Name (NamePattern1) 10049**] at [**Male First Name (un) 1833**] and Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1756**] [**Last Name (NamePattern1) 10050**].
- Continuing home medications
.
#) Renal insufficiency: Unknown baseline creatinine. Hydrating as noted
above.
- Renal lytes to check FeNa
- PCP contact for baseline value
.
#) Hypothyroidism: Continue home medications
.
#) Anxiety, pain: Continue home medications
.
#) Hypertension: Holding home labetolol for now.
.
#) Intrarenal aortic anerusym: Further details unknown, pulses are
bilaterally symmetric.
.
ICU Care
Nutrition: as noted above, replete electrolytes, regular diet in AM if
respiratory status more stable
Glycemic Control:
Lines: Currently with two peripherals, will pursue additional access if
needed.
18 Gauge - [**2121-8-20**] 09:14 PM
Prophylaxis:
DVT: Subutaneous heparin, home PPI and bowel regimen
Stress ulcer:
VAP:
Comments:
Communication: Comments: Patient, Son [**Name (NI) 751**] [**Name (NI) 10048**] ([**Telephone/Fax (1) 10051**],
([**Telephone/Fax (1) 10052**]
Code status: Full, per documentation from nursing home stating she
wishes full resuscitation, also discussed with patient
Disposition:
|
Physician
|
Classify the following medical document.
|
TITLE:
Chief Complaint:
24 Hour Events:
-K improved by PM lytes
-[**9-25**] f/u scheduled with heme/onc
-touched base with SW and case manager-working on rehab vs home health
nurse [**First Name (Titles) **] [**Last Name (Titles) **] anticipated monday.
-will need to t/b with heme/onc in regards to final recs on dc.
-started on topical miconazole out of concern for yeast infection.
Allergies:
Iodine; Iodine Containing
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2116-9-18**] 11:29 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2116-9-19**] 07:33 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.8
C (98.2
Tcurrent: 36.8
C (98.2
HR: 104 (95 - 114) bpm
BP: 86/59(64) {86/11(22) - 125/93(100)} mmHg
RR: 13 (12 - 24) insp/min
SpO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Height: 60 Inch
Total In:
1,280 mL
300 mL
PO:
830 mL
300 mL
TF:
IVF:
450 mL
Blood products:
Total out:
1,550 mL
1,115 mL
Urine:
1,550 mL
1,100 mL
NG:
Stool:
Drains:
Balance:
-270 mL
-815 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 95%
ABG: ///28/
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
281 K/uL
13.7 g/dL
140 mg/dL
0.7 mg/dL
28 mEq/L
4.4 mEq/L
22 mg/dL
104 mEq/L
140 mEq/L
41.3 %
7.9 K/uL
[image002.jpg]
[**2116-9-13**] 04:01 AM
[**2116-9-14**] 04:43 AM
[**2116-9-15**] 04:06 AM
[**2116-9-16**] 05:52 AM
[**2116-9-17**] 04:56 AM
[**2116-9-18**] 04:50 AM
[**2116-9-18**] 03:11 PM
[**2116-9-19**] 04:13 AM
WBC
7.0
5.1
5.4
7.1
8.2
8.8
9.5
7.9
Hct
48.6
43.7
41.4
45.9
40.3
39.3
42.5
41.3
Plt
247
254
265
[**Telephone/Fax (3) 8751**]
281
281
Cr
0.8
0.8
0.8
0.7
0.8
0.9
0.7
Glucose
122
112
124
125
117
130
140
Other labs: PT / PTT / INR:10.7/35.2/0.9, ALT / AST:16/24, Alk Phos / T
Bili:83/0.3, LDH:127 IU/L, Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:3.1
mg/dL
Assessment and Plan
47 year old female PMH breast cancer who presents with bilateral
lower extremity edema of 1 day duration, found to have pericardial
effusion.
.
# Pericardial effusion: Drain placed on [**9-12**], fluid showed
adenocarcinoma. The drain was pulled on [**9-17**] after output decreased.
Pt went to CT [**Doctor First Name **] for window procedure yesterday. Pt has been in NSR
since admission (with occ PVCs). Fluid overload has improved since
draining of effusion.
- continue pleural drains for 24-48 hrs per [**Doctor First Name **] recs
- Continue Indomethacin/dilaudid PO for pain control
.
# CORONARIES: CAD risk factors of HTN and smoking. Pleuritic chest pain
does not support angina or ACS. No prior history of CAD. Lisinopril
restarted for hypertension at
home dose.
.
# Breast Cancer: Pt has been non-compliant with onc f/u. Patient's
last appointment [**2115-1-30**] reports she is to continue Aromasin
(aromotase inhibitor) which she is currently not taking. We now have
evidence of metastatic spread of her tumor with pleural effusion
showing adenocarinoma and evidence of bony mets to the spine by CT.
Also concern for malignant pleural effustions. Appreciate oncology
consult.
-will obtain bone scan non-urgently
-f/u onc recs
.
# Asthma: Significant wheezing on exam on admission, but has since
improved. CXR reports atelectasis vs early pneumonia in the right
middle lobe, but no evidence of infection and afebrile. Also likely
COPD given smoking history and lung volumes on CXR.
- Continue Ipratropium NEBs standing; Albuterol NEBs prn
- Continue outpatient singulair
- If spikes or has leukocytosis consider CAP coverage, no antibiotics
for now
.
# Depression/Insomnia: Continue outpatient trazadone 200 mg qhs.
.
# Constipation: bowel regimen uptitrated yesterday without effect.
Will continue to to titrate to BM.
.
# Hyperkalemia: rising k, ? tumor lysis, will re-check K this
afternoon.
.
# Social: Patient currently lives in rooming house. Reports stresses at
home. Has not followed with medical care (multiple do not show
appointments). Appreciate SW consult. Will f/u with social work today
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2116-9-17**] 02:11 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2189-12-24**] Discharge Date: [**2189-12-30**]
Date of Birth: [**2124-7-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Scapular pain
Major Surgical or Invasive Procedure:
[**2189-12-24**] Redo-Sternotomy, Coronary Artery Bypass Graft x 3 (SVG to
Diag to OM, SVG to PDA), Aortic Valve Replacement w/ 25mm CE
Magna pericardial tissue valve
History of Present Illness:
65 y/o male s/p CABG in [**2179**] now experiencing mild scapular back
pain. Cardiac cath revealed severe native coronary artery
disease with patent grafts. Echo performed showed severe aortic
stenosis with a valve are of 0.7cm2. He was then referred for
surgical intervention.
Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graft [**2179**],
s/p PTCA of RCA [**2178**], Hypertension, Hypercholesterolemia,
Diabetes Mellitus, Chronic Obstructive Pulmonary Disease,
Anemia, s/p Anal fistulotomy
Social History:
Patient smoked one ppd x 53 years, quit in [**2189-5-23**]
Divorced and lives alone. He has four children. Retired, used to
work as a cop.
Family History:
Father died at age 77 from an MI. Mother was
diabetic and had an MI in her 70's.
Physical Exam:
VS: 70 14 140/80 5'9" 220#
Skin: Unremarkable with well-healed MSI
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, -carotid bruit
Chest: CTAB -w/r/r
Heart: RRR, 4/6 SEM
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, 2+ pulses throughout, -edema or
varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2189-12-24**] Echo: PRE-CPB: The left atrium is mildly dilated. There
is severe symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Transmitral Doppler and tissue velocity
imaging are consistent with normal LV diastolic function. Right
ventricular chamber size and free wall motion are normal. Right
ventricular chamber size is normal. Right ventricular systolic
function is normal. There are simple atheroma in the aortic
root. There are simple atheroma in the ascending aorta. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. No masses or vegetations are seen on the
aortic valve. There is moderate aortic valve stenosis (area
0.8-1.19cm2) Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. No mass or
vegetation is seen on the mitral valve. There is a minimally
increased gradient consistent with trivial mitral stenosis. Mild
(1+) mitral regurgitation is seen. POST-CPB: On phenylephrine
infusion. There is a well-seated bioprosthetic valve in the
aortic position with no AI seen. Flow is seen in the LMCA. The
measured gradient across the aortic valve is now 6 mmHg. There
is preserved biventricular systolic function. LVEF 65%. There is
no [**Male First Name (un) **]. MR is trace. The aortic contour is normal post
decannulation.
[**2189-12-29**] CXR: Bilateral pleural effusions have significantly
decreased in size since prior exam. Small bilateral pleural
effusions remain. The cardiac silhouette, mediastinal and hilar
contours are stable in size status post CABG and AVR. The
pulmonary vasculature is normal and there is no pneumothorax. No
consolidations are seen bilaterally.
[**2189-12-24**] 01:33PM BLOOD WBC-13.8*# RBC-3.33*# Hgb-7.3*#
Hct-22.3*# MCV-67* MCH-21.9* MCHC-32.8 RDW-15.0 Plt Ct-65*#
[**2189-12-26**] 05:10PM BLOOD WBC-8.2 RBC-2.90* Hgb-6.5* Hct-19.3*
MCV-67* MCH-22.3* MCHC-33.6 RDW-15.5 Plt Ct-110*
[**2189-12-30**] 05:50AM BLOOD WBC-7.4 RBC-3.51* Hgb-8.5* Hct-24.9*
MCV-71* MCH-24.3* MCHC-34.3 RDW-18.7* Plt Ct-273#
[**2189-12-24**] 01:33PM BLOOD PT-19.5* PTT-50.7* INR(PT)-1.9*
[**2189-12-28**] 06:25AM BLOOD PT-16.0* INR(PT)-1.5*
[**2189-12-29**] 06:10AM BLOOD PT-35.0* INR(PT)-3.8*
[**2189-12-29**] 10:55AM BLOOD PT-43.4* INR(PT)-5.0*
[**2189-12-30**] 05:50AM BLOOD PT-32.3* INR(PT)-3.5*
[**2189-12-24**] 03:18PM BLOOD Glucose-93 UreaN-11 Creat-0.6 Cl-115*
HCO3-28
[**2189-12-30**] 05:50AM BLOOD Glucose-113* UreaN-18 Creat-0.9 Na-139
K-4.1 Cl-100 HCO3-33* AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 80687**] was a same day admit (underwent pre-op work-up as on
outpatient) and was brought directly to the operating room where
he underwent a redo coronary artery bypass graft x 3 and aortic
valve replacement. Please see operative report for surgical
details. Following surgery he was transferred to the CSRU for
invasive monitoring in stable condition. Later on op day he was
weaned from sedation, awoke neurologically intact and extubated.
Beta blockers and diuretics were initiated and he was gently
diuresed towards his pre-op weight. He was then transferred to
the telemetry floor. On post-op day three his chest tubes and
epicardial pacing wires were removed. Post-op his HCT was low
and on day three it was 19. He was therefore transfused with
several units of blood. By discharge it was 24.9. Also on
post-op day three he had an episode of atrial fibrillation. He
was bolused with Amiodarone and given Lopressor. Lopressor was
titrated, Amiodarone was eventually given PO and he was started
on Heparin. Coumadin was started on post-op day four and
titrated for goal INR between [**12-26**]. INR abruptly rose up to 5 by
post-op day five and Coumadin was held and INR trended down
towards therapeutic level by discharge. On post-op day five
antibiotics were started d/t left arm phlebitis. Physical
therapy followed patient during entire post-op course for
strength and mobility. He appeared to be doing well on post-op
day six and was discharged home with VNA services and the
appropriate follow-up appointments. Dr. [**Last Name (STitle) **] was contact and
will manage his Coumadin as an outpatient.
Medications on Admission:
Aspirin 325mg qd, Benicar 40mg qd, Avandamet 500mg qd,
Ninpeolomine 3mg qd
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. 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. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*1*
6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take 400mg [**Hospital1 **] for 1 week. Then 200mg [**Hospital1 **] for 1 week.
Then 200mg QD until stopped by your cardiologist.
Disp:*60 Tablet(s)* Refills:*1*
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
10 days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
14. Nifedipine (Bulk) Powder Sig: One (1) Miscellaneous TID
(3 times a day) as needed for anal fissures: 0.2% gel rectally
for anal fissures.
Disp:*30 1* Refills:*0*
15. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day).
Disp:*90 Packet(s)* Refills:*0*
16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Adust dosage according to Dr. [**Last Name (STitle) **]. Goal INR 2-3.0.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Coronary Artery Disease/Aortic Stenosis s/p Redo-Sternotomy,
Coronary Artery Bypass Graft x 3, Aortic Valve Replacement
PMH: s/p Coronary Artery Bypass Graft [**2179**], s/p PTCA of RCA
[**2178**], Hypertension, Hypercholesterolemia, Diabetes Mellitus,
Chronic Obstructive Pulmonary Disease, Anemia, s/p Anal
fistulotomy
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.
Dr. [**Last Name (STitle) **] will manage your Coumadin.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in 2 weeksProvider: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2190-1-29**] 12:00
Completed by:[**2189-12-30**]
|
Discharge summary
|
Classify the following medical document.
|
TITLE:
Chief Complaint:
24 Hour Events:
-HD on [**5-21**]
-pressures steady with one drop to systolic of 79, improved with 500 cc
bolus
-expect floor transfer on [**5-22**] if pressures remain stable
Allergies:
Penicillins
swelling
itchi
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Dextrose 50% - [**2109-5-21**] 07:00 AM
Morphine Sulfate - [**2109-5-21**] 09:50 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2109-5-22**] 05:54 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.8
C (98.3
Tcurrent: 36.8
C (98.2
HR: 86 (70 - 86) bpm
BP: 113/23(45) {70/23(34) - 137/89(95)} mmHg
RR: 15 (10 - 19) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 94.8 kg (admission): 92.7 kg
Total In:
1,341 mL
30 mL
PO:
480 mL
TF:
IVF:
836 mL
30 mL
Blood products:
Total out:
615 mL
0 mL
Urine:
115 mL
NG:
Stool:
Drains:
Balance:
726 mL
30 mL
Respiratory support
O2 Delivery Device: None
SpO2: 94%
ABG: ///27/
Physical Examination
General: A+O x3, NAD, sitting in bed with no discomfort
HEENT: moist mucous membranes, oropharynx clear, left EJ peripheral
line in place with no signs of infection.
CV: RRR S1 S2, systolc [**2-1**] murmur
Resp: CTAB, no wheezes or rhonchi, intermittant crackle in lower lung
fields
Abdomen: soft/NT/ND +BS
Ext: Right AKA site C/D/I with no surrounding erythema. No edema or
cyanosis in Left lower extremity, pulse felt in left lower extremity.
Labs / Radiology
343 K/uL
8.1 g/dL
78 mg/dL
6.9 mg/dL
27 mEq/L
5.9 mEq/L
42 mg/dL
102 mEq/L
141 mEq/L
25.3
12.1 K/uL
[image002.jpg]
[**2109-5-20**] 11:46 PM
[**2109-5-21**] 08:28 AM
WBC
11.0
Hct
28
26.1
Plt
390
Cr
6.9
Glucose
78
Other labs: PT / PTT / INR:12.5/27.2/1.1, ALT / AST:[**8-17**], Alk Phos / T
Bili:104/0.2, Lactic Acid:1.3 mmol/L, LDH:132 IU/L, Ca++:8.0 mg/dL,
Mg++:2.0 mg/dL, PO4:5.9 mg/dL
Assessment and Plan
[**Last Name **] PROBLEM - ENTER DESCRIPTION IN COMMENTS
s/p R AKA
.H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)
.H/O DIABETES MELLITUS (DM), TYPE II
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
Pt is 67 yo f with hx of DM, ESRD on HD, and leg fracture, now s/p AKA
of right leg and transferred to [**Hospital Unit Name 10**] in setting of hypotension.
.
# Hypotension: BP was in upper 70s in OR, improved from high 80s to low
100s with 500ml bolus, bp improved to 90s-119 with bolus and stable
since. [**Month (only) 11**] have been secondary to fluid loss during procedure combined
with sedation medications. Per pt has baseline BP 90-100, likely in
setting of being HD pt with fistula.
- pt received HD on [**5-21**], with one episode SBP=70 afterwards, responded
well to 500 cc bolus of fluids. Will monitor, continuous and/or bolus
not needed at this time.
- no need for pressors at this time
- PICC to be placed for access.
.
# Hypoxia: New post-op O2 requirement noticed after surgery, not
requiring O2 currently with good O2 sats. HD yesterday, planned for
today to maintain volume status. Pt with no known OSA.
- HD yesterday and planned for today, [**5-22**]
- oxgygen as needed to keep sats >92%
- incentive spirometry
.
# AKA: s/p surgery, had chonic fracture of femur with broken plate for
last 3 year. Wheelchair bound.
- ortho to review femur xray done [**5-21**]. Patient emotionally labile in
regards to losing her right leg.
- wound care
- Coumadin 1.5 mg - 2 mg, 2-2.5, x 6 weeks
- social work consult
# Pain: Pt c/o leg pain and phantom foot pain. Pt states pain not
controlled, but vitals within normal range.
- increase gabapentin as needed within renal dosing guidelines.
Consider supplemental dose after HD.
- continue percocet
- morphine IV PRN for breakthrough pain
- heat packs/ice packs
#Fever: up to 100.3 this am with moderate leukocytosis (12.1)
- blood cx, urine cx
-incentive spirometry for possible atelectasis- related fever
.
# ESRD on HD: Normal HD is MWF, missed regular HD today. Likely the
reason potassium is elevated. Also would explain edema on CXR. Makes
some urine output in urostomy bag. Nephro following
- monitor UO
- HD planned for today
- renally dose meds
.
# DM on insulin: Long standing DM, complicated by nephropathy,
neuropathy, and vascular disease
- lantus (on 8 units), will increase dose as needed with increasing PO
intake
- SSI Q6H with humalong
- gabapentin and ASA and statin
- start diabetic renal diet today
.
# GERD:
- continue PPI
.
# Peripherial vascular disease: has stenosis of right axillary artery,
s/p 1 month tx of plavix
- continue statin
- may need futher plavix tx as out pt
- continue ASA
.
# Hyperkalemia: K likely elevated in setting of renal failure
- HD today
- monitor on tele
.
# Anemia: hct of 26 today, likely secondary to surgical blood loss and
baseline anemia secondary to renal failure
- monitor hct
- transfuse 1 unit PRBCs today prior to transfer
.
# Colostomy:
- colostomy care
.
# Hyperlipidemia:
- will continue home statin dose
ICU Care
Nutrition: normal renal diet
Glycemic Control: SSI
Lines:
18 Gauge - [**2109-5-20**] 09:39 PM
Prophylaxis:
DVT: coumadin
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: stable, can transfer to floor after transfusion
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2108-7-10**] Discharge Date: [**2108-7-12**]
Date of Birth: [**2025-11-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Quinine / Latex
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Aortic valvuloplasty
History of Present Illness:
82 y/o woman with a history of CHF, EF 20%, RV paced with DOE
and worsening aortic stenosis was referred for aortic
valvuloplasty and upgrade to [**Hospital1 **]-V pacer. Patient got IVF prior
to procedure and desated to 80s post-procedure. Was 97% on 6L
prior to transfer. Got 40 IV lasix and TTE which showed 3+ AR.
Upon arival to ICU patient was not SOB and had no chest pain.
Said she was feeling well. Prior to this admission was SOB with
basic activities. Needed 1-2L NC prn.
Past Medical History:
1. CARDIAC RISK FACTORS: no DM, no HTN, no documented HLD
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
Atrial fibrillation, not on Coumadin
s/p pacemaker approximately five years ago
.
3. OTHER PAST MEDICAL HISTORY:
Lung adenocarcinoma s/p right upper lobe lobectomy, s/p
tracheostomy and percutaneous endoscopic gastrostomy placement
COPD
Hypothyroidism
[**2103**] CVA versus TIA (no residual)
Aortic stenosis
Meniere's disease
Restless leg syndrome
History of left breast cancer s/p bilateral mastectomies
Mildly hard of hearing (uses a left sided hearing aid)
Remote ear surgery
Resection of ovary d/t possible ovarian cyst
Social History:
Lives with husband, uses [**Name2 (NI) **] at baseline. Has O2 that she
uses prn for dyspnea.
Family History:
Father had MI at 72
Physical Exam:
GENERAL: NAD.
NECK: Supple with no JVD
CARDIAC: RRR, 3/6 SEM
LUNGS: CTAB anteriorly
ABDOMEN: Soft, NTND.
EXTREMITIES: no edema, groin shows no hematoma
Pules: 2+ DP pulses bilaterally
Pertinent Results:
[**2108-7-12**] 04:15AM BLOOD WBC-5.5 RBC-3.97* Hgb-11.5* Hct-34.6*
MCV-87 MCH-28.9 MCHC-33.2 RDW-15.0 Plt Ct-179
[**2108-7-12**] 10:55AM BLOOD PTT-23.9
[**2108-7-12**] 04:15AM BLOOD Glucose-88 UreaN-13 Creat-0.8 Na-142
K-4.0 Cl-105 HCO3-26 AnGap-15
[**2108-7-12**] 04:15AM BLOOD CK(CPK)-509*
[**2108-7-11**] 06:45PM BLOOD CK(CPK)-484*
[**2108-7-12**] 04:15AM BLOOD CK-MB-70* MB Indx-13.8* cTropnT-1.15*
[**2108-7-11**] 06:45PM BLOOD CK-MB-78* MB Indx-16.1* cTropnT-0.60*
[**2108-7-11**] 11:50AM BLOOD CK-MB-9 cTropnT-0.19*
[**2108-7-12**] 04:15AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
[**2108-7-10**] 06:50PM BLOOD Type-ART O2 Flow-6 pO2-135* pCO2-40
pH-7.44 calTCO2-28 Base XS-3 Intubat-NOT INTUBA Comment-NC
[**2108-7-10**] 06:08PM BLOOD Type-ART Rates-/18 pO2-107* pCO2-42
pH-7.43 calTCO2-29 Base XS-2 Intubat-NOT INTUBA Comment-2L NASAL
C
.
ECHO [**7-10**]:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with near
akinesis of the basal half of the inferior and inferolateral
walls. There is mild hypokinesis of the remaining segments (LVEF
= 35 %). [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets are severely
thickened/deformed. A vegetation cannot be excluded if
clinically suggested. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Severe (4+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Thickened aortic valve leaflets with severe aortic
regurgitation. Cannot excluded endocarditis if clinically
suggested. Regional and global left ventricular systolic
dysfunction. Mild aortic valve stenosis.
.
Cardiac catheterization [**7-10**]:
COMMENTS:
A transvenous temporary pacing wire was placed through the right
CFV
into the right ventricle and pacing capture was tested. The
right CFA
sheath was upsized to 8F. 3000u of Heparin was given
prophylactically
and a therapeutic ACT was confirmed. A straight wire was able to
cross
the aortic valve after much difficulty. This was then exchanged
for an
Amplatz super stiff wire over a Pigtail catheter. An 18x60mm
Tyshek II
balloon was advanced to the aortic valve. Rapid ventricular
pacing was
initiated at 180 bpm with successful reduction of BP to less
than 50mmHg
and the Tyshek II balloon was fully inflated across the aortic
valve.
This procedure was then repeated x 2. Subsequent
echocardiography
revealed significant aortic insufficiency and the procedure was
terminated. Patient was given 40mg IV lasix as well as IV nitro
drip for
afterload reduction. The patient left the lab free of angina and
in
stable condition.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Successful aortic valvuloplasty.
3. Severe aortic insufficiency.
Brief Hospital Course:
#1 Aortic stenosis s/p Valvuloplasty: Pt underwent a
valvuloplasty on [**2108-7-10**]. complicated by hypertension requiring
nipride drip and low oxygen levels thought to be related to IVF
during the procedure. The patient was transferred to the CCU for
close monitoring. An ECHO after the procedure found that the EF
had improved to 35% with the aortic valve area 1.6 and gradient
27. 3+ AR was noted and pt was started on Norvasc for prevention
of progression. Aspirin was also increased to 325 mg daily. Pt
had a CK leak with positive troponin after the procedure. This
was thought to be due to the procedure itself. No EKG changes or
ischemic symptoms. Pt did have some chest discomfort on [**7-11**]
that was thought to be related to her constipation, relieved
with bowel movement. Cardiac catheterization showed no
significant CAD.
.
#2 Acute on Chronic Systolic Congestive Heart Failure: pt has a
history of 2 recent hospital admissions for CHF. Appeared
euvolemic during this hospital stay. Weight is 40.4kg here. No
peripheral edema or lung crackles. Pt uses oxygen at home
chronically. Continued on home dose of Lasix. No ACEi, [**Last Name (un) **] or
beta blocker is indicated because of severe valve disease per
Dr. [**Last Name (STitle) **]. Daily weights, symptoms of CHF and diet reviewed
with pt and family before discharge.
.
#3 V- paced: EP saw patient and adjusted pacer settings and
feels like patient does not need [**Hospital1 **]-V pacer this admission. Pt
will f/u with Dr. [**Last Name (STitle) **] in [**Month (only) 205**] for further assessment.
.
#4 Hypothyroidism: Stable, continue synthroid
.
#5 History of Lung CA s/p right upper lobectomy: Resp status
stable after initial desaturation after valvuloplasty. Pt was
maintained on low flow oxygen which she uses at home.
.
#6 Restless leg: Continued carbidopa-levodopa
.
#7 dispo: VNA at discharge for PT and continued monitoring of
BP, HR and fluid status.
Medications on Admission:
CARBIDOPA-LEVODOPA 50 mg-200 mg Tablet SR QHS
FLUTICASONE 50 mcg Spray prn
FUROSEMIDE 20 mg QAM
LATANOPROST 0.005 % gtt- 1 drop to each eye every night
LEVOTHYROXINE 100 mcg QAM
LIDOCAINE 5 % Adhesive Patch daily PRN
ONDANSETRON HCL 8 mg PRN nausea
PANTOPRAZOLE 40 mg Tablet QAM
POTASSIUM CHLORIDE 10 mEq
Capsule, Sustained Release - 1 Capsule(s) by mouth three times a
day
PROPOXYPHENE N-ACETAMINOPHEN [DARVOCET-N 100] - (Prescribed by
Other Provider) - 100 mg-650 mg Tablet - 1 Tablet(s) by mouth as
needed for pain
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth every morning
CALCIUM POLYCARBOPHIL [FIBERCON] - (Prescribed by Other
Provider) - 625 mg Tablet - 2 Tablet(s) by mouth every morning
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
Capsule(s) by mouth qam
Discharge Medications:
1. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig:
One (1) Tablet PO HS (at bedtime).
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO TID (3 times a day).
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. FiberCon 625 mg Tablet Sig: Two (2) Tablet PO once a day.
13. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
14. Darvocet-N 100 100-650 mg Tablet Sig: One (1) Tablet PO
every four (4) hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 8685**] home care
Discharge Diagnosis:
Aortic Stenosis
Acute on Chronic systolic congestive Heart Failure
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ([**Hospital1 **]
or cane).
Discharge Instructions:
You had an aortic valvuloplasty and you were transferred to the
CCU afterwards because of low blood pressure. Another
Echocardiogram was done which showed that the aortic valve is
not tight anymore but also does not close completely. Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) 7756**] will follow this closely after you go
home. Please check your oxygen level if you feel short of
breath. It should be more than 92%. You blood pressure should
also be about 110-130/ 50's-80's. If your blood pressure is
lower or higher than this consistantly, please call Dr. [**Last Name (STitle) **].
The pacemaker settings were adjusted and Dr. [**Last Name (STitle) **] will
decide in [**Month (only) 205**] if you need to have the pacemaker itself changed.
We made the following changes to your medicines:
1. Start Norvasc to control your blood pressure
2. Increase your aspirin to 325 mg daily.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Cardiology Appointment:Wednesday, [**7-25**] @2pm
With: [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **],MD
Address: 131 ORNAC, JCB #650, [**Location (un) **],[**Numeric Identifier 17125**]
Phone: [**Telephone/Fax (1) 71179**]
PCP [**Name Initial (PRE) 648**]: [**Last Name (LF) 2974**], [**7-13**] @ 1:40pm
With:[**Doctor First Name 6811**] E.[**Name8 (MD) **],MD
Location: [**Location (un) 2274**]-CONCROD
Address: [**Hospital Ward Name **], [**Location (un) **],[**Numeric Identifier 15215**]
Phone: [**Telephone/Fax (1) 28262**]
Department: CARDIOLOGY, DR [**Last Name (STitle) **]
When: THURSDAY [**2108-8-9**] at 3:40 PM in the [**Location (un) 1514**] office.
Please call to confirm this appt.
Completed by:[**2108-7-12**]
|
Discharge summary
|
Classify the following medical document.
|
Chief Complaint:
HPI:
53yo male with esophageal ca s/p esophagogastrectomy in [**2184**] and s/p
multiple stents (last one on [**2188-7-28**]) tx from OSH for management of food
impaction. Pt has been vomnitting all his food and meds for 1 day. He
was admitted to the ICU for elective intubation and EGD. EGD was
successfully performed, food was removed and pushed through from the
esophagus and the patient was extubated. Advanced endoscopy will be
consulted tomorrow for a definite stricture/stent management
Post operative day:
Allergies:
Trazodone
Unknown;
Sertraline
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Fentanyl - [**2188-8-13**] 10:00 PM
Other medications:
Past medical history:
Family / Social history:
PMH:Esophageal cancer s/p esophagogastrectomy in [**2184**]
CAD s/p MI (pt denies but in OSH records)
GERD
s/p L colectomy (unclear why)
hx of c.diff colitis
ETOH abuse
[**Last Name (un) 574**]:
Omeprazole 20mg PO BID
Seroquel 25mg PO QHS
Vitamin B12 100mg PO daily
Multivitamin
Celexa 40mg PO daily
Oxycodone 5/325mg PO Q6H PRN
Flowsheet Data as of [**2188-8-14**] 12:02 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.7
C (98
Tcurrent: 36.7
C (98
HR: 67 (63 - 99) bpm
BP: 119/63(78) {94/58(68) - 200/134(150)} mmHg
RR: 24 (12 - 26) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
614 mL
PO:
TF:
IVF:
614 mL
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
614 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CMV/ASSIST
Vt (Set): 350 (350 - 350) mL
RR (Set): 14
PEEP: 5 cmH2O
FiO2: 40%
PIP: 25 cmH2O
SpO2: 100%
ABG: ////
Ve: 5.2 L/min
Physical Examination
General Appearance: Thin, NAD
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Tender: in epigastric area
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Labs / Radiology
[image002.jpg]
Assessment and Plan
Assessment And Plan: 53yo male with esophageal ca s/p
esophagogastrectomy in [**2184**] and s/p multiple stents (last one on
[**2188-7-28**]) tx from OSH for management of food impaction. EGD performed,
obstruction disimpacted.
Neurologic: no issues, neurologically intact
Pain: Fentanyl prn
Cardiovascular: Stable. Rec ASA to discuss with primary care team
Pulmonary: Extubated after procedure, stable
Gastrointestinal: Advanced endoscopy consult in the morning, NPO for
now
Renal: no issues
Hematology: stable
Infectious Disease: no issues
Endocrine: RISS no requirement
Fluids: D5NS at 90
Electrolytes:
Nutrition: NPO
General:
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2188-8-13**] 09:00 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: floor
Total time spent: 35 minutes
|
Physician
|
Classify the following medical document.
|
SICU
HPI:
57M with h/o hep C cirrhosis s/p OLT [**12-31**] complicated by hepatic artery
thrombosis and biliary ischemia, s/p ERCP/CBD stent [**10-2**],
re-transplanted [**2124-10-25**] with subsequent hepaticojejunostomy for bile
leak [**2124-11-5**], admitted for hypotension, WBC 32 likely from C-diff pan
colitis.
Chief complaint:
PMHx:
PMH/PSH: UGIB ([**2120**]), Hep C cirrhosis, s/p OLT [**12-31**], three Grade II
varices with portal gastropathy s/p banding, L leg cellulitis, nec
fasc, osteomyelitis and group A strep sepsis [**11/2123**] requiring skin
graft, Chronic thrombocytopenia, Hypersplenism, MVA [**2101**], surgery to R
leg, mult fx L leg, Failure to thrive after liver transplant, Mult ARF
with unclear baseline creatinine (was as low as 0.8 in [**12-31**], range
0.8-4.5)
Current medications:
24 Hour Events:
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2124-12-14**] 01:13 PM
Vancomycin - [**2124-12-15**] 02:56 AM
Metronidazole - [**2124-12-16**] 06:15 PM
Ciprofloxacin - [**2124-12-16**] 09:09 PM
Infusions:
Phenylephrine - 2 mcg/Kg/min
Propofol - 10 mcg/Kg/min
Other ICU medications:
Pantoprazole (Protonix) - [**2124-12-16**] 09:09 PM
Furosemide (Lasix) - [**2124-12-16**] 09:32 PM
Sodium Bicarbonate 8.4% (Amp) - [**2124-12-16**] 09:36 PM
Other medications:
Flowsheet Data as of [**2124-12-17**] 03:41 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**27**] a.m.
Tmax: 36.5
C (97.7
T current: 35.6
C (96
HR: 95 (95 - 120) bpm
BP: 94/61(72) {82/49(59) - 127/75(90)} mmHg
RR: 24 (11 - 28) insp/min
SPO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 62.3 kg (admission): 53.6 kg
Height: 68 Inch
CVP: 4 (3 - 16) mmHg
Total In:
4,441 mL
362 mL
PO:
Tube feeding:
IV Fluid:
2,429 mL
103 mL
Blood products:
200 mL
Total out:
948 mL
0 mL
Urine:
98 mL
NG:
250 mL
Stool:
600 mL
Drains:
Balance:
3,493 mL
362 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 400 (400 - 400) mL
RR (Set): 24
RR (Spontaneous): 0
PEEP: 8 cmH2O
FiO2: 50%
PIP: 33 cmH2O
SPO2: 100%
ABG: 7.35/35/168/20/-5
Ve: 9 L/min
PaO2 / FiO2: 336
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: CTA bilateral : )
Abdominal: Soft, Non-tender, Distended
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: Moves all extremities, Sedated
Labs / Radiology
85 K/uL
10.6 g/dL
224 mg/dL
3.9 mg/dL
20 mEq/L
4.0 mEq/L
117 mg/dL
107 mEq/L
138 mEq/L
30.6 %
14.1 K/uL
[image002.jpg]
[**2124-12-16**] 04:35 AM
[**2124-12-16**] 06:20 PM
[**2124-12-16**] 06:34 PM
[**2124-12-16**] 07:56 PM
[**2124-12-16**] 09:06 PM
[**2124-12-16**] 09:57 PM
[**2124-12-16**] 11:10 PM
[**2124-12-17**] 12:17 AM
[**2124-12-17**] 02:38 AM
[**2124-12-17**] 02:48 AM
WBC
13.0
14.1
Hct
29.4
30.6
Plt
61
85
Creatinine
3.9
3.9
TCO2
21
21
20
21
21
20
18
20
Glucose
203
224
Other labs: PT / PTT / INR:20.1/56.4/1.9, ALT / AST:13/16, Alk-Phos / T
bili:86/0.3, Amylase / Lipase:44/, Fibrinogen:282 mg/dL, Lactic
Acid:1.2 mmol/L, Albumin:1.9 g/dL, LDH:162 IU/L, Ca:8.5 mg/dL, Mg:2.5
mg/dL, PO4:5.5 mg/dL
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name **]), IMPAIRED SKIN INTEGRITY,
DIARRHEA, OLIGURIA/ANURIA, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,
HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA), HYPOTENSION (NOT
SHOCK), ACIDOSIS, METABOLIC, ALTERATION IN NUTRITION, ELECTROLYTE &
FLUID DISORDER, OTHER, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), SEPSIS
WITHOUT ORGAN DYSFUNCTION
Assessment and Plan: 57M with h/o hep C cirrhosis s/p OLT [**12-31**]
complicated by hepatic artery thrombosis and biliary ischemia, s/p
ERCP/CBD stent [**10-2**], re-transplanted [**2124-10-25**] with subsequent
hepaticojejunostomy for bile leak [**2124-11-5**], admitted for hypotension,
WBC 32 likely from C-diff pan colitis.
Neurologic: no pain meds, minimize propofol
Cardiovascular: wean Neo
Pulmonary: intubated for resp distress
Gastrointestinal / Abdomen: s/p OLT x 2, C.diff with pan colitis on PO
vanc/flagyl, hold TF
Nutrition: TPN, NPO
Renal: ARF, Cr 3.9, oliguric despite 100 lasix
Hematology: Hct stable at 30.6, INR down to 1.9 (home coumadin for OLT)
Endocrine: RISS
Infectious Disease: C.diff, PO vanc/IV
flagyl/Cipro/Fluc/Bactrim/Valcyte, Nitazoxanide, transplant wants daily
blood cx and fungal cx, vanc enemas stopped due to intolerance, IVIG Q3
days, cholestyramine to bind toxin
Lines / Tubes / Drains: PIV, foley, rt IJ [**Last Name (LF) 2643**], [**First Name3 (LF) **], NGT, ETT
Wounds:
Imaging:
Fluids:
Consults: Transplant
Billing Diagnosis: Acute renal failure, Other: c diff colitis
ICU Care
Nutrition:
TPN w/ Lipids - [**2124-12-16**] 04:29 PM 74.[**Telephone/Fax (3) 1697**] mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2124-12-13**] 03:00 AM
Arterial Line - [**2124-12-13**] 03:58 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent: 35 minutes
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2140-10-17**] Discharge Date: [**2140-10-22**]
Date of Birth: [**2084-5-2**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
.
HPI: Mr.[**Known lastname 25925**] is a 56 M with h/o multiple sclerosis and an upper
GIB who presented to an OSH after an epsiode of BRBPR this
morning. The patient is cared for during the week by a PCA who
noted approximately 1 cup of BRBPR after a BM and in the shower
the AM of admission. The PCA also noted that his stool was
normal color and that the patient appeared pale and somnolent.
At home, the patient's blood pressure was 71/42, then 79/47
after drinking Gatorade. At the OSH, the patient was hypotensive
in the 70s and had a Hct of 24 for which he received 2U of PRBCs
and 3L IVF. He underwent NGL at the OSH, which was negative. He
was started on omeprazole and transferred to [**Hospital1 18**]. Also of
note, he was intermittently hypoglycemic at OSH but here his
glucose is 133. In the ED, he was hemodynamically stable with a
repeat Hct of 35, he was found to have UTI and was hypothermic
with a rectal temperature of 92. He was started on levofloxacin.
The patient has never had a colonoscopy, but had a sigmoidoscopy
in [**7-27**] after an episode of BRBPR and found to have hemorrhoids.
Of note, the patient was discharged on [**10-9**] after ICU
hospitalization for PNA which was treated with a course of
vancomycin, zosyn, and levofloxacin.
.
ROS: +chronic constipation, +difficulty breathing x 1 episode
today, + difficulty swallowing, + decreased PO intake; denied
CP, palpitations, syncope, headache, change in vision,
dizziness, lightheadedness, change in bowel or bladder function
.
PMH:
progressive multiple sclerosis (followed by Dr. [**Last Name (STitle) 25923**] [**Name (STitle) 25924**])
neurogenic bladder (s/p suprapubic tube placement)
h/o multiple UTI's
h/o upper GIB (ulcerative esophagitis and gastritis [**12-24**] NSAIDS)
GERD
HTN
CHF (unknown EF)
h/o "sepsis"
L eye blindness
intrathecal baclofen pump (10 years)
??sleep apnea - sleep study scheduled for [**10-26**]
.
Social History:
Retired college professor. Disabled, has personal care
assistant. Married with 3 children. No smoking. No EtOH.
.
Family History:
Father had CAD and CVA. Mother has [**Name (NI) 2481**] disease. Brother
has diabetes.
.
Allergies: Percocet makes him sleepy
.
Medications:
Lisinopril 20 mg PO BID
Albuterol [**11-23**] PUFF IH Q4-6H:PRN
Multivitamins 1 CAP PO DAILY
Amlodipine 5 mg PO DAILY
Oxybutynin 5 mg PO BID
Brimonidine Tartrate 0.15% Ophth. 1 DROP OU Q8H
Paroxetine HCl 40 mg PO DAILY
Fentanyl Patch 25 mcg/hr TP Q72H
Gabapentin 400 mg PO Q8H
.
Physical Exam:
Vitals: T 95.0 BP 145/85 HR 88 RR 18 O2 96% on 2L NC
Gen: NAD, lying on in bed on his side
HEENT: sluggish pupils, dry MM. EOMI.
Neck: Supple without LAD
Cardio: RRR, nl s1/s2, no m/r/g
Resp: mild rhonchi in L mid-lung field
Abd: soft, nt, nd, +BS. No rebound/guarding. Suprapubic cath and
baclofen pump in place.
Ext: extreme spacicity LE > UE, 3+ symmetric pedal edema
Neuro: A & O to person, place, month, year, day, but not date;
able to recall recent holiday and president. CN II-XII grossly
intact. Pt does not move LE. 3/5 strength UE BL (only with
repeated prompting).
.
Asssesment: 56 M with lower GIB, likely hemorrhoids vs AVM vs
polyp vs malignancy.
.
Plan:
# GIB
- continue carafate and PPI [**Hospital1 **]
- Golytely prep
- colonoscopy in AM or Wednesday
- [**Hospital1 **] Hct
- Transfuse for Hct < 26
.
# UTI - Unclear whether this is a true infection or colonization
[**12-24**] suprapubic catheter.
- Will not continue levaquin at this time
- F/u UCx, BCx
- Restart abx if pt appears sick
.
# Elevated PTT: lab error vs drug effect vs lupus anticoagulant
- repeat and if still high, check lupus anticoagulant
.
# Hyperglycemia: patient reported hypoglycemic at OSH but here
he is mildly hyperglycemic.
- follow fingersticks
.
# Prophylaxis: PPI, no heparin products given recent GI bleed,
TEDs in place
.
# FEN: NPO after MN for procedure, maintenance IVF
.
# Access: R PICC, L PIV 22" x 2 - will replace 1 with larger
bore
.
# Communication - Wife, [**Name (NI) 2048**] [**Name (NI) 25925**] - cell: [**Telephone/Fax (1) 25928**],
work: [**Telephone/Fax (1) 25929**], home: [**Telephone/Fax (1) 25930**]
.
FULL CODE
Past Medical History:
progressive multiple sclerosis (followed by Dr. [**Last Name (STitle) 25923**] [**Name (STitle) 25924**])
neurogenic bladder (s/p suprapubic tube placement)
h/o multiple UTI's
h/o upper GIB (ulcerative esophagitis and gastritis [**12-24**] NSAIDS)
GERD
HTN
CHF (unknown EF)
h/o "sepsis"
L eye blindness
Social History:
Retired college professor. Disabled, has personal care
assistant. Married with 3 children. No smoking. No EtOH.
Family History:
Father had CAD and CVA. Mother has [**Name (NI) 2481**] disease. Brother
has diabetes.
Pertinent Results:
[**2140-10-17**] 06:10PM GLUCOSE-128* UREA N-27* CREAT-0.9 SODIUM-136
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-22 ANION GAP-15
[**2140-10-17**] 06:10PM ALT(SGPT)-30 AST(SGOT)-26 ALK PHOS-105 TOT
BILI-0.4
[**2140-10-17**] 06:10PM CALCIUM-8.7 PHOSPHATE-4.5 MAGNESIUM-2.1
[**2140-10-17**] 06:10PM WBC-4.4 RBC-4.23* HGB-12.0* HCT-35.8* MCV-85
MCH-28.4 MCHC-33.6 RDW-16.4*
[**2140-10-17**] 06:10PM NEUTS-59.6 LYMPHS-33.2 MONOS-4.9 EOS-1.1
BASOS-1.3
Brief Hospital Course:
[**Hospital Unit Name 13533**]: Mr. [**Known lastname 25925**] was transfered to the [**Hospital Unit Name 153**] with concern
of rapid GI bleeding. He was given fluids, but his hematocrit
remained stable. GI was consulted and they will scope him in the
morning. His prep will be started on transfer.
Wife to find out names of "steroid" for MS as well as
?antibiotic for UTI ppx?
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q8H (every 8 hours) as needed.
10. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
11. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
15. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
16. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed.
17. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
18. Methylprednisolone Sodium Succ 1,000 mg/8 mL Recon Soln Sig:
One (1) g Injection once a month: To be given by VNA, last given
[**2140-10-21**].
Disp:*qs 3 months* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Lower Gastrointestinal Bleeding
Acute Blood Loss Anemia
Multiple Sclerosis
Discharge Condition:
stable
Discharge Instructions:
Please take your medications as listed below. Please follow up
with your PCP and your neurologist. Call your doctor if you
experience recurrent bleeding or black stool, lightheadedness,
shortness of breath, chest pain, or other concerning symptoms.
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2140-10-27**] 12:00
2. Please follow up with your PCP in the next week to have your
blood counts checked, and to arrange for a surgical evaluation
to have your hemorhoids treated
3. Please follow up with Dr. [**Last Name (STitle) **] to have your sleep study
arranged at [**Location (un) 620**] (in a hospital setting).
4. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2140-11-16**] 1:00
5. Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2140-11-16**] 1:00
|
Discharge summary
|
Classify the following medical document.
|
Chief Complaint:
24 Hour Events:
FEVER - 102.3
F - [**2191-8-25**] 08:00 PM
-dilantin level within normal ranges after adjusting for low albumin
(14)
-sputum cultures show 2+ gram - and 1+ gram positive consistent with
MRSA
-no neuro recs left
-nutrition consulted but did not leave TPN recs yet
-fever spiked to 102.4 around 8 pm and was re-pancultured
-around 1 AM BP fell to 70s systolic when nursing turned patient; after
repositioning, BP failed to improve, was given a 500 cc NS bolus. Pt
was restarted on levo to maintain pressures.
- episode of aberrancy on telemetry lasting one minute, unable to
assess on ECG. Following ECG was unchanged from prior.
Allergies:
Hydromorphone
Unknown;
Metoclopramide
Unknown;
Last dose of Antibiotics:
Cefipime - [**2191-8-25**] 02:00 PM
Infusions:
Norepinephrine - 0.02 mcg/Kg/min
Other ICU medications:
Fosphenytoin - [**2191-8-26**] 12:00 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2191-8-26**] 07:19 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 39.1
C (102.3
Tcurrent: 37.8
C (100
HR: 105 (89 - 108) bpm
BP: 103/42(63) {70/30(43) - 175/70(109)} mmHg
RR: 28 (18 - 53) insp/min
SpO2: 96%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 91 kg (admission): 94.2 kg
Height: 70 Inch
Total In:
386 mL
573 mL
PO:
60 mL
TF:
IVF:
276 mL
573 mL
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
386 mL
573 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 455 (394 - 488) mL
PS : 10 cmH2O
RR (Spontaneous): 25
PEEP: 5 cmH2O
FiO2: 40%
[**Year (4 digits) 1093**]: 82
PIP: 16 cmH2O
SpO2: 96%
ABG: 7.28/34/96.[**Numeric Identifier 274**]/17/-9
Ve: 11.7 L/min
PaO2 / FiO2: 242
Physical Examination
Cardiovascular: Gen: unresponsive to voice/command.
CV: RRR, nl S1/S2. no r/g/m
Lungs: reduced BS at bases
Abd: distended, not tense. No sign of tenderness. ABS.
Extremiteis: no c/c/e. Sacral edema
Neuro: Does not respond to sternal rub. Withdraws to pain stimulus in
feet
Labs / Radiology
299 K/uL
9.9 g/dL
213 mg/dL
5.8 mg/dL
17 mEq/L
3.6 mEq/L
18 mg/dL
109 mEq/L
142 mEq/L
32.4 %
13.7 K/uL
[image002.jpg]
[**2191-8-23**] 02:26 PM
[**2191-8-23**] 02:28 PM
[**2191-8-24**] 04:51 AM
[**2191-8-24**] 05:04 AM
[**2191-8-25**] 03:35 AM
[**2191-8-25**] 04:35 AM
[**2191-8-25**] 05:40 PM
[**2191-8-26**] 02:26 AM
[**2191-8-26**] 02:44 AM
[**2191-8-26**] 06:10 AM
WBC
11.9
11.2
13.7
Hct
33.7
32.8
33.5
34.6
32.4
Plt
[**Telephone/Fax (3) 8641**]
Cr
12.6
12.5
7.9
5.8
TCO2
23
17
24
18
17
Glucose
177
180
172
213
Other labs: PT / PTT / INR:23.7/40.6/2.3, ALT / AST:21/49, Alk Phos / T
Bili:162/0.8, Amylase / Lipase:55/88, Albumin:2.6 g/dL, Ca++:8.4 mg/dL,
Mg++:1.8 mg/dL, PO4:2.3 mg/dL
Fluid analysis / Other labs: Vanco - 16.4
Imaging: CXR: inreased hilar density. No effusions
Microbiology: Sputum cultures [**2191-8-22**]- MRSA
All blood cultures negative to date.
Assessment and Plan
ALTERATION IN NUTRITION
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 2**])
FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)
ALTERED MENTAL STATUS (NOT DELIRIUM)
.H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 2**])
HYPERTENSION, BENIGN
HYPOGLYCEMIA
DIABETES MELLITUS (DM), TYPE II
SEIZURE, WITHOUT STATUS EPILEPTICUS
73 yom HD-dependent, admitted with left acute on chronic SDH c/b
seizure, transferred to MICU for concern of sepsis with hypoxia and
hypotension.
# Respiratory Distress: etiology includes volume overload given
resuscitation with anuric renal failure and likely PNA supported by
sputum GS significant for GNR and GPC. Barriers to intubation include
mental status, fluid overload and underlying infection.
- respiratory failure: continue PSV with daily [**Last Name (LF) 1093**], [**First Name3 (LF) 116**] attempt to
wean once HD re-initiated
- volume overload: continue HD
- pneumonia: continue vanomycin (day 10) and cefepime (10) for GP and
GN coverage
will adjust as cultures and sensitivies return
- mental status: continue no sedation for further evaluation of mental
status, correct electrolyte disturbances, treat infection
# Hypotension / Fevers: Spiked temperatures overnight. Pt was pan
cultured. Pt has known MRSA pneumonia. Has completed a course of
vanco today. Hypotension as also noted and pt was restarted on
levophed
- continue vancomycin / cefepime for concern of pneumosepsis pending
cultures and sensitivities
- f/u cultures
- CXR
- continue levophed for hypotension, avoid aggressive volume
- CT head
# Sinus tachy with aberrancy
continue strict monitoring of
electrolytes. Called renal to discuss HD or CVVH. Recommended
starting it tomorrow. Continue monitoring on tele.
# High Bilious Output: continued output, reduced to about 300cc over
last 24 hrs (down from 1500 - 2000cc). He is having BM and Xray
confirmed no obstruction or ileus. This may represent inflammatory
process without outflow obstruction. However, liver enzymes do not
support inflammatory process of gallbladder or pancreas. Hct trending
down. Hct 32.4 today. Transfuse if < 21.
- continue [**Hospital1 **] PPI
# ESRD: Continue HD or CVVH as tolerated by BP
# AF: patient in NSR. Continue to hold anti-coagulation for underlying
SDH
# Right Upper Extremity Swelling: u/s shows non occlusive clot
- will not pull out PICC as non-occlusive
# Seizure: no gross evidence of ongoing seizure activity
- c/w neuro regarding fosphenytoin dosing considering possible HD
# SDH: continue to hold anticoagulation, will follow neurology recs
# Glaucoma / Cataracts: continue home eye drops
# DM: continue SSI with lantus baseline
# Access: double lumen PICC on right; axillary A-line, temp line for HD
# Nutrition: consult regarding TPN
# PPX: pneumoboots, PPI; bowel reg
# Code: full; confirmed with wife on admission via phone
# Dispo: to remain in ICU while intubated; may attempt extubation s/p
HD
ICU Care
Nutrition:
Glycemic Control:
Lines:
PICC Line - [**2191-8-21**] 02:07 AM
Dialysis Catheter - [**2191-8-22**] 04:10 PM
Arterial Line - [**2191-8-23**] 11:58 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:
|
Physician
|
Classify the following medical document.
|
CCU NURSING 1730-1900
S. INTUBATED
O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA
CV: PT RETURNED FROM CATH LAB AT ~1730 S/P CARDIAC ARREST W/? PEA RHYTHM, SBP 40/ FOR SUSTAINED PERIOD AFTER UNABLE TO CROSS OCCLUDED LAD LESION VIA R BRACHIAL APPROACH. INTUBATED, IABP PLACED IN L FEMORAL SITE, PA CATHETER IN R FEMORAL SITE, R BRACHIAL SHEATH D/C'D, INITIALLY RECEIVED ATROPINE/EPI/DOPA AND LEVO WIDE OPEN - AFTER IABP PLACED, BP IMPROVED, DOPA WEANED TO OFF AND LEVO WEANED TO .125 MCGS - TRANSFERRED TO CUU FOR FURTHER MANAGEMENT TO STABILIZE; TROPONIN 2, CPK/MB REMAIN ELEVATED
CV: HR 80'S SR WITH FREQUENT APC'S, IABP AT 1:1 INITIAL MAPS 80 - TRENDING DOOWN TO 59-60 - LEVO INCREASED TO .2 MCGS/KG W/IMPROVEMENT IN MAPS, IABP TIMING W/FOS, INITIALLY AUGMENTING > 60 POINTS HIGHER THAN PLATEAU - 30CC BALLOON DECREASED TO 26 CC SLOWLY NOW W/AD/PLATEAU PRESSURES WITHIN 25 POINTS; PULSES PRE-PROCEDURE DOP/DOP BILAT, NOW LDP DOP, R DP CONTINUOUS FLOW HEARD (IE VENOUS FLOW) BUT UNABLE TO DOP ART PULSE; PT'S BILAT NOW BOTH ABSENT, L FOOT WARM AND PALE, R FOOT COOL AND MOTTLED TO CALF - CCU TEAM AWARE AND [**Name (NI) 3651**] PT; R BRACHIAL SITE OOZING, R RADIAL PULSE FAINTLY PALPABLE; R AND L FEM STES OOZING BILAT; MIXED VENOUS SAT 42 - CO 2.4/CI 1.7 SVR 1800, LACTYATE 10.9
RESP: LUNGS COARSE, INTUBATED ON 100% FIO2 LAST ABG 7.34/38/106/21/-5, SUX FOR MOD AMOUNTS THICK BLOODY SPUTUM, ORAL CAVITY BLEEDING AS WELL
GI: ABDOMEN SOFT, NO STOOL
HEME: CALCULATED HCT IN CATH LAB 21 - RECEIVING 1 UNIT PRBC'S, REPEAT HCT PRIOR TO TRANSFUSION CAME BACK 28.9
GU/RENAL: FOLEY IN PLACE NOW DRAINING CLEAR YELLOW URINE IN LG AMTS INITIALLY - NOW TAPERING OFF, BUN/CR 34/1.4
NEURO: PT OPENING EYES SPONTANEOUSLY LIFTING ARMS UP IN AIR TOWARD TUBE, MOVING LEGS ON BED, OPENING MOUTH TO SPEAK; FENTANYL GTT STARTED AT 50MCGS, VERSED AT 1MG/HR, PT NOW APPEARS MORE RESTLFUL
SKIN: PT RETURNED TO CCU W/ECCYMOTIC AREA IN 4TH ICS TO LEFT OF STERNUM POST-CPR, FAMILY INFORMED [**Month (only) 83**] BE BROKEN RIBS SECONDARY TO CPR
SOCIAL: SON MARK AND DAUGHTER [**Name (NI) **] IN TO VISIT THROUGHOUT DAY, SPOKE WITH RN AT LENGTH REGARDING PT'S CONDITION AND PLAN OF CARE, ALSO SPOKE W/MD [**First Name (Titles) **] [**Last Name (Titles) **] AND CCU TEAM, DR [**Last Name (STitle) **] ALSO CONFIRMED THAT PT IS STILL FULL CODE DESPITE CARDIAC ARREST IN LAB, FAMILY WANTS TO CONTINUE FULL TREATMENT, FULL CODE FOR NOW; CATHOLIC PRIEST [**Name (NI) **] AND VISITED PT PER FAMILY'S REQUEST.
A: PT W/HX SEVERE PVD, S/P FEMORAL BYPASSES BILAT, NOW S/P STEMI C/B CARDIAC ARREST IN CATH LAB, INABILITY TO OPEN LAD LESION, CARDIOGENIC SHOCK WITH IABP/SWAN IN PLACE, PRESSORS TO MAINTAIN BP, SHEATHS IN FEMORAL SITES BILAT W/COMPROMISED BLOOD FLOW TO R LEG
P: CONTINUE MONITOR HEMODYNAMICS AND SUPPORT PATIENT W/IABP @ 1:1, PRESSORS, ? ADD INOTROPES IN LIGHT OF LOW CO/CI; FOLLOW FEMORAL AND BRACHIAL SHEATH SITES, ASSESS CHEST CONTUSION, ASSESS DISTAL PULSES; FOLLOW LACTATE LEVELS; SEDATION/PAIN MEDS AS NEEDED FOR COMFORT; ASSESS IABP FUNCTION/TIMING, KEEP FAMILY INFORMED OF PATIENTS CONDITION, PLAN OF CARE, EMOTI
|
Nursing/other
|
Classify the following medical document.
|
Chief Complaint: 51 yof with h/o ESLD [**12-26**] ETOH cirrhosis c/b HRS
requiring HD admitted for possible KL transplant.
24 Hour Events:
- did large volume para - 4.5 liters removed and fluid sent for
analysis which showed 130 WBC / 510 RBC / 0 PMN / 27 L / 66 macrophages
/ protein 2.7
- dobhoff clogged -- placed order for IR dobhoff placement in AM.
- hematology recs: continuing antibiotics, lactulose and rifaximin
- renal recs: HD today [**11-20**]
Allergies:
Sulfa (Sulfonamide Antibiotics)
Wheezing;
Phenylephrine
Symptomatic bra
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2169-11-17**] 08:00 AM
Micafungin - [**2169-11-19**] 09:27 PM
Piperacillin - [**2169-11-19**] 09:27 PM
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2169-11-20**] 05:53 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.6
C (97.8
Tcurrent: 36.2
C (97.1
HR: 76 (76 - 89) bpm
BP: 95/42(58) {87/40(56) - 125/65(83)} mmHg
RR: 15 (15 - 23) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 99 kg (admission): 94.5 kg
Height: 62 Inch
Total In:
710 mL
269 mL
PO:
380 mL
240 mL
TF:
10 mL
IVF:
220 mL
29 mL
Blood products:
100 mL
Total out:
4,500 mL
0 mL
Urine:
NG:
Stool:
Drains:
4,500 mL
Balance:
-3,790 mL
269 mL
Respiratory support
O2 Delivery Device: None
SpO2: 98%
ABG: ///18/
Physical Examination
General: somnolent,. NAD
HEENT: jaundice
Heart: RRR, no MRG
Lungs: CTAB no WRR
Abdomen: mild distension, soft, diffusely tender, no RG
Extremities: no edema, DP 2+
Labs / Radiology
148 K/uL
9.5 g/dL
99 mg/dL
3.9 mg/dL
18 mEq/L
3.9 mEq/L
27 mg/dL
100 mEq/L
135 mEq/L
28.0 %
14.9 K/uL
[image002.jpg]
[**2169-11-13**] 03:09 AM
[**2169-11-13**] 06:30 PM
[**2169-11-14**] 04:16 AM
[**2169-11-15**] 02:33 AM
[**2169-11-15**] 11:14 AM
[**2169-11-16**] 02:29 AM
[**2169-11-17**] 04:06 AM
[**2169-11-18**] 02:53 AM
[**2169-11-19**] 04:08 AM
[**2169-11-20**] 03:51 AM
WBC
20.1
18.1
14.3
14.2
16.5
16.3
13.5
14.9
Hct
24.4
25.7
26.5
26.7
30.3
30.5
28.4
27.4
28.0
Plt
175
148
132
120
127
130
132
148
Cr
2.1
3.6
4.2
3.0
3.9
4.5
3.0
3.9
TCO2
21
Glucose
170
143
104
129
113
119
95
99
Other labs: PT / PTT / INR:23.0/50.3/2.2, ALT / AST:29/108, Alk Phos /
T Bili:83/19.6, Amylase / Lipase:/62, Lactic Acid:1.7 mmol/L,
Albumin:3.7 g/dL, LDH:391 IU/L, Ca++:9.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.3
mg/dL
Microbiology
- [**11-19**]
paracentesis fluid
1+ PMN
s, no bacteria
- [**11-19**]
c.diff toxin negative
- [**11-17**]
c.diff toxin negative
Radiology
- No new imaging
Assessment and Plan
51 yof with ESLD [**12-26**] ETOH cirrhosis complicated by HRS req. dialysis.
Patient admitted for possible L-K transplant for high MELD score but
unable to tolerate testing [**12-26**] hypotension.
.
#. Hypotension: thought to be [**12-26**] fluid redistribution into
extravascular compartments, now off pressors for the past several days
and now s/p significant therapeutic and diagnostic paracentesis
yesterday
- continue midodrine 15 mg TID
- goal MAP >65; restart levo if needed and use IVF PRN boluses
- f/u hepatology recs
- f/u renal recs
- antibiotics as below
.
#. Leukocytosis: trending down from 20 now stable in teens s/p empiric
7 day course of vancomycin and zosyn for hypotension. No infectious
source identified to date with negative C.Diff and recent paracentesis
not demonstrating SBP.
- d/w ID rational for duration of empiric antibiotic course
stop vs.
extended
- follow up cultures (blood, paracentesis)
- discontinue PO vancomycin as C. Diff negative x 5
- continue Micafungin 100 mg IV Q24h for empiric fungal coverage(day
1=[**11-13**])
- f/u stool cytotoxin assay, serum histoplasma (send out)
.
#. End-stage liver disease: Patient currently stable and fully oriented
with no clinically symptoms of acute liver decompensation. Patient has
been evaluated by the transplant team as an outpatient who recommended
admission for possible tranplant based on elevated MELD score. s/p EGD
on [**11-7**]. s/p dobhoff placement on [**11-7**]. Listed for transplant for
kidney/liver. MELD [**11-7**] 40, [**11-11**] = 42.
- Liver Transplant Today
- Continue lactulose
- Continue rifaximin
- Since patient on broad-spectrum antibiotics, d/c
d cipro for SBP
prophylaxis and then after 7-day course of broad-spectrum antibiotics
ends (on [**11-18**]), plan to restart cipro for SBP prophylaxis = today;
confirm vanc/zosyn treatment course length first with ID then add back
or not the cipro
- Active T & S
- F/u hepatology recs, transplant recs
.
# Renal Failure: Creatinine on transfer to MICU 4.2. Requires dialysis
three times a week. Patient is candidate for dual liver-renal
transplant and followed by Dr. [**Last Name (STitle) 9881**]. Hepato-renal syndrome. Cr
now 3.9 up from 3.0.
- Kidney Transplant Today
- HD today per renal
- continue nephrocaps
- f/u renal recs
- per renal, no more epo
.
# Nausea: Perhaps due to liver disease, pressors, CVVH, medications.
New Dobhoff placed by IR (d/t clog) on [**11-18**].
- try to unclog Dobhoff; if not, call IR for help
- Ok to take PO as tolerated/desired by patient, encourage
- Dobhoff replaced; tubefeeds should be running slowly, advance as
tolerated slowly if possible
- Zofran 8mg q8h IV prn
aggressive giving of this medication as
needed
- Morphine 0.5-1mg IV q4h prn
- Hold on ativan if possible, given ESLD
- per transplant surgery, d/c
d PPN
.
# Metabolic acidosis: bicarb improved s/p HD. Resolved.
- Hold on suctioning out bile
- Monitor daily
.
# Alcohol abuse: Patient has not had a drink since [**Month (only) 93**], therefore no
need for CIWA.
- Discontinued folic acid, thiamine, MVI
feel that she is now
repleted (ie; getting nutrition, has been supplemented a lot)
.
# Heel ulcer:
- f/u wound care recs; heel boot
.
FEN: Dobhoff
f/u IR placed Dobhoff this AM
.
PPX: DVT ppx with Pneumoboots; omeprazole 20mg daily; bowel regimen =
lactulose. Out of bed today.
.
ACCESS: Power PICC, R IJ HD catheter, A-line.
.
CODE STATUS: Full code (confirmed with patient).
.
EMERGENCY CONTACT: [**Name (NI) **] [**Known lastname 4887**] (husband, [**Name (NI) 117**] [**Telephone/Fax (1) 9882**] (cell),
[**Telephone/Fax (1) 9883**], [**Telephone/Fax (1) 9884**].
.
DISPOSITION: MICU for continued BP monitoring, may be suitable for
floor given stable BP for past several days without pressure
requirements. Presently, awaiting & listed for liver/kidney transplant.
ICU Care
Lines:
PICC Line - [**2169-11-6**] 06:43 PM
Dialysis Catheter - [**2169-11-6**] 08:00 PM
Arterial Line - [**2169-11-14**] 06:50 PM
Code status: Full code
|
Physician
|
Classify the following medical document.
|
Chief Complaint:
24 Hour Events:
- films ordered will not be ready until wednesday
- pt scheduled for transfer to [**Male First Name (un) 1174**] tomorrow
- chest tube switched to water seal
- repeat CXR no increase in size of PTX
S: Pt doing okay this am, breathing comfortably, no CP/ABD pain. Had
difficultly sleeping.
Lower extremities tight & mildly uncomfortable.
Allergies:
Heparin Agents
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
senna, colace, bisacodyl, enema prn, Alb/Atrovent nebs, Lactulose,
Fondaparinux, oxycodone
Other medications:
Flowsheet Data as of [**2133-2-3**] 07:31 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.1
C (97
Tcurrent: 36
C (96.8
HR: 98 (98 - 118) bpm
BP: 97/64(72) {97/62(72) - 112/69(77)} mmHg
RR: 23 (21 - 34) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 112 kg (admission): 91.5 kg
Height: 65 Inch
Total In:
1,201 mL
150 mL
PO:
720 mL
TF:
IVF:
481 mL
150 mL
Blood products:
Total out:
695 mL
205 mL
Urine:
695 mL
145 mL
NG:
Stool:
Drains:
Balance:
506 mL
-55 mL
Respiratory support
Ventilator mode: Standby
Vt (Spontaneous): 276 (276 - 276) mL
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
PIP: 0 cmH2O
SpO2: 99%
ABG: ///28/
Physical Examination
GEN: NAD, no resp distress
HEENT: trach inplace
CV: mildly tachy, RR, no m/r/g
RESP: Left lung field CTA, right lung with insp/expiratory stridorous
BS, but moving air well
ABD: soft, NT/ND, NABS
EXTR: [**1-11**]+ pitting edema bilaterally, no skin breakdn
Neuro: AXO
Labs / Radiology
301 K/uL
7.1 g/dL
93 mg/dL
0.8 mg/dL
28 mEq/L
3.8 mEq/L
10 mg/dL
101 mEq/L
135 mEq/L
22.1 %
4.2 K/uL
[image002.jpg]
[**2133-1-25**] 05:25 AM
[**2133-1-26**] 04:25 AM
[**2133-1-27**] 05:24 AM
[**2133-1-28**] 04:47 AM
[**2133-1-29**] 04:00 AM
[**2133-1-30**] 06:45 AM
[**2133-1-31**] 06:07 AM
[**2133-2-1**] 04:59 AM
[**2133-2-2**] 05:37 AM
[**2133-2-3**] 06:00 AM
WBC
3.4
3.2
3.0
3.3
3.7
3.5
2.8
3.9
4.4
4.2
Hct
21.4
22.9
22.9
21.6
21.3
21.8
23.7
21.8
23.5
22.1
Plt
79
124
170
227
292
[**Telephone/Fax (2) 1141**]81
301
Cr
1.0
1.0
1.0
0.9
0.9
0.9
0.8
0.8
0.9
0.8
Glucose
[**Telephone/Fax (3) 1063**]05
85
124
93
120
112
93
Other labs: PT / PTT / INR:14.1/32.4/1.2, Differential-Neuts:78.7 %,
Band:0.0 %, Lymph:13.8 %, Mono:4.3 %, Eos:3.0 %, Fibrinogen:618 mg/dL,
Lactic Acid:3.6 mmol/L, Ca++:9.1 mg/dL, Mg++:1.9 mg/dL, PO4:3.2 mg/dL
CXR from [**2133-2-2**] 2pm (after clamping chest tube)
Comparison is made to earlier in the same day. A
pleural catheter in the left hemithorax is unchanged. The patient is s
tatus
post tracheostomy. Multiple large bilateral pulmonary masses are again
present with similar partial left lower lobe atelectasis. No evidence
of
pneumothorax or pleural effusion. Subcutaneous air about the left ches
t wall
is unchanged in extent.
IMPRESSION: No evidence of persistent pneumothorax.
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name **])
CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,
CERVICAL, ENDOMETRIAL)
PNEUMOTHORAX, OTHER (NOT HOSPITAL ACQUIRED OR TRAUMATIC)
[**Last Name 121**] PROBLEM - ENTER DESCRIPTION IN COMMENTS
Heparin Induced Thrombocytopenia
TACHYCARDIA, OTHER
Improved after chest tube placement
PULMONARY EMBOLISM (PE), ACUTE
ANEMIA, OTHER
ICU Care
Nutrition: Soft mechanical diet with supplemental TF
Glycemic Control: ISS
Lines:
PICC Line - [**2133-1-13**] 09:48 PM
Prophylaxis:
DVT: Fondaparinux
Stress ulcer: PPI
Communication: Comments:
Code status: DNR (do not resuscitate)
Disposition: transfer to NY presbyterian today
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2185-8-29**] Discharge Date: [**2185-9-2**]
Date of Birth: [**2105-4-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Quinolones / Vancomycin Analogues / Levaquin
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Bronchial stenosis
Major Surgical or Invasive Procedure:
Flexible bronchoscopy, rigid bronchoscopy with stent removal and
balloon dilation of the bronchus intermedius, endobronchial
biopsy of the bronchus intermedius.
History of Present Illness:
Ms.[**Known lastname 32872**] is an 80 year-old woman with lung cancer who has
undergone right upper lobectomy and radiation therapy 17 years
ago. She presented in [**2185-3-25**] with progressive dyspnea and
productive cough. She was ultimately found to have stenosis of
the bronchus intermedius and underwent placement of a metal
stent
[**2185-8-18**]. She continues to complain of cough, mainly over the
past 3 days; she reports sputum productive of brownish sputum.
She notes her baseline level of dyspnea, which she tells me is
10
-15 feet on level ground. She denies fever, chills, or night
sweats. She presents today for bronchoscopy and stent
evaluation.
Past Medical History:
COPD, GERD, CAD with stent placement, breast cancer, s/p l
Mastectomy; colon cancer, s/p colectomy; History of syncopes and
collapse (not in the last 1.5 years), LLE DVT one year ago
Social History:
SOCIAL HISTORY:
Cigarettes: [ ] never [x] ex-smoker [ ] current Pack-yrs:____
60 pack year smoking history, quit 18 years ago
ETOH: [x] No [ ] Yes drinks/day:
Drugs:
Exposure: [x] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation: retired, former hairdresser
Marital Status: [ ] Married [x] Single
Lives: [ ] Alone [ ] w/ family [ ] Other:lives in
nursing home since [**2184-3-25**]
Family History:
nc
Physical Exam:
AO x 3
PERRL/EOMI
RRR
Bilateral rhonchi
Soft BS+
no rashes; + ecchymoses on arms
no cyanosis, clubbing, or edema
Pertinent Results:
[**8-29**]: CT Chest
FINDINGS: The new stent in the bronchus intermedius is fully
expanded and
contains eccentric intraluminal soft tissue in its distal
course. There is
residual narrowing just proximal to the tip of the stent in the
right main
stem bronchus(3.20). The right middle and lower lobe bronchi are
patent.
Evaluation of the upper mediastinum is limited due to extensive
streak
artifact from multiple surgical clips however there is no
evidence of disease recurrence at the resection site post- right
upper lobectomy. The
infectious/inflammatory component of the right upper lung
consolidation has resolved with residual post-radiotherapy
related consolidation in the right apex, unchanged. The small
right pleural effusion has slightly increased in size, and
marked peribronchial wall thickening in subsegmental and
subsegmental bronchi of the right lower lobe persists with
centrilobular nodularity throughout the right lung, suggesting
superimposed infection or inflammation. There is increased
peribronchial thickening which is severe surrounding the
segmental course of a right lower lobe bronchus (3.23) which is
most likely due to inflammation or infection, attention to this
area should be made on followup to exclude disease recurrence.
This is best seen on the coronal sequences (400B.36).
Atelectasis in the periphery of the right lower lobe (3.37) is
new and mild. No new pathological enlargement of mediastinal or
axillary lymph nodes by CT size criteria. Centrilobular
emphysema in the left upper lobe is mild and unchanged. Discrete
sub 2 mm nodules in the left lower lobe (4.150 and 4.176) are
stable. Calcification of the aorta is unchanged, the heart size
is normal with no pericardial effusion. Pulmonary arteries are
normal, calcification of the aortic valve is stable.
Limited views of the upper abdomen are unremarkable except to
note atrophy of both kidneys and the pancreas.
No new destructive or sclerotic bone lesions, post-surgical
changes in the
right hemithorax are unchanged with extensive degenerative
changes throughout the thoracic spine.
IMPRESSION:
1) New stent in the bronchus intermedius with residual proximal
stenosis in the right main stem bronchus. The distal stent
contains intraluminal
secretions/granulation tissue
2)New peribronchial wall thickening in a subsegmental bronchus
in the right lower lobe, the presence of enlarged small right
pleural effusion and multiple centrilobular nodules suggest
superimposed infection or inflammation.
3)Stable sub-2-mm left lower lobe nodules.
4)Status post right upper lobectomy with post-surgical changes
including
radiation fibrosis in the right apex is stable.
5)Calcification of the coronary artery and aortic valve and
mitral valve is unchanged.
[**2185-8-30**] WBC-47.8* RBC-3.45* Hgb-10.9* Hct-34.9* MCV-101*
MCH-31.7 MCHC-31.4 RDW-15.3 Plt Ct-254
[**2185-9-1**] WBC-12.6* RBC-2.67* Hgb-8.6* Hct-25.7* MCV-97 MCH-32.3*
MCHC-33.4 RDW-15.5 Plt Ct-143*
[**2185-8-30**] Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-15
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2185-8-31**]: C diff neg
Bcx x2 NGTD, Ucx neg
Brief Hospital Course:
80F hx bronchial stenosis admitted evaluation. Flex bronch and
chest CT revealed granulation tissue around metal stent placed
[**8-3**]. Stent was subsequently removed and the airway was
dilated. The patient's WBC [**Known firstname **] to 47.8 and she was started on
Linezolid and Zosyn emperically. C. Diff was negative. The
following day WBC count decreased to 16.1. The elevated WBC
count may be attributed to a reaction to a colonized stent.
Following stent removal the patient did well, maintaining
original O2 requirements without SOB or complication. A R PICC
was placed for abx.
At time of discharge, patient's vitals are stable, she is
afebrile. She is tolerating a regular diet, ambulating and
breathing without difficulty.
Medications on Admission:
vitamin B12, aspirin, Advair, Synthroid 50 mcg, Lasix,
Omeprazole, albuterol neb'''' atenolol 12.5' Keppra, Dilantin,
Lipitor, Coumadin, baclofen, oxygen 2L
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day)
as needed for pain.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Phenytoin 50 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
13. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
17. Linezolid 600 mg/300 mL Parenteral Solution Sig: One (1)
Intravenous Q12H (every 12 hours) for 6 days.
18. Zosyn 2.25 gram Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5399**] Nursing Home - [**Hospital1 **]
Discharge Diagnosis:
Bronchus intermedius stenosis s/p stent retrieval dilation and
bronchial biopsy, COPD, GERD, CAD with stent placement, breast
cancer, s/p l Mastectomy; colon cancer, s/p colectomy; History
of syncopes and collapse (not in the last 1.5 years), LLE DVT
one year ago
Discharge Condition:
Fair
Discharge Instructions:
Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 7769**] if develops increased
shortness of breath, cough or chest pain.
Followup Instructions:
Follow-up with Dr.[**Name (NI) 5070**] [**Name (STitle) 766**] [**9-12**] at 11:30 in the Chest
Disease Center in the [**Hospital Ward Name 121**] Building [**Hospital1 **] I [**Telephone/Fax (1) 7769**]
Flexible Bronchoscopy [**2188-9-12**]:30 in the Chest Disease Center
NOTHING TO EAT OR DRINK AFTER MIDNIGHT [**2185-9-12**] for flex
bronchoscopy
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2185-9-6**]
|
Discharge summary
|
Classify the following medical document.
|
[**Age over 90 **] y/o M ([**Hospital1 328**] speaking only) with hx of HTN, hyperlipidemia, GERD
and CKD presented from home with increasing confusion. Mr. [**Known lastname 14418**]
became acutely confused while at synagogue. He stood up, was clutching
his head, complaining that he could not see or hear. [**Name8 (MD) **] MD was present
and found pt to have normal pulse, non-diaphoretic, and told family pt
likely hypoglycemic; pt took grape juice and remained at service. He
remained confused, did not respond when people shook his hand, could
not follow readings. He then returned home, walked on his own into the
house, and continued complaining of inability to hear. His son called
EMS, and he was brought in to the ED by EMS. Pt was reportedly well
prior to this event, which began acutely. Only recent illness was cough
2 weeks prior with clear CXR per son, treated with prednisone X [**3-17**]
days and abx X 5 days.
.
In the [**Name (NI) 73**], pt was agitated and unable to answer questions; he was
sedated with 2 mg Ativan. His son, wife, and family were present.
Initial vs were T 97.4, P 72, BP 110/46, R 20, 100%. Head CT was
negative for bleeds. The pt continued to become more and more agitated,
tachypneic, and was noted to have ST depressions. He was intubated for
tachypnea and agitation to protect his airway; sedation with
fentanyl/versed; VSS. CXR showed possible RUL PNA. He had an mri
which showed multi embolic strokes. He was started on a heparin gtt
which was stopped today.. Pt was extubated on [**4-19**] and has remained
stable since. He has had daily ekg
Pt alert, oriented per family to interpret. Mae. Follows commands.
Perrl. Pt cooperative today. A-febrile. Hr 48-50
s, sinus. Sbp
90-100
s. skin w+d. +pp. denies pain. Ls cta. O2 sat 96% ra. Nard
noted. Abd soft/nt/nd. +bs. Tol po
s. foley removed. Voided via
urinal. Stood and took few steps to chair with 1-2 assist. Tol well.
Pt is to have carotid ultrasound at 08:30 [**2196-4-21**].
Demographics
Attending MD:
[**Doctor Last Name **] [**Doctor Last Name **] F.
Admit diagnosis:
ALTERED MENTAL STATUS;PNEUMONIA
Code status:
Full code
Height:
Admission weight:
72.4 kg
Daily weight:
72.6 kg
Allergies/Reactions:
Augmentin (Oral) (Amox Tr/Potassium Clavulanate)
Unknown;
Precautions:
PMH:
CV-PMH:
Additional history:
Surgery / Procedure and date:
Latest Vital Signs and I/O
Non-invasive BP:
S:106
D:37
Temperature:
97
Arterial BP:
S:
D:
Respiratory rate:
8 insp/min
Heart Rate:
52 bpm
Heart rhythm:
SB (Sinus Bradycardia)
O2 delivery device:
None
O2 saturation:
94% %
O2 flow:
FiO2 set:
50% %
24h total in:
1,266 mL
24h total out:
365 mL
Pertinent Lab Results:
Sodium:
138 mEq/L
[**2196-4-20**] 02:56 AM
Potassium:
3.7 mEq/L
[**2196-4-20**] 02:56 AM
Chloride:
104 mEq/L
[**2196-4-20**] 02:56 AM
CO2:
24 mEq/L
[**2196-4-20**] 02:56 AM
BUN:
25 mg/dL
[**2196-4-20**] 02:56 AM
Creatinine:
0.9 mg/dL
[**2196-4-20**] 02:56 AM
Glucose:
95 mg/dL
[**2196-4-20**] 02:56 AM
Hematocrit:
37.1 %
[**2196-4-20**] 02:56 AM
Finger Stick Glucose:
136
[**2196-4-20**] 04:00 PM
Valuables / Signature
Patient valuables: Hearing aids: (Right Ear, Left Ear )
Other valuables:
Clothes: Sent home with:
Wallet / Money:
No money / wallet
Cash / Credit cards sent home with:
Jewelry:
Transferred from: [**Hospital 2517**]
Transferred to: [**Wardname 7098**]
Date & time of Transfer: [**2196-4-20**]
.
.
|
Nursing
|
Classify the following medical document.
|
[**2137-4-26**] 4:55 PM
MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # [**Clip Number (Radiology) 41666**]
MRV HEAD W/O CONTRAST
Reason: repeat MRI for VST
Admitting Diagnosis: CAVERNOUS SINUS THROMBOSIS
Contrast: MAGNEVIST Amt: 17
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
27 year old woman with VST
REASON FOR THIS EXAMINATION:
repeat MRI for VST
No contraindications for IV contrast
______________________________________________________________________________
PROVISIONAL FINDINGS IMPRESSION (PFI): RXRa SAT [**2137-4-27**] 12:42 PM
Areas of restricted diffusion are demonstrated in the thalamus bilaterally and
basal ganglia, more significant on the left and also in the splenium of the
corpus callosum, high signal intensity is noted in the straight sinus and
perisplenial veins, there is also evidence of slow flow in the left transverse
sinus and sigmoid sinus, consistent with venous sinus thrombosis. These
findings were discussed with Dr. [**First Name (STitle) 33594**] [**Name (STitle) 21808**] on [**2137-4-25**].
______________________________________________________________________________
FINAL REPORT
MRI AND MRA OF THE BRAIN AND MRV OF THE HEAD
CLINICAL INDICATION: 27-year-old woman with venous sinus thrombosis.
COMPARISON: Prior MRI from an outside institution ([**Hospital 3591**] Hospital).
TECHNIQUE: Pre-contrast sagittal and axial T1-weighted images were obtained,
axial FLAIR, axial T2, axial magnetic susceptibility, and axial
diffusion-weighted sequences. The T1-weighted images were repeated after the
administration of gadolinium contrast in axial T1, sagittal MP-RAGE,
multiplanar reconstructions were provided.
MRV of the head. 2D time-of-flight venography of the head was provided,
multiple source images were reviewed and also maximum-intensity projection
images.
FINDINGS: The images without contrast, demonstrate slow flow in the left
transverse sinus, sigmoid sinus, straight sinus, and perisplenial veins,
consistent with venous sinus thrombosis. Restricted diffusion is noted in the
thalamus, basal ganglia, and splenium of the corpus callosum, these areas are
more significant on the left, few scattered foci of restricted diffusion are
noted in the subcortical white matter bilaterally in the frontal lobes. There
is no evidence of hemorrhagic transformation. The ventricles and sulci are
normal in size and configuration with no evidence of hydrocephalus. The
orbits are unremarkable. The paranasal sinuses demonstrate mucosal thickening
in the sphenoid sinus and right ethmoidal air cells.
IMPRESSION: Venous sinus thrombosis involving the left transverse sinus,
sigmoid sinus, perisplenial veins, and straight sinus as described in detail
above. Areas of restricted diffusion, consistent with ischemia, possibly
subacute involving the thalamus, basal ganglia, splenium of the corpus
(Over)
[**2137-4-26**] 4:55 PM
MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # [**Clip Number (Radiology) 41666**]
MRV HEAD W/O CONTRAST
Reason: repeat MRI for VST
Admitting Diagnosis: CAVERNOUS SINUS THROMBOSIS
Contrast: MAGNEVIST Amt: 17
______________________________________________________________________________
FINAL REPORT
(Cont)
callosum, caudate nucleus, and bifrontal subcortical white matter.
MRV OF THE HEAD:
There is lack of flow throughout the straight sinus, left transverse sinus,
and sigmoid sinus, consistent with venous sinus thrombosis.
A preliminary report was communicated and discussed with Dr. [**First Name (STitle) 33594**] [**Name (STitle) 21808**]
on [**2137-4-25**].
|
Radiology
|
Classify the following medical document.
|
[**2109-12-22**] 7:35 PM
MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 27735**]
Reason: Invasive sinusitis? Brain abscess?
Contrast: MAGNEVIST Amt: 20
______________________________________________________________________________
FINAL ADDENDUM
ADDENDUM:
Additional information has been obtained from CareWeb Clinical Lookup since
the approval of the original report. Reason for exam should also state
delirium.
[**2109-12-22**] 7:35 PM
MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 27735**]
Reason: Invasive sinusitis? Brain abscess?
Contrast: MAGNEVIST Amt: 20
______________________________________________________________________________
[**Hospital 3**] MEDICAL CONDITION:
62 year old diabetic with bloody, prurulent nasal drainage and rapidly
progressive mental status changes
REASON FOR THIS EXAMINATION:
Invasive sinusitis? Brain abscess?
______________________________________________________________________________
FINAL REPORT
MRI OF THE BRAIN, [**2109-12-22**]:
INDICATION: Diabetic with purulent bloody nasal discharge. Rapidly
progressive mental status changes. Rule out brain abscess from invasive
sinusitis.
TECHNIQUE: Sagittal T1W images which demonstrate a small portion of the upper
cervical spine reveal mottled marrow signal within the C2 and C3 vertebra.
There is also patchy decreased T1 signal in the clivus. This could represent
an infiltrative marrow process, such as metastases or myeloma, and clinical
correlation is recommended.
There is also mucosal thickening in the sphenoid sinuses, and within the
maxillary and ethmoid air cells. Fluid levels are identified in the posterior
ethmoid air cells and in the left sphenoid sinus. There is opacification of
some of the mastoid air cells as well and a fluid level in the posterior
mastoid air cell on the right.
Overall, the sulcal and gyral pattern of the brain is normal. The ventricles
are prominent, but not dilated. There is a mild degree of T2 signal
hyperintensity in the periventricular white matter. There is also a faint
focus of increased T2 signal along the cortical surface of the right frontal
lobe. There is no clearly identifiable abnormal enhancement in this location
or elsewhere within the brain. No enhancing masses are identified to suggest
the presence of an abscess. There is no abnormal dural enhancement to
indicate empyema.
Flow is identified in the major branches of the Circle of [**Location (un) 286**] and in the
major intracranial veins.
IMPRESSION:
1) Sinusitis is identified, no definite penetration of the paranasal sinuses
into adjacent structures, is identified.
2) There are no cerebral abscesses or empyema.
3) There is a small focus of increased T2 signal in the right frontal lobe
which could represent the site of small cortical infarction, age
indeterminate.
4) Bony evaluation is recommended, since irregular marrow signal is
identified in the clivus and upper cervical vertebra.
(Over)
[**2109-12-22**] 7:35 PM
MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 27735**]
Reason: Invasive sinusitis? Brain abscess?
Contrast: MAGNEVIST Amt: 20
______________________________________________________________________________
FINAL REPORT
(Cont)
|
Radiology
|
Classify the following medical document.
|
CRITICAL CARE ATTENDING
01:00
I saw and examined Ms. [**Known lastname 6072**] with Dr. [**Last Name (STitle) 6369**], whose note reflects
my input. I would add/emphasize that this [**Age over 90 **]-year-old woman presents
from rehab (after a recent discharge) with altered mental status and
dyspnea. Her recent hospitalization was complicated (cholecystitis,
sepsis, respiratory failure, NSTEMI with CHF, acute renal failure, and
possible S. milleri endocarditis) and is well-detailed in OMR. In the
ED, was treated with NIMV, dexamethasone, nebs, and antibiotics for
wheezing and respiratory distress. Tolerated for a while but became
unable to tolerate due to agitation (and also had increasing BP); she
was intubated.
PMH, SH, FH, Meds, Allergies as per Dr. [**Last Name (STitle) 6369**]
s note.
On exam she is sedated on the ventilator. Pupils are midline and
small. Lungs are clear without wheezes at present. Heart is regular
with holosystolic murmur. Abdomen is soft without clear tenderness.
There is a sacral decub. Scant edema. She is sedated, so neurologic
exam is limited. However, she has sustained bilateral lower extremity
clonus. Upper extremity reflexes are brisk but there is no clonus.
Toes are mute. (Note that she was seen by neurology prior to
intubation and they did not find localizing signs.) PICC site looks
clean.
Labs review in OMR. Notable for 7.37 / 57 / 121; no leuks on UA; HCO3
33 (increased); WBC 8.
Imaging
CXR showed ?some improvement from prior.
CT torso interpreted as
ground glass opacities predominately with in
upperlobes may represent infection. small b/l pleural eff; contracted
gallbladder with enhancing wall, significantly decompressed compared to
prior study and may represent chronic cholecystitis. diverticulosis w/o
diverticulitis.
CT of the head interpreted as
severely limited study secondary to
motion artifact. low density noted within the left aspect of the pons
and midbrain which could represent artifact vs infarct.
Assessment and Plan
[**Age over 90 **]-year-old woman with recent admission notable for cholecystitis,
NSTEMI with LV systolic dysfunction, S. milleri bacteremia (treated
presumptively as endocarditis/discitis but no confirmatory imaging was
able to be obtained) now presents with apparently acutely altered
mental status, respiratory distress, and abnormal chest imaging.
Notably, there is no fever and no leucocytosis.
It is unclear which came first: respiratory distress
delirium, or
delirium
increased SVR
increased MR
pulmonary edema. Her CT
imaging could be either pulmonary edema (seems a bit more likely) or
infectious.
Finally, the lower extremity clonus raises the possibility of serotonin
syndrome, though seems less likely given lack of fever, rigidity, and
chronicity of most of her medications.
Although infection seems less likely, a [**Age over 90 **]-year-old woman could
certainly present with meaningful infection without fever. Given the
apparent acuity of symptoms and the broad differential diagnosis, we
will therefore plan:
We will plan:
1) LP (primarily to exclude HSV)
2) Viral DFA
3) Sputum culture and mini-BAL
4) Treat empirically for HCAP at present.
5) Leave PICC in place pending BCx and further evaluation.
6) Discuss with her prior I.D. physicians tomorrow: given
previous uncertainty of endocarditis and osteomyelitis, would
management be changed by TEE or MRI at this point? (while intubated)
7) Ask neuro to re-examine; discuss role of spine MRI (several
reassuring signs on exam, but will discuss our finding of clonus)
8) Hold serotenergic meds pending further evaluation
9) If above is unrevealing, consider trial of CHF treatment.
She is critically ill. 50 minutes.
------ Protected Section ------
Procedure: LP (unsuccessful)
2:30
Multiple attempts at LP by resident and myself. Unsuccessful
unable
to enter space.
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) 906**], MD
on:[**2163-6-7**] 02:34 ------
Critical Care Staff Addendum
2:30 am
Unable to complete LP. Will consult neuro for assistance.
Although pretest probability is low, HSV and Listeria could present in
this way. Will therefore cover empirically while reviewing with
neurology.
25 minutes
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) 906**], MD
on:[**2163-6-7**] 02:38 ------
|
Physician
|
Classify the following medical document.
|
Chief Complaint: Elective intbuation for bronchoscopy
Reason for ICU admission: hypoxia
HPI:
Ms [**Known lastname 11669**] is an 81 year old woman with past medical history
significant for chronic low back pain, coronary artery disease,
hypertension, hyperlipidemia, and question of vasculitis, transferred
to medicine from PACU after undergoing bronchoscopy for workup or a
right lower lobe mass and developing a new oxygen requirement now
transfered to the [**Hospital Unit Name 10**] for possible radiation.
.
Briefly, Ms [**Known lastname 11669**] began having a chronic cough and some hemoptysis
this past [**Month (only) 1961**]. Workup for this included a CT scan, which revealed
a large (6cm) cavitary lesion. She underwent extensive evaluation for
possible metastatic disease including head MRI, PetCT and bronchoscopy,
however although Pet revealed markedly FDG avid right lower lobe mass
with a satellite nodule, transbronchial biopsy and washings were non
diagnostic. Patient was electively admitted [**2151-3-22**] to have repeat
rigid bronchoscopy with FNA of lymph nodes under ultrasound guidance.
Patient was extubated without difficulty however she remained hypoxic
was still requiring supplemental oxygen on admission to MICU [**Location (un) **].
.
Patient denied any pain, but reported being slightly disoriented still.
Had a heavy cough and reports some difficulty breathing, no nausea.
.
In the PACU, 137/68 96 93% on 50% face tent. Patient was given Lasix
20mg IV and was admitted to MICU team for further management.
.
In MICU [**Location (un) **] she continued to be hypoxic, thought [**1-26**] PNA, and was
electively intubated on [**2151-3-23**] and started on Vancomycin/Cefepime. At
this time she was also having episodes of VT that were treated with
amiodarone load and then gtt. Since then these episodes seem to be
resolved. She had an a-line and [**Date Range 864**] placed as well. She was extubated
on [**3-24**] but overnight was having increased work of breathing, many
secretions, coughing and was re-intubated. Currently on propofol with
good oxygenation.
The biopsy results came back positive for non-small cell carcinoma
and today rad-onc was consulted. She was transferred to the [**Hospital Unit Name 10**] to
initiate this treatment with rad-onc.
On admission to the [**Hospital Unit Name 10**] the patient was intubated, sedated but able
to answer questions. She denied pain and trouble breathing. Rest of ROS
limited [**1-26**] intubation.
Patient admitted from: [**Hospital1 1**] [**Hospital1 192**]
History obtained from [**Hospital 31**] Medical records
Patient unable to provide history: Sedated
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Levofloxacin - [**2151-3-23**] 12:20 AM
Ampicillin/Sulbactam (Unasyn) - [**2151-3-23**] 02:00 PM
Cefipime - [**2151-3-24**] 06:30 PM
Vancomycin - [**2151-3-25**] 08:00 AM
Infusions:
Fentanyl - 25 mcg/hour
Midazolam (Versed) - 1 mg/hour
Other ICU medications:
Morphine Sulfate - [**2151-3-25**] 05:00 AM
Other medications:
CURRENT HOME MEDICATIONS: </b>
Lasix 20 mg daily
Lisinopril 20/HCTZ 12.5 mg a day
Inderal 20 mg q.i.d. (for tremor)
Gemfibrozil 600 mg b.i.d
Simvastatin 20 mg a day
Omeprazole 20 mg a day
Caltrate 600 mg a day
Iron 65 mg a day
Aspirin 81 mg a day
Protonix 40 mg a day
Alprazolam 0.25 mg q.i.d. p.r.n.
Lyrica 150 mg a day
Darvocet p.r.n.
SLNG as needed
.
CURRENT IN-HOSPITAL MEDICATIONS: </b>
Codeine Sulfate 15 mg PO/NG Q4H:PRN cough [**3-22**] @ 2256
Morphine Sulfate 0.5-1 mg IV Q4H:PRN pain
Acetaminophen 325-650 mg PO/NG Q6H:PRN pain/fever [**3-22**] @ 2329
Simvastatin 20 mg PO/NG DAILY [**3-22**] @ 2329
Aspirin 81 mg PO/NG DAILY Start: In am [**3-22**] @ 2329
Lidocaine 5% Patch 1 PTCH TD DAILY [**3-23**] @ 0925
Alprazolam 0.25 mg PO/NG TID:PRN anxiety [**3-23**] @ 0925
Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION [**3-23**] @ 1511
Midazolam 0.5-2 mg/hr IV DRIP INFUSION
Albuterol Inhaler 6 PUFF IH Q4H:PRN wheezing [**3-23**] @ 1638
Ipratropium Bromide MDI 6 PUFF IH Q4H:PRN wheezing [**3-23**] @ 1638
CefePIME 2 g IV Q24H [**3-23**] @ 1708
Vancomycin 1000 mg IV Q 24H
Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP > 60 [**3-23**] @
[**2053**]
Pantoprazole 40 mg IV Q24H [**3-24**] @ 0148
Lorazepam 0.5 mg IV Q6H:PRN anxiety - please give ONLY IF UNABLE TO
TAKE PO XANAX
Past medical history:
Family history:
Social History:
CAD - with reversible defect on p-mibi [**2146**]
Diastolic Dysfunction - EF 67%
Low anterior resection [**2146**] for complicated diverticular disease
HTN
Hyperlipidemia
Vasculitis?
Lower extremity neuropathy
Post operative pulmonary embolis
<br><b>PAST SURGICAL HISTORY: </b>
ILEOSTOMY [**1-26**] DIVERTICULITIS s/p takedown in [**2146**]
No family history of lung cancer
Sister with breast cancer
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Ex smoker, 20 pack year history. Denies alcohol or drug use.
Lives with room mate, is originally from [**Country 10520**].
Review of systems:
Flowsheet Data as of [**2151-3-25**] 10:27 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**52**] AM
Tmax: 37.6
C (99.6
Tcurrent: 36.5
C (97.7
HR: 102 (83 - 133) bpm
BP: 112/64(81) {96/50(65) - 160/90(116)} mmHg
RR: 22 (20 - 33) insp/min
SpO2: 92%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 73.7 kg (admission): 74.4 kg
Total In:
1,485 mL
571 mL
PO:
TF:
IVF:
1,425 mL
571 mL
Blood products:
Total out:
655 mL
360 mL
Urine:
655 mL
360 mL
NG:
Stool:
Drains:
Balance:
830 mL
211 mL
Respiratory
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 450 (450 - 450) mL
Vt (Spontaneous): 426 (426 - 675) mL
PS : 8 cmH2O
RR (Set): 20
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
PIP: 18 cmH2O
Plateau: 17 cmH2O
Compliance: 37.5 cmH2O/mL
SpO2: 92%
ABG: 7.41/41/175/23/1
Ve: 10.5 L/min
PaO2 / FiO2: 350
Physical Examination
VITAL SIGNS - Temp99.1 F, BP 118/65mmHg, HR 109-125 BPM, RR 22',
O2-sat 97% on AC 450X20 50% FiO2 5 peep
GENERAL - well-appearing female in NAD, comfortable, intubated
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM,
NECK - supple, no JVD, RIJ without erythema/exudate
LUNGS - good air movement, resp unlabored bronchial BS on right middle
with otherwise CTA anterior lung fields
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding but
slight TTP RUQ.
EXTREMITIES - trace edema bilaterally
Labs / Radiology
563 K/uL
8.2 g/dL
108 mg/dL
0.8 mg/dL
18 mg/dL
23 mEq/L
105 mEq/L
3.6 mEq/L
138 mEq/L
26.7 %
15.5 K/uL
[image002.jpg]
[**2146-12-26**]
2:33 A3/30/[**2150**] 07:13 AM
[**2146-12-30**]
10:20 P3/30/[**2150**] 04:21 PM
[**2146-12-31**]
1:20 P3/30/[**2150**] 04:39 PM
[**2147-1-1**]
11:50 P3/30/[**2150**] 10:31 PM
[**2147-1-2**]
1:20 A3/31/[**2150**] 03:44 AM
[**2147-1-3**]
7:20 P3/31/[**2150**] 03:54 AM
1//11/006
1:23 P3/31/[**2150**] 07:39 AM
[**2147-1-26**]
1:20 P3/31/[**2150**] 04:06 PM
[**2147-1-26**]
11:20 P4/1/[**2150**] 02:13 AM
[**2147-1-26**]
4:20 P4/1/[**2150**] 05:04 AM
WBC
17.8
28.1
19.3
15.5
Hct
28.6
30.2
28.0
26.7
Plt
695
648
766
563
Cr
1.0
1.1
1.0
0.8
TropT
0.07
0.25
0.19
TC02
29
31
28
26
27
Glucose
89
129
116
110
118
100
108
Other labs: PT / PTT / INR:16.3/95.5/1.4, CK / CKMB /
Troponin-T:42//0.19, ALT / AST:[**4-6**], Alk Phos / T Bili:72/0.2,
Differential-Neuts:91.2 %, Lymph:6.0 %, Mono:2.2 %, Eos:0.5 %, Lactic
Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:11.2 mg/dL, Mg++:1.9 mg/dL,
PO4:2.2 mg/dL
Fluid analysis / Other labs: Last ABG: 7.41/41/175/27 on 450X20 50%
peep5
Imaging: CXR [**2151-3-25**]: FINDINGS: As compared to the previous examination,
the monitoring and support devices are in unchanged position. The
extent of the right-sided pleural effusion has minimally decreased. On
the left, no effusion is present. In unchanged manner, mild-to-moderate
pulmonary edema is present. Unchanged retrocardiac atelectasis. No
evidence of newly appeared focal parenchymal opacities suggesting
pneumonia.
.
CTA CHEST ([**2151-1-15**])
IMPRESSION:
1. Large, necrotic right lower lobe cavitated 6 cm mass, and adjacent
necrotic 2 cm nodule, both with peripheral enhancement. Differential
diagnosis includes necrotic neoplasm, infection (including
granulomatous infection), or vasculitis, such as Wegener's
granulomatosis. Recommend biopsy/tissue sampling - the larger mass is
amenable to either bronchoscopic or percutaneous approach for biopsy.
2. Emphysema.
3. Stable nonspecific mild subpleural interstitial fibrosis.
.
ECHO: ([**2150-3-26**])
The left atrium is elongated. The right atrium is moderately dilated.
Left ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality cannot be
fully excluded but appears the inferior wall is hypokinetic.
Transmitral Doppler and tissue velocity imaging are consistent with
Grade I (mild) LV diastolic dysfunction. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. There is no pericardial
effusion. Compared with the prior study (images reviewed) of [**2147-5-23**],
there is no significant change
IMPRESSION: Focal left ventricular dysfunction c/w CAD. Mild mitral
regurgitation.
Microbiology: [**2151-3-23**] 6:00 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2151-3-23**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml.
PATHOLOGY: ([**2151-3-23**])
II. Right lung, transbronchial biopsy:
Poorly-differentiated non-small cell carcinoma with squamoid features.
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 2**])
Ms [**Known lastname 11669**] is an 81 year old woman with past medical history
significant for coronary artery disease and hypertension, admitted for
elective bronchoscopy to workup right lower lobe mass found to be
non-small cell carcinoma complicated by hypoxic respiratory failure now
transfered to the [**Hospital Unit Name 10**] for possible radiation.
.
#. Hypoxic Respiratory Failure: Likely [**1-26**] PNA and underlying
malignancy although BAL at bedside did not reveal any organisms. CXR
not consistent with ARDS and other etiologies more likely than PE. Does
have history of diastolic CHF and was getting 20mg IV lasix PRN in MICU
to help with hypoxia given CXR finding of increased pulm edema.
- Continue ARDSNET ventilation
- Treat malignancy as below
- contiue current abx (vanc/cfp) for HCAP. Today is day [**3-7**].
- Attempt weaning vent settings after rad onc treatment
- consider therapeutic thoracentesis if continues to be hypoxic
- F/U rad-onc recs although preliminarily they believe this will not be
helpful to the acute hypoxia it may help the airway
irritation/secretions that caused her to be reintubated
overnight->suggest CT Chest to better evaluate. Attending will see her
later today
- Lasix 20mg IV PRN with goal -500-1L today.
.
# Hypercalcemia: Albumin only 2.2 so corrected calcium actually >12.
With appropriately low PTH this is likely from malignancy related tumor
factors.
- Follow up parathyroid related peptide
- Treat with lasix PRN
- Consider bisphosphonates
.
# Anemia: LIkely ACD however hct lower today than has been (26 from
28).
- Check PM hct and if lower send hemolysis labs, iron studies.
.
#. Non-small Cell CA: Biopsy results confirmed this diagnosis - patient
is unaware of the diagnosis.
- Follow up rad-onc recs re: radiation treatment in next week
- DVT prophylaxis
.
# VT. Possibly triggered by hypoxia/respiratory distress. 4 episodes
over ~30 minutes which broke with amiodarone (150 x 2 and then 0.5
mg/min drip) and respiratory support. Was intubated and started on
amiodarone drip with no more episodes. Completed amiodarone drip,
monitored off PO with no more episodes.
- Monitor on telemetry
.
# Troponin leak. With known h/o CAD this was likely demand ischemia in
setting of tachyarrhythmia, hypoxia. No significant increase in CK,
CK-MB. Troponins now down-trending.
- Trend EKG
- Continue ASA, statin.
.
# Hyperlipidemia: Continue statin.
.
# Chronic Diastolic Heart Failure: Has h/o HF with normal EF on TTE
last year. Currently with pulm edema on CXR that may be contributing to
hypoxia as above.
- I/O - 500-1L today
- Daily weights
.
#. FEN - No IVF, E- replete PRN, N- NPO ->will need to start tube feeds
after rad-onc recs
.
#. Access - [**Last Name (LF) 864**], [**First Name3 (LF) 865**]
.
#. PPx -
-DVT ppx with SC heparin
-Bowel regimen colace/senna
-Pain management with fent/midaz
.
#. Code - full
.
# Communication: with neice
.
#. Dispo - ICU pending clinical improvement
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2151-3-23**] 01:58 PM
18 Gauge - [**2151-3-23**] 02:20 PM
Arterial Line - [**2151-3-23**] 03:30 PM
Multi Lumen - [**2151-3-23**] 05:45 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
|
Physician
|
Classify the following medical document.
|
Chief Complaint: resp failure
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
CARDIOVERSION/DEFIBRILLATION - At [**2167-10-19**] 11:50 AM
aqdenosine 6mg given X 1 by cardiologist to assess pt's rhythm. Pt
tolerated well.
Held Valium ansd Benedryl and has done well without
Allergies:
Penicillins
Rash; blisters;
Tetracycline
Rash;
Sulfa (Sulfonamides)
Rash;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2167-10-20**] 11:48 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.5
C (97.7
Tcurrent: 36.5
C (97.7
HR: 118 (76 - 144) bpm
BP: 131/72(85) {93/43(0) - 154/134(138)} mmHg
RR: 26 (12 - 36) insp/min
SpO2: 94%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 106 kg (admission): 94.2 kg
Height: 67 Inch
Total In:
1,945 mL
680 mL
PO:
TF:
IVF:
1,800 mL
560 mL
Blood products:
Total out:
2,300 mL
680 mL
Urine:
2,245 mL
680 mL
NG:
55 mL
Stool:
Drains:
Balance:
-355 mL
0 mL
Respiratory support
O2 Delivery Device: High flow neb, Tracheostomy tube
Ventilator mode: MMV/PSV/AutoFlow
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 319 (319 - 319) mL
PS : 10 cmH2O
RR (Set): 12
RR (Spontaneous): 15
PEEP: 5 cmH2O
FiO2: 50%
RSBI Deferred: No Spon Resp
PIP: 15 cmH2O
SpO2: 94%
ABG: ///36/
Ve: 5.5 L/min
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
10.0 g/dL
548 K/uL
128 mg/dL
0.8 mg/dL
36 mEq/L
4.1 mEq/L
6 mg/dL
105 mEq/L
148 mEq/L
32.7 %
7.6 K/uL
[image002.jpg]
[**2167-10-13**] 05:00 AM
[**2167-10-14**] 02:06 AM
[**2167-10-15**] 07:34 AM
[**2167-10-16**] 03:50 AM
[**2167-10-16**] 06:22 AM
[**2167-10-17**] 02:58 AM
[**2167-10-18**] 03:43 AM
[**2167-10-18**] 05:02 PM
[**2167-10-19**] 03:36 AM
[**2167-10-20**] 02:30 AM
WBC
5.9
7.5
5.6
6.1
7.0
7.1
7.1
6.9
7.6
Hct
27.2
26.8
27.0
27.0
29.7
28.9
29.2
27.8
32.7
Plt
296
306
335
[**Telephone/Fax (3) **]
452
467
548
Cr
0.7
0.6
0.5
0.7
0.7
0.6
0.7
0.8
0.7
0.8
Glucose
134
134
121
[**Telephone/Fax (3) 1444**]
104
108
131
128
Other labs: PT / PTT / INR:48.3/33.3/5.5, CK / CKMB /
Troponin-T:72//<0.01, ALT / AST:25/19, Alk Phos / T Bili:106/0.2,
Amylase / Lipase:[**10-22**], Differential-Neuts:83.4 %, Lymph:10.4 %,
Mono:2.8 %, Eos:3.0 %, Fibrinogen:710 mg/dL, Lactic Acid:1.1 mmol/L,
Albumin:3.5 g/dL, LDH:192 IU/L, Ca++:10.0 mg/dL, Mg++:2.5 mg/dL,
PO4:4.3 mg/dL
Assessment and Plan
1. Tachycardia: runs of atach versus AVNRT. On bblocker be not very
effective- EP consult for ? is there an ablatable focus.
2. Resp Failure
Trach mask trials as tolerating (needing QHS support at
present)
PMV trials
S/P rx for pan [**Last Name (un) 46**] Klebs PNA.
Per IP not stent planned as technically not possible to
place into her airway
3. DVT and coagulopathy On warfarin but high inr. Hold warfarin until
inr 2-2.5 range or bridge with loveox if may get procedures
4. Feeding tube Getting reglan trial but still with emesis. Need to
coordinate IR advance of G to J tube with Thoracics
5. Hypernatremia Replete free water.
Please see today
s ICU team note for other issues.
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2167-10-19**] 12:00 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent:
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2130-7-3**] Discharge Date: [**2130-7-6**]
Service: Medicine Intensive Care Unit - Green
CHIEF COMPLAINT: The patient came in with hematemesis,
melanotic stools.
HISTORY OF PRESENT ILLNESS: This is an 83 year old female
with past medical history of cerebrovascular accident,
congestive heart failure, hypertension, prior seizure
disorder treated one month ago for congestive heart failure
flare, diagnosed at [**Hospital6 256**] in
the Emergency Department by chest x-ray. The patient had two
episodes of hematemesis and multiple episodes of melena. The
patient was admitted to the Emergency Department from the
nursing home PD. No 1:2 contact and could not communicate
well with anyone at the nursing home. In the Emergency Room
the patient had one episode of hypotension. A right internal
jugular central line was placed. The patient had nasogastric
lavage which was grossly bloody with no clots. The patient
received 1.9 liters of fluid and was hemodynamically stable.
The patient also received 5 mg Vitamin K subcutaneously. The
patient received 1 unit of fresh frozen plasma in the
Emergency Department and 1 unit of fresh frozen plasma on the
way to the unit. The patient was Do-Not-Resuscitate,
Do-Not-Intubate and the patient had no shortness of breath or
chest pain.
PHYSICAL EXAMINATION: On physical examination the patient
had a temperature of 97. The patient had a blood pressure of
116/63, pulse of 80, respiratory rate of 21 and was sating
96% on room air. Pertinent physical findings revealed the
patient's chest was clear to auscultation bilaterally.
Heart, regular rate and rhythm, no murmurs, rubs or gallops.
Abdomen was soft and obese and she had some right upper
quadrant tenderness. Extremities were 1+ edema bilateral
lower. Neurologically she had some right facial weakness,
otherwise cranial nerves were grossly intact.
LABORATORY DATA: She came in with a hematocrit of 31.6 and
an INR of 4.2. The patient had a chest x-ray which showed a
right venous catheter and bilateral mid to lower lung sound
atelectasis. The patient had electrocardiogram, sinus at 96
with normal axis, normal intervals, no ST-T wave changes
except for flip Ts in 1 and AVL which were consistent with
previous electrocardiogram.
HOSPITAL COURSE: The patient was admitted to the Medicine
Intensive Care Unit and diagnosed with gastrointestinal
bleed. The patient received 2 units of blood and a total of
4 units of fresh frozen plasma over the course of the stay
for the gastrointestinal bleed. On [**7-6**], the patient
underwent an upper esophagogastroduodenoscopy that showed
gastritis and two ulcers in the duodenal bulb which were not
given any treatment. There was no blood and they stabilized
on their own. The patient also received Protonix 40 mg
intravenously b.i.d.
Cardiac - The patient has a history of congestive heart
failure, coronary artery disease, kept hematocrit greater
than 30 with 2 units of packed red blood cells and gave only
careful hydration, one bolus of 250 cc. The patient also had
Zestril changes to Captopril in case of bleed. That should
be decided by outpatient doctor, what to do with cardiac
medications.
Chest - We monitored the patient for congestive heart
failure. The patient was fine.
Heme - The patient received fresh frozen plasma and packed
red blood cells as previously stated. The patient also
received Vitamin K as previously stated. INR was reduced to
1.3. The patient is to have Pneuma boots in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
rather than Coumadin because of bleed risk. Outpatient
doctor [**First Name (Titles) **] [**Last Name (Titles) 11197**] in future for Coumadin.
Neurological - The patient had previous cerebrovascular
accident and we continued on Phenobarbital and Prozac with
seizure history.
Infectious disease - No issues.
Genitourinary - The patient had Foley catheter placed to
monitor intake and output. Electrolytes were monitored over
the course of the stay. The patient had a brief episode of
hypernatremia treated with free water. The patient prepared
for discharge with discontinuation of right internal jugular
line, central line, right nasal cannula, Foley catheter and
Telemetry.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Back to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], already talked to
the nurse on the floor.
DISCHARGE DIAGNOSIS:
1. Upper gastrointestinal bleed due to duodenal bulb ulcers
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg p.o. q. 12 hours
2. Phenobarbital 90 mg p.o. q. AM
3. Fluoxetine 20 mg p.o. q.d.
4. Colace 100 mg p.o. b.i.d. prn
The patient did not receive ACE inhibitors in-house on [**7-6**] due to low blood pressure. Outpatient doctor to decide,
though the patient's pressure remains low.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 23023**]
MEDQUIST36
D: [**2130-7-6**] 11:53
T: [**2130-7-6**] 14:23
JOB#: [**Job Number 31671**]
|
Discharge summary
|
Classify the following medical document.
|
CVICU
HPI:
52yoM POD # 1 from AVR (25 StJude Mech)/Asc Ao replacement/CABG
x1(LIMA-LAD)
PMHx:
Complete Heart Block(PPM), Postop DVT in LUE [**3-20**] following lead
extraction, Hyperlipidemia, s/p Dual chamber pacemaker '[**87**], s/p
replacement PM generator '[**96**], s/p Lead extraction & reimplantation of
PPM [**3-20**], Hernia repair as child
Current medications:
Acetaminophen, Albumin 5% (25g / 500mL), Aspirin EC, CefazoLIN,
Docusate Sodium, Furosemide, Insulin, Ketorolac, Magnesium Sulfate,
Metoclopramide, Metoprolol Tartrate, Milk of Magnesia, Morphine
Sulfate, Oxycodone-Acetaminophen, Potassium Chloride, Ranitidine,
Warfarin
24 Hour Events:
WOUND CULTURE - At [**2105-2-3**] 01:25 PM
OR RECEIVED - At [**2105-2-3**] 01:25 PM
INVASIVE VENTILATION - START [**2105-2-3**] 01:25 PM
ARTERIAL LINE - START [**2105-2-3**] 01:50 PM
[**Location (un) **] LINE - START [**2105-2-3**] 01:51 PM
CCO PAC - START [**2105-2-3**] 01:51 PM
EKG - At [**2105-2-3**] 03:30 PM
EXTUBATION - At [**2105-2-3**] 08:35 PM
Allergies:
Penicillins
Unspecified
Last dose of Antibiotics:
Cefazolin - [**2105-2-4**] 04:05 AM
Other ICU medications:
Ranitidine (Prophylaxis) - [**2105-2-3**] 05:44 PM
Morphine Sulfate - [**2105-2-3**] 09:30 PM
Insulin - Regular - [**2105-2-4**] 03:01 AM
Furosemide (Lasix) - [**2105-2-4**] 06:00 AM
Flowsheet Data as of [**2105-2-4**] 08:40 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**06**] a.m.
HR: 85 (73 - 104) bpm
BP: 98/64(71) {98/64(71) - 102/79(85)} mmHg
RR: 23 (12 - 32) insp/min
SPO2: 98%
Heart rhythm: V Paced
Wgt (current): 135.5 kg (admission): 125 kg
Height: 71 Inch
CVP: 14 (3 - 16) mmHg
PAP: (31 mmHg) / (21 mmHg)
CO/CI (Fick): (7.7 L/min) / (3.2 L/min/m2)
CO/CI (CCO): (6 L/min) / (3.9 L/min/m2)
SvO2: 69%
Mixed Venous O2% sat: 82 - 82
Total In:
5,712 mL
685 mL
PO:
120 mL
200 mL
Tube feeding:
IV Fluid:
5,592 mL
235 mL
Blood products:
250 mL
Total out:
1,195 mL
820 mL
Urine:
785 mL
600 mL
NG:
50 mL
Stool:
Drains:
Balance:
4,517 mL
-136 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Set): 600 (550 - 600) mL
Vt (Spontaneous): 771 (771 - 771) mL
RR (Set): 18
RR (Spontaneous): 14
PEEP: 5 cmH2O
FiO2: 50%
RSBI: 14
PIP: 17 cmH2O
Plateau: 17 cmH2O
SPO2: 98%
ABG: 7.37/44/198/23/0
Ve: 14.2 L/min
PaO2 / FiO2: 396
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: bases)
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
188 K/uL
10.1 g/dL
133 mg/dL
0.7 mg/dL
23 mEq/L
4.9 mEq/L
14 mg/dL
108 mEq/L
138 mEq/L
30.9 %
12.6 K/uL
[image002.jpg]
[**2105-2-3**] 12:01 PM
[**2105-2-3**] 12:21 PM
[**2105-2-3**] 12:24 PM
[**2105-2-3**] 01:32 PM
[**2105-2-3**] 01:51 PM
[**2105-2-3**] 02:42 PM
[**2105-2-3**] 03:40 PM
[**2105-2-3**] 07:28 PM
[**2105-2-3**] 07:47 PM
[**2105-2-4**] 02:43 AM
WBC
13.1
12.6
Hct
29
28
29.6
29.6
30.9
Plt
[**Telephone/Fax (3) 11170**]
Creatinine
0.6
0.7
TCO2
23
24
25
24
24
26
Glucose
153
136
113
106
115
138
133
Other labs: PT / PTT / INR:12.9/27.7/1.1, Fibrinogen:181 mg/dL, Lactic
Acid:4.4 mmol/L, Mg:1.8 mg/dL
Imaging: CXR: sm pleural effusions L>R
Microbiology: NGTD
ECG: SR
Assessment and Plan
CORONARY ARTERY BYPASS GRAFT (CABG), VALVE REPLACEMENT, AORTIC
MECHANICAL (AVR), ACUTE PAIN
Assessment and Plan: s/p AVR(25 StJude Mech)Asc Ao replacement/CABG
x1(LIMA-LAD)[**2-3**] now extubated successfuly
Neurologic: Neuro checks Q: 4 hr, Pain controlled, On percocet and
toradol
Cardiovascular: Aspirin, Beta-blocker, HD stable. Pacemaker
interrogation by EP was normal, remove epicardial wires. Start home
dose of zocor today. Will start 5 mg coumadin tonight for mechanical
valve. SBP goal <120.
Pulmonary: IS, OOB
chair, ambulate. [**Month (only) 11**] discontinuing chest tube
later based on output.
Gastrointestinal / Abdomen: Bowel regimen
Nutrition: Regular diet
Renal: Foley, Adequate UO, Diurese for goal of [**12-12**].5 L negative today.
Hematology: Serial Hct, post-operative anemia, monitor for now
Endocrine: RISS with adequate BG control, Blood glucose goal of <150
Infectious Disease: No evidence of infection. Peri-op cefazolin
Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Consults: Cardiovascular, P.T.
ICU Care
Nutrition: Heart healthy
Glycemic Control: RISS, blood glucose goal <150
Lines:
18 Gauge - [**2105-2-3**] 01:52 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle: HOB elevated, mouth care
Communication: Patient discussed on morning rounds by surgical team
Code status: Full code
Disposition: Transfer to floor
Total time spent: 20 min
|
General
|
Classify the following medical document.
|
[**2136-2-13**] 1:08 PM
CT ABD & PELVIS WITH CONTRAST Clip # [**Clip Number (Radiology) 26937**]
Reason: Changes from reference CT scan. ? continued abdominal proces
Admitting Diagnosis: ISCHEMIC BOWEL
Contrast: OMNIPAQUE Amt: 130
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
74 year old man enteritis/colitis with continued diarrhea. Looking for areas of
inflammation for possible biopsy on [**2136-2-14**]. Would like PO/IV contrast
REASON FOR THIS EXAMINATION:
Changes from reference CT scan. ? continued abdominal process.
No contraindications for IV contrast
______________________________________________________________________________
FINAL REPORT
HISTORY: 74 year male with enteritis and continued diarrea.
COMPARISON: Prior CTs from [**Hospital3 **] dated [**2136-2-3**], [**2-5**], [**2135**], and [**2136-2-7**] and prior CT from [**Hospital1 26938**] dated [**2136-2-9**].
TECHNIQUE: Multidetector helical acquisition was obtained through the abdomen
and pelvis with 130 mL of intravenous contrast. Additional sagittal and
coronal reformatted images were obtained.
ABDOMEN:
There is stable cardiomegaly. The lung bases are clear. The liver,
gallbladder, adrenals, pancreas and spleen appear normal. There are small
stable bilateral renal cysts. There is atherosclerotic disease of the aorta.
There is no retroperitoneal adenopathy.
There is interval increase in the amount of abdominal ascites. There is
unchanged mural thickening, edema and heterogeneous enhancement essentially
contiguously from the distal jejunum through the terminal ileum to the
ileocecal valve. The colon is fluid filled; however, the colonic wall is
normal in thickness and enhancement.
PELVIS:
The bladder is collapsed with a Foley catheter within it with interval
decrease in the perivesicular stranding. There is pelvic ascites, which has
increased from the prior exam. There is no pelvic adenopathy or mass. The
osseous structures are intact.
IMPRESSION:
Unchanged mural thickening, edema and heterogeneous enhancement essentially
contiguously from the distal jejunum through the terminal ileum to the
ileocecal valve. Interval increase in the amount of ascites. This is most
suggestive of an inflammatory enteritis (eg, autoimmune or eosinophilic but
not Crohn's) or infectious enteritis given the appearance and progression from
[**2136-2-5**] through [**2136-2-9**] CTs.
Decreased perivesicular stranding.
(Over)
[**2136-2-13**] 1:08 PM
CT ABD & PELVIS WITH CONTRAST Clip # [**Clip Number (Radiology) 26937**]
Reason: Changes from reference CT scan. ? continued abdominal proces
Admitting Diagnosis: ISCHEMIC BOWEL
Contrast: OMNIPAQUE Amt: 130
______________________________________________________________________________
FINAL REPORT
(Cont)
|
Radiology
|
Classify the following medical document.
|
MICU Intern Progress Note:
24 Hour Events:
FEVER - 103.0
F - [**2170-5-17**] 12:00 AM
- HIV, pcp negative
[**Name Initial (PRE) **] sent [**Doctor First Name **], ANCA
- changed CTX to Cefepime
- continues to [**Last Name (LF) **], [**First Name3 (LF) **] far cultures negative
Allergies:
Atorvastatin
Nausea/Vomiting
Ibuprofen
Nausea/Vomiting
Levofloxacin
Hives;
Last dose of Antibiotics:
Ceftriaxone - [**2170-5-15**] 05:36 PM
Azithromycin - [**2170-5-16**] 10:00 AM
Vancomycin - [**2170-5-16**] 08:07 PM
Cefipime - [**2170-5-17**] 12:29 AM
Infusions:
Fentanyl (Concentrate) - 200 mcg/hour
Midazolam (Versed) - 4 mg/hour
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2170-5-16**] 04:00 PM
Famotidine (Pepcid) - [**2170-5-16**] 07:30 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2170-5-17**] 07:19 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 39.4
C (103
Tcurrent: 38.3
C (101
HR: 92 (85 - 94) bpm
BP: 118/55(75) {99/48(64) - 133/63(86)} mmHg
RR: 16 (13 - 29) insp/min
SpO2: 96%
Heart rhythm: ST (Sinus Tachycardia)
Height: 59 Inch
CVP: 15 (8 - 15)mmHg
Total In:
2,422 mL
182 mL
PO:
TF:
IVF:
2,322 mL
182 mL
Blood products:
Total out:
643 mL
400 mL
Urine:
643 mL
400 mL
NG:
Stool:
Drains:
Balance:
1,779 mL
-218 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST
Vt (Set): 350 (350 - 350) mL
RR (Set): 26
RR (Spontaneous): 0
PEEP: 18 cmH2O
FiO2: 60%
RSBI Deferred: PEEP > 10
PIP: 30 cmH2O
Plateau: 24 cmH2O
Compliance: 58.3 cmH2O/mL
SpO2: 96%
ABG: 7.31/47/90.[**Numeric Identifier 433**]/20/-2
Ve: 9.2 L/min
PaO2 / FiO2: 150
Physical Examination
General Appearance: Overweight / Obese, intubated, sedated
Cardiovascular: (S1: Normal), (S2: Normal), distant heart sounds, no
m/r/g appreciated
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
anterior and posterior crackles throughout, No(t) Bronchial: , Wheezes
: end expiratory wheezes and squeaking
Abdominal: Soft, Bowel sounds present, non-tender, nondistended
Musculoskeletal: diffuse tenderness to palpation
Skin: warm and well perfused
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): self, person, place, Movement: Purposeful,
Tone: wnl. AAO X 3, slightly tearful during exam. Follows commands.
Decreased sensation to light touch entire left side including facial
area. Motor: [**3-4**] upper extremity bilateral and [**4-3**] lower extremity
bilateral.
Labs / Radiology
373 K/uL
9.9 g/dL
106 mg/dL
1.2 mg/dL
20 mEq/L
3.5 mEq/L
28 mg/dL
110 mEq/L
142 mEq/L
29.1 %
8.7 K/uL
[image002.jpg]
[**2170-5-15**] 08:45 PM
[**2170-5-15**] 11:14 PM
[**2170-5-16**] 02:55 AM
[**2170-5-16**] 03:45 AM
[**2170-5-16**] 03:59 AM
[**2170-5-16**] 06:56 AM
[**2170-5-16**] 02:43 PM
[**2170-5-16**] 05:11 PM
[**2170-5-17**] 04:44 AM
[**2170-5-17**] 05:00 AM
WBC
7.9
8.7
Hct
31.1
29.1
Plt
321
373
Cr
0.6
1.2
TCO2
25
25
28
26
27
27
26
25
Glucose
93
106
Other labs: PT / PTT / INR:16.3/30.1/1.4, CK / CKMB /
Troponin-T:41/2/<0.01, ALT / AST:27/36, Alk Phos / T Bili:121/0.3,
Differential-Neuts:78.2 %, Lymph:17.5 %, Mono:3.5 %, Eos:0.7 %, Lactic
Acid:1.1 mmol/L, LDH:583 IU/L, Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:2.6
mg/dL
Assessment and Plan
54F w DM2, HTN, NSTEMI who p/w fever, cough, myalgias, n/v/d and found
to have hypoxia and multi-focal infiltrates on CXR.
# Respiratory distress: [**1-1**] multi-focal pneumonia requiring intubation.
Differential includes PNA secondary to staph, pneumococal, atypicals
(Mycoplasma, Chlamyadia), aspiration PNA. Also on differential less
common etiologies such as Histoplasma, Ehrlichia and Babesia.
Legionella and influenza negative. Continues to have fevers. Also on
differential is autoimmune etiology. S/p ceftriaxone.
- continue vancomycin ([**5-13**] -
- continue cefepime
- continue azithro ([**5-13**] - )
- consider adding doxycycline if patient
s clinical status worsens
- consider gentle diuresis (goal: even to negative -500cc per 24 hrs)
- f/u serologies for Mycoplasma, Chlamyadia, Histoplasma, Ehrlichia and
Babesia
- f/u urine S. pneumoniae AG
- f/u bl cxs, urine cx
- f/u HIV test
- f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], ANCA to eval vasculitis
- ID c/s
- CIS
- continue mechanical ventilation
- follow ABGs
- consider mini BAL
# ARF: possibly pre-renal [**1-1**] hypotension, sepsis vs autoimmune
vasculitis
- monitor UOP
- check urine lytes
- goal even to -500cc per 24 hrs
- renally dose meds
- avoid nephrotoxins
# Headache: Chronic. CT head unremarkable. Prior to admission MRI/MRA
unremarkable. Low suspicion of meningitis on admission.
- Continue sedation
# Tranaminitis: Trending down. Slight elevation in AST/ALT/alkphos but
TBili wnl. Final CT abd/pelivs fatty liver only.
- Trend LFTs daily.
# HTN
Hold outpatient metoprolol until BP stable.
# s/p NSTEMI
Continue ASA and Statin.
# Depression/anxiety: Continue sertraline.
# DM: HISS
ICU Care
Nutrition:
- nutrition consult for tube feeds
Glycemic Control:
Lines:
18 Gauge - [**2170-5-13**] 07:49 PM
20 Gauge - [**2170-5-14**] 12:18 PM
Multi Lumen - [**2170-5-15**] 08:00 PM
Arterial Line - [**2170-5-15**] 08:00 PM
Prophylaxis:
DVT: heparin SC
Stress ulcer: famotidine
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:
------ Protected Section ------
I have seen and examined the patient with the resident and agree
substantially with the assessment and plan with the following
emphasis/changes:
54 year old history of DM who presents with fever, cough, headache and
found to have significant hypoxemia and multifocal pneumonia. Worsened
respiratory status requiring endotracheal intubation.
Overnight, continues to have problems oxygenating and continues to have
fevers.
T 100.3 P 87 BP 116/60 RR SaO2: 94% on PEEP 18, Fio2 0.6
Gen: Intubated, sedated
Chest: bilateral crackles and wheeze
Heart: S1 S2 reg
Abd: soft, NT ND
Ext: No edema
Neuro: sedated
WBC: 8.7
Plt: 273
CXR: bilateral infiltrates
Cultures: No growth
ECHO: EF 55%, no vegetations, borderline pulmonary hypertension,
1. Respiratory Failure secondary to Pneumonia
a. Continue broad-spectrum antibiotics (Cefepime/Vanco/Azithro)
b. ID consult to discuss additional coverage/other etiologies
c. Increase PEEP and follow to see if improvement in oxygenation;
maintain Fio2 of 0.6
d. Maintain low tidal volume ventilation with goal plateau pressure <
30 mmHg
2. Headache: If respiratory status stabilizes, will perform LP
3. Nausea/vomiting/diarrhea: resolved
4. Depression/anxiety: continue Zoloft
Addendum: At the end of the afternoon, patient
s oxygen saturation
worsened. We paralyzed patient with minimal improvement and increased
PEEP from 18 to 20 with improvement in saturation from saturation from
89% to 94%. She still has room on her Fio2 and can bring up as needed
overnight. Hemodynamics remain stable.
Critical Care Time: 90 minutes
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) 402**], MD
on:[**2170-5-17**] 11:46 PM ------
|
Physician
|
Classify the following medical document.
|
Hyponatremia (low sodium, hyposmolality)
Assessment:
SIADH associated with TBI. Serum Na 143 with serum osmolality 302
Action:
Q 4hour Na & osmolality monitored
Salt tabs 2 grams TID continue
3% saline infusion discontinued
Mannitol dosing changed to 12.5 gm Q 12 hours
Neuro checks Q2 hour; dilantin dosing continues
Response:
Serum NA 142; osmolality 300
Fluid balance continues negative > 1Liter today
No change neuro exam at this time; no seizure activity noted
Pt craves water.
Plan:
Continue monitoring NA/osmolality Q4 hour; goal remains Na 145,
osmolality >300<320
Continue to monitor urine output & total fluid balance
Continue salt tabs and Mannitol dosing
Neuro checks Q 2/hour: monitor for altered mental status
Altered mental status (not Delirium)
Assessment:
A&O x2-3 today; pt is cooperative and appropriate; speech is clear &
articulate.
Action:
Periods of sound napping provided
Monitored for changes in mental status
Response:
At times, pt is transiently disoriented to place when wakens from deep
sleep; reorients quickly; more restful following napping.
Pt continues to engage with staff and family/visitors appropriately;
remains A&O x2-3, cooperative & appropriate in manner. Decrease in
impulsive behavior noted; pt able to recall and comply with activity
restrictions but less so with dietary restrictions- which requires
close supervision.
Plan:
Cont to monitor for changes in MS
Cont to provide time to sleep; reorient as needed.
Ineffective Coping
Assessment:
Pt
s S.O. spent night in room. Family presented today with calm, rested
demeanor and behavior after sleeping at home last night. Parents
conversing amicably together in room, even joking. Parent
s behaviors
are notably more relaxed and they are compliant with call in
guidelines.
Action:
Ongoing access to patient provided to family.
Updates provided and; questions answered; POC reviewed.
Dietary restrictions reviewed as needed.
Plan made for family member to remain overnight
Response:
Parents visited throughout the day and able to return home in late
afternoon without obvious distress.
Mother spoke of returning to work next week; family has plans for
father and sister to be at home with patient when ready for discharge.
Father spoke calmly & excitedly of plans to discuss discharge plans
next week with appropriate health team members.
Parents demonstrated understanding of current care actions and goals
and were able to reinforce these to pt when he had questions (i.e.
regarding diet restrictions).
Plan:
Continue with current plan for flexible visitations and overnight stay
of one family member.
Cont to provide support and reassurance to all family members
Headache
Assessment:
Continue complaints of right side posterior HA pain that remains sharp
and rated [**2181-4-2**]
Action:
Percocet 2 tablets provided
Response:
Pain rating reduced to [**2-8**].]
Return of HA in late afternoon to [**5-7**]; pt did not want to take
something that would put him to sleep yet. Tylenol 650mg given without
change in c/o after 45 minutes.
Plan:
Continue to assess, treat, and evaluate pain.
Intracerebral hemorrhage (ICH)
Assessment:
Pt 1 week s/p assault causing fall onto head with TBI: bil frontal IPH
and right occipital epidural bleed requiring evacuation. Pt
s course
then complicated by 2 episodes of increased cerebral edema and
herniation associated with hyponatremia. Neuro exam has remained stable
with perrl/brisk @ 3-5mm, consistently following commands and absent of
focal deficits. No seizures; therapeutic dilantin levels.
Action:
Q 2 hour neuro checks; hemodynamics monitored
Dilantin dosing continues and changed to po route
Changes made in sodium/osmolality therapy: see above problem
Response:
[**Name2 (NI) 7080**] & unchanged neuro exam
BP remains within goal range of <160 systolic without intervention
Plan:
Q 2 hour neuro checks; maintain safe environment; monitor & treat bp to
keep within goal range with prn medications.
Pt continues on pureed diet with nectar thickened liquids. Pt
tolerating po diet with some coughing following ingestion of ice chips
added to fluids. Pt continues to crave & request
water
. He ingests
his thickened fluids quickly in spike of encouragement to drink slowly.
He continues to require reinforcement about restrictions and
supervision with fluid diet.
|
Nursing
|
Classify the following medical document.
|
Admission Date: [**2199-12-26**] [**Year/Month/Day **] Date: [**2199-12-30**]
Date of Birth: [**2119-1-27**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cephalosporins / Flagyl
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2199-12-27**] ORIF left intratrochanteric hip fracture
History of Present Illness:
80 y/o female s/p fall to floor from standing
Past Medical History:
Chronic anemia - receives transfusions monthly per patient (has
right portacath for chonic transfusions), recent dementia like
symptoms, Diverticulitis, Colitis, ? COPD
Social History:
Had recently been staying with family secondary to increasing
difficulty, her own home is a single story [**Last Name (un) **].
Family History:
Noncontributory
Physical Exam:
Upon admission:
O: T: BP: 132/41 HR:86 R16 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-27**] EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date (thought it was
[**2099**]).
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: poor effort on right not tested on leftSternocleidomastoid
and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Has left shoulder fx left grip , left hip fx is able to
wiggle toes. Right Bicep 4+ and Tricep 4+ grip 4+; Unable to
test
drift does not appear to drift on right
Sensation: Intact to light touch
CT/MRI: Small left sided occiptal subdural
Pertinent Results:
[**2199-12-26**] 10:50AM PT-13.8* PTT-27.0 INR(PT)-1.2*
[**2199-12-26**] 10:50AM PLT COUNT-232
[**2199-12-26**] 10:50AM WBC-13.6* RBC-3.40* HGB-10.1* HCT-28.8*
MCV-85 MCH-29.7 MCHC-35.0 RDW-21.8*
[**2199-12-26**] 10:50AM cTropnT-<0.01
[**2199-12-26**] 10:50AM CK(CPK)-19*
[**2199-12-26**] 10:50AM GLUCOSE-132* UREA N-16 CREAT-0.4 SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-31 ANION GAP-10
[**2199-12-26**] 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-NEG
[**2199-12-26**] 01:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2199-12-26**] 07:41PM WBC-11.1* RBC-3.33* HGB-9.9* HCT-27.8* MCV-84
MCH-29.8 MCHC-35.7* RDW-21.0*
[**2199-12-26**] 07:41PM PLT COUNT-227
Brief Hospital Course:
She was admitted to the Trauma Service and transferred to the
trauma ICU. On initial workup she was noted to have a left
chronic subdural hemorrhage with acute blood, a proximal humerus
fracture, right inferior ramus and acetabular fracture and a
left intratrochanteric fracture. She was evaluated by
Neurosurgery for the SDH which was nonoperative. It was
recommended that a repeat head CT be done which was stable. It
was initially thought there may be a fracture of her cervical
spine at C1-C2; an MRI was done and reviewed by Neurosurgery and
no fracture was noted, just degenerative changes. The cervical
collar was removed. She will follow up with Dr. [**First Name (STitle) **] in 4
weeks for a repeat head CT and will continue with the Keppra
until that time.
Orthopedics was consulted for the hip fracture; she was taken to
the operating room on [**2199-12-27**] for ORIF of the left hip.
Postoperatively she was transferred to the regular nursing unit.
It was recommended to start Lovenox for a total of 4 weeks. she
may weight bear as tolerated and will follow up with Dr.
[**Last Name (STitle) **] in 2 weeks. Her humeral fracture was managed non
operatively with a sling.
Given her history of chronic anemia and need for monthly blood
transfusions her hematocrits were monitored closely and remained
relatively stable given her hip surgery. Last hematocrit on [**12-30**]
was 23.4 (postop Hct was 23.5 on POD #1). She is followed by her
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**] in [**Hospital1 **], MA.
She was evaluated by Physical and Occupational therapy and has
been recommended for rehab after her acute hospital stay.
Medications on Admission:
Lasix 40 QD, Spironlactone 25mg
[**Last Name (LF) 244**], [**First Name3 (LF) **] 325 QD + prn, Combivent and Advair
[**First Name3 (LF) **] Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-27**]
Puffs Inhalation Q6H (every 6 hours) as needed.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mg/0.3ml
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*qs 30mg/0.3ml* Refills:*0*
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime: hold
for loose stools.
10. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Zinc Sulfate 220 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
[**Location (un) **] Diagnosis:
s/p Fall
Subdural hemorrhage
Left proximal humerus fracture
Left acetabular fracture
Left intratrochanteric hip fracture
Pressure ulcer coccyx region (unstageable)
Right pelvic ring fracture
[**Location (un) **] Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
[**Location (un) **] Instructions:
DO NOT bear any weight on your left arm because of your
fracture. Continue to wear the sling for comfort.
Continue the Keppra until follow up with Neurosurgery.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **], Orthopedics in two weeks.
Please call [**Telephone/Fax (1) 1228**] to schedule an appointment.
Follow up with Dr. [**First Name (STitle) **], Neurosurgery in 4 weeks for a repeat
head CT scan. Call [**Telephone/Fax (1) 1669**] for an appointment. A follow up
MRI of your cervical spine is also being recommend at that time.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab regarding an incidental finding on MRI imaging of your
cervical spine (copy of report included in your [**Last Name (Titles) **]
summary). You or a family member will need to call for an
appointment.
Completed by:[**2200-1-1**]
|
Discharge summary
|
Classify the following medical document.
|
TITLE:
Chief Complaint:
24 Hour Events:
INVASIVE VENTILATION - STOP [**2196-4-19**] 11:17 AM
received from EW at 1421
- MR head final read: Small acute infarcts in the left occipital and
right posterior temporal lobes. Embolic etiology should be considered.
- Stroke team consulted; recs: MRA (or CTA) of head/neck; check HbA1c
and lipid panel; continue heparin gtt; F/U telemetry for signs of A-fib
(if develops, will need anticoagulation); keep euglycemia/euthermic
- EEG pending
- Endocrine consulted; recs: Suspect that this is PRIMARY adrenal
insufficiency (not secondary/panhypopit) given the hypotension and
hyperkalemia which are not seen in secondary insufficiency. Therefore,
no need to pursue further pituitary fxn testing. Add on cortisol to
admission labs (pre-steroids). Consider CT of adrenals to check for
atrophied glands. Continue hydrocort 50 IV q8h while in ICU, start to
taper [**4-20**] if clinicall stable (go to 25 IV q8h).
- Antimicrobials (levofloxacin, acyclovir) stopped [**4-19**]
- Continued heparin gtt per neuro recs
Allergies:
Augmentin (Oral) (Amox Tr/Potassium Clavulanate)
Unknown;
Last dose of Antibiotics:
Vancomycin - [**2196-4-17**] 02:30 PM
Ampicillin - [**2196-4-17**] 02:42 PM
Levofloxacin - [**2196-4-18**] 07:36 PM
Acyclovir - [**2196-4-19**] 09:41 AM
Infusions:
Heparin Sodium - 550 units/hour
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2196-4-20**] 07:16 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**98**] AM
Tmax: 36.4
C (97.6
Tcurrent: 36.4
C (97.6
HR: 48 (44 - 59) bpm
BP: 92/39(52) {92/39(52) - 111/55(69)} mmHg
RR: 9 (6 - 12) insp/min
SpO2: 96%
Heart rhythm: SB (Sinus Bradycardia)
Wgt (current): 72.6 kg (admission): 72.4 kg
Total In:
1,470 mL
740 mL
PO:
120 mL
TF:
IVF:
1,350 mL
740 mL
Blood products:
Total out:
1,295 mL
244 mL
Urine:
1,295 mL
244 mL
NG:
Stool:
Drains:
Balance:
175 mL
496 mL
Respiratory support
O2 Delivery Device: None
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 12
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
PIP: 21 cmH2O
Plateau: 16 cmH2O
SpO2: 96%
ABG: ////
Ve: 5.9 L/min
Physical Examination
Exam deferred in early morning as patient
resting peacefully. Will reassess later in the day.
Labs / Radiology
Chem 7and CBC/diff and coags and LFTS from today
pending
CBC
9.3 / 37.1 / 243; Diff 89P, 6.5L
Results from [**4-19**]:
237 K/uL
12.8 g/dL
110 mg/dL
1.2 mg/dL
22 mEq/L
4.3 mEq/L
28 mg/dL
99 mEq/L
132 mEq/L
37.3 %
10.1 K/uL
[image002.jpg]
[**2196-4-17**] 01:17 PM
[**2196-4-17**] 03:27 PM
[**2196-4-17**] 11:00 PM
[**2196-4-18**] 05:30 AM
[**2196-4-18**] 02:13 PM
[**2196-4-19**] 12:55 AM
WBC
10.6
6.6
6.6
9.5
10.1
Hct
41.6
37.7
36.5
34.5
37.3
Plt
200
212
217
214
237
Cr
1.5
1.3
1.2
1.2
1.2
TropT
0.21
1.08
0.92
0.45
Glucose
125
80
139
134
118
110
Other labs: PT / PTT / INR:13.2/53.6/1.1, CK / CKMB /
Troponin-T:288/15/0.45, ALT / AST:29/64, Alk Phos / T Bili:96/0.4,
Amylase / Lipase:/20, LDH:232 IU/L, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL,
PO4:3.9 mg/dL
HbA1c
pending
Lipids
pending
TSH [**4-18**]
0.26; TSH [**4-17**]
1.1
Cortisol
[**4-17**]
15.7 (admission lab)
ACTH, renin
pending
HSV PCR on CSF - negative
EKG [**4-20**]
MRI head
There are small foci of slow diffusion in the inferior
posterior left occipital lobe and in the posterior right temporal lobe,
consistent with acute infarctions. There is corresponding high signal
on T2-weighted and FLAIR images, indicating that they are at least [**6-25**]
hours old. There is a small chronic lacunar infarct in the right pons.
There are multiple small foci of high T2 signal in the subcortical,
periventricular, and deep white matter of the cerebral hemispheres,
likely related to chronic small vessel ischemic disease. The ventricles
and sulci are normal in size and configuration for age. There is no
evidence of intracranial blood products. There is a 4-mm oval, smoothly
marginated, fluid-intensity lesion in genu of the corpus callosum in
the midline, which may represent a prominent perivascular space or a
cyst, rather than a chronic infarct, given its smooth margins. The
major arterial flow voids appear patent. The pituitary gland appears
normal in size. IMPRESSION: Small acute infarcts in the left
occipital and right posterior temporal lobes. Embolic etiology should
be considered.
Micro: No growth in blood or CSF or urine cultures
Assessment and Plan
[**Age over 90 **] y/o M with hx of HTN, hyperlipidemia, GERD and CKD presents from
home today with confusion and complaints of inability to hear, in the
ED found to be febrile to 100.8, was intubated for agitation and
tachypnea, admitted to MICU.
.
# CHANGE IN MENTAL STATUS: Pt confused, with headache, complaining of
inability to hear. DDx of change in mental status includes
sepsis/infection, acute intracranial process (found to have
multi-embolic stroke on MRI), seizure, infectious
meningitis/encephalitis, hypoxemia (e.g. from arrhythmia), electrolyte
imbalance, adrenal insufficiency, toxins. LP performed in ED does not
show a pattern typical for bacterial infection. Acute hearing loss may
be more consistent with viral infectious etiology. Non-infectious
etiology including vasculitis or microvascular thrombosis/TIA could
also cause acute hearing loss. Given low TSH, abnormal [**Last Name (un) 402**] stim test
suspect panhypopituitarism related to ? central process; however as pt
received high-dose dexamethasone in ED for empiric meningitis
treatment, his decreased pituitary axis is likely related to that
rather than a pre-existing proceess. His low response to the [**Last Name (un) 402**] stim
test is somewhat surprising though and he may have underlying primary
(adrenally mediated, not pituitary-mediated) adrenal insufficiency.
- Endocrine following; appreciate recs.
- Start to taper hydrocort today if clinically stable (go to 25 IV
q8h).
- No need to pursue further pituitary fxn testing.
- Consider CT of adrenals to check for atrophied glands
- Neuro following for stroke; believes triggering event may have been
paroxysmal arrhythmia that led to multiple emboli to brain. See below
for recs.
- Antibiotics/acyclovir stopped yesterday (HSV PCR negative in CSF)
- Infectious work-up as below (see #FEVER)
- EEG given UE shaking, read pending
.
# STROKE. MR head final read: Small acute infarcts in the left
occipital and right posterior temporal lobes. Embolic etiology should
be considered.
- Neuro following; appreciate recs.
- Consider MRA (or CTA) of head/neck
will confirm purpose of this
study with neuro
- HbA1c and lipid panel pending
- Plan to stop heparin gtt today
- F/U telemetry for signs of A-fib (if develops, will need
anticoagulation)
- Maintain euglycemia/euthermic
# ELEVATED TROPONIN: likely demand in the setting of an acute
infection. Had ST depressions when agitated and moving. Troponins
elevated to 1.08, now normalizing. Repeat EKG ~unchanged.
- cycle enzymes
- Continue daily EKGs while enzymes remain elevated
- high dose statin/asa, consider starting low-dose beta blocker when
pressure permits
- on heparin gtt without bolus per cards recs
- will need workup after acute issues improve with stress test
- TTE shows EF 55-60%, possible inferior/inferolateral hypokinesis but
otherwise normal
.
# FEVER/POSSIBLE PNA. Pt with rectal temp to 100.8 on DOA, spiked to
100.7 o/n on [**4-17**]-5, b/l UE shaking. Unclear source: ddx includes
meningitis given confusion and headache and deafness but normal LP and
HSV PCR, possible LUL PNA given CXR findings, viral infection (URI),
endocarditis but negative blood cultures and TTE, abdominal process (eg
diverticulitis). UTI unlikely with negative UA. Urine legionella
negative. Urine cx negative.
- Follow blood cx, CSF cx
- sputum cx contaminated
- Levofloxacin stopped [**4-19**], acyclovir stopped [**4-19**] given lack of
compelling evidence for infectious process
.
# ARF. Acute on chronic, with mildly elevated Cr to 1.3 one year prior
that normalized to baseline of 1.1. For acute elevation, suspect
component of prerenal, ?ATN in setting of possible sepsis though not
objectively hypotensive on admission; urine lytes with FeNa 4% and FeUN
51%. Neg urine eos, Na 98. Urine sediment benign.
- Now at baseline creatinine; creatinine clearance by Cockcroft-gault
is 41.
- IVF (bolus to maintain UOP > 50 cc/hr)
- Renally dose meds; avoid nephrotoxins
- D/C foley
.
# HYPONATREMIA: likely secondary to appropriate ADH response to
dehydration, improving; ?adrenal insufficiency. Resolved.
- IV fluids as needed for UOP > 50 cc/hr
- Follow-up ACTH/renin
- trend electrolytes
.
# HYPERKALEMIA. Elevated to 6.7 with EKG changes; pt received
insulin/dextrose, bicarb, calcium, kayexalate X2. Likely secondary to
acute on chronic kidney disease. Resolved.
- Normalized now that pt is at baseline creatinine. Will follow results
of daily labs.
.
# SUDDEN HEARING LOSS. Resolved. Likely in setting of confusion, acute
stroke.
.
# Elevated coags/LFTs.
- Unclear etiology, repeat labs pending.
.
# Hypertension. Hold home meds for now (lasix, diltiazem, isosorbide
mononitrate)
.
# Hyperlipidemia. High dose statin as above.
.
# GERD. Continue home PPI.
.
# Agitation/discomfort. Morphine prn pain.
.
# RESPIRATORY DISTRESS. Pt initially intubated for tachypnea/airway
protection in setting of agitation/change in mental status/tachypnea.
Pt now successfully extubated on [**4-19**].
.
# FEN: IVF boluses as needed, replete electrolytes, advance diet as
tolerated
# Prophylaxis: On heparin drip for embolic stroke, pneumoboots; PPI
# Access: peripheral
# Communication: Son, [**Name (NI) 2476**] [**Name (NI) 14418**], [**Telephone/Fax (1) 14419**]
# Code: Presumed full per initial discussion with family, unable to
discuss with patient.
# Disposition: ICU pending clinical improvement
call out to floor (CM
should see pt)
ICU [**Name (NI) 81**]
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2196-4-19**] 04:33 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:
------ Protected Section ------
MICU ATTENDING ADDENDUM
I saw and examined the patient, and was physically present with the ICU
team for the key portions of the services provided. I agree with the
note above, including the assessment and plan. I would emphasize and
add the following points: [**Age over 90 **]M HTN, HLD, CKD p/w hyperkalemia, ARF, and
acute alteration in mental status / agitation c/b respiratory failure.
MRI c CVA x2. Cortisol prior to dex 15.7.
Exam notable for Tm 97.6 BP 100/50 HR 50 RR 18 with sat 99 on VAC
500x12 5 0.5. WD man, comfortable, NAD PERRL. CTA B. RRR s1s2. Soft
+BS. No edema / rash. Labs notable for WBC 9K, HCT 37, K+ 3.7, Cr 0.9.
Agree with plan to manage acute CVA with full dose aspirin, suspect we
can d/c heparin - will d/w neuro. For adrenal insufficiency - will
taper HC today. For [**Last Name (LF) 1882**], [**First Name3 (LF) **] continue asa, statin. Elevated LFTs /
ARF / hyperkalemia - resolved. ADAT. Remainder of plan as outlined
above.
Total time: 35 min
------ Protected Section Addendum Entered By:[**Name (NI) 453**] [**Last Name (NamePattern1) 775**], MD
on:[**2196-4-20**] 06:51 PM ------
|
Physician
|
Classify the following medical document.
|
Chief Complaint: Shock , MODS
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
44F admitted with multiorgan failure secondary to diffuse
microangiopathy and DIC of unknown etiology. Issues include CVA, RCA
NSTEMI, respiratory failure s/p trach, hemopytsis, ARF, limb ischemia.
24 Hour Events:
Empiric hydrocortisone strated yesterday.
Progressive limb ischemia. Heparin gtt being started this am.
Increased levophed requiremen to 0.18 overnight secondary to HoTN.
Discussed case with hematology who did not recommend empiric trial of
plamapheresis because of concerns about patient being able to tolerate
procedure.
Got 1 U cryo overnight.
Vanco course completed.
CMV serologies sent.
History obtained from Medical records
Patient unable to provide history: Sedated, Encephalopathy
Allergies:
Sulfasalazine
Unknown;
Last dose of Antibiotics:
Vancomycin - [**2193-8-16**] 08:00 PM
Infusions:
Norepinephrine - 0.14 mcg/Kg/min
Heparin Sodium - 850 units/hour
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2193-8-18**] 06:06 AM
Other medications:
prevacid
RISS
peridex
plavix
thiamine
folate
mvit
asa
Calcium Acetate
nystatin
hydyrocort 50 q6 (day 2)
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2193-8-18**] 08:53 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37
C (98.6
Tcurrent: 36.6
C (97.8
HR: 106 (90 - 111) bpm
BP: 105/70(79) {80/22(35) - 113/87(92)} mmHg
RR: 31 (17 - 37) insp/min
SpO2: 91%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 78.1 kg (admission): 92 kg
Height: 66 Inch
Total In:
4,187 mL
1,043 mL
PO:
TF:
732 mL
239 mL
IVF:
2,892 mL
774 mL
Blood products:
103 mL
Total out:
155 mL
12 mL
Urine:
55 mL
12 mL
NG:
Stool:
Drains:
Balance:
4,032 mL
1,031 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 624 (219 - 908) mL
PS : 5 cmH2O
RR (Spontaneous): 35
PEEP: 5 cmH2O
FiO2: 50%
RSBI: 71
PIP: 17 cmH2O
SpO2: 91%
ABG: ///16/
Ve: 25.7 L/min
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
7.3 g/dL
65 K/uL
156 mg/dL
2.7 mg/dL
16 mEq/L
4.4 mEq/L
66 mg/dL
98 mEq/L
133 mEq/L
23.5 %
18.8 K/uL
[image002.jpg]
[**2193-8-13**] 11:34 AM
[**2193-8-14**] 03:49 AM
[**2193-8-14**] 03:48 PM
[**2193-8-14**] 09:27 PM
[**2193-8-15**] 04:56 AM
[**2193-8-15**] 04:28 PM
[**2193-8-16**] 03:26 AM
[**2193-8-17**] 03:52 AM
[**2193-8-17**] 04:29 PM
[**2193-8-18**] 03:51 AM
WBC
25.3
25.7
27.6
24.8
22.0
18.8
Hct
25.9
25.8
26.1
25.6
26.5
26.8
24.9
24.0
23.5
Plt
104
119
83
91
88
88
93
65
65
Cr
2.8
2.6
3.4
2.0
2.4
2.7
Glucose
126
130
153
156
154
156
Other labs: PT / PTT / INR:16.9/32.5/1.5, CK / CKMB /
Troponin-T:6617/144/2.54, ALT / AST:471/218, Alk Phos / T Bili:156/1.4,
Amylase / Lipase:189/98, Differential-Neuts:85.0 %, Band:2.0 %,
Lymph:6.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6053 ng/mL, Fibrinogen:179
mg/dL, Lactic Acid:2.5 mmol/L, Albumin:3.1 g/dL, LDH:1870 IU/L,
Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL
Imaging: CXR: trach in place. Clear lungs
Assessment and Plan
Ciritically ill patient with MODS of unclear etiology now progressing
to digital ischemia in the setting of persistant levophed use and DIC.
The patient appears to
NEURO: Nodding intermittently to questions which is somewhat improved.
Increased respiratory rate may be secondary pain or metabolic in
nature. Will check VBG and will also try fentanyl gtt.
CV: Persistent pressor requirement in the setting of distributive shock
and ongoing DIC. Will continue steroids as seoncdary pressor. On asa
and plavix.
LUNGS: High MV (23) may be either CNS, metabolic or increased VD/VT.
Wil try fentanyl first, then bicarb. If neither decrease MV then will
get PetCo2 monitor to infer alveolar dead space.
GI: Tube feeds at goal.
ENDO: Persistent hypoglycemia an ominus sign, but FS maintained on D10
gtt. Will continue to check.
GU: Will ask renal about HD today vs CVVH
ID: On no abx. CMV serologies pending. Will pan CT scan to look for
focal abscess.
RHEUM: Consult has no further recs. CPKs appear to be trending down.
HEME: Heme consult appreciated. Cryo/blood products as needed. Will
start
PPX: peridex, pneumoboots, prevacid
DISPO: Critically ill, prognosis very grim. Will speak with family
today.
ICU Care
Nutrition:
Nutren Renal (Full) - [**2193-8-18**] 05:01 AM 30 mL/hour
Glycemic Control: Blood sugar well controlled, Comments: On D10 drip
Lines:
Multi Lumen - [**2193-8-11**] 07:09 PM
Dialysis Catheter - [**2193-8-13**] 06:08 PM
Prophylaxis:
DVT: Boots(Systemic anticoagulation: Heparin gtt)
Stress ulcer:
VAP: HOB elevation, Mouth care
Comments:
Communication: Family meeting held Comments:
Code status: Full code
Disposition :ICU
Total time spent: 30 minutes
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
Chief Complaint: CML with GVHD
24 Hour Events:
NASAL SWAB - At [**2124-10-15**] 01:15 PM
rapid respiratory viral culture
PICC LINE - START [**2124-10-15**] 04:32 PM
dressing changed
PICC LINE - STOP [**2124-10-15**] 04:37 PM
dressing changed
- Speech and swallow cancelled as he had passed his last one just fine
and nursing felt that it was not indicated
- Flu swab negative, dc'ed respiratory precautions
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2124-10-15**] 08:00 PM
Voriconazole - [**2124-10-15**] 08:00 PM
Piperacillin/Tazobactam (Zosyn) - [**2124-10-16**] 03:34 AM
Infusions:
Other ICU medications:
Other medications:
Acyclovir 3. Albuterol-Ipratropium 4. Albuterol 0.083% Neb Soln 5.
Budesonide 6. Calcium Carbonate
7. Docusate Sodium 8. Enoxaparin Sodium 9. Fentanyl Patch 10. Heparin
Flush (10 units/ml) 11. Lansoprazole Oral Disintegrating Tab
12. Lidocaine 5% Patch 13. Lidocaine 5% Patch 14. Lorazepam 15.
Methadone 16. Metoprolol Tartrate
17. Methadone 18. Morphine Sulfate IR 19. Morphine Sulfate 20.
Multivitamins W/minerals 21. Mycophenolate Mofetil
22. Mycophenolate Mofetil 23. Ondansetron 24. Pancrease MT 16 25.
Piperacillin-Tazobactam 26. Polyethylene Glycol
27. Pregabalin 28. PredniSONE 29. Senna 30. Sulfameth/Trimethoprim SS
31. Tobramycin Inhalation Soln
32. Vancomycin 33. Vitamin D 34. Voriconazole
Changes to medical and family history:
In [**Location (un) 308**] prior discharge summary from [**2124-7-6**], discovered that
patient had profuse bleeding while on full anticoagulation with
lovenox, thus has been on reduced dose of 40 mg Q12H since that time
Review of systems is unchanged from admission except as noted below
Review of systems: no CP, feels still has increased work of breathing
from baseline, mild cough, +abd pain (not any worse)
Flowsheet Data as of [**2124-10-16**] 07:40 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.9
C (98.4
Tcurrent: 36.2
C (97.1
HR: 69 (63 - 99) bpm
BP: 108/68(77) {98/55(66) - 136/83(89)} mmHg
RR: 12 (11 - 21) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 69.3 kg (admission): 69.3 kg
Height: 61 Inch
Total In:
1,130 mL
251 mL
PO:
TF:
IVF:
1,130 mL
251 mL
Blood products:
Total out:
1,160 mL
710 mL
Urine:
1,160 mL
710 mL
NG:
Stool:
Drains:
Balance:
-30 mL
-459 mL
Respiratory support
O2 Delivery Device: Nasal cannula, Aerosol-cool, Face tent
SpO2: 99%
ABG 7.40/70/57 ([**10-14**])
Physical Examination
Gen: sleeping, easily aroused, alert and oriented
CV: rrr nl s1/s2 no murmurs
Pulm: crackles b/l
Abd: +BS, distended, very tender diffusely, no rebound or guarding
Ext: erythema anteriorly and warm, moving all exts
Labs / Radiology
204 K/uL
8.9 g/dL
75 mg/dL
0.5 mg/dL
43 mEq/L
3.9 mEq/L
14 mg/dL
98 mEq/L
143 mEq/L
27.2 %
4.6 K/uL
[image002.jpg]
[**2124-10-14**] 08:50 PM
[**2124-10-14**] 11:16 PM
[**2124-10-15**] 04:02 AM
[**2124-10-16**] 03:46 AM
WBC
5.4
4.6
Hct
28.7
27.2
Plt
231
204
Cr
0.7
0.5
TCO2
46
45
Glucose
200
75
Other labs: PT / PTT / INR:11.1/25.7/0.9, Differential-Neuts:88.0 %,
Band:2.0 %, Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Ca++:8.7 mg/dL,
Mg++:2.2 mg/dL, PO4:2.9 mg/dL
Microbiology: [**10-15**] Negative for Respiratory Viral Antigen. Viral ctx
pending
[**10-15**] sputum ctx pending
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS.
[**10-14**] blood pending
Assessment and Plan
IMPAIRED SKIN INTEGRITY
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
HYPOXEMIA
58 yo M with history of CML treated with allogeneic stem cell
transplant in [**2121**] and complicating graft versus host disease presents
from rehab following an episode of hypoxia to the 70s earlier today.
Patient was discharged from the ICU to the high level rehab facility on
[**2124-10-11**].
#. Hypoxia:
Patient with underlying bronchiolitis related to GVHD and with multiple
respiratory pahtogens in recent past. The patient may have developed a
healthcare associated pneumonia given his recent prolonged
hospitalizations. On CT, there is collapse of nearly entire LLL and
some of RLL as well as persistent pleural effusions. No evidence of
obstruction by mucous plug, so bronch is not likely to be helpful in
this case. Recent 7 day course of tamiflu from [**2124-10-2**] to
[**2124-10-8**]
- Cover for healthcare associated pneumonia with vancomycin and zosyn
(zosyn chosen with regard to prior sensitivities). Day 3 of a 8 day
course.
- Continue prednisone 30 mg daily
- Pulmonary hygiene with mechanical in-exsufflator, incentive
spirometry, acapella valve, deep suction
- f/u sputum ctx
- Follow-up blood cultures
- pt can be put in for diet?
#Fever: In [**Name (NI) **], pt. with low grade fever of 100.1F, could represent
atelectasis vs. HAP vs. cellulitis on LE given erythema and warmth.
WBC trending down, afebrile.
-Will continue empiric treatment with Vanc and Zosyn as above
-Trend WBC counts and fever curves
-f/u Blood cultures
.
#. CML s/p BMTs, complicated by chronic GVHD:
At previous admission patient was started on a prednisone taper of 60
mg daily and had been titrated down to 30 mg daily.
- Continue mycophenolate mofetil
- Continue prednisone at 30 mg daily and reassess prior to planned
taper down to 20 mg daily on [**2124-10-19**].
#. Chronic abdominal pain and back pain:
Thought to be attributable to GVHD after negative prior work-up.
- Continue fentanyl patch, methadone, morphine, lidocaine patches,
pregabalin
#. Hx of PE, DVT:
Patient with multiple prior thrombotic events.
- Continue enoxaparin 40 mg Q12H
ICU Care
Nutrition:
Glycemic Control:
Lines:
PICC Line - [**2124-10-14**] 10:00 PM
Prophylaxis:
DVT: LMW Heparin
Stress ulcer: lansoprazole
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ?c/o once can move without desats, maybe today
|
Physician
|
Classify the following medical document.
|
Chief Complaint: Respiratory Distress
24 Hour Events:
-No CVVH done yesterday as line became clotted. Pt. remained
intubated, weaned off sedation. Started on high dose lactulose with
good effect.
VAC was changed on [**4-17**] by ortho, stable.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2120-4-17**] 12:00 AM
Micafungin - [**2120-4-18**] 08:10 AM
Piperacillin - [**2120-4-18**] 04:00 PM
Daptomycin - [**2120-4-18**] 06:04 PM
Infusions:
Norepinephrine - 0.03 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2120-4-18**] 02:55 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2120-4-19**] 07:03 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**22**] AM
Tmax: 37.8
C (100
Tcurrent: 37.3
C (99.1
HR: 67 (47 - 76) bpm
BP: 94/68(79) {86/42(60) - 141/71(84)} mmHg
RR: 12 (12 - 35) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Height: 72 Inch
CVP: 3 (0 - 4)mmHg
Total In:
3,726 mL
492 mL
PO:
TF:
IVF:
3,186 mL
372 mL
Blood products:
Total out:
2,813 mL
1,010 mL
Urine:
29 mL
10 mL
NG:
790 mL
Stool:
Drains:
Balance:
913 mL
-518 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 553 (542 - 919) mL
PS : 5 cmH2O
RR (Spontaneous): 13
PEEP: 5 cmH2O
FiO2: 30%
RSBI: 51
PIP: 11 cmH2O
SpO2: 99%
ABG: 7.27/53/104/22/-2
Ve: 7.9 L/min
PaO2 / FiO2: 347
Physical Examination
Gen: NAD, becomes mildly agitated when awoken, but does not follow
commands
Pulm: coarse bilaterally
CV: RRR, 2/6 systolic murmur heard all fields
Abd: + BS, soft, mildly distended, dry dressing over previous
paracentesis site without noticeable drainage.
Peripheral Vascular: radial pulses and L PT pulse intact, RLE with
ex-fix in place, no drainage, no worsening erythema
Skin: warm, dry
Neurologic: intubated, becomes mildy agitated with awakening, opened
eyes, but not to command, moving all extremities
Labs / Radiology
114 K/uL
7.9 g/dL
177 mg/dL
3.3 mg/dL
22 mEq/L
4.5 mEq/L
25 mg/dL
104 mEq/L
137 mEq/L
26.6 %
13.3 K/uL
[image002.jpg]
[**2120-4-17**] 09:29 PM
[**2120-4-18**] 04:05 AM
[**2120-4-18**] 04:19 AM
[**2120-4-18**] 10:22 AM
[**2120-4-18**] 10:28 AM
[**2120-4-18**] 02:34 PM
[**2120-4-18**] 02:58 PM
[**2120-4-18**] 11:07 PM
[**2120-4-19**] 03:51 AM
[**2120-4-19**] 04:08 AM
WBC
13.5
14.9
13.3
Hct
27.2
26.8
26.6
Plt
115
111
114
Cr
2.3
2.3
2.6
3.3
TCO2
25
27
25
24
26
25
Glucose
188
193
180
177
Other labs: PT / PTT / INR:17.6/35.6/1.6, CK / CKMB / Troponin-T:60//,
ALT / AST:43/148, Alk Phos / T Bili:187/2.5, Amylase / Lipase:/101,
Differential-Neuts:79.4 %, Band:1.0 %, Lymph:12.6 %, Mono:3.9 %,
Eos:3.7 %, Lactic Acid:2.1 mmol/L, Albumin:3.3 g/dL, LDH:219 IU/L,
Ca++:9.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.7 mg/dL
Assessment and Plan
62M NASH, NSTEMI, trimalleolar fracture s/p ex-fix with deep infection
s/p multiple debridements, OSA, progressive ARF [**3-12**] hepatorenal
syndrome on midodrine and albumin and volume overload originally
brought to ICU with respiratory distress and bradycardia in the setting
of volume overload and aspiration.
# Respiratory Distress: Pt. remains intubated but doing well on SBT
without significant change in pCO2. Seems more arousable now off
sedation and with high dose lactulose. Patient has significant history
of sleep apnea as well. Original respiratory distress likely volume
overload as well as aspiration given history, CXR with bilateral
infiltrate as well as volume overload from ascites, renal failure and
oliguria. On dapto, micafungin, zosyn. Patient received lasix/diuril
in attempt to diurese, however unsuccessful. CVVH held on [**4-18**] due to
the fact that his dialysis catheter became clotted. On [**4-18**] he had an
episode of vomiting, repeat CXR not markedly different, but concern for
possibly evolving L opacity. Right was improved.
- continue ventilator today, consider extubation soon
- continue lactulose 60 mg q4h for encephelopathy
- continue zosyn/dapto/micafungin renally dosed; h/o MRSA in lungs
- continue famotidine
- CVP <4 or rise in pressor requirement >0.1 indicates approaching
euvolemia
he is approaching this today and will discuss with renal
drive
# Acute renal failure now without Dialysis Access: Patient with large
volume of ascites which is not helping his respiratory status and now
with worsening renal function and decreasing urine output. Per
hepatology and renal notes, he has suspected hepatorenal syndome and
has been on albumin, octreotide and midodrine. However, there has been
worsening on this regimen, so unclear if actually a different etiology.
Acidemia mixed respiratory and metabolic, CNS appears comfortable at
pCO2 at 50.
- address line placement today, either tunneled or temporary, will
discuss with renal
- plan for HD tomorrow
- renally dose medications
- continue midodrine for HRS
albumin stopped on [**4-13**]
- f/u renal recs in AM
- strict I&Os
- tx as above
#Cirrhosis: Not transplant candidate per hepatology. Has had some
increasing encephalopathy on the floor. No fever or abdominal pain
concerning for SBP though always a possibility. Paracentesis performed
[**4-13**] with 3 L removed and no evidence of SBP. Albumin and nadolol DC
on [**4-13**].
- If IAB >3.5, consider parascentesis
- increase lactulose as above, 60 mg q4h
- continue rifaximin
- continue midodrine
- f/u liver recs
# Mental Status: continues to be agitated at times.
- re-order restraints
- continue to hold sedating meds
# Leukocytosis: WBC now 13.5 not on steroids, temps 96, hypotensive but
bradycardic. Cannot rule out sepsis.
- continue daptomycin, micafungin, pip-tazo
# RLE Cellulitis/Osteomyelitis: has cx with VRE and C. glabrata.
Followed by ortho and will likely need s/p washout in the OR on [**4-15**].
[**Month (only) 11**] need amputation in future.
- Plan for bedside wound vac change tomorrow per ortho, OR on Monday
- continue daptomycin, micafungin, pip-tazo
- f/u sensitivities for C. glabrata
- monitor wound cultures, blood cultures
- surveillance blood cultures
- f/u ortho recs
wound vac changed per ortho
- f/u ID recs
# Gut Motility/Concern for Ileus: Moved bowels overnight. On reglan.
- Continue Reglan
- Give PO meds
- Give lactulose as above
- restart tube feeds today
# Bradycardia
originally thought likely d/t hypoxemia. Intubated on
[**4-13**] and pt. has had HR in 50s. Nadolol held starting on [**4-13**].
- octreotide was DC
- continue to hold nadolol
- continue to monitor
# Anemia: HCT stable though trending down slowly. EGD on [**3-29**] showed
varices and is now s/p banding/glueing. Hct stable today.
- check QD HCTs
- continue PPI
- hold nadolol 20mg in setting of bradycardia
- transfusion goal of 21 or evidence of bleeding or hypoperfusion
- will need follow up EGD
will speak with liver regarding this
# Thrombocytopenia: Stable, >100. Likely secondary to cirrhosis.
- daily PLT
- transfuse <10 or evidence of bleeding
# Diabetes mellitus: Continue SSI
- follow up [**Hospital 294**] Clinic recs now that patient is intubated
- increase ISS
- will continue dose of lantus (8 units) today; increase tomorrow as
needed
# Hypertension: of note, will target peripheral BPs as A line appears
to be giving diminished readings
- hold nadolol d/t intermittent bradycardia
- Holding metoprolol and amlodipine
# Obstructive sleep apnea: - pt. intubated
# Rheumatoid arthritis: not on home medications. Will monitor for
symptoms. No acute treatment needed currently.
# Depression: Continue escitalopram and bupropion.
# FEN: intubated, extubation trial today if more alert, OG tube in
place
- NPO now except for meds
- NGT to suction
# PPX: H2 blocker, SC heparin, bowel regimen
# ACCESS: PICC double lumen, HD line, A-line
Lines:
PICC Line - [**2120-4-12**] 10:10 PM
Arterial Line - [**2120-4-13**] 09:25 PM
Dialysis Catheter - [**2120-4-13**] 09:29 PM
# CODE: FULL CODE
# CONTACT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11361**] c [**Telephone/Fax (1) 11362**] / home [**Telephone/Fax (1) 11363**]
- will clarify if [**Hospital1 **] is legal HCP
# DISPO: ICU
|
Physician
|
Classify the following medical document.
|
BONE MARROW SCAN Clip # [**Clip Number (Radiology) 77369**]
Reason: 30YR OLD WOMAN WITH ESRD ON HD, S/P TIB/FIB FX WITH HARDWARE INFECTION S/P HARDWARE REMOVAL WITH EX-FIX
______________________________________________________________________________
FINAL REPORT
RADIOPHARMECEUTICAL DATA:
6.4 mCi Tc-[**Age over 90 26**]m Sulfur Colloid ([**2177-10-17**]);
HISTORY: 30 year old female with history of end stage renal disease on dialysis
with right tibia/fibula fractures complicated by hardware infection. Hardware
recently removed and external fixator placed. Concern for osteomyelitis.
RADIOPHARMECEUTICAL DATA: 403.0 uCi In-111 WBCs (administered [**2177-10-15**]) 6.4
mCi Tc-[**Age over 90 26**]m labeled sulfur colloid (administered [**2177-10-17**]).
COMPARISON: Indium-111 tagged white blood cell scan [**2177-10-16**].
PHYSICAL EXAM: Open wound of the anterior distal right lower extremity covered
with vacuum dressing. External fixator securing lower right leg with anterior,
medial, and lateral hardware components.
Autologous white blood cells labeled with In-111 were injected on [**2177-10-15**] and I
In-111 imaging was performed on [**2177-10-16**]. Today, [**2177-10-17**], Tc-[**Age over 90 26**]m labeled sulfur
colloid was administered and further imaging performed.
Dual photopeak imaging was obtained of the lower extremities in anterior and
lateral projections. Indium-111 photopeak imaging again demonstrates marked
focal uptake of tracer along the anterior aspect of the distal third of the
right distal lower extremity, in the same distribution as seen on yesterday's
images. Tc-[**Age over 90 26**]m photopeak imaging shows expanded bone marrow activity extending
into the distal lower extremities. On the left leg, there is smooth distal
tapering of the activity. Bone marrow activity is present in the proximal right
tibia with sharp cutoff at the level of the patient's wound with photopenia of
the right tibia at the site of the wound.
There are photopenic defects of the proximal [**12-11**] of the right tibia and fibula
which are presumed due to the fixator hardware overlying these sites.
Compared with the prior white cell study dated [**2177-10-16**], there is still active
accumulation of white cells in the lower third of the right distal lower
extremity.
IMPRESSION: Increased uptake in the distal third of the right distal lower
extremity consistent with continued active infection. No other sites of white
blood cell uptake. Extension of the bone marrow to the distal lower extremities
bilaterally compatible with prolonged stimulation. Cut off of bone marrow
activity at the site of white cell uptake is suggestive of osteomyelitis
involving the distal third of the right tibia.
(Over)
BONE MARROW SCAN Clip # [**Clip Number (Radiology) 77369**]
Reason: 30YR OLD WOMAN WITH ESRD ON HD, S/P TIB/FIB FX WITH HARDWARE INFECTION S/P HARDWARE REMOVAL WITH EX-FIX
______________________________________________________________________________
FINAL REPORT
(Cont)
[**First Name8 (NamePattern2) 59**] [**Last Name (NamePattern1) 729**], M.D.
[**Initials (NamePattern4) 61**] [**Last Name (NamePattern4) 62**] [**Last Name (NamePattern1) 63**], M.D. Approved: TUE [**2177-10-21**] 4:15 PM
West [**Medical Record Number 77368**]
RADLINE [**Telephone/Fax (1) 31**]; A radiology consult service.
To hear preliminary results, prior to transcription, call the
Radiology Listen Line [**Telephone/Fax (1) 32**].
|
Radiology
|
Classify the following medical document.
|
Chief Complaint:
24 Hour Events:
BLOOD CULTURED - At [**2192-8-28**] 03:08 PM
-40mg IV lasix with good urine output (approx 500cc)
-medications changed to PO if possible to avoid excess urine, decreased
free water flushes with TFs
-switched to AC overnight for persistent apnea
Allergies:
Aspirin
Unknown;
Penicillins
Unknown;
Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)
Rash;
Last dose of Antibiotics:
Levofloxacin - [**2192-8-27**] 06:19 PM
Vancomycin - [**2192-8-28**] 08:00 AM
Metronidazole - [**2192-8-28**] 09:06 PM
Amikacin - [**2192-8-28**] 09:07 PM
Infusions:
Other ICU medications:
Pantoprazole (Protonix) - [**2192-8-28**] 08:00 AM
Heparin Sodium (Prophylaxis) - [**2192-8-28**] 08:00 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2192-8-29**] 07:05 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.7
C (99.8
Tcurrent: 37.2
C (98.9
HR: 73 (57 - 78) bpm
BP: 144/58(81) {128/51(71) - 165/71(96)} mmHg
RR: 15 (11 - 29) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 77 kg (admission): 66.5 kg
Height: 66 Inch
Total In:
2,294 mL
358 mL
PO:
TF:
324 mL
238 mL
IVF:
1,400 mL
71 mL
Blood products:
Total out:
2,400 mL
790 mL
Urine:
2,400 mL
790 mL
NG:
Stool:
Drains:
Balance:
-106 mL
-432 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV
Vt (Set): 450 (450 - 450) mL
Vt (Spontaneous): 430 (319 - 480) mL
PS : 0 cmH2O
RR (Set): 12
RR (Spontaneous): 3
PEEP: 5 cmH2O
FiO2: 40%
RSBI Deferred: No Spon Resp
PIP: 18 cmH2O
Plateau: 16 cmH2O
SpO2: 100%
ABG: ///32/
Ve: 7.3 L/min
Physical Examination
GEN: Intubated, sedated
HEENT: NCAT MMM anicteric pale conjunctiva
CV: RRR S1S2
PULM: rhonchi at mid-lung fields, likely [**1-7**] intubation otherwise clear
while supine
ABD: soft, distended, nontender +bs no palp masses
EXT: WWP 1+ bipedal edema 1+dp pulses no cyanosis
SKIN: no new lesions, rashes noted
Labs / Radiology
666 K/uL
8.0 g/dL
152 mg/dL
1.1 mg/dL
32 mEq/L
3.5 mEq/L
13 mg/dL
102 mEq/L
138 mEq/L
24.9 %
15.4 K/uL
[image002.jpg]
[**2192-8-24**] 03:46 AM
[**2192-8-24**] 09:00 PM
[**2192-8-25**] 01:47 AM
[**2192-8-25**] 02:07 AM
[**2192-8-27**] 04:35 AM
[**2192-8-27**] 05:32 AM
[**2192-8-28**] 04:12 AM
[**2192-8-28**] 08:43 AM
[**2192-8-28**] 02:53 PM
[**2192-8-29**] 05:54 AM
WBC
24.0
26.1
16.1
15.7
15.4
Hct
26.1
28.7
22.5
23.4
24.9
Plt
195
312
583
548
666
Cr
0.9
0.9
1.1
1.1
1.0
1.1
TropT
0.10
TCO2
28
27
28
Glucose
141
69
216
83
105
152
Other labs: PT / PTT / INR:15.5/27.6/1.4, CK / CKMB /
Troponin-T:37/3/0.10, ALT / AST:[**9-23**], Alk Phos / T Bili:79/0.3,
Amylase / Lipase:153/139, Differential-Neuts:88.3 %, Band:3.0 %,
Lymph:7.9 %, Mono:3.0 %, Eos:0.7 %, Fibrinogen:661 mg/dL, Lactic
Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:256 IU/L, Ca++:7.5 mg/dL,
Mg++:2.0 mg/dL, PO4:2.8 mg/dL
Assessment and Plan
82 year old female with a history of breast cancer, CVA, hypertension
with recent MICU stay for E.coli urosepsis, providencia UTI, and RLL
aspiration PNA presents from medical floor after likely PEA arrest now
with worsening mental status than on previous transfer now 48 hours
after the event.
# Cardiopulmomary Arrest: Patient found pulseless, ashen, and cool,
down for no longer than 10 minutes. Patient not monitored on telemetry
at the time of the event. She quickly regained rhythm after intubation
and 1gm epinephrine w/ CPR. In the setting of underlying RLL
infiltrate, concern for worsening pulmonary edema on the floor, most
likely etiology respiratory arrest w/ mucous plug. No further events
since admission to ICU, although continues to have episodes of apnea
while on PS.
- treat underlying cause of PNA, provide respiratory support with
ventilator for now
- continue to trend lactate
- monitor on telemetry, patient appears to be hemodynamically stable
-CT head to evaluate for any acute insults that may be causing her
apneic periods
.
# Hypercarbic Respiratory Failure: S/p intubation x2. Hypercarbic
likely to arrest d/t pulmonary etiology (mucus plugging, apneic
period). Overnight with significant secretions needing frequent
suctioning. Will continue to wean as tolerated to PS although not ready
for extubation. Will discuss goals of care with niece this morning
(extubation, trach placement etc.)
- Wean FIO2 as tolerated, to PS
- weak cough, no gag per RT
- suction prn, nebs prn
- -d/w family re: trach
.
# HAP/Aspiration PNA/sepsis: Patient on broad spectrum coverage since
admission, has grown GPC pairs/clusters in sputum and E.coli in blood
and urine. CT from [**8-25**] showed persistent RLL infiltrate. CBC showing
new bands on diff in setting of code.
- continue vanc/levo/flagyl, patient currently on day 11 of ABX, (3
more days)
- sputum from [**8-27**] - GRAM STAIN (Final [**2192-8-27**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND
CLUSTERS.
RESPIRATORY CULTURE (Preliminary): NO GROWTH.
- only positive blood culture so far from [**8-17**] - ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
# Urosepsis: E.coli bacteremia, and e.coli/providencia UTI. Repeat
cultures have been negative. Has been on amikacin, last day [**9-2**].
- f/u amikacin levels this morning
.
# Acute Kidney Failure: Creatinine 1.1 from baseline of 0.6, currently
on CVVH. Likely prerenal in etiology secondary to episode of
hypoperfusion.
- suspect that some of renal failure is likely due to poor forward flow
and patient looks volume overloaded by physical exam
- trend creatinine
- goal I/O is negative 1 liter per day, would give lasix as
needed to achieve this
.
# Hypertension: On lisinopril, metoprolol as outpatient
- restart lisinopril today, uptitrate as tolerated
- lasix 40mg IV qd, monitor UOP
.
# Dementia: Currently intubated without need for sedative medications.
Concern for possible cerebral ischemic insult during her PEA arrest
that may be causing her apnea.
- continue namenda and aricept
- -CT head as above
.
FEN: tubes feeds, monitor electrolytes, repleted K aggressively this
morning for K of 2.6
.
# Prophylaxis: SC heparin, d/c bowel regimen in the setting of
persistent diarrhea, PPI
.
# Communcation: Sister [**Name (NI) **] [**Name (NI) 5333**] [**Telephone/Fax (1) 5334**], will decide on trach in
the morning
.
# Code: FC - plan to reassess with sister today
.
# Disposition: ICU care for now
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2192-8-29**] 02:32 AM 40 mL/hour
Glycemic Control:
Lines:
PICC Line - [**2192-8-27**] 01:15 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
------ Protected Section ------
ERROR: In note patient is said to be on CVVH. This is an error and
should be disregarded. Patient is currently not on any form of HD and
has not been during this admission.
------ Protected Section Addendum Entered By:[**Name (NI) 5095**] [**Name8 (MD) 5096**], MD
on:[**2192-8-30**] 10:46 ------
|
Physician
|
Classify the following medical document.
|
T/Sicu Nsg Note
0700>>[**2197**]
Events- Second left pleural CT for persistent pneumotx
weaned from levo after additional IVF(FFP)
improved MAP..CPP values
tolerating small doses fentanyl w/effect>>improved sedation
CT for many scans including TLS...pnd
resolving met acidosis
Neuro- perrl @ 3>2mm/brisk with impaired corneals
impaired gag/cough..sedation ongoing
no spont movements noted except overbreathing vent
Pt localizes to nailbed pressure when propofol suspended x 20 min: no movement of LUE; LE's moving more vigorously.
[**Last Name (un) **] catheter in place with ICP values of high teens to 11
CPP initial <60 d/t map in low 70's..improved with increased levo> increased bp/map.
Extra 500mg dilantin given for level of 2.5 today. No seizure activity noted.
CVS- levo increased initially to improve map's; able to wean off with stable neurohemodynamics. Adequate svo2 & co/ci..see careview data.
Maintained on ivf of 100/hr.
Electrolytes repleted prn.
Resp- fio2 weaned to 40% with adequate PaO2 and sats.
RR weaned to x 14 with goal of PCO2 of normocardia. Pt easily breaths over vent when lightened; more in phase with vent with improved sedation...pco2 currently 34.
Coarse/diminished [**Last Name (un) 124**] sounds with left lung fields more decreased.
** Second left pleural ct placed for persistent pneumothorax. Both left ct have air leaks; right pleural ct has [**Last Name (un) **] small leak. Small sanginous drainage from all tubes.
..Resolving base deficit/met acidosis...lactate now <1
..sputum cultures sent; secretins are thick & bloody
Renal- adequate hourly u/o
urine culture sent
ID- afebrile wkith wbc wnl
remains on vanc, clina, ceftaz
cultures requested today; [**Doctor First Name **] blood cultures x2 done
heme- hct 33 after 1u pc's on nights...now tending to 28..to follow
INR 1.3...1u ffp given with repeat INR 1.3
platelets cont on downward trend..no heparin being given
endo- riss coverage for glucose 120-145
GI- npo with ogt to LCS with bilious drainage
soft abd w/absent bowel sounds
protonix
peripheral/vascular- warm extremities with +3 palpable pulses. LUE with ^^ edema>>elevated on pillow. LLE remains in knee immobilizer.
compression boot on RLE only
skin- forehead and left eyebrow lacs have been sutured by OMF resident; pressure dsg applied to site for 24 hours, after which it can be removed . Wound care: cleanse lacs with 1/2 stenth H2O2 to remove dry blood and apply bacitracin to keep areas moist..[**Hospital1 **] & prn.
..^^ edema of left shoulder area; bruising noted at shoulder, skin intact.
..anterior torso with red, peticheal markings(from windshield trauma) is intact.
..back & buttocks intact
..skin under c-collar is intact..pressure line noted n chin probably from field collar. [**Location (un) **]-J collar now in place.
**NO sc Heparin**
Social- family in/out throughout the day for brief visits. Updates re pt progress provided. Wife has multiple supports availabe and is handling pt's situation well. Social [**Last Name (un) **]
|
Nursing/other
|
Classify the following medical document.
|
Chief Complaint: respiratory and renal failure
24 Hour Events:
DIALYSIS CATHETER - STOP [**2117-7-23**] 04:30 PM
placed in IR
UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At
[**2117-7-23**] 04:30 PM
- Pt's position was being changed, and her tunneled HD line was pulled
out. CVVH stopped. Renal will have to assess when CVVH needs to be
restarted. If needs before Monday, renal will have to put in temporary
dialysis catheter.
- Pt on levophed for hyptension
- HCT stable
- Pt on pressure support
Allergies:
Flagyl (Oral) (Metronidazole)
Rash;
Last dose of Antibiotics:
Cefipime - [**2117-7-23**] 04:00 PM
Ciprofloxacin - [**2117-7-23**] 06:00 PM
Micafungin - [**2117-7-23**] 08:17 PM
Vancomycin - [**2117-7-24**] 12:36 AM
Infusions:
Norepinephrine - 0.03 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2117-7-23**] 12:00 PM
Heparin Sodium (Prophylaxis) - [**2117-7-24**] 12:36 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2117-7-24**] 07:38 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.4
C (99.3
Tcurrent: 37
C (98.6
HR: 89 (73 - 97) bpm
BP: 104/41(60) {76/34(47) - 114/71(81)} mmHg
RR: 16 (13 - 21) insp/min
SpO2: 98%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 98.2 kg (admission): 110 kg
Height: 66 Inch
Total In:
7,372 mL
606 mL
PO:
TF:
1,560 mL
466 mL
IVF:
5,692 mL
80 mL
Blood products:
Total out:
6,812 mL
25 mL
Urine:
23 mL
25 mL
NG:
Stool:
Drains:
Balance:
560 mL
581 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Set): 400 (400 - 400) mL
Vt (Spontaneous): 174 (174 - 577) mL
PS : 15 cmH2O
RR (Set): 18
RR (Spontaneous): 21
PEEP: 10 cmH2O
FiO2: 60%
RSBI Deferred: PEEP > 10
PIP: 25 cmH2O
SpO2: 98%
ABG: 7.36/49/77/26/0
Ve: 7.5 L/min
PaO2 / FiO2: 128
Physical Examination
General Appearance: No(t) Well nourished, No acute distress, Overweight
/ Obese
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), Coarse breath sounds
bilaterally
Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,
Obese, anisarcic (slightly worse than yesterday)
Extremities: Right: 1+, Left: 1+
Skin: Warm
Neurologic: Alert, opens eyes. Tracks movement.
Labs / Radiology
258 K/uL
8.0 g/dL
104 mg/dL
2.0 mg/dL
26 mEq/L
4.8 mEq/L
26 mg/dL
98 mEq/L
134 mEq/L
26
11.3 K/uL
[image002.jpg]
[**2117-7-23**] 04:02 AM
[**2117-7-23**] 09:52 AM
[**2117-7-23**] 10:06 AM
[**2117-7-23**] 12:45 PM
[**2117-7-23**] 12:57 PM
[**2117-7-23**] 03:49 PM
[**2117-7-23**] 04:23 PM
[**2117-7-23**] 06:05 PM
[**2117-7-24**] 03:10 AM
[**2117-7-24**] 05:02 AM
WBC
11.3
Hct
26.5
25.4
26.1
26
Plt
258
Cr
1.7
2.0
TCO2
27
28
27
28
29
Glucose
154
211
107
104
Other labs: PT / PTT / INR:16.3/34.6/1.4, CK / CKMB /
Troponin-T:88/10/0.76, ALT / AST:20/21, Alk Phos / T Bili:98/0.3,
Differential-Neuts:75.0 %, Band:0.0 %, Lymph:16.0 %, Mono:9.0 %,
Eos:0.0 %, Fibrinogen:489 mg/dL, Lactic Acid:1.1 mmol/L, Albumin:3.1
g/dL, LDH:363 IU/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL
Imaging: [**2117-7-24**] CXR: Radiology read pending. HD line no longer present,
otherwise no interval change
Microbiology: BC [**7-21**] and [**7-23**] pending
[**2117-7-21**] Urine culture: yeast, awaiting speciation
[**2117-7-22**] Mini-BAL: gram stain negative, but awaiting culture
finalization (pre-lim shows no growth)
[**2117-7-21**] Stool culture pending, but c.diff negative
Assessment and Plan
SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)
SHOCK, OTHER
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name **])
PULMONARY HYPERTENSION (PULM HTN, PHTN)
ALTERATION IN NUTRITION
ANEMIA, CHRONIC
OBESITY (INCLUDING OVERWEIGHT, MORBID OBESITY)
ALTERED MENTAL STATUS (NOT DELIRIUM)
RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)
HEART DISEASE, OTHER
HEMOPTYSIS
RESPIRATORY FAILURE, CHRONIC
C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE)
78 y/o female with MMP including OSA requiring trach, d CHF, AFib,
chronic C. diff infection presents from LTAC with worsening mental
status and failure to improve.
# Septic shock -potentially septic picture, CT with no evidence of
intrathoracic/abdominal source for infection. Restarted levophed
overnight for MAPS < 60
-Ucx grew yeast, requested speciation
- awaiting results of blood culture. Mini-BAL gram stain was negative,
but final culture pending (pre-lim shows no growth). Stool culture
pending, but C.diff negative
- cont Vanc/Cef/Cipro/Mica. If cx negative on Sunday, d/c abx
- Levophed to maintain MAPs > 60, if too much ventricular ectopy switch
to neosynephrine.
# Respiratory Failure
potentially related to sepsis
-Pt tolerated pressure support well, try to decrease PEEP today
-check ABGs Q6H
#Renal failure:
- CVVH on hold due to no access. Will discuss when pt needs temporarily
line vs. waiting until monday for permanent line.
- f/u renal recs
# anemia/coagulopathy- hcts stable, patient oozing from every needle
stick. Site of line removal looks stable, with no hematoma formation.
Guiac + and has h/o trach bleed. Per thoracics: if rebleeds, would want
to consider source in deep lung parenchyma.
- Hct Q8H
-cont. SQ heparin
-transfuse for hct <22
# Hx of C.diff Infection
- C diff negative x 3
- ID recs: PO vanc 14 days after last dose of antibiotics; on
antibiotics now
# Diastolic Heart Failure/volume overload
- Holding CVVH for now
# dysrrhthmias
- HR stable in 80s
-currently on levophed, if too much ventricular ectopy, switch to
neosynephrine
ICU Care
Nutrition:
Vivonex (Full) - [**2117-7-24**] 04:00 AM 65 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2117-7-20**] 04:16 PM
Arterial Line - [**2117-7-21**] 03:00 PM
20 Gauge - [**2117-7-22**] 09:30 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care, Daily wake up
Comments:
Communication: Comments:
Code status: Full code
Disposition:ICU
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2182-5-8**] Discharge Date: [**2182-5-14**]
Date of Birth: [**2120-10-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Decreased exercise tollerance.
Major Surgical or Invasive Procedure:
Aortic valve replacement and mitral valve replacement [**2182-5-8**].
History of Present Illness:
This is a 61 yo male with long history of aortic stenosis with
slowly evolving decreased exercise tollerance
Past Medical History:
Hypertension.
Depression.
Rheumatic fever.
Cholecysectomy.
Social History:
Patient lives with wife in [**Name (NI) 5176**]. He works as a gynecologist.
Denies tobacco use. Reports occasional ETOH on weekends.
Family History:
Non-contributory.
Pertinent Results:
[**2182-5-11**] 05:45AM BLOOD WBC-12.8* RBC-3.10* Hgb-9.2* Hct-27.4*
MCV-88 MCH-29.6 MCHC-33.5 RDW-14.2 Plt Ct-158
[**2182-5-14**] 05:50AM BLOOD PT-14.3* PTT-42.5* INR(PT)-1.3
[**2182-5-13**] 04:55PM BLOOD Glucose-106* UreaN-27* Creat-1.1 Na-139
K-4.4 Cl-103 HCO3-28 AnGap-12
[**2182-5-13**] 04:55PM BLOOD Mg-2.2
Brief Hospital Course:
Dr. [**Known lastname 58695**] was admitted on [**2182-5-8**] and proceeded directly to the
operating room for an aortic valve replacement and mitral valve
replacement with Dr. [**Last Name (STitle) **]. Please see op note for full
details. He was seccessfully weened and extubated on his
operative evening.
On POD one he continued to progress well and was transferred out
of the intensive care unit. Also on POD one, he converted to
atrial fibrillation treated with IV and PO lopressor.
On POD two he continued to be in atrial fibrillation (rate
controlled) and was started on amiodarone and heparin IV for
anticoagulation. His chest tubes and cardiac pacing wires were
removed.
On POD three he strated on PO coumadin for anticoagulation. In
the aftrenoon he converted to a normal sinus rhythm.
PODs four and five were uneventful with ongoing heparin drip and
PO coumadin. He continued to have a significant amount of
peripheral edema and his lasix was increased. Physical therapy
continued to follow pt closely and on POD five he was found to
be safe for home from their standpoint.
On POD six, his INR continued to be low at 1.3 but it was
decided that his heparin could be discontinued and he would be
discharged home with PO coumadin only.
Medications on Admission:
Atenolol 20 mg daily.
Prozac 50 mg daily.
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(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. 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Fluoxetine HCl 20 mg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): 5 mg on [**5-14**] and [**5-15**]. Have VNA draw blood and check
INR on [**5-16**] and Dr. [**Last Name (STitle) 3306**] will dose coumadin.
Disp:*150 Tablet(s)* Refills:*2*
10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
11. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a
day for 7 days: To start following 400 mg [**Hospital1 **] dosing.
Disp:*14 Tablet(s)* Refills:*0*
12. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day: To beging after 400 mg [**Hospital1 **] and 400 mg daily doses are
completed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
Aortic stenosis/ Aortic insufficiency.
Mitral stenosis.
Post-operative atrial fibrillation.
Discharge Condition:
Stable.
Discharge Instructions:
Shower daily and wash incisions with soap and water -- rinse
well. Do not apply any creams, lotions, powders, or ointments.
No swimming or tub bathing.
No lifting greater than 10 pounds.
No driving x 6 weeks.
Followup Instructions:
Call to schedule appointments with:
[**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] follow-up appointment in 4
weeks
[**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 58696**] follow-up appointment in 2 weeks
Cardiologist in [**2-3**] weeks
Please have NVA draw blood and check INR on [**5-16**] and call
results into Dr. [**Last Name (STitle) 3306**]' office.
Completed by:[**2182-5-14**]
|
Discharge summary
|
Classify the following medical document.
|
Admission and NPN 01-0700:
This is a 54 yo male pt with a hx of HCV, hepatocellular CA, cirrhosis, etho, who has been living in a nursing home transitioning to hospice. Plan was for pt to go back to [**Country 1948**] where he would likely die soon. Instructions were that he wanted to remain full code in hopes that he would be able to make it back to [**Country 1948**]. Yesterday, pt was noted to have MS changes and was sent to ED. On arrival he was noted to be hypotensive SBP 60s, given NS boluses and started on Levophed drip. Lactate was 10.6, EKG showed peaked T wave and K was 6.8. An NG tube was placed and was given Kayexalate; coffee ground material was aspirated. Given IV vancomycin, Flagyl, Levofloxacin, Albumin, and Protonix. LFTs were c/w cholangitis and RUQ US showed no significant changes from prior exam. Surgery was consulted and felt that pt is not a surgical candidate given comorbidities and overall prognosis. This was communicated to pt's friends who accompanied him in the [**Name (NI) **], but they felt uncomfortable changing his code status. His brother is flying to [**Name (NI) 47**] from [**Country 1948**] and the wish was expressed that the pt be supported fully, including intubation if necessary, until his brother arrives today ([**6-17**]). CXR showed pulmonary edema, a presept catheter was inserted in ED and started on sepsis protocol, transferred to [**Hospital Unit Name 65**] to continue sepsis protocol and intubate if needed.
ROS:
Neuro: Pt is lethargic, answers questions intermittently with an unclear speech, oriented to name and place (names [**Hospital3 1015**]), R/O hepatic encephalitis started on Lactulose,
c/o abdominal pain given Morphine sulfate 2 mg IV. RUQ US preliminary showed portal vein thrombosis, rt lobe liver lesions consistent with HC, minimal amount of ascites, gallbladder thickening with no evidence of acute cholecystitis.
Resp: Breathing regularly on NC 4 L/min, at times desats to 88% reminded to take deep breaths goes up to 94-95%, RR 20-26, LS coarse all through, CXR showed multifical pneumonia/asymmetric pulmonary edema.
CV: ST HR 105-115, BP 97-114/43-56, with presep cath and 2 peripheral IV lines, on Levophed at 0.15 mcg/kg/min, with edema all over especially extremities and ascites, on Vancomycin, Flagyl and Zosyn, bld tests revealed Hct 35, WBC 9.6, Lactate 6.2, INR 2.1 given vit. K.
EKG done in ICU, CVP 12-14, SVO2 80-84, sepsis protocol continued.
GI/GU: With NGT in place, to be kept NPO (except for meds) for possible intubation. Abdomen softly distended with ascites, with Foley cath drained 100-140 ml/hr clear yellowish u/o.
Integ: With jaundice, icteric eyes, edema all over, peripheral pulses weak.
Social:No contacts from family/friends during the night.
Plan: Minitor BP and continue Levophed to maintain MAP above 60, monitor CVP and bolus with 500 ml NS if less than 12, monitor for worsening of pulmonary edema, repeat CXR, continue sepsis protocol, monitor lytes especially K and replete accordingly (or give Kayexalate if K is high), Keep NPO except for meds for possible intubation if needed.
|
Nursing/other
|
Classify the following medical document.
|
Admission Date: [**2186-11-24**] Discharge Date: [**2186-11-28**]
Date of Birth: [**2108-3-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Accupril / Celebrex
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
"spitting up dark vomit"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 78y/o lady with dementia, HTN, SLE on
Prednisone/Plaquenil, [**Known lastname 2091**] stage IV (baseline Cr 1.5), amyloid
angiopathy with recent ICH who presents from nursing home due to
hematemesis.
.
She is a resident at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]; at her baseline she is
disoriented and does not speak very much, though she can answer
questions appropriately. She has had a complicated recent course
including hospitalizations x2 at [**Hospital1 2177**] over the past month for
multiple intracerebral hemorrhages/hemorrhagic strokes. It was
felt that these strokes were related to hypertension and amyloid
angiopathy. Goal SBP has been less than 150. Prior to her recent
hospitalization she reportedly fell, was on the ground for a
prolonged amount of time, and was also noted to be "spitting up
dark vomit."
.
On the day of presentation she reported "burning" but did not
elaborate when asked. She had a BP 200/100. Vomited dark
brown/marroon vomit and the paramedics were called. En route,
she again vomited maroon emesis.
.
She was recently admitted to [**Hospital1 2177**] in [**Month (only) 216**] for a cerebellar ICH,
and again on [**11-21**] for lethargy/somnolence. CT scan of the head
revealed a new left posterior temporal lobe intraparenchymal
hemorrhage without mass effect. No MRI done due to agitation.
BP controlled and she was subsequently discharged. Of note, she
had a few runs of SVT there that were beta blocker responsive.
.
In the ED, initial VS: T98.3, HR 108, BP 171/120, RR 18, POx
100% 3L NC. Labs notable for Hct 47.3 (at baseline), Cr 1.8 (at
baseline), lipase slightly elevated at 111. She had no more
episodes of emesis after arrival. NG lavage mstly clear with
some maroon sediment and coffee ground emesis. She had PIVx2
placed, was started on normal saline @150cc/hr, Pantoprazole 80
mg IV bolus then drip at 8mg/hr. Her SBP was noted to be >180;
she was given Diltiazem 10mg IV given recent ICH. She was
admitted to Medicine for management of upper GI bleed. VS prior
to transfer were: T98.4, HR74, BP156/78, RR16, POx98%RA.
.
This morning on the medicine floor, she had no further episodes
of hematemesis or coffee grounds. Repeat HCT to 43 this AM. She
was noted to be hypertensive to 200-210 systolic. The stroke
team was involved given the finding of ?ICH on CT head. After
obtaining [**Hospital1 2177**] records, teams were reassured that imaging
abnormalities were present during most recent admission a few
days ago. Strict BP control recommended, along with MRI. She
got hydralazine 10mg IV x2 which brought BP down to 160s. She
then developed SVT with rates to 160s that was initially
responsive to vagal maneuvers but eventually required lopressor
5mg IV x2. She retained hemodynamic stability throughout these
episodes.
.
Upon arrival to the MICU, she complains of no pain but resists
continued questioning, getting somewhat irritated with physical
exam as well. Denies abdominal pain, N/V/D, bloody emesis, chest
pain, SOB. No further ROS could be elicited.
Past Medical History:
- intracerebral hemorrhages, involved the left cerebellar and
right parietal lobes
- dementia
- [**Hospital1 2091**] IV, baseline Cr 1.5-1.8
- HTN
- SLE
- DM2
- DJD, knees
- acute gout flare, on prednisone taper
- rotator cuff surgery
- patient has had most of her care at [**Hospital1 2177**]
Social History:
Widowed, now at [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **]. Never smoker. No alcohol. Never
drugs.
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 96.1F, BP 182/91, HR 80, R 18, O2-sat 98% RA
GENERAL - elderly lady in NAD
HEENT - EOMI, sclerae anicteric, dry MM, OP clear
NECK - no JVD, no carotid bruits
LUNGS - CTA bilaterally
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - (+) bowel sounds; no tenderness to palpation in any
quadrant; no rebound
RECTAL: deferred; was guaiac negative in the ED
EXTREMITIES - warm, no edema, 2+ DP pulses bilaterally
NEURO - awake, oriented to self only.
Smile reveals very mild flattening of left nasolabial fold and
very mild down-turning of left mouth.
Sensation to light touch intact V1-V3.
Can keep eyes closed when attempted to force open.
Tongue is midline.
Normal muscle bulk and tone.
Sensation to light touch grossly intact throughout.
Right hand finger-to-nose test is slow/deliberate with hesitancy
as approaches target; left hand is even more inaccurate
Slow alternating movements of hands in lap; cannot perform task
faster.
LEs with 4+/5 strength of hip flexion and toe dorsi/plantar
flexion.
UEs with 5/5 flexion/extension at elbow.
Oriented to self only. When asked if this might be a restaurant
or school or hospital or apartment, she says, "I'm, I think it
is a sool, shool, a shool."
Two minutes after telling her where she is, when asked if she
remembers which hospital this is she does not remember.
DISCHARGE PHYSICAL EXAM:
VS: 96.8 128/76 68 18 96%RA
Exam is otherwise unchanged
Pertinent Results:
LABS:
On admission:
[**2186-11-23**] 09:30PM BLOOD WBC-10.3 RBC-5.43* Hgb-15.6 Hct-47.3
MCV-87 MCH-28.8 MCHC-33.1 RDW-14.1 Plt Ct-270
[**2186-11-23**] 09:30PM BLOOD Neuts-86* Bands-0 Lymphs-11* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2186-11-23**] 09:30PM BLOOD PT-12.4 PTT-23.9 INR(PT)-1.0
[**2186-11-23**] 09:30PM BLOOD Glucose-208* UreaN-31* Creat-1.8* Na-144
K-4.2 Cl-104 HCO3-24 AnGap-20
[**2186-11-23**] 09:30PM BLOOD ALT-25 AST-27 AlkPhos-76 TotBili-0.2
[**2186-11-23**] 09:30PM BLOOD Lipase-111*
[**2186-11-23**] 09:30PM BLOOD Albumin-4.4 Calcium-10.6* Phos-3.1 Mg-1.8
On discharge:
[**2186-11-28**] 07:00AM BLOOD WBC-8.4 RBC-5.07 Hgb-14.7 Hct-44.1 MCV-87
MCH-29.1 MCHC-33.4 RDW-13.9 Plt Ct-229
[**2186-11-28**] 07:00AM BLOOD Plt Ct-229
[**2186-11-28**] 07:00AM BLOOD Glucose-139* UreaN-35* Creat-1.6* Na-140
K-4.3 Cl-104 HCO3-25 AnGap-15
[**2186-11-27**] 07:05AM BLOOD ALT-17 AST-16 LD(LDH)-252* AlkPhos-50
TotBili-0.4
[**2186-11-28**] 07:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1
IMAGING:
[**11-24**] CT head:
IMPRESSION:
1. New hyperdense focus within the left parietal lobe may
represent new
hemorrhagic stroke versus hemorrhagic tumor versus a focus of
hemorrhage.
Additional low-attenuating region within the right parietal and
iso- to
hyperdense focus within the left cerebellar region may
correspond to patient's history of hemorrhagic stroke. Overall,
findings may suggest an embolic phenomenon; however, correlation
with clinical history is recommended.
NOTE ADDED AT ATTENDING REVIEW: The hemorrhagic lesions in the
left cerebellar hemisphere and left parietal lobe might
represent hemorrhagic infarctions, however, the possibility of
neoplasms should be considered. The hypodense right parietal
mass with a thin hyperdense rim would be an unusual appearance
for infarction, acute or chronic, and the possibility of
neoplasm should be strongly considered. Given these findings, an
MR with contrast is recommended to pursue the possibility than
one or more of the lesions may be due to a malignancy, such as
metastatic disease.
After discussion by Dr. [**Last Name (STitle) **] with Dr. [**Last Name (STitle) 7886**] of Stroke
Neurology, at 10:30 am on [**2186-11-24**] by telephone, it appears
these lesions were pursued with CT as well as MR [**First Name (Titles) 151**] [**Last Name (Titles) **]
enhancement during a recent evaluation at [**Hospital6 **].
These studies are not available for comparison at this time, but
apparently reports interepreted the lesions described above as
benign hemorrhages. As discussed with Dr. [**Last Name (STitle) 7886**], the best
approach may be to obtain these studies and compare them to the
current examination. If this is not possible, then it would be
best to obtain an MR [**First Name (Titles) 151**] [**Last Name (Titles) **] when the patient's renal
function will permit this.
[**11-25**] CXR: In comparison with study of [**2184-2-14**], there is little
overall
change. No evidence of acute cardiopulmonary disease.
Specifically, the left base appears clear.
Brief Hospital Course:
78 year old female with dementia, HTN, SLE on
Prednisone/Plaquenil, [**Date Range 2091**] stage IV (baseline Cr 1.8) and amyloid
angiopathy with recent ICH who presented from nursing home due
to hematemesis on [**2186-11-24**] noted to have hypertensive
emergency, recent bleeds on head CT unchanged. She was
transferred briefly to the ICU for careful neuro checks,
frequent blood pressure monitoring, management of SVT (see
below), but was stable for transfer back to the floor within 1
day. Non-emergenct EGD showed no active bleeding, only candidal
esophagitis. Please see below for more details on each hospital
problem.
.
ACTIVE PROBLEMS:
# AMYLOID ANGIOPATHY/ICH: Given hypertensive urgency in the ED
with recent ICH, stat head CT obtained when she arrived on the
floor. The CT showed multiple sites of bleed, initially
concerning for acute new hemorrhage. She was evaluated
emergently by the Neuro Stroke service, who reviewed reports
from her OSH CT and MRI the previous week were obtained and it
was decided that what we were seeing was more likely due to
older bleeds. They recommended conservative managment with
aggressive control of BP, with goal BP <140/90. She was started
on metoprolol for blood pressure control (as well as prevention
of SVT- see below) and restarted on home dose of felodipine.
She will be continued on these two medications at discharge.
Good blood pressure control will be of paramount importance in
preventing new intracranial bleeds, so this is something that
should continued to be monitored frequently (at least every 8
hours) at her rehab facility.
.
# MAROON EMESIS: Hct at baseline on admission, NG lavage in ED
showed mostly clear fluid with some dark sediment. Made NPO and
started PPI IV. Repeat hematocrits showed no clinically
significant drop, and she hemodynamically stable with no
recurrence of hematemesis. EGD on [**2186-11-27**] revealed esophageal
candidiasis, likely as a result of her high dose prednisone
(even though this was started just 1 week ago). No other signs
to point to underlying immunodeficiency, however it would not be
unreasonable to order an HIV test as an outpatient, will defer
to outpatient PCP. [**Name10 (NameIs) **] was started on fluconazole 200 mg qday
for a planned 3 week course (from [**Date range (1) 97861**]). LFTs sent at
the initiation of therapy to establish a baseline (normal).
Continued on omeprazole 20 mg for additional gastric protection
on discharge. A biopsy of the candidal plaques as taken, so this
will need to be followed up as an outpatient.
.
# SUPRAVENTRICULAR TACHYCARDIA: Placed on telemetry on arrival
given concern for GI bleed, noted to have short runs of narrow
complex tachycardia which initially self-resolved on the morning
of admission. Then went into another run of SVT (appeared to be
AVNRT) to the 160s which was sustained. Attempted carotid
massage and vagal maneuvers, then metoprolol 5 mg IV x2 with
minimal response (rate decreased to 130s). She was then
transferred to the ICU for higher level of nursing care, and her
SVT broke while en route, converting back to sinus rhythm in the
80s. She was started on metoprolol for rate control. She
remained on telemetry throughout her stay and did not have a
recurrence.
.
#. DEMENTIA/DELIRIUM: Per daughter, pt is forgetful at
baseline, usually oriented to herself but not time or place.
She appeared to be baseline mental status throughout most of her
stay, but she was at times somewhat agitated. Likely a degree
of acute delirium, given her illness and frequent transfers
between floors. Her medication list from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] listed
seroquel 12.5 mg [**Hospital1 **] as one of her outpatient medications, so
she was started on this dose of seroquel with PRN haloperidol.
Her agitation was decreased with this medications, but she was
somewhat sleepy. She seemed to do better with a decreased dose
of 6.25 mg qHS, with additional 6.25 mg PRN (never needed to be
given this). She is being discharged on this decreased dose of
seroquel.
.
# HYPERNATREMIA: Na elevated to 146 on admission, likely due to
poor PO intake in the setting of dementia. Improved after
getting boluses of D5W, unlikely to have contributed to her
mental status.
.
# HYPERTENSION: BP control as above.
.
INACTIVE PROBLEMS:
#. [**Name2 (NI) 2091**]: Cr 1.7, remained within recent range through her
hospitalization. She was also continued on her calcitriol.
.
#. SLE, gout: Continued on outpatient doses of plaquenil and
allopurinol. She also came in on Prednisone for gout flare, and
supposedly this was to be tapered, but have not been able to
touch base with the PCP on this. Will send her back to [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **] on a taper over 6 days. She will be covered with sliding
scale insulin for steroid-induced hyperglycemia during these 6
days.
.
TRANSITIONAL ISSUES:
- Amyloid angiopathy: will need very tight control of her BP
with checks every 8 hours at her ECF. Does not need repeat
imaging unless clinical status changes
- Esophageal candiasis: given 3 week course of fluconazole,
should have LFTs checked and consider HIV test as screen for
causes of immunosuppression
- Follow up biopsy of esophagus
DNR/DNI throughout hospital stay, confirmed w daughter/HCP
[**Name (NI) **]
Outstanding tests:
Esophageal biopsy [**11-27**] - returned consistent with candidal
esophagitis.
Medications on Admission:
- prednisone 40 mg PO daily (being tapered)
- hydrochloroquine 200 mg PO BID
- felodipine 10 mg PO daily
- allopurinol 150 mg PO daily
- seroquel 12.5 mg PO daily
- prilosec 20 mg PO daily
- calcitriol 0.25 mcg PO daily
- folic acid 1 mg PO daily
- colace 100 mg PO BID
- Tylenol PRN
- Senna PRN
- Miralax PRN
Discharge Medications:
1. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days.
2. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for
2 days.
3. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
2 days.
4. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. felodipine 10 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
6. allopurinol 300 mg Tablet Sig: 0.5 Tablet(s) (150 mg) PO once
a day.
7. quetiapine 25 mg Tablet Sig: 0.25 Tablet PO qHS (bedtime),
may repeat x1 as needed.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Please hold for SBP<100 or HR<60
.
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
15. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day for 6 days: Sliding scale:
200-250 1 unit, 251-300 2 units, 301-350 3 units, 351-400 4
units.
16. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 weeks: Please stop on [**12-18**] .
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Hypertensive urgency
Esophageal candidiasis
Amyloid angiopathy with h/o intracranial hemorrhage
Supraventricular tachycardia
Chronic kidney disease
Hypernatremia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure to take care of you at [**Hospital1 18**]. You were
admitted to the hospital after you vomited some blood. We
looked down your throat with a camera, and we did not see any
bleeding but did find that you have a thrush infection of your
throat. We are prescibing you a 3 week course of a medicine
called fluconazole to help treat this.
We did a CT scan of your head and found that the bleeding from
your strokes looks stable. Because of your high blood pressure,
you are at an increased risk to bleed again. It is very
important that you continue taking your blood pressure medicines
and have your blood pressure checked regularly to make sure that
it does not get too high again.
Changes to your medications:
START fluconazole 200 mg daily for 3 weeks (until [**12-18**])
START metoprolol 25 mg three times a day
DECREASE prednisone to 30 mg for 2 days, then 20 mg for 2 days,
then 10 mg for 2 days, then stop
START insulin sliding scale four times a day (can stop when done
with prednisone taper)
Followup Instructions:
Please follow up with the on-staff doctor [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
|
Discharge summary
|
Classify the following medical document.
|
Neonatology Attending Admission Note
Infant known to [**Hospital1 21**] NICU as was delivered and initially admitted here ([**2170-12-8**]). Subsequently transferred later on delivery day to [**Hospital3 50**] for surgical management of imperforate anus. Has done well s/p colostomy for imperforate anus and transferred today for continued care.
Infant now a 10 day old, former 34 [**2-5**] week twin who was born to a 35 y.o. G1P0-2 mother with prenatal screens of A+, antibody negative, HBsAg negative, RPR NR, RI, GBS unknown. Pregnancy complicated by poor fetal growth of this twin which prompted early delivery. Delivery by cesarean section as this twin was in breech position. Infant did well at delivery with Apgars of [**8-7**].
Hospital course at [**Hospital3 50**]:
1. Respiratory: Briefly intubated for surgical procedure and postoperatively. Currently in RA. No apnea of prematurity.
2. Cardiology: Initial ECHO done at [**Hospital1 21**] prior to transfer to [**Hospital1 **] was normal.
3. FEN/Gastrointestinal: Colostomy performed for imperforate anus. Initially maintained on IVFs. Started feedings on 2nd post-op day. Now receiving NeoSure24 140cc/k/day.
4. Genitourinary: Initial renal u/s suggestive of hydronephrosis. Subsequent study was normal. VCUG revealed mild obstruction from posterior urethral valves. Will need urodynamic studies at a later date. Infant placed on amoxicillin prophylaxis mainly for colonic-urethral fistula.
5. Infectious Diseases: Received 48 hour course of amp/gent then switched to amox prophylaxis.
6. Neurology/Neurosurgery: Initial HUS concerns for PV echogenicity, but follow-up normal. Ophthalmology exam normal. Spine u/s revealed tethered cord.
7. Oral-cleft palate: Followed by plastics service, feeds with [**Last Name (un) **] nipple.
8. Genetics: consult obtained. No syndrome identified. Signature Chip results pending.
9. Hematology: Course of phototherapy
10: Orthopedics: Hypoplastic sacrum, right clavicular anomaly. Hip US normal.
Consultative services: cardiology, genetics (Dr. [**First Name4 (NamePattern1) 908**] [**Last Name (NamePattern1) 2906**]), neurosurgery (Dr. [**Last Name (STitle) 2907**], plastics (Drs. [**Name5 (PTitle) 1172**]/Mullikan), orthopedics (Drs. [**Name5 (PTitle) 2908**]/[**Doctor Last Name 2909**], [**Telephone/Fax (1) 2910**]), urology (Dr. [**Last Name (STitle) 2634**]
Exam:
Vital signs in CareView
Resting comfortably on radiant warmer. AFSF. Low-set ears. Cleft palate. Neck supple. Lungs CTA, =. CV RRR, no murmur, 2+FP. Abd soft, +BS. Colostomy bag intact. Nl phallus, testes desc bilat. Imperforate anus. Sacral dimple. Negative hip exam. Ext pink and well perfused. Clinodactyly.
Impression:
1. Preterm male newborn
2. Imperforate anus, s/p colostomy
3. Cleft palate
4. Multiple congenital anomalies
Plan:
Will continue current feedings and amoxicillin. Continue to encourage po feeds. Follow-up on all recommended tests and appointments by consultative services.
Orthopedics: anticipate no functional concerns secondary to clavicular anomaly (pseudoarthrosis). Rec f/u as outpatient in [**12-31**] months
Plastics: Cleft repair at 8-10 months of age
Neurosurgery: Spine MRI at 3 months of age
Genetics: f/u on Sig Chip results
Urolog
|
Nursing/other
|
Classify the following medical document.
|
Admission Date: [**2185-3-9**] Discharge Date: [**2185-4-20**]
Date of Birth: [**2145-10-21**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Zithromax / Biaxin / Plaquenil / Amantadine /
Amoxicillin / Fish Product Derivatives / Hydromorphone / Ativan
/ Versed / Tegaderm / Zyrtec / Vicodin / Dilaudid / Midazolam /
Shellfish Derived / Fentanyl / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
[**2185-3-10**]
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Small bowel resection.
4. Temporary abdominal closure.
5. primary classical cesarean delivery
[**2185-3-11**]
Re-exploration, washout and temporary closure
[**2185-3-14**]
Re-exploration of the abdomen, end-ileostomy, abdominal fascial
closure.
History of Present Illness:
Patient is a 38 year old female with an extensive past medical
history significant for chronic abd pain and Sphincter of Oddi
stenosis. She is s/p major duodenal papilla sphincteroplasty
with open J tube and open G tube placement on [**2184-4-20**]. She
responded very well to this surgery in terms of management of
her chronic abdominal pain.
She is now 25 weeks pregnant. She presents [**2185-3-9**] with
exquisite epigastric abdominal pain that woke her from sleep at
4am. It started suddenly and has been unremitting and not
controlled with her home darvocet pain meds. She was seen
earlier this month with less intense abd pain and was monitored
clinically. Per pt, she saw Dr. [**Last Name (STitle) **] in clinic and he reduced
a hernia.
Pt denies fevers or chills, vomiting, or diarrhea. She has some
nausea and still has flatus. She also has abdominal wall pain
secondary to known neuromas from her previous surgeries that had
been treated by Dr. [**Last Name (STitle) 957**] with
injections.
Past Medical History:
Past Medical History:
- Sphincter of Oddi dysfunction with stricture of the main
pancreatic duct s/p major duodenal papilla sphincteroplasty with
open J tube and open G tube placement
- Pancreatic insufficiency and pancreatitis
- h/o Lyme disease
- Thyroiditis
- [**Last Name (un) 8061**] syndrome with vasculitis
- Chronic neuropathic pain and optic neuritis
PSH:
Age 4, tonsillectomy and an adenoidectomy.
[**2173**] - rhinoplasty.
[**2164**] - cystoscopy.
[**12/2169**] and [**4-/2173**] - pelviscopy (? hystero-salpingoscopy or
colposcopy)
[**2172**] to [**2175**] - three Hickman catheters for IV antibiotics for
Lyme disease.
[**2174**] - Laparoscopic cholecystectomy @ [**Hospital1 112**], [**2174**]
[**2177**] - Hernia repair
[**2-/2183**] - EGD
[**5-/2183**] - Lipoma and incisional hernia on the left side and a
lipoma on the right side 1.5 cm2.
[**4-/2184**] - Biliary and pancreatic sphincteroplasty, open G tube
and
J tube for sphincter of oddi stenosis
Social History:
lives with husband, does not work
denies tobacco, alcohol, or illicit drug use
Family History:
non-contributory
Physical Exam:
On day of admission:
T 97.9 P 84 BP 100/52 R 20 SaO2 99%RA
Gen: mild distress with obvious pain
Neck: supple
Heent: an-icteric
Lungs: clear
Heart: RRR
Abd: well healed horizontal incisions, very tender over
epigastric incision site. Small palpable nodule. No hernia
palpated although exam limited by tenderness.
soft, nondistended,
gravid, nontender uterus
Extrem: warm, well-perfused
Pertinent Results:
[**2185-3-9**] 04:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2185-3-9**] 03:13PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2185-3-9**] 09:00AM GLUCOSE-90 UREA N-6 CREAT-0.3* SODIUM-136
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-21* ANION GAP-15
[**2185-3-9**] 09:00AM ALT(SGPT)-12 AST(SGOT)-17 LD(LDH)-149 ALK
PHOS-52 AMYLASE-54 TOT BILI-0.2
[**2185-3-9**] 09:00AM LIPASE-20
[**2185-3-9**] 09:00AM CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-1.6 URIC
ACID-2.3*
[**2185-3-9**] 09:00AM HBsAg-NEGATIVE
[**2185-3-9**] 09:00AM WBC-7.9 RBC-3.57* HGB-11.5* HCT-34.6* MCV-97
MCH-32.2* MCHC-33.2 RDW-14.2
[**2185-3-9**] 09:00AM NEUTS-81.9* LYMPHS-13.0* MONOS-4.7 EOS-0.4
BASOS-0
[**2185-3-9**] 09:00AM PLT COUNT-182
[**2185-3-9**] 09:00AM PT-13.0 PTT-36.1* INR(PT)-1.1
.
[**2185-3-10**] Pathology:
SPECIMEN SUBMITTED: terminal illium, placenta:
DIAGNOSIS:
1. Terminal ileum (A - C):
Recent hemorrhage and mucosal necrosis consistent with ischemic
type injury. The changes extend to the margins of resection
focally.
2. [**Doctor Last Name 11468**] placenta (156 grams) D - G:
A. Umbilical cord with three vessels.
B. Fetal membranes: No evidence of chorioamnionitis.
C. A thrombus is noted in a vessel beneath the amniotic surface
of the placenta.
Clinical: Fetal demise/? bowel obstruction. Small bowel
volvulus/fetal demise. 38 year old IU FD at 25 weeks.
Hysterotomy for delivery.
Gross: The specimen is received fresh, in two parts, each
labeled with the patient's name "[**Known firstname 1154**] [**Known lastname 11469**]" and the medical
record number.
Part 1 is additionally labeled "terminal ileum", and consists of
an unoriented segment of small intestine measuring 44 cm in
length x 3.5 cm in diameter. The two stapled ends each measure
3.0 cm in length. The serosa of the entire specimen appears dark
red to black. The specimen is opened along the antimesenteric
side to reveal a dark red to black lumen filled with blood. The
attached mesentery measures 9.5 x 4.5 x 0.5 cm, pink to red in
color. The specimen is sectioned to reveal dark red to black cut
surfaces. The specimen is represented as follows: A=stapled
margins, B=representative sections of mucosa, C=section of
mucosa with adjacent mesentery.
Part 2 is additionally labeled "placenta", and consists of a
[**Doctor Last Name **] placenta. The umbilical cord has three vessels, is 8.0
cm in length and 1.0 cm in average diameter and has a normal
insertion. The umbilical cord has no twists and is otherwise
unremarkable. The fetal membranes have a 100% marginal
insertion, are normal in color and do not have attached granular
deposits of decidua. The point of rupture is not identified. The
trimmed disc weighs 156 grams and measures 18 x 17.5 x 1.3 cm.
The fetal identified shows patchy subchorionic fibrin and a
normal arborizing fetal vascular pattern without thrombosis. The
maternal surface is complete and does not have adherent blood
clot or decidual hemorrhage. On cut sections, the placenta is
unremarkable. The specimen is represented as follows: D=cross
sections of the vocal cord, E=sections of placental membrane,
F-G=sections of placental disc.
.
[**2185-3-9**] Abdominal MRI:
1. Pancreas divisum anatomy. The pancreas otherwise appears
normal.
2. Small amount of free fluid in the abdomen and pelvis.
3. Moderate amount of stool throughout the colon. The patient
may be
constipated, worsened by compressive effect of the gravid uterus
on the
sigmoid colon. No evidence of bowel obstruction.
4. No anterior abdominal wall hernia is identified.
Brief Hospital Course:
She was admitted to labor and delivery for evaluation and
management of abdominal pain. General sugery consult was
obtained. Initial workup included an MRI on HD#1 which did not
report any significant findings. Her pain persisted and on the
morning of hospital day 2 her clinical picture changed with the
development of oliguria, leukocytosis, change in hematocrit, and
change in abdominal exam. In addition, sadly
at this time an intrauterine fetal demise was diagnosed. The
decision was made to proceed to the operating room for
exploratory laparotomy by the general surgeons as well as
cesarean delivery for the intrauterine fetal demise.
Intraoperatively, the demised fetus was delivered by primary
classical cesarean section and found to be grossly normal.
Please see Dr.[**Name (NI) 11470**] (obstetrics) and Dr.[**Name (NI) 11471**] (surgery)
operative notes for full details.
[**3-10**]: exploratory laparotomy, c-section, resection 10cm TI,
abdomen remained open, continued on pressors, given prbc for low
hematocrit, remained intubated
[**3-11**]: returned to the operating room for a second look, bowel
looked better, abdomen still open to suction, remained
intubated, weaned off pressors; given 4units albumin, 1u prbc
[**3-12**]: remained intubated, on vasopressors
[**3-14**]: returned to the operating room for end-ileostomy, closure,
started cipro/vanc/flagyl, TPN
[**3-15**]: remained intubated, back on pressors, bladder pressures
okay, hct falling, kept paralzyed, started diflucan for
candidiasis, got 1 upRBC
[**3-16**] off pressors, cont TPN, remained intubated
[**3-17**] 1 u pRBC, autodiuresing, still on vent, no pressors, TPN
[**3-18**] febrile, TPN, autodiuresing, pan cultured, on CPAP
[**Date range (1) 11472**] extubated, autodiuresing, discontinued vancomycin,
ciprofloxacin and flagyl, started meropenem
[**3-21**] continued ICU care, episodes of emesis, NGT replaced
[**3-22**] bolused for high NGT output, pain control, transferred to
floor for continued monitoring, continued meropenem and
fluconazole
[**3-23**] foley catheter removed
[**3-24**] NGT clamping trials started, discontinued meropenem and
fluconazole
[**3-25**] NGT removed, diet advanced to clears
[**3-27**] diet advanced to fulls, seen by PT, ostomy care
[**3-28**] - [**3-30**] regular diet, increased loperamide for high ostomy
output; TPN cycled, TPN fat taken out, cycled, volume halved
[**3-31**] ostomy leaking
[**4-1**] hydrocort for benzoin reaction, started hydrocort
[**4-2**] -[**4-7**] continued cycled TPN, monitor ostomy output and
adjust medications as needed; Calorie counts performed x 3days
with results as follows: [**4-4**] cal counts = 880 cal, 24g fat,
18.5g prot, [**4-5**] cal counts = 1000cal, [**4-6**] cal counts = 1236
cal, 24.5g protein.
[**4-7**] no events
[**4-8**] started tincture of opium
[**Date range (1) 11473**] No events
[**4-13**] advanced to clears.
[**4-14**] TPN returned to 24 hour infusion from cycled. Continued on
clears and IV fluids. No events.
[**Date range (1) 11474**] continued clears and IVF; no major events
[**4-17**] decreased IVF, but still thirsty. No leakage from ostomy.
Complaint of migraine; started on fioricet prn with good effect.
[**4-19**] On clears/TPN. No events.
At the time of discharge on [**2185-4-20**], the patient was doing well,
afebrile with stable viral signs. The patient was tolerating a
clear/full diet, ambulating, voiding without assistance, and
pain was well controlled. The patient was dischaged home with
VNA for ostomy care and infusion services for TPN. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
Flonase
Prilosec 20mg [**Hospital1 **]
Sucralfate 1g QID
Creon 20 3 capsules TID
Metamucil 2 caplets [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Folic acid 400 mcg daily
Demerol prn
Darvocet N100 [**Hospital1 **]-TID
Zofran 8mg QD-TID PRN
Fioricet PRN migraine
[**Doctor First Name **] 180mg PRN
Vitamin B-6
Vitamin B-12
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Loperamide 2 mg Capsule Sig: [**12-10**] Capsules PO Q4H (every 4
hours) as needed for excessive ostomy output.
Disp:*120 Capsule(s)* Refills:*2*
4. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q4-8HOURS as needed for nausea.
Disp:*120 Tablet, Rapid Dissolve(s)* Refills:*2*
5. Psyllium Packet Sig: One (1) packet PO TID (3 times a
day).
6. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for migraine.
7. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**12-10**]
Tablets PO Q6H (every 6 hours) as needed.
Disp:*120 Tablet(s)* Refills:*2*
9. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO
Q6HOURS ().
Disp:*QS - 1 month mL* Refills:*0*
10. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
12. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Small bowel mesenteric volvulus around a fixed point of a
former jejunostomy tube
2. 25-week fetal demise.
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
.
TPN Instruction:
-Continue to cycle TPN for 12 hours overnight.
-Weekly Labwork: Your electrolytes will be checked weekly per
the VNA. Adjustments to your TPN formula will be made
accordingly [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) 553**] [**Last Name (NamePattern1) 11475**](Home Hyperal Service
Coordinator), [**Telephone/Fax (1) 11476**], FAX: [**Telephone/Fax (1) 11477**].
-Check you blood sugars 4 times per day, at the same time each
day.
-Treat with insulin injections as indicated.
Followup Instructions:
Please call the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] to arrange a
follow up appointment in [**1-11**] weeks at ([**Telephone/Fax (1) 6347**]
Please call the office of Dr. [**Last Name (STitle) **] (Obstetrics) to arrange a
follow up appointment in 2 weeks at ([**Telephone/Fax (1) 11478**]
Completed by:[**2185-4-20**]
|
Discharge summary
|
Classify the following medical document.
|
Chief Complaint:
24 Hour Events:
TRANSTHORACIC ECHO - At [**2196-1-13**] 09:00 AM
- ENT deferred inpatient consult and recommended that patient follow-up
as an oupatient for work-up of hoarseness, should be arranged when he
is closer to discharge (clinic x27500)
- Morphine 2 mg iv x1 and q6 h prn for resipratory anxiety ; Deferred
fentanyl patch until am
- restarted klonipin
- TTE -(LVEF>55%). Increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is moderately dilated with
moderate global free [**Known lastname **] hypokinesis. There is abnormal septal
motion/position consistent with right ventricular pressure/volume
overload. Mild (1+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
- LEFT LENI - no dvt
- RUQ u/s - PENDING
- updated code status to DNR/DNI
- Hct - 22.7 > 22.7 > 25.2
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Levofloxacin - [**2196-1-13**] 04:00 AM
Ceftriaxone - [**2196-1-14**] 05:00 AM
Infusions:
Other ICU medications:
Other medications:
Review of systems is unchanged from admission except as noted below
Review of systems: pt sleeping
Flowsheet Data as of [**2196-1-14**] 07:05 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37
C (98.6
Tcurrent: 36.3
C (97.4
HR: 103 (90 - 113) bpm
BP: 109/53(64) {101/53(64) - 128/74(84)} mmHg
RR: 29 (20 - 32) insp/min
SpO2: 93%
Heart rhythm: ST (Sinus Tachycardia)
Height: 71 Inch
Total In:
1,228 mL
50 mL
PO:
250 mL
TF:
IVF:
623 mL
50 mL
Blood products:
355 mL
Total out:
3,850 mL
1,050 mL
Urine:
3,850 mL
1,050 mL
NG:
Stool:
Drains:
Balance:
-2,622 mL
-1,000 mL
Respiratory support
O2 Delivery Device: Non-rebreather
SpO2: 93%
ABG: ///25/
Physical Examination
General Appearance: Well nourished, tachypnec,
HEENT: : Normocephalic, eyes closed
Cardiovascular: mildly tachy, ns1/ Prominent p2,
Respiratory / Chest: recruitment of extra-respiratory muscles,
bibasilar rales,
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: minimal peripheral edema; 2+ distal pulses, no cyanosis
Neurologic: sleeping
Labs / Radiology
26 K/uL
9.0 g/dL
157 mg/dL
1.1 mg/dL
25 mEq/L
3.5 mEq/L
46 mg/dL
108 mEq/L
142 mEq/L
26.3 %
7.4 K/uL
[image002.jpg]
[**2196-1-13**] 12:44 AM
[**2196-1-13**] 11:36 AM
[**2196-1-13**] 05:11 PM
[**2196-1-14**] 04:45 AM
WBC
4.3
4.1
5.0
7.4
Hct
22.7
22.7
25.2
26.3
Plt
20
21
25
26
Cr
3.1
1.8
1.1
Glucose
122
148
157
Other labs: ALT / AST:1092/765, Alk Phos / T Bili:92/0.6,
Differential-Neuts:79.1 %, Band:0.0 %, Lymph:16.7 %, Mono:3.0 %,
Eos:0.1 %, D-dimer:150 ng/mL, Fibrinogen:499 mg/dL, LDH:747 IU/L,
Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.8 mg/dL
Assessment and Plan
HYPOTENSION (NOT SHOCK)
RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 11**])
ANXIETY
1. Hypoxia: Known metastatic lung cancer, but presents with change in
sputum with occasional hypoxia. Given CXR and recent chemo, infection
likely. Thus have started on broad spectrum antibiotics and sputum
cultures are sent. Other potential infections include fungal and
viral. Non infectious etiologies include pulmonary embolism and
progression of his cancer. Given acute renal failure and abnormal
chest x-ray, both CTA and V/Q scan are suboptimal choices. Though
getting a Q scan to assess solely perfusion could be considered.
Having progression of his know metastatic disease especially in the
form of lymphangitic spread could explain current hypoxia, though the
progression may be somewhat acute.
- Vanc, ceftriaxone, levofloxacin
- Repeat CXR in AM
- Consider non-contrast CT versus perfusion scan
- follow up viral and sputum cultures
- urine legionella antigen
2. Hypotension Acute Renal failure: Patient presents with acute renal
failure in the setting of hypotension, NSAID use, and hypovolemia.
Thus cause for renal failure is likely multifactorial. Will evaluate
with u/a, urine culture, will need to evaluate urine sediment. As well
will give aggressive IVF. Concern with AMS, hypotension, ARF and LFT
abnormalities, that patient could have tamponade. Pulsus 6 on initial
eval but will recheck.
- IVF
- urine studies
- renally dose meds
3. Thrombocytopenia: Unclear etiology, concerning for TTP, DIC or
consumption in the setting of occult bleeding. Will repeat diff in AM
and hct. If persistent low plt with schistocytes and no signs of DIC
will contact heme for phasmaphoresis.
- Tx plt if <20
- [**Last Name (un) 4201**] hct/plt
- consider heme c/s if still low and concern for TTP
4. Acute hepatitis: Given hypotension, potentially ischemic secondary
to poor perfusion. Will also send off hepatitis serologies as could
have reactivation of Hep B in the setting of chemotherapy.
Additionally could be infection or metatastases.
- hepatitis serologies
- repeat LFTs
- Likely do CT torso
- echo
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2196-1-12**] 10:17 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: DNR / DNI
Disposition:
|
Physician
|
Classify the following medical document.
|
[**2170-6-26**] 12:02 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # [**Clip Number (Radiology) 77183**]
CT PELVIS W/CONTRAST
Reason: fx, solid organ injury
Field of view: 44 Contrast: OPTIRAY Amt: 130
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
83 year old man with found down, unk mech
REASON FOR THIS EXAMINATION:
fx, solid organ injury
No contraindications for IV contrast
______________________________________________________________________________
WET READ: JMGw TUE [**2170-6-26**] 12:55 AM
no traumatic injury. prostate seeds. diffuse bony sclerotic changes compatible
with metastatic dz or post radiation changes. emphysema. probable aspiration
PNA at the right base.
______________________________________________________________________________
FINAL REPORT
HISTORY: 83-year-old man found down.
CT TORSO: Helical imaging was performed from the thoracic inlet to the pubic
symphysis after uneventful administration of intravenous contrast. Sagittal
and coronal reformatted images were prepared.
COMPARISON: None.
CT CHEST: There is biapical emphysema. Bibasilar consolidations, more
pronounced on the right are concerning for aspiration pneumonia. The left
atrium of the heart is enlarged and the main pulmonary artery is enlarged.
There is atherosclerotic calcification of the thoracic aorta and coronary
vessels. There is no hilar, axillary, or mediastinal lymphadenopathy. Tip of
an ET tube is positioned 3.2 cm from the carina. Lobes of the thyroid appear
normal.
CT ABDOMEN: There is heterogeneous perfusion to the spleen likely due to
phase of contrast timing. There are dense calcifications within the spleen
which may represent granulomas. The adrenals appear unremarkable. The
pancreas, gallbladder, and liver all appear within normal limits. The kidneys
enhance and excrete contrast symmetrically without hydronephrosis. There is
slight cortical defect along the interpolar region of the right kidney (2:67),
which may be related to a site of prior infarction. There is a gastric tube
within the stomach which extends into the duodenum. Abdominal loops of small
bowel appear normal. The stomach appears normal. There is no free air or
free fluid. There is no significant retroperitoneal or mesenteric
lymphadenopathy.
CT PELVIS: There are radiation seeds within the prostate, but also the
seminal vessicles. There is a Foley within a decompressed bladder. Pelvic
loops of small and large bowel appear normal in caliber. There is no free air
or free fluid. There is a stent within the distal aorta just proximal to the
bifurcation. There is no pelvic or inguinal lymphadenopathy. There is right
flank edema.
(Over)
[**2170-6-26**] 12:02 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # [**Clip Number (Radiology) 77183**]
CT PELVIS W/CONTRAST
Reason: fx, solid organ injury
Field of view: 44 Contrast: OPTIRAY Amt: 130
______________________________________________________________________________
FINAL REPORT
(Cont)
BONE WINDOWS: Particularly within the left hemipelvis are diffuse sclerotic
changes. The T10 vertebral body exhibits diffuse sclerotic changes without
bone expansion. There are no fractures.
IMPRESSION:
1. No evidence for traumatic injury in the chest, abdomen or pelvis.
2. Prostate brachytherapy seeds.
3. Left hemipelvis Paget disease. Sclerotic T10 vertebral body likely
reflects earlier Paget disease, but metastatic disease cannot be excluded.
3. Ground-glass opacity in bilateral bases, concerning for aspiration
pneumonia, more pronounced on the right where there is high density material
that could be barium aspirtated in the past or calcification.
4. Extensive atherosclerotic disease including coronary calcifications.
Distal aortic stent graft. Possible pulmonary hypertension.
5. ET tube 3.5 cm from the carina.
|
Radiology
|
Classify the following medical document.
|
`
Pt 55 y/o m who presented from [**Hospital 108**] Hospital with mental status
changes, lethargy, Tmax of 103, and hyperglycemia
FS 560. Pt went
unresponsive while at [**Name (NI) 108**], pt was nasally intubated and Tx to
[**Hospital1 54**]. [**9-15**]: PT had MRI/MRA of head, neck and pelvis. PT was noted to
have clear carotids, 3 small vessel infarcts
1 in the cerebal peduncle
and 2 located in bilateral thalamus, ? septic arthritis in pelvis. Pt
was extubated on [**9-16**]. Found to have new bilat opacities on cxr [**9-20**].
Started on Vanco and zosyn. Bs trending up despite [**Hospital1 **] nph increased
doses. Started on insulin drip [**9-21**] and Sliding scale.
obtructive sleep apnea (OSA)
Assessment:
Tolerating cpap at night on autset
Action:
When patient falls asleep and is snoring cpap placed on patient. Wears
3l nc when awake
Response:
Sats 92% or greater on cpap and 3l nc. Resp 18-22. bs clear upper. Di
minished at the bases.
Plan:
Cpap at night or when he is sleeping and snoring.
Transfers, Impaired
Assessment:
Inability to be pivoted to the chair.
Action:
Using hovercraft to move patient from bed to chair.
Response:
Sits up for 3 or more hours at a time in stretcher chair.
Plan:
Oob to chair once a day.
Pneumonia, bacterial, ventilator acquired (VAP)
Assessment:
Fever curve improved on iv antibiodics.
Action:
On vanco and zosyn iv.
Response:
Wbc down to 10.6 from 12.7. Temp max 99.9. Vanco level 28.9 this am.
Plan:
Cont antibiodics till 8/18 per micu team. Monitor cult results. Trough
level of vanco drawn prior to 1600 dose. Awaiting level to come back
prior to giving dose. Will need to let micu resident know level to
decide if med to be given.
Constipation (Obstipation, FOS)
Assessment:
No stool since [**9-20**].
Action:
Was receiving colace and senna. Given lactulose and ducolax today.
Response:
Had one large brown soft guiac neg stool.
Plan:
Cont bowel regimen
Altered mental status (not Delirium)
Assessment:
S/p 3 small vessel infarcts that effect his alertness.
Action:
Neuro assessment q 4hours while in icu. On asa and lipitor
Response:
More awake in chair. Speech slurred. Right side weak. Will at times
squeeze your hand with his right hand at other times will not. Wiggles
toes on right foot at times. At other times does not. Left side beys
commands consistently. Very lethargic after he has been up in chair and
put back to bed. Then will only nod when asked a question. Pearl .
Opens right eye. Left eye remains closed most of the time.
Plan:
Cont to monitor neuro status.
.H/O hypertension, benign
Assessment:
Bp I mproved on increased doses of captopril and lopressor
Action:
On lisinopril 40mg qd. . Lopressor increased today to 25mg per ft [**Hospital1 **].
Response:
Sbp 100-140
Plan:
Cont current antihypertensive regimen.
```
Hyperglycemia
Assessment:
Bs 200-300 range despite high doses of nph [**Hospital1 **] and humologess
Action:
Seen by [**Last Name (un) **]. Changed to [**Hospital1 **] glargine dosing, increased ss humalog,
and [**Hospital1 **] metformin dosing.
Response:
Will watch bs qid as ordered to see results of increased dosage of
insulin
Plan:
Monitor bs as ordered. Insulin and metafromin as ordered.
Hypotension (not Shock)
Assessment:
Episode of hypotension related to antihypertensives, diuresis and
sleep. Sbp down to 78
Action:
Dr [**First Name (STitle) **] made aware and 500cc fluid bolus given
Response:
Sbp up to 100-120
Plan:
Cont to monitor bp.
|
Nursing
|
Classify the following medical document.
|
Chief Complaint: shortness of breath, hypoxia
HPI:
This is a 56 yo F with h/o metastatic melanoma who was admitted on
[**2187-7-9**] for IL-2 therapy and now is transferred to the [**Hospital Unit Name 4**] in the
setting of shortness of breath and hypoxia. Began IL-2 in PM of [**7-9**]
and has since gotten a total of 8 doses. Course has been complicated by
intermittent rigors, n/v/diarrhea, and hypotension responsive to IVF
boluses. Weight is 5% up from baseline. Initially began to complain
shortness of breath yesterday afternoon when she triggered for RR 24,
O2 sat 85% RA, increased to 93% on 50% shovel [**Date Range 1269**]. Remained hypoxic
throughout the evening and IVFs stopped, IL-2 held, and given albuterol
nebs for reported wheezing. Awoke at 1 am acutely short of breath and
gasping for air with O2 sats 76% on 2L NC --> 92 % on NRB with RR 40.
Other vitals notable for BP 120/60 (had previously been running SBPs in
80-90s), HR 112. CXR revealed marked bilateral interstitial markings
with blurring of the heart border concerning for pulmonary edema vs.
ARDS. Given lasix 12 mg IV X 1 with only 100 ccs of urine output and
then given lasix 20 mg IV X 1 and started on dopamine gtt at 2
mcg/kg/hr per biologics attending with subsequent 600 ccs in urine
output. ABG 7.39/37/62/23. Given another lasix 20 mg IV and transferred
to [**Hospital Unit Name 4**] for ongoing respiratory distress and hypoxia.
.
Upon arrival to the [**Hospital Unit Name 4**], the patient feels her breathing is slightly
improved but still labored. Denies chest pain/pressure,
lightheadedness, nausea, confusion, fevers. Intermittent chills. Placed
on BIPAP [**Hospital Unit Name 1269**] at 5/5 FiO2 70% with O2 sats 97-99%, given morphine 1 mg
IV X 1. Urine output in past hour 1L. Switched dopamine to
neosynephrine for HR 150s.
Patient admitted from: [**Hospital1 5**] [**Hospital1 **], 7 [**Hospital Ward Name 200**]
History obtained from [**Hospital 19**] Medical records
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Phenylephrine - 1 mcg/Kg/min
Other ICU medications:
Lorazepam (Ativan) - [**2187-7-13**] 06:00 AM
Morphine Sulfate - [**2187-7-13**] 06:05 AM
Other medications:
IL-2 (last dose [**2187-7-12**] at 9am)
Lasix 20 mg IV X 1, Lasix 10 mg IV X 1
Dopamine gtt at 2 mcg/kg/min
Neosynephrine gtt
Cephalexin 500 mg po bid
Tylenol 975 mg q6h
Naproxen 375 mg q12h
Gelclair 15 ml tid prn
Ranitidine 150 mg [**Hospital1 **]
Ativan 1-2 mg q4h prn
Albuterol neb q6h prn
Loperamide prn
Benadryl 25-50 mg q6h prn
Sarna qid prn
Compazine q6h prn
Meperidine 50-100 IV q2h prn
Nystatin qhs
HISS
Past medical history:
Family history:
Social History:
- Metastatic Melanoma - s/p R total maxillectomy with resection
of the pterygopalatine fossa as well as resection of tumor at the
skull base foramina at [**Hospital 7022**] in [**4-9**]. PET scan [**5-10**] with
increased uptake in lungs (multiple pulm nodules), left hilar and
subcarinal LAD. Admitted for IL-2 therapy on [**2187-7-9**], s/p 8 doses
- DM II, insulin dependent
- HTN
- Hypercholesterolemia
- h/o cervical CA s/p radical hysterectomy, XRT/chemo in [**2173**]
No family history of melanoma.
Occupation: Worked as part owner of seafood distributing company in [**Location (un) 7023**]
Drugs: denies
Tobacco: quit 5 years ago
Alcohol: denies
Other: Recently widowed, husband passed from bladder CA 8 mos ago. Has
2 daughters.
Review of systems:
Constitutional: Fatigue
Ear, Nose, Throat: Dry mouth
Cardiovascular: No(t) Chest pain, No(t) Palpitations, Tachycardia,
Orthopnea
Respiratory: Dyspnea, Tachypnea
Gastrointestinal: No(t) Abdominal pain, Nausea, loose BMs
Genitourinary: Foley
Integumentary (skin): no rash
Flowsheet Data as of [**2187-7-13**] 06:26 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 35.9
C (96.6
Tcurrent: 35.9
C (96.6
HR: 126 (124 - 126) bpm
BP: 108/70(79) {83/44(53) - 108/70(79)} mmHg
RR: 30 (29 - 32) insp/min
SpO2: 95%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
13 mL
PO:
TF:
IVF:
13 mL
Blood products:
Total out:
0 mL
1,000 mL
Urine:
200 mL
NG:
Stool:
Drains:
Balance:
0 mL
-987 mL
Respiratory
O2 Delivery Device: Bipap [**Year (4 digits) 1269**]
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 790 (790 - 790) mL
PS : 5 cmH2O
RR (Spontaneous): 28
PEEP: 5 cmH2O
FiO2: 70%
PIP: 11 cmH2O
SpO2: 95%
Ve: 21.2 L/min
Physical Examination
General Appearance: Thin, Anxious, moderate amt of distress due to
tachypnea, speaking in short sentences due to shortness of breath
Eyes / Conjunctiva: PERRL, slightly dry MM
Head, Ears, Nose, Throat: Normocephalic, Poor dentition, has upper
palate prosthesis
Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal), II/VI
systolic flow murmur over LUSB
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 :
throughout lung fields b/l up to apices, anterior crackles also
appreciated, No(t) Wheezes : no wheezes appreciated, Diminished:
diminished at bases b/l)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Trace, Left: Trace
Skin: Warm, no rashes
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): person, place, Movement: Purposeful, Tone: Not
assessed
Labs / Radiology
103
10.3
180
0.5
27
20
114
3.9
147
30.7
7.7
[image002.jpg]
Other labs: PT / PTT / INR://1.1, ALT / AST:32/30, Alk Phos / T
Bili:/2.0, Ca++:7.9, Mg++:2.6, PO4:3.5
CXR (my read) - marked increased in interstitial lung markings (R > L)
without significant blunting of costophrenic angles but blurring of
entire heart border compared to prior CXR on [**2187-7-9**]
Assessment and Plan
56 yo F with h/o metastatic melanoma on IL-2 therapy being transferred
to [**Hospital Unit Name 4**] in setting of shortness of breath and hypoxia.
.
#) Hypoxia - In setting of recent IL-2 therapy. CXR with increased
interstitial markings bilaterally concerning for pulmonary edema vs.
increased capillary leakage leaking to ARDS-type picture vs. pulmonary
hemorrhage. Has been given lasix with 600 ccs of urine output, but
minimal improvement in overall respiratory status. Acuity of onset of
symptoms, lack of fevers do not fit with multi-focal PNA as being
primary cause of pt's respiratory distress, but remains in the
differential. Lastly, PE is a consideration, but less likely given
hypoxia can be explained by pt's worsening interstitial lung markings.
ABG with significant A-a gradient (PaO2 62, FiO2 100).
- Continue diuresis with lasix IV. Seems to be putting out well to 20
mg IV that she received prior to leaving floor.
- Closely monitor I/Os.
- BIPAP for now until achieve further diuresis. If worsening MS, starts
tiring in spite of BIPAP with increased work of breathing, unable to
further diurese, or unable to tolerate [**Last Name (LF) 1269**], [**First Name3 (LF) 124**] need to intubate.
- Recheck ABG in [**2-2**] hour.
- Daily CXRs.
- Hold on empiric abxs for now.
- Hold IL-2.
- Per biologics attending, would consider use of renal doses of
dopamine gtt. However, given HR to 150s on dopamine gtt, will switch
over to neosynephrine for BP support.
- Consider use of steroids to dampen inflammatory response to IL-2 if
respiratory status does not clearly improve with further diuresis. Will
need to speak with biologics attending first.
.
#) Hypotension - Ongoing issue for past 48 hours, again likely related
to IL-2. Has been getting maintenance IVFs as well as intermittent IVF
boluses.
- Will switch to neosynephrine gtt as above given HR 150s on dopamine
gtt.
- Maintain MAPs > 65.
- Hold on IVFs for now given respiratory distress.
- If has fever, will panculture, start on broad spectrum abxs.
- [**Month (only) 8**] be limited in terms of diuresis due to hypotension.
.
#) Non anion gap metabolic acidosis - AG 13. [**Month (only) 8**] also be secondary to
IL-2. Has had several loose stools thought to be related to IL-2 and
has been receiving maintanence NS, which may also be contributing.
- Holding IL-2 for now.
- Closely monitor acid-base status.
.
#) Hypernatremia
Appears total body fluid overloaded although may be
intravascularly deplete due to ongoing capillary leak from IL-2.
Suspect that hyponatremia will improve with diuresis with lasix.
- Monitor serum Na.
- Hold on giving back free H2O for now.
.
#) Anemia
Hct 32.8 on admission, currently 30.7. Likely related to
anemia of chronic disease.
- Guaiac stools.
- Maintain active T&S.
- Transfuse for Hct < 24 (onc pt).
.
#) Thrombocytopenia
Plts downtrending since admission. Receiving
heparin through central line although time course for fall in plts is
fast for HIT. No signs of active bleeding. INR wnl.
- Continue to closely monitor plts.
- If continues to fall without clear precipitating factor, will hold
heparin and check PF-4 Ab.
- Review med list for other possible offending agents.
.
#) Metastatic melanoma - Current respiratory compromise likely [**3-5**] IL-2
related toxicity.
- Holding further IL-2 for now.
- Further management per primary oncology team.
.
#) DM II - As NPO for now given BIPAP, will give only [**2-2**] of standing
insulin dose and continue to cover with HISS.
.
#) FEN/GI - NPO for now as on BIPAP, replete lytes prn
#) Ppx - hep SQ,H2 blocker,holding bowel regimen given recent loose
stools
#) Code - Full, confirmed with patient
#) Access - R subclavian TLC
#) Communication - with patient and daughter [**Name (NI) 7024**] [**Name (NI) 7025**] [**Telephone/Fax (1) 7026**]
#) Dispo - ICU level of care
ICU Care
Nutrition:
Comments: NPO for now as on BiPAP
Glycemic Control: Comments: halve insulin dosing while NPO
Lines:
Multi Lumen - [**2187-7-13**] 05:27 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: H2 blocker
VAP:
Comments:
Communication: ICU consent signed Comments: Daughter [**Name (NI) 161**], left
message. Discussed pt with Dr. [**Last Name (STitle) 2958**], biologics attending, and
briefly with Dr. [**Last Name (STitle) 911**], overnight ICU intensivist.
Code status: Full code
Disposition: ICU
|
Physician
|
Classify the following medical document.
|
Chief Complaint:
24 Hour Events:
INVASIVE VENTILATION - STOP [**2124-9-14**] 05:23 PM
- recieved 1uPRBC and 1u PLT
- CBI for hematuria
- ambisome decresed to 250 q24 (from 400) given concern for hematuria
- ID: check stool for c diff
- CXR: Dense right upper lobe consolidation with volume loss, new since
the [**2124-9-13**] study.
Allergies:
Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)
Rash;
Last dose of Antibiotics:
Ambisome - [**2124-9-14**] 09:24 PM
Linezolid - [**2124-9-15**] 03:51 AM
Meropenem - [**2124-9-15**] 07:53 AM
Infusions:
Other ICU medications:
Fentanyl - [**2124-9-15**] 05:26 AM
Pantoprazole (Protonix) - [**2124-9-15**] 07:53 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2124-9-15**] 08:22 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.4
C (97.6
Tcurrent: 36.4
C (97.6
HR: 105 (90 - 105) bpm
BP: 137/81(93) {77/57(62) - 151/110(117)} mmHg
RR: 22 (15 - 24) insp/min
SpO2: 99%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 113.7 kg (admission): 125 kg
Total In:
3,049 mL
1,296 mL
PO:
TF:
IVF:
1,826 mL
1,296 mL
Blood products:
481 mL
Total out:
1,645 mL
400 mL
Urine:
1,645 mL
400 mL
NG:
Stool:
Drains:
Balance:
1,404 mL
896 mL
Respiratory support
O2 Delivery Device: None, Venti mask
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 488 (445 - 518) mL
PS : 5 cmH2O
RR (Spontaneous): 20
PEEP: 5 cmH2O
FiO2: 50%
PIP: 11 cmH2O
SpO2: 99%
ABG: ///24/
Ve: 9 L/min
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: Sclera edema
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous: BL)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: 3+, Left lower extremity
edema: 3+
Musculoskeletal: Muscle wasting
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
71 K/uL
8.2 g/dL
140 mg/dL
0.7 mg/dL
24 mEq/L
3.5 mEq/L
58 mg/dL
108 mEq/L
140 mEq/L
23.0 %
2.7 K/uL
[image002.jpg]
[**2124-9-12**] 03:50 AM
[**2124-9-12**] 03:48 PM
[**2124-9-12**] 08:00 PM
[**2124-9-13**] 03:42 AM
[**2124-9-13**] 05:18 AM
[**2124-9-13**] 03:40 PM
[**2124-9-14**] 03:49 AM
[**2124-9-14**] 06:15 PM
[**2124-9-15**] 12:10 AM
[**2124-9-15**] 04:30 AM
WBC
1.0
1.8
2.0
2.0
1.8
2.2
2.5
2.7
Hct
20.6
22.8
24.4
24.3
24.3
24.0
23.8
24.7
23.0
Plt
10
107
112
101
91
72
66
49
85
71
Cr
0.5
0.8
0.8
0.7
0.7
Glucose
111
107
113
167
140
Other labs: PT / PTT / INR:11.6/30.4/1.0, ALT / AST:94/93, Alk Phos / T
Bili:503/7.4, Differential-Neuts:78.3 %, Band:0.0 %, Lymph:14.0 %,
Mono:6.9 %, Eos:0.7 %, Fibrinogen:404 mg/dL, Lactic Acid:2.5 mmol/L,
Albumin:2.1 g/dL, LDH:390 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.8
mg/dL
Imaging: Provisional Findings Impression: [**First Name9 (NamePattern2) **] [**Doctor First Name **] [**2124-9-14**] 4:54 PM
1. Dense right upper lobe consolidation with volume loss, new since the
[**2124-9-13**] study.
2. Worsening of already very low lung volumes.
3. ET and left subclavian central venous catheter, unchanged in
position.
Microbiology: [**9-12**] EBV viral load: non-detected
B glucan, galactomanin pending.
.
[**2124-9-14**] 6:53 pm SPUTUM Site: INDUCED Source: Induced.
GRAM STAIN (Final [**2124-9-15**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
.
CMV pending.
Assessment and Plan
57-year-old gentleman with CLL and [**Doctor Last Name **]
s transformation (aggressive
large B-cell lymphoma) s/p allo SCT in [**2-24**] w/ AMS and hypothermia in
the setting of BK viremia, transferred to MICU after PEA arrest on
[**9-10**], with apical infiltrates on CXR (as of [**9-11**]) concerning for
possible aspiration PNA and pancytopenia.
# Worsening AMS: No significant change from yesterday, but overall
improvement compared to several days ago. Underlying etiology of AMS
is unclear. Represents the main obstacle to extubation of this
patient. Could be infectious, including fungemia in his setting with
so many risk factors and an elevated beta glucan. CSF studies all
negative including BK/[**Male First Name (un) 561**] and adenovirus. Patient received two doses of
cidofovir so far, first on [**8-25**] and [**9-1**], (was pretreated in ICU with
probenecid and IVF). EEG negative for seizures. Hepatic
encephalopathy less likely given EEG pattern and waxing and [**Doctor Last Name 533**]
mental status not correlating with LFTs prior to arrival.
-D/c Benadryl
-Attempt to extubate today as the pt. seems to reached a stable level
of improvement in AMS after discussing re-intubation plans with pt.
wife.
# Pancytopenia: Most likely due to immunosuppression/infection/GVHD.
HCT goal >25, plt goal > 50. Linezolid is currently day 4 which was
added for his PNA. Patient continues to be having melanic stools, but
Hct has remained stable at this time.
- transfuse 1 units pRBCs. The patient remains hemodynamically stable
and has not required any pressors.
- Continue to check HCT [**Hospital1 **], if unstable, dropping GI consult- stress
ulceration vs. GVHD
- Continue broad Abx coverage with Meropenem, Linezolid (day 4 of 10
day course for PNA) and ambisome 400mg IV q24h
- continue neutropenic precautions
- T&C 2 units
- Restraints for now in setting of agitation
- follow up BK virus load and Bcx, CMV and EBV PCR, pending Blood Cx
- amio held as pt in sinus
.
# PNA- bilateral apical infiltrates could be [**12-20**] aspiration PNA
(although RUL infiltrates are abormal for aspiration PNA could be
possible in this patient due to positioning during code and recumbent
position). Started on Linezolid (currently day 4 of a 10 day total
course). Plt have been slowly trending down, so continue to monitor
[**Hospital1 **].
- continue linezolid IV 600mg q12h as per ID recs
-F/u CXR today
- monitor Plts and transfuse for Plt < 50
.
# CLL with BMT c/b GVHD:
- Continue immunosuppressant and prophylactic regimens
- appreciate Dr. [**Last Name (STitle) 21**]
s recs
- follow-up any pending heme/onc recs
# Melena
GVHD vs. stress ulcer; Hct has been stable
-Continue to follow HCt [**Hospital1 **]
- If trending down, GI consult
- Transfuse pRBCs for Hct < 25 (1 unit pRBCs today to assist with
# Hematuria
Etiology is BK cystitis vs. secondary to Ambisome.
- Bladder scan
- Replace with triple lumen catheter
- Manual irrigation, consider CBI if not resolved
-Consider decreasing Ambisome dose or switching to another antifungal
[**Doctor Last Name **]
.
# Nutrition
The patient can get TPN via double lumen
-TPN via double lumen
ICU Care
Nutrition:
Glycemic Control:
Lines:
PICC Line - [**2124-9-10**] 07:31 AM
Prophylaxis:
DVT: Boots
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
|
Physician
|
Classify the following medical document.
|
[**2156-6-14**] 2:16 PM
CT CHEST W/O CONTRAST Clip # [**Clip Number (Radiology) 81612**]
Reason: Pls eval for interval change, possible same-time interventio
Admitting Diagnosis: S/P PEDESTRIAN STRUCK
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
38 year old man with multitrauma intubated right hemothorax
REASON FOR THIS EXAMINATION:
Pls eval for interval change, possible same-time interventional CT-guided
drainage/chest tube? Will call to discuss.
No contraindications for IV contrast
______________________________________________________________________________
FINAL REPORT
PROCEDURE: CT chest without contrast.
REASON FOR EXAM: Trauma with right hemothorax. Assess for interval change.
TECHNIQUE: MDCT chest performed without IV contrast. 5-mm and 1.25-mm axial
slices were acquired with coronal and sagittal reformats.
Comparison was made to the previous study on [**2156-6-11**].
FINDINGS:
A moderately large right hemothorax persists athough there has been interval
improvement in the degree of aeration in the lower lobes bilaterally with a
slight decrease in the left pleural effusion. The remaining lungs are
unchanged and a chest drain, which enters the anterior chest wall has been
slightly withdrawn since the previous study with no appreciable pneumothorax.
The patient remains intubated and the tip of the ET tube high in the trachea
and approximately 9 cm above the carina with overinflation of the cuff and
requires repositioning. The NG tube passes into the stomach. The aorta,
pulmonary artery and heart size is normal. No pericardial effusion.
This examination was not designed for subdiaphragmatic evaluation, which is
unremarkable.
Posterior rib fractures are unchanged in position, a number of which are
displaced and overriding in the upper posterior hemithorax in addition to a
nondisplaced scapular fracture.
Impression:
1) Proximal position ET tube and apparent overdistention of cuff. Recommend
readjusting the ET tube to a lower in position and decreasing the volume of
air within the cuff.
2)Stable moderately large organizing right hemothorax with improved aeration
in both lower lungs bilaterally and decreasing left pleural effusion.
3)Multiple rib fractures are predominantly right-sided, a number of which are
displaced and overriding in the upper chest wall in addition to a stable
nondisplaced left scapular fracture.
(Over)
[**2156-6-14**] 2:16 PM
CT CHEST W/O CONTRAST Clip # [**Clip Number (Radiology) 81612**]
Reason: Pls eval for interval change, possible same-time interventio
Admitting Diagnosis: S/P PEDESTRIAN STRUCK
______________________________________________________________________________
FINAL REPORT
(Cont)
The TICU nurse [**First Name (Titles) 3450**] [**Name (NI) 14921**] at the time of reporting regarding the position
of the ET tube which had been already adjusted.
|
Radiology
|
Classify the following medical document.
|
[**2108-9-18**] 10:25 AM
CT CHEST W&W/O C ; CTA ABD W&W/O C & RECONS Clip # [**Clip Number (Radiology) 26518**]
Reason: evidence of pancreatic mass/insulinoma
Admitting Diagnosis: RULE OUT INSULINOMA
Contrast: OPTIRAY Amt: 200
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
67 year old woman with morbid obesity and episodes of hypoglycemia concering
for insulinoma
REASON FOR THIS EXAMINATION:
evidence of pancreatic mass/insulinoma
No contraindications for IV contrast
______________________________________________________________________________
WET READ: JKSd TUE [**2108-9-18**] 3:20 PM
Extremely limited evaluation of the chest and abdomen given patient's body
habitus.
Complete collapse of the left upper lobe and partial collapse of the left
lower lobe. Cause of obstruction is not seen on this study. Leftward shift of
midline structures.
Patchy opacity in the right upper lobe, nonspecific, may be infectious of
inflammatory in nature. Diffuse mosaic pattern in the right lung is
consistent with air-trapping and may represent small airways disease.
Pancreas barely visible; however, no gross mass identified.
Possible left adrenal nodule measuring up to 1.5 cm (however, not entirely
clear this is part of the adrenal gland given very low quality study).
Cholelithiasis.
WET READ VERSION #1
______________________________________________________________________________
FINAL REPORT
INDICATION: 67-year-old woman with morbid obesity and episodes of
hypoglycemia, concerning for insulinoma. Please assess for evidence of
pancreatic mass/insulinoma. In addition, chest x-ray demonstrates
opacification of the left hemithorax.
TECHNIQUE: MDCT-acquired images were obtained from the lung apices through
the abdomen prior to and after the administration of 200 cc of Optiray
intravenous contrast. Arterial and venous phase images were obtained. Coronal
and sagittal reformatted images were also displayed.
FINDINGS: Please note that evaluation is extremely limited given patient's
body habitus.
CT CHEST: There is complete collapse of the left upper lobe and partial
collapse of the left lower lobe with leftward shift of mediastinal structures.
The obstructing cause is not seen on this study. This is new when compared to
the chest radiograph of [**2105-3-18**].
There are patchy opacities in the right lung apex, nonspecific, but may be
(Over)
[**2108-9-18**] 10:25 AM
CT CHEST W&W/O C ; CTA ABD W&W/O C & RECONS Clip # [**Clip Number (Radiology) 26518**]
Reason: evidence of pancreatic mass/insulinoma
Admitting Diagnosis: RULE OUT INSULINOMA
Contrast: OPTIRAY Amt: 200
______________________________________________________________________________
FINAL REPORT
(Cont)
infectious or inflammatory in nature. Mosaic pattern of ground-glass opacity
within the right lung is consistent with air trapping, and may represent
underlying small airways disease. There is a small right-sided pleural
effusion and adjacent compressive atelectasis.
There is cardiomegaly without pericardial effusion. No definite mediastinal,
hilar, or axillary lymphadenopathy is seen, although again, evaluation is
extremely limited.
CT ABDOMEN: The spleen, stomach, and liver are within normal limits. Multiple
small calcified gallstones are present within the gallbladder. Evaluation of
the kidneys is limited, although they do appear grossly normal.
There may be a left adrenal nodule measuring up to 1.5 cm, although it is
unclear whether this is definitively part of the left adrenal gland.
Unfortunately, further assessment of this nodule cannot be made on this study.
The right adrenal gland appears normal.
The pancreas is markedly atrophic and extremely difficult to see on this
study. However, no gross mass within the pancreas is identified.
BONE WINDOWS: No concerning osseous lesions are identified.
IMPRESSION:
Extremely limited evaluation given patient's body habitus.
1. Complete collapse of the left upper lobe and partial collapse of the left
lower lobe. An obstructing cause is not seen. Leftward shift of midline
structures. Small right-sided pleural effusion.
2. Patchy opacities in the right lung apex are nonspecific, but may be
infectious or inflammatory in nature. Mosaic ground-glass pattern to the
right lung is most consistent with air trapping and may reflect underlying
small airways disease.
3. Cardiomegaly.
4. The pancreas is not well seen given limitations of the examination and is
also likely atrophic. However, no gross mass identified.
5. Possible left adrenal nodule measuring up to 1.5 cm. However, it is
unclear whether this actually part of the left adrenal gland or adjacent to it
and further characterization cannot be made on this study.
6. Cholelithiasis.
(Over)
[**2108-9-18**] 10:25 AM
CT CHEST W&W/O C ; CTA ABD W&W/O C & RECONS Clip # [**Clip Number (Radiology) 26518**]
Reason: evidence of pancreatic mass/insulinoma
Admitting Diagnosis: RULE OUT INSULINOMA
Contrast: OPTIRAY Amt: 200
______________________________________________________________________________
FINAL REPORT
(Cont)
Findings were discussed with Dr. [**First Name8 (NamePattern2) 26519**] [**Name (STitle) 26520**] at approximately 2:30 p.m. on
[**2108-9-18**] in person.
|
Radiology
|
Classify the following medical document.
|
Attending Physician: [**Name10 (NameIs) 449**]
Referral date: [**2110-12-6**]
Medical Diagnosis / ICD 9: [**Last Name (un) 10353**] / 959.9
Reason of referral: eval and treat, CPT, risk to fall
History of Present Illness / Subjective Complaint: 79F adm to outside
hospital s/p fall down flight of stairs with R pelvic fx (comminuted
iliac [**Doctor First Name **] to acetabulum), R scapula fx, multiple rib fractures.
Transferred to [**Hospital1 5**] [**2110-12-5**]. patient also hypertensive and Hct
dropped; now s/p ORIF R acetabulum [**2110-12-5**]
Past Medical / Surgical History: hep A, R LE fracture, sexual
reassignment surgery (M to F) 30 years ago
Medications: insulin, Glucagon, Percocet, Dilaudid, Albuterol
Radiology: small R hydropneumothorax; rib fractures R [**4-13**]; fracture of
R scapular spine; R T7 transverse process fx; fracture sup post
endplate T12; extensive comminuted fracture R iliac bone extending into
acetabulum with large hematoma
Labs:
25.2
8.8
142
7.0
[image002.jpg]
Other labs:
Activity Orders: R LE NWB, R UE NWB with sling for OOB
Social / Occupational History: baseline lives with partner in
[**Name2 (NI) 10354**]-- they own a business together and have multiple dogs
(poodles)
Living Environment: raised ranch-- level to enter but steps up to
second part of house
Prior Functional Status / Activity Level: baseline completely
independent without AD, no other h/o falls
Objective Test
Arousal / Attention / Cognition / Communication: pt A and Ox3, pleasant
and cooperative, consistently follows all commands
Hemodynamic Response
Aerobic Capacity
HR
BP
RR
O[2 ]sat
HR
BP
RR
O[2] sat
RPE
Supine
102
160/63
30
100 % (50% face tent)
Rest
/
Sit
110
152/58
31
87 % (RA)
Activity
/
Stand
/
Recovery
/
Total distance walked:
Minutes:
Pulmonary Status: BS: diminished t/o but moving air in all fields;
cough weak, congested, non-productive; breathing pattern shallow and
rapid
Integumentary / Vascular: R chest tube to suction; R A line, foley
cath, epidural in place; incision not visualized
Sensory Integrity: grossly intact to LT
Pain / Limiting Symptoms: c/o upper R back and R hip pain [**6-11**] at rest,
[**8-11**] with activity/ sitting EOB
Posture: received in sling RUE; bilat fwd shoulders in sitting, fwd
head
Range of Motion
Muscle Performance
R shoulder flexion to 80 with empty end feel, limited by pain; R hip
flexion to 90, limited by pain, abd/add WNL; otherwise WNL t/o
R shoulder flex [**1-6**], elbow flex 3+, elbow ext 3+, good grip, R hip
flexion [**1-6**], knee ext 3-/5, ankle [**5-6**]; L UE and LE grossly 4-5/5 t/o
Functional Status:
Activity
Clarification
I
S
CG
Min
Mod
Max
Gait, Locomotion: rolls to L with modA, rolls to R with maxA;
sup to sit with maxAx2
dependent slide transfer to stretcher chair
Rolling:
T
Supine /
Sidelying to Sit:
Tk
Transfer:
Dependent slide to stretcher chair
Sit to Stand:
NA
Ambulation:
NA
Stairs:
NA
Balance: able to sit at edge of bed for 7 minutes initially requiring
hand held assist but quickly weaned to S using R UE to support self--
pt reports severe pain seated at edge of bed
Education / Communication: pt ed: role of PT, plan of care;
communication with RN re: patient status
Intervention: DB &C
Diagnosis:
1.
Ventilation, Impaired
2.
Transfers, Impaired
3.
Range of Motion, Impaired
4.
Muscle Performace, Impaired
5.
Respiration / Gas Exchange, Impaired
6.
Knowledge, Impaired
Clinical impression / Prognosis: 79f s/p fall with multiple fractures
p/w above impairments c/w fracture as well as vent pump dysfunction as
patient is limited in her chest excursion and secretion clearance by
pain. Patient is well below her baseline and would benefit from d/c to
rehab once medically stable. Patient has a very high baseline,
excellent support and good potential to recover from her injuries. Her
functional status may be limited until she can increase weight bearing
through either RUE or RLE but she should be able to become independent
at wheelchair level at this current functional status.
Goals
Time frame: 1 week
1.
SpO2 >92 % on RA with all activities
2.
I secretion clearance
3.
increase ROM R shoulder flexion to 110, R hip flexion to 110
4.
increase strength 1/3 ms [**Last Name (Titles) 10355**] t/o
5.
sup to sit with [**Female First Name (un) 332**]
6.
sit to stand with modA
Anticipated Discharge: Rehab
Treatment Plan:
Frequency / Duration: 3-5x/week x1 week
Pt ed, functional mob training-- sup to sit, sit to stand, stand pivot
transfers, therex/ROM, d/c planning
Recommend up with nursing daily via stretcher chair slide
T Patient agrees with the above goals and is willing to participate in
the rehabilitation program.
|
Rehab Services
|
Classify the following medical document.
|
Chief Complaint: fevers, leukocytosis
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
53M severe COPD - fractured his right elbow [**9-18**] and underwent external
fixation. Returns to the hospital because of persistent vomiting and
diarrhea at rehab. Has been on gent and PO vanco for recent pseudomonas
pneumonia and CDiff. Also concern about a broken external fixation
devise.
In ER Temp was 102.3 and WBC count 26. Pins were noted to be missing
from his right arm and ortho is taking him back to the OR to replace
these. A CXR showed stable effusions and opacities.
History obtained from housestaff
Patient unable to provide history: on vent
Allergies:
Codeine
Unknown;
Compazine (Oral) (Prochlorperazine Maleate)
Unknown;
Penicillins
Rash; itchiness
Metformin
Nausea/Vomiting
Heparin Agents
Unknown;
Last dose of Antibiotics:
Vancomycin - [**2126-11-10**] 06:00 PM
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: Fever
Flowsheet Data as of [**2126-11-10**] 11:58 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.6
C (99.7
Tcurrent: 37.2
C (98.9
HR: 109 (98 - 112) bpm
BP: 107/70(78) {92/59(64) - 107/71(78)} mmHg
RR: 18 (18 - 30) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Height: 66 Inch
Total In:
1,768 mL
PO:
TF:
IVF:
768 mL
Blood products:
Total out:
0 mL
650 mL
Urine:
250 mL
NG:
400 mL
Stool:
Drains:
Balance:
0 mL
1,118 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CMV/ASSIST
Vt (Set): 500 (500 - 500) mL
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
PIP: 26 cmH2O
Plateau: 19 cmH2O
SpO2: 100%
ABG: 7.41/52/112/33/7
Ve: 8.3 L/min
PaO2 / FiO2: 224
Physical Examination
General Appearance: Thin
Head, Ears, Nose, Throat: Normocephalic, trach
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: (Percussion: Dullness : bases), (Breath Sounds:
Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present
Musculoskeletal: right arm external fixation
Neurologic: Responds to simple questions
Labs / Radiology
8.7 g/dL
354 K/uL
86 mg/dL
0.6 mg/dL
33 mEq/L
3.4 mEq/L
8 mg/dL
102 mEq/L
141 mEq/L
29.2 %
21.3 K/uL
[image002.jpg]
[**2126-11-10**] 07:17 PM
[**2126-11-10**] 11:17 PM
WBC
21.3
Hct
29.2
Plt
354
Cr
0.6
TCO2
34
Glucose
86
Other labs: PT / PTT / INR:16.0/32.7/1.4, ALT / AST:[**11-23**], Alk Phos / T
Bili:96/0.3, Differential-Neuts:87.4 %, Lymph:7.1 %, Mono:5.3 %,
Eos:0.2 %, Lactic Acid:0.7 mmol/L, Ca++:8.5 mg/dL, Mg++:1.4 mg/dL,
PO4:3.5 mg/dL
Imaging: CXR bilateral effusions, basilar opacities, no change
elbow x-ray - Stable position of external fixator without evidence of
hardware complication
Microbiology: awaiting cultures
ECG: NSR 100, no ischemia
Assessment and Plan
fever, leukocytosis - likely sites of infection include resp tract,
UTI, CDiff, line infection. Right arm fracture seems less likely. Will
continue abx . Consider replacing lines once fever clears. Await micro
studies.
broken external fixator - to OR tomorrow
vomiting, diarrhea, possible ileus - continue PEG drainage for now,
will retry TFs once surgery complete, treat CDiff as above
resp failure - cont current vent settings
ICU Care
Nutrition: NPO
Glycemic Control:
Lines:
Midline - [**2126-11-10**] 07:00 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 35 minutes
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
Chief Complaint: 79M with CHF, afib, Alzheimer's admitted with
influenza
24 Hour Events:
On pressure support most of day; did well but switched back to AC in
evening
Held coumadin, will need to be started on heparin gtt once INR no
longer supratherapeutic
Started on tube feeds; will watch lytes closely per nutrition
Had episode of ?rigors around 8pm, VSS, was able to pull away from
noxious stimuli
DDx was undersedation vs seizure vs bacteremia
Sent blood cultures and stat labs; increased sedation; gave ativan 2mg
IV x 1 with resolution
Blood pressures dropped about one hour later into SBP 80s; responded to
IV fluids and weaning sedation
Cardiac enzymes came back with troponin 0.13; EKG unchanged apart from
RVR
Started metoprolol 12.5 TID, increased simvastatin to 80, already on
ASA
Patient unable to provide history: Sedated
Allergies:
No Known Drug Allergies
Antibiotics:
Oseltamivir 75mg PO BID
Levofloxacin 750mg IV daily
Vancomycin 1g IV BID
Infusions:
Midazolam (Versed) - 0.5 mg/hour
Fentanyl - 12.5 mcg/hour
Other medications:
ASA 325 daily, Simvastatin 80 daily, Metoprolol 12.5mg PO TID
Famotidine
Flowsheet Data as of [**2151-2-7**] 07:34 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.2
C (98.9
Tcurrent: 37.2
C (98.9
HR: 131 (96 - 131) bpm
BP: 136/85(104){79/52(62) - 136/85(104)} mmHg
RR: 18 (6 - 20) insp/min
SpO2: 98%
Heart rhythm: AF (Atrial Fibrillation)
Height: 68 Inch
CVP: 11 (6 - 14)mmHg
Total In:
3,727 mL
542 mL
PO:
TF:
100 mL
111 mL
IVF:
3,512 mL
312 mL
Blood products:
Total out:
771 mL
325 mL
Urine:
766 mL
325 mL
NG:
5 mL
Stool:
Drains:
Balance:
2,956 mL
217 mL
Respiratory support
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 550 (550 - 550) mL
Vt (Spontaneous): 748 (748 - 960) mL
PS : 12 cmH2O
RR (Set): 14
PEEP: 8 cmH2O
FiO2: 40%
RSBI: 17
PIP: 24 cmH2O
Plateau: 18 cmH2O
SpO2: 98%
ABG: 7.34/27/155/17/-9
Ve: 7.8 L/min
PaO2 / FiO2: 388
Physical Examination
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Endotracheal tube
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)
Rub, (Murmur: No(t) Systolic, No(t) Diastolic), irregularly irregular
tachycardic
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Breath Sounds: Bronchial: bilateral)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,
Tone: Not assessed
Labs / Radiology
128 K/uL
11.3 g/dL
102 mg/dL
0.7 mg/dL
17 mEq/L
4.0 mEq/L
14 mg/dL
111 mEq/L
136 mEq/L
32.2 %
10.5 K/uL
[image002.jpg]
Micro
2/8,[**2-6**] blood cx NGTD
[**2-5**] urine cx negative
[**2-5**] urine legionella antigen negative
[**2-5**] sputum >25 polys no organisms on gram, culture NGTD legionella cx
NGTD
CXR: read pending, L lower lung field opacity sm L effusion
[**2151-2-5**] 05:47 PM
[**2151-2-6**] 04:21 AM
[**2151-2-6**] 04:39 AM
[**2151-2-6**] 05:37 AM
[**2151-2-6**] 08:49 AM
[**2151-2-6**] 01:46 PM
[**2151-2-6**] 08:14 PM
[**2151-2-6**] 08:18 PM
[**2151-2-7**] 05:02 AM
[**2151-2-7**] 05:14 AM
WBC
6.6
10.5
Hct
32.9
32.2
Plt
113
128
Cr
0.7
0.8
0.7
TropT
0.13
0.13
TCO2
22
20
20
21
21
21
15
Glucose
91
117
102
Other labs: PT / PTT / INR:63.0/70.3/7.6, CK / CKMB /
Troponin-T:213/12/0.13, Differential-Neuts:91.8 %, Band:Units: %
Range: 0-5 %, Lymph:5.0 %, Mono:2.9 %, Eos:0.1 %, D-dimer:3745 ng/mL,
Lactic Acid:1.2 mmol/L, Albumin:2.3 g/dL, Ca++:7.2 mg/dL, Mg++:2.0
mg/dL, PO4:1.2 mg/dL
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name **])
Oxygenating adequately with good RSBI this AM, wean PSV as tolerated
?exubate today
PNEUMONIA, VIRAL
Bandemia improved, afebrile
Continue oseltamivir for influenza currently day 3
Pt. had pus from LLL on [**2-5**] bronch so continue levofloxacin for
?bacterial superinfection. Consider d/c vancomycin.
Followup cultures and reculture if febrile
SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)
Off of pressors, making adequate urine. Hypotensive yesterday in
setting of ativan, now with improved BP. Continue antibiotics as above.
MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)
Enzymes elevated yesterday in setting of RVR, suspect demand ischemia.
CK
s trending down with flat tropn, continue to trend. Continue medical
management with aspirin, statin, beta blocker; will titrate beta
blocker upward for further rate control today.
ATRIAL FIBRILLATION (AFIB)
Still tachycardic, increase metoprolol. Holding anticoagulation [**1-30**]
supratherapeutic INR. Will restart heparin drip when INR <2.
INR elevated
Patient on coumadin at home, held here. No evidence of active bleeding
with stable Hct. Consider PO vitamin K.
Will repeat DIC labs.
HEART FAILURE (CHF), SYSTOLIC, CHRONIC
Clinically ~euvolemic, goal net even today. Consider checking TTE to
assess pump function (no echo on file here)
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2151-2-6**] 02:00 PM 20 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
18 Gauge - [**2151-2-5**] 06:00 AM
Multi Lumen - [**2151-2-5**] 12:21 PM
Arterial Line - [**2151-2-5**] 02:37 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Comments:
Code status: Full code
Disposition:ICU
|
Physician
|
Classify the following medical document.
|
CVICU
HPI:
86yoM s/p CABG/MVR [**4-19**]
EF 70 Cr 1.8 Wt 68.5K HgbA1c 6.3
[**Last Name (un) **]: ASA 325', Diltiazem SR 240', Furosemide 80", Metolazone 2.5 Q
M-W-F, Metoprolol 25', Warfarin 2alt4mg, Potassium 20'''
Coumadin - atrial fibrillation - started [**5-13**] (1),
On Fondaparinux sq due to HITT until INR theraputic
trach collar started [**5-13**] tolerating (speech ordered for passy muir)
Rehab screen started [**5-13**] - plan for dc [**5-19**] or after with chole tube
Follow up with Dr [**Last Name (STitle) **] in [**5-27**] weeks to evaluate GB
D5w for free water deficit
lopressor resumed [**5-13**], no statin due to previous ^lft when started
EP to do 1 week pacer check [**5-13**] (spoke with fellow [**5-13**])
PMHx:
PMH: ^lipids, AFib, TURP, Ing Hernia repair, Sleep Apnea-CPAP -home,
CRI(1.8), Ascites, Squamous Cell CA-excision groin, Lower Back
Arthritis, depression
Current medications:
Albuterol 0.083% Neb Soln 4. Artificial Tears Preserv. Free 5. Aspirin
6. Bisacodyl 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8.
Ciprofloxacin 9. Dextrose 50% 10. Erythromycin 0.5% Ophth Oint 11.
Fondaparinux Sodium 12. Hydrocortisone Na Succ. 13. Hydrocortisone Na
Succ. 14. Insulin 15. Insulin 16. Ipratropium Bromide Neb 17.
Lansoprazole Oral Disintegrating Tab 18. Lactulose 19. Magnesium
Sulfate 20. Metoclopramide 21. Metoprolol Tartrate 22. MetRONIDAZOLE
(FLagyl) . Potassium Chloride TraMADOL (Ultram) 28. Warfarin
24 Hour Events:
coumadin started for AFib
Post operative day:
[**5-12**] perc trach, lap->open J-tube, chole tube, incidental gangren GB
[**5-9**] R BKA
[**4-28**] R leg thrombectomy, peroneal/BK [**Doctor Last Name 1539**] stent, fem-[**Doctor Last Name 1539**] bpg
[**4-26**] PPM
[**4-23**] RLE [**Doctor Last Name **] Stent, AT Aplasty/Stent
[**4-19**] CABGx3 (LIMA to LAD, SVG to OM, SVG to Dx)/MVR(29tissue)
Allergies:
Heparin Agents
Thrombocytopeni
Last dose of Antibiotics:
Ciprofloxacin - [**2154-5-13**] 05:00 PM
Metronidazole - [**2154-5-14**] 02:00 AM
Other ICU medications:
Metoprolol - [**2154-5-14**] 06:29 AM
Flowsheet Data as of [**2154-5-14**] 09:46 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**56**] a.m.
Tmax: 36.6
C (97.9
T current: 36.3
C (97.3
HR: 82 (80 - 83) bpm
BP: 133/55(78) {113/46(67) - 143/60(84)} mmHg
RR: 22 (20 - 35) insp/min
SPO2: 96%
Heart rhythm: V Paced
Wgt (current): 71.7 kg (admission): 61.3 kg
Height: 67 Inch
CVP: 17 (8 - 18) mmHg
Total In:
2,477 mL
843 mL
PO:
Tube feeding:
727 mL
579 mL
IV Fluid:
1,750 mL
234 mL
Blood products:
Total out:
1,100 mL
595 mL
Urine:
900 mL
320 mL
NG:
25 mL
Stool:
Drains:
175 mL
275 mL
Balance:
1,377 mL
249 mL
Respiratory support
O2 Delivery Device: Trach mask
SPO2: 96%
ABG: 7.47/37/84.[**Numeric Identifier 1000**]/23/3
PaO2 / FiO2: 168
Physical Examination
General Appearance: No acute distress, Cachectic, trached and open J
tube/chole tube
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), Vpaced
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : , Diminished: bases), (Sternum: Stable )
Abdominal: Soft, Bowel sounds present
Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Diminished)
Neurologic: Follows simple commands, (Responds to: Verbal stimuli),
Moves all extremities, opens eyes responds appropriately to questions
Labs / Radiology
249 K/uL
9.0 g/dL
141 mg/dL
1.4 mg/dL
23 mEq/L
4.0 mEq/L
66 mg/dL
111 mEq/L
144 mEq/L
27.8 %
20.6 K/uL
[image002.jpg]
[**2154-5-12**] 12:55 AM
[**2154-5-12**] 04:24 PM
[**2154-5-12**] 04:56 PM
[**2154-5-12**] 09:51 PM
[**2154-5-13**] 04:16 AM
[**2154-5-13**] 04:24 AM
[**2154-5-13**] 05:52 AM
[**2154-5-13**] 10:34 AM
[**2154-5-13**] 02:11 PM
[**2154-5-14**] 04:19 AM
WBC
26.8
24.7
19.5
20.6
Hct
32.0
30.0
28
26.5
27.2
27.8
Plt
[**Telephone/Fax (3) 7767**]49
Creatinine
1.6
1.3
1.3
1.4
TCO2
31
28
27
28
28
Glucose
156
90
111
121
109
141
Other labs: PT / PTT / INR:19.1/30.7/1.8, CK / CK-MB / Troponin
T:139/8/0.61, ALT / AST:55/72, Alk-Phos / T bili:91/5.2, Amylase /
Lipase:108/54, Differential-Neuts:95.0 %, Band:0.0 %, Lymph:3.0 %,
Mono:2.0 %, Eos:0.0 %, Fibrinogen:242 mg/dL, Lactic Acid:2.1 mmol/L,
Albumin:2.7 g/dL, LDH:348 IU/L, Ca:8.1 mg/dL, Mg:3.0 mg/dL, PO4:3.1
mg/dL
Assessment and Plan
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), ALTERATION IN NUTRITION,
IMPAIRED SKIN INTEGRITY, PERIPHERAL VASCULAR DISEASE (PVD) WITH
CRITICAL LIMB ISCHEMIA
Assessment and Plan: 86yo man s/p CABG/MVR. post-op course c/b ARF,
resp failure, LE thrombosis
Neurologic: Pain controlled, tylenol and ultram
Cardiovascular: Aspirin, Beta-blocker, Statins, plavix, change
Bblockers to oral dosing
Pulmonary: Trach, (Ventilator mode: Other), Trach collar trials
Gastrointestinal / Abdomen:
Nutrition: Tube feeding, advancew tube feedings to goal rate
Renal: Foley, Adequate UO, monitor I/O, BUN/Cr
hypernatremic over past weekend, received 1.5L free water. now
normalized will give free water vis feeding tube
Hematology: stable hct
Endocrine: Regular insulin, on iv steroids x 7 days will stop today
elevated FSBS will add lantus today
Infectious Disease: gm neg in sputum/urine.
WBC elevated at 20.6, no fevers
currently on cipro/flagyl
Lines / Tubes / Drains: Foley, J-Tube, Trach, Surgical drains (hemovac,
JP)
Wounds: Dry dressings
Imaging: CXR from [**5-12**] with mod left effusion
Consults: General surgery, Vascular surgery, CT surgery, Hem / Onc ,
Nephrology, P.T.
ICU Care
Nutrition: Nutren 2.0 (Full) - [**2154-5-14**] 07:17 AM 35 mL/hour
Glycemic Control: Regular insulin sliding scale, Comments: add Lantus
today
Lines: Arterial Line - [**2154-5-1**] 02:30 PM
Multi Lumen - [**2154-5-9**] 02:53 PM
Prophylaxis: DVT: (Systemic anticoagulation: Fondaparinux Sodium)
Stress ulcer: PPI
VAP bundle: HOB elevation, Mouth care
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2141-11-5**] Discharge Date: [**2142-2-18**]
Date of Birth: [**2141-11-5**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Name2 (NI) 4027**] #2, is the
former 1070 gm male newborn Twin B who was admitted to the
Neonatal Intensive Care Unit for management of prematurity.
The baby was [**Name2 (NI) **] to a 36 year old gravida 3, para 1 mother.
Prenatal screens - A positive, antibody negative, hepatitis B
Streptococcus unknown. Also cystic fibrosis was negative,
Chlamydia, gonorrhea culture negative.
Maternal history - Hypothyroidism, pregnancy notable for
spontaneous dichorionic/diamniotic twins. Pregnancy
complicated by preterm labor and cervical shortening noted
during routine examination at 23 5/7 weeks. Mother was
was placed on bedrest and was treated with magnesium sulfate.
Betamethasone. On the day of delivery, [**11-5**], mother presented in active labor despite high doses of
magnesium.
Delivery was by cesarean section. This infant emerged floppy
without spontaneous respirations. The infant was dried, bulb
suctioned and stimulated. Poor respiratory effort continued
and positive pressure was begun with some improvement. Was
intubated in the Delivery Room, Apgars 1 at one minute and 6
at five minutes. The baby was shown to the parents and then
transferred to the Newborn Intensive Care Unit.
HOSPITAL COURSE: (By systems) Respiratory - The baby
received three doses of Surfactant and was on the
conventional ventilator with pressures of 22/5 and a rate of
18. Weaned by day of life #24 to nasopharyngeal CPAP which
he required until nasal cannula oxygen on day of life #51.
He transitioned to room air on day of life 64 and remained in
room air until day of life 76 where he had an increase in
apnea and bradycardia. He was on CPAP for approximately 24
hours. He was also noted to have spits at this time. Sepsis
evaluation was negative, and ultimately this episode was
thought to be related to reflux. He was then again
transitioned to room air where he remained.
The baby was loaded with caffeine citrate on day of life #4.
He remained on caffeine citrate until day of life #63. At
the time of discharge he has been without significant apnea,
bradycardia or desaturation for greater than five days.
Cardiovascular - The patient had a presumed patent ductus
arteriosus which was treated with one course of Indomethacin
on day of life 3 to 4. He had an echocardiogram on [**11-10**] after treatment with Indomethacin which showed no patent
ductus arteriosus. The baby's baseline heartrate is 130s to
160s. He is cardiovascularly stable with blood pressures
with systolics in the 60s to 80s, diastolics 30s to 40s and
mean blood pressure 40s to 50s.
Fluids, electrolytes and nutrition - The patient initially
had an umbilical artery catheter but was unable to have an
access to umbilical venous catheter. The umbilical artery
catheter was removed on day of life #3. He had a PICC line
inserted which remained in place for several weeks. He was
started on enteral feedings on day of life #7 and was
advanced to full strength breastmilk 32 with ProMod,
demonstrated some initial spits, ultimately was thought to
have reflux. He was started on Reglan and Zantac on day of
life #60 and had rice cereal added to his breastmilk 32 with
ProMod. The Reglan and Zantac were discontinued on [**1-31**] and he was transitioned to Enfamil AR which he is
currently feeding all p.o. He is receiving supplemental
iron, Ferrous Sulfate .3 cc p.o. q.d. which equals 2
mg/kg/day of 25 mg/cc. The baby is taking in greater than
170 cc/kg/day. His birthweight was 1070 gm, 50th percentile,
discharge weight 4160, 50th percentile. Admission length 37
cm, 50th percentile, discharge length 52 cm, 25th to 50th
percentile. Admission head circumference, 20.5 less than
10th percentile, question accuracy of this measurement as at
one week of age his head circumference was 24 cm, 10th
percentile. Discharge head circumference 35 cm, 75th
percentile.
Gastrointestinal - He had a bilirubin on day of life #4 of 5,
.4, .3. He responded to single phototherapy and had a
rebound bilirubin of 1.8, 0.4, 1.4.
Hematology - Baby is A positive, Coomb's negative, received
four transfusions of red blood cells during this admission,
last one being on [**2142-1-21**] for a hematocrit of 24.
He has not had a repeat hematocrit since then, he is pink and
well perfused.
Infectious disease - The baby had a sepsis evaluation on
admission because of prematurity and presentation at birth,
he had a white count of 7.3, 38 polys, 0 bands, 57 lymphs,
platelets of 299,000. Admission hematocrit of 54%. He was
started on Ampicillin and gentamicin. He had adequate
gentamicin levels of 1.3, 1.1 and a trough of 5.5.
Antibiotics were discontinued as the baby was clinically
doing well for gestational age. He then had a sepsis
evaluation on day of life #30 for increased apnea and
bradycardia. At that time his blood count was 18 wit 51
polys, 0 bands, platelet count of 645,000, hematocrit 41. He
was not started on antibiotics and clinically improved. On
day of life #38 he again had a sepsis evaluation for
increased apnea and bradycardia. The complete blood count
was also within normal limits. Blood culture was negative
and the baby received 48 hours of Vancomycin and was
clinically improved. On day of life #75 again he had
increased apnea and bradycardia. He had a blood culture and
complete blood count sent. His complete blood count had a
white count of 11.8 with 14 polys, 0 bands, platelets 383 and
his blood culture remained negative. He did have a urine
catheter specimen sent that was positive for enterococcus, and
klebsiella. He had a repeat complete blood count
after starting on Vancomycin and Gentamicin that was within
normal limits. His antibiotics were continued for five days
and after being off of antibiotics for one week he had a
repeat urine culture sent that showed no growth. To follow
up on this presumed urinary tract infection, he had a renal
ultrasound which showed nephrocalcinosis on [**1-31**] and
then [**2-8**] he had a vesicoureterogram done at
[**Hospital3 1810**] that was within normal limits. He has
had no further issues.
Neurological - The baby had an initial head ultrasound on day
of life #3 which was within normal limits with no evidence of
intraventricular hemorrhage. On day of life #10 he had
another head ultrasound which showed a Grade 3 bilateral
intraventricular hemorrhage. He had serial head ultrasounds
after this to follow his ventriculomegaly that was noted on
this ultrasound also and these were improving, until [**2-1**] when his ventriculomegaly was mildly increased from his
previous scan. He had his last scan on [**2-12**] which showed
a resolving clot with ventricular size stable. Plan is to do
an outpatient head ultrasound at the [**Hospital3 1810**] in
the next week or two and certainly prior to being followed up
in the Neonatal Neurology follow up program at the [**Hospital3 18242**]. Dr. [**Last Name (STitle) 37122**] has seen [**Known lastname **] here at the [**Hospital6 1760**] and has also met with the
parents, his phone #[**Telephone/Fax (1) 47462**]. Baby's neurological
examination is appropriate for gestational age.
Sensory - Audiology, hearing screen as passed.
Ophthalmology, the baby has had serial eye examinations which
showed some mild retinopathy of prematurity with his last
examination being on [**2142-2-7**] which showed Stage 1
retinopathy of prematurity, both eyes, 2 to 3 clock hours
with a plan to follow up in three to four weeks with Dr.
[**Last Name (STitle) 36137**] from ophthalmology at [**Hospital3 1810**], phone
[**Telephone/Fax (1) 36249**].
Psychosocial - Parents have been visiting daily, are
optimistic about [**Known lastname **] outcome. They have been
appropriately grieving [**Known lastname **] twin, [**Known lastname **] who died of
pulmonary hemorrhage and shock on day of life #2. They had a
[**Hospital1 **] service for him about one week after his death and
met with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2142-2-17**] regarding autopsy
results and a bereavement meeting. They look forward to
transitioning home and are appropriately anxious about this
transition.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with family.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47463**], phone
[**Telephone/Fax (1) 37304**], fax [**0-0-**].
CARE RECOMMENDATIONS: Continue Enfamil AR adlib, minimum of
130 cc/kg. Medications - Ferrous Sulfate .3 cc p.o. q.d.
which equals 2 mg/kg/day of 25 mg/cc. Car seat screening
passed on [**2142-2-17**]. State newborn screen, baby had
serial newborn screen, the last one being on [**12-29**] that
was within range. Immunizations received - Hepatitis B
vaccine [**12-25**] and [**1-26**]. DTAP [**1-5**], HIB
[**1-5**], IPV [**1-5**], pneumococcal 7 valiant conjugate
vaccine [**1-5**], Synagis [**2-8**].
Immunizations recommended - Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: 1. [**Month (only) **] at less than 32 weeks; 2. [**Month (only) **] between
32 and 35 weeks with plans for daycare during respiratory
syncytial virus season, with a smoker in the household or
with preschool siblings; or 3. With chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
FOLLOW UP: Follow up appointments recommended with primary
care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47463**], parents plan to call on
[**2-18**] and will be seen during the first week of discharge.
Neonatal Neurology Program, [**Telephone/Fax (1) 47462**]. Follow up head
ultrasound the week of [**2-19**] at [**Hospital3 1810**],
[**Telephone/Fax (1) 47462**]. Ophthalmology, Dr. [**Last Name (STitle) 36137**] [**Telephone/Fax (1) 36249**],
last examination on [**2142-2-7**], plan to follow up in
three to four weeks, [**2-28**] to [**3-7**]. Mother will call
for an appointment. [**First Name (Titles) 407**] [**Last Name (Titles) **] Group,
[**Telephone/Fax (1) 37503**] and Infant Follow Up Program at [**Hospital3 18242**] will contact the family.
Follow-up renal ultrasound suggested for several monthsa time to
evaluate resolution of stones,, or need for further evaluation.
DISCHARGE DIAGNOSIS:
1. Former 27 [**2-16**] week premature male
2. Status post respiratory distress syndrome
3. Status post rule out sepsis
4. Status post presumed urinary tract infection
5. Status post intraventricular hemorrhage
6. Mild retinopathy of prematurity
7. Gastrointestinal reflux
8. Status post apnea and bradycardia of prematurity
9. Renal calcifications
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 36144**]
MEDQUIST36
D: [**2142-2-18**] 15:52
T: [**2142-2-18**] 16:05
JOB#: [**Job Number 47464**]
|
Discharge summary
|
Classify the following medical document.
|
Admission Date: [**2159-3-4**] Discharge Date: [**2159-3-8**]
Date of Birth: [**2115-11-6**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 13561**]
Chief Complaint:
left upper and lower extremity numbness/tingling
Major Surgical or Invasive Procedure:
Intubation
CT Scan
MRI/MRA
CTA
Lumbar Puncture
History of Present Illness:
ID/CC: Loss of strength and sensation in lower extremities
HPI: Pt is a 43 year old male with hx of lumbar disc disease,
s/p
L4-L5 laminectomy at [**Hospital3 15054**] in [**2156**], with residual R leg
numbness
and foot drop from surgery, who presents with acute onset of L
leg plegia and sensory loss. He says that at baseline he walks
with a cane because of a foot drop on the R and also has some
sensory loss in the R leg. He also at baseline has severe pain
over his spine in the L4 area that he has had since the surgery.
He says that last night (midnight 24 hours prior to presentation
to the ED) he was sleeping and awoke because he thought his dog
was sitting on his L leg (it felt heavy and numb). He awoke and
saw that his dog was not on his leg. He tried to move his leg
and
could not. It was numb and completely plegic. He says he felt
very scared and therefore did not tell anyone aobut this for the
entire day. Around 8 pm, however, he realized he had to be
evaluated and he presented to the [**Hospital6 **],
who then sent him to the [**Hospital1 18**] for further evaluation. He denies
any recent back trauma.
Past Medical History:
spinal disease operated on [**2156**] at [**Hospital6 **]
chronic pain
Social History:
Denies tobacco, ETOH, drugs. Used to work as a UPS supervisor,
fired 2 yrs ago when got back injury at work. Has not worked
since. Lives at home with
wife and 3 kids, says situation at home has been stressful since
he has been out of work. Is currently involved in at least one
lawsuit (his former neurosurgeon) as well as a sticky
financial/worker's compensation situation.
Family History:
no h/o seizures, neurological problems
Physical Exam:
Exam findings have fluctuated throughout his hospital course.
On admission to neuro:
VS: T 98.6 HR77 BP 148/87 RR18 Sat 95% on room air
PE: overweight male, very distressed and tearful.
HEENT OP benign, head atraumatic
Neck Supple, full ROM, no carotid bruits
Chest CTA B
CVS RRR w/o MGR
ABD soft, NTND, + BS
EXT no C/C/E, distal pulses full, no rashes or petechiae
Neuro:
MS: AA&Ox3, appropriately interactive, normal affect
Attention: WORLD backwards
Speech: fluent w/o paraphasic error, repetition, naming intact
L/R confusion: No L/R confusion
Praxis: Able to mimic saluting the flag, rolling dice, brushing
teeth with either hand.
CN: I--not tested; II,III--PERRLA, VFF by confrontation, visual
acuity 20/X, optic discs sharp; III,IV,VI-EOMI w/o nystagmus, no
ptosis; V--sensation intact to LT/PP, masseters strong
symmetrically; VII--face symmetric without weakness; VIII--hears
finger rub bilaterally; IX,X--voice normal, palate elevates
symmetrically, gag intact; [**Doctor First Name 81**]--SCM/trapezii [**5-17**]; XII--tongue
protrudes midline, no atrophy or fasciculation. Of note, tongue
at times is protruded far to the left, usually when the patient
is questioned about his symptoms.
Motor: normal bulk and tone, no tremor, rigidity or
bradykinesia,
no pronator drift.
Strength:
Upper extremities [**5-17**] throughout. In the lower extremities pt
has
no spontaneous movement, able to wiggle R toes and slide R leg
along the bed, no withdrawal to pain in the LLE.
Of note, motor strength returned to R leg then slowly to L leg,
moving toes only on command at discharge but able to walk with
nurses and get out of bed on his own at times.
Refl:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 1 | 2 | 2 | 1 | 0 | dn |
R | 1 | 2 | 2 | 1 | 0 | dn |
[**Last Name (un) **]: Diminished sensation to light touch, pin prick,
temperature, vibration to T8 anteriorly and posteriorly, but no
saddle anesthesia. No joint position in L foot. In R foot able
to
detect movement of toes, but not the direction. This sensation
defect improved over the next few days and resolved by
discharge.
Pertinent Results:
[**2159-3-5**] 02:52AM BLOOD WBC-10.4 RBC-4.89 Hgb-14.7 Hct-41.6
MCV-85 MCH-30.0 MCHC-35.3* RDW-13.8 Plt Ct-268
[**2159-3-4**] 12:25AM BLOOD Neuts-82.6* Lymphs-13.5* Monos-3.1
Eos-0.7 Baso-0.2
[**2159-3-5**] 02:52AM BLOOD Plt Ct-268
[**2159-3-5**] 02:52AM BLOOD PT-13.2 PTT-25.2 INR(PT)-1.1
[**2159-3-4**] 12:25AM BLOOD ESR-4
[**2159-3-5**] 02:52AM BLOOD Glucose-104 UreaN-16 Creat-0.9 Na-146*
K-3.4 Cl-110* HCO3-27 AnGap-12
[**2159-3-5**] 02:52AM BLOOD ALT-74* AST-24 AlkPhos-79 TotBili-0.7
[**2159-3-5**] 02:52AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.9 Cholest-211*
[**2159-3-5**] 02:52AM BLOOD Triglyc-594* HDL-35 CHOL/HD-6.0
LDLmeas-107
[**2159-3-4**] 12:25AM BLOOD CRP-0.67*
[**2159-3-4**] 09:30AM BLOOD IgG-1149
[**2159-3-4**] 09:33AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0
Lymphs-92 Monos-8
[**2159-3-4**] 09:33AM CEREBROSPINAL FLUID (CSF) TotProt-53*
Glucose-91
[**2159-3-4**] 09:33AM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
MRI/MRA BRAIN:
Mild sinus disease. There are a few nonspecific T2
high-signal-intensity foci. No definite evidence of acute
infarction, mass effect, or hemorrhage. Normal MRA of
intracranial circulation
MRI SPINE
There are degenerative changes in the cervical spine with
osteophyte formation producing mild canal narrowing at C3-C4,
C5-C6, and C6-C7, and T8-T9. These do not appear to produce
spinal cord compression. No definite contrast enhancement
XRAY-L-Spine with oblique
Five views of the lumbosacral spine, including oblique
projections show no fracture or spondylolisthesis. The height of
the vertebral bodies is normal. The intervertebral disc spaces
are normal. The SI joints are normal and the visualized hip
joints are normal. There is no evidence for bony destruction.
The visualized soft tissue structures are normal
Brief Hospital Course:
The patient was initially thought to be in acute need of
neursurgery per his reported symptoms of paraparesis and h/o
back surgery, but spine imaging proved negative for cord
compression or major pathology (past scarring from surgery was
visualized.) The following differential was considered:
1. Cord compression/infarct: Decadron was started in the ICU due
to acute symptoms. However, nonrevealing imaging made surgical
treatment less likely. In addition, the patient's neurological
symptoms were also inconsistent with a cord compression as he
complained of L arm paresis and some sensory loss as well as a
paraparesis and some sensory loss that did not correspond to a
level. [**Doctor Last Name 60437**] sign was positive. He also demonstrated an
unusual cranial nerve exam consisting of a tongue that
occasioanlly protrudes far to the left when he is asked about
his symptoms, as well as a [**Doctor Last Name 11586**] and Rinne test that he
localized to the right side of his head only.
2. Infection. The pt reported severe tenderness on exam as well
as paresis but epidural abscess was not found on imaging. He was
empirically started on IV abx in the ICU which were subsequently
d/ced when the LP was done and was negative.
3. Demyelinating disease. LP and head/spine imaging negative for
MS, GB.
On the neurology floor, a differential including conversion vs.
malingering evolved due to inconsistent physical exam as well as
the following:
1. Social stressors. Extensive discussions with the patient
regarding his social situation revealed several social
stressors. The patient is involved in a sticky worker's
compensation situation after he was fired from his job several
years ago for back injury. He has been bed-ridden and depressed
since his operation 2 yrs ago which was apparently not done
correctly. He has also had [**10-22**] chronic pain for which he has
been taking 80mg oxycontin TID for several months. He believes
he is addicted.
2. Inconsistent history. Several aspects of his medical course
were not correctly relayed to us, per his father's report as
well as his neurosurgeon's report at the [**Hospital3 **] (pt states
he has an appt [**3-15**] with Dr. [**Last Name (STitle) **] who reports no such
appt.)
3. Secondary gain. He reported to the team that his worker's
comp would end once he received back surgery but that he wanted
to get the surgery even if he had to pay for it himself.
However, his father reported that the situation is reversed:
that the patient cannot get worker's comp UNTIL he received back
surgery and that therefore he is very anxious to be operated on.
4. Lawsuits. He is also involved in at least one lawsuit against
his former neurosurgeon.
Given the above factors and the apparent volitional aspect of
his symptoms, malingering seemed more likely than a conversion
disorder. A psychiatry consult was called and gave the
unequivocal diagnosis of malingering. The patient was informed
that he has no neurological diagnosis and that his transient
weakness may be evoked by stress and will resolve on its own.
The patient's symptoms continued to resolve over the next few
days as PT attempted to get him out of bed to clear him for home
discharge. He was D/Ced home feeling much better.
Medications on Admission:
oxycontin 80mg PO TID
Discharge Medications:
1. Oxycodone HCl 40 mg Tablet Sustained Release 12HR Sig: Two
(2) Tablet Sustained Release 12HR PO Q8H (every 8 hours) for 4
days.
Disp:*20 Tablet Sustained Release 12HR(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
transient left-sided weakness
Discharge Condition:
stable
Discharge Instructions:
Continue to take your medications as prescribed by Dr. [**Last Name (STitle) 5263**].
You should follow up with her in the next week. Please follow up
with Dr. [**Last Name (STitle) **] as previously scheduled on [**3-15**] for neurosurgical
evaluation.
Followup Instructions:
If your symptoms recur contact your PCP for advice or come
directly to the emergency room. Follow up with Dr. [**Last Name (STitle) **] as well
for neurosurgery evaluation.
|
Discharge summary
|
Classify the following medical document.
|
TITLE:
Chief Complaint:
24 Hour Events:
Pt. started on standing haldol as per neuroloy recs, but patient had QT
prolongation to 0.49, so patient was changed to zyprexa 5mg QID.
Treatment with cidofovir was initiated yesterday, with probenecid for
renal protection
Patient to get an EEG today
Allergies:
Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)
Rash;
Last dose of Antibiotics:
Daptomycin - [**2124-8-25**] 10:20 PM
Micafungin - [**2124-8-26**] 01:38 AM
Meropenem - [**2124-8-26**] 04:00 AM
Infusions:
Other ICU medications:
Haloperidol (Haldol) - [**2124-8-25**] 10:36 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2124-8-26**] 06:37 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36
C (96.8
Tcurrent: 35.6
C (96.1
HR: 114 (108 - 126) bpm
BP: 114/73(84) {76/44(32) - 154/114(151)} mmHg
RR: 29 (15 - 29) insp/min
SpO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
3,820 mL
1,853 mL
PO:
TF:
IVF:
3,620 mL
1,743 mL
[**Year (4 digits) **] products:
Total out:
485 mL
345 mL
Urine:
485 mL
345 mL
NG:
Stool:
Drains:
Balance:
3,335 mL
1,508 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 97%
ABG: ///17/
Physical Examination
gen-altered, moving around in bed, moaning
HEENT-nc/at, PERRL but slightly sluggish, +conjunctival and scleral
edema, +scleral icterus, dry MM, NGT in place
neck-supple, no LAD
chest-b/l slight expiratory wheezes,bibasilar crackles
heart- s1s2 tachycardic, +systolic flow murmur throughout precordium
abd-+hypoactive bs, soft, NT, ND
ext-no c/c/ 2+edema. R.knee and dorsal surface of hand with slight
erythema.
neuro-AAOx0, moving all 4 extremities, no noticeable tremor.
Labs / Radiology
41 K/uL
6.6 g/dL
110 mg/dL
0.5 mg/dL
17 mEq/L
3.2 mEq/L
16 mg/dL
112 mEq/L
137 mEq/L
19.6 %
6.2 K/uL
[image002.jpg]
[**2124-8-26**] 04:40 AM
WBC
6.2
Hct
19.6
Plt
41
Cr
0.5
Glucose
110
Other labs: PT / PTT / INR:17.2/32.5/1.5, ALT / AST:141/97, Alk Phos /
T Bili:391/6.3, Differential-Neuts:88.0 %, Lymph:8.2 %, Mono:3.5 %,
Eos:0.2 %, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:597 IU/L,
Ca++:7.5 mg/dL, Mg++:1.6 mg/dL, PO4:2.2 mg/dL
Assessment and Plan
This is a 57-year-old gentleman with CLL and large cell transformation
s/p MURD SCT on [**3-10**], recently discharged from [**Hospital1 19**] to rehab, now
readmitted for increased diarrhea, abdominal pain, and waxing/[**Doctor Last Name 533**]
mental status.
#AMS-Likely etiology is thought to be infectious due to adenovirus and
BK virus being detected in the [**Doctor Last Name 573**], but <500 copies of adenovirus and
BK being very highly positive in the [**Last Name (LF) 573**], [**First Name3 (LF) **] thought to be due to BK
encephalitis. Due to deterioration in mental status and persistent
altered state, ID has recommended adding viral studies to the CSF and
to start empiric treatment with IV cidofovir at 5mg/kg IV weekly. In
addition, he will need IV hydration with NS and he must receive oral
probenecid (as this does not come IV) for renal protection. Other
etiologies of AMS could include toxic metabolic or medication effect
given recent recent ativan and morphine for pain control. In addition,
malignant process such as return of cancer could be possible but CSF
did not show malignant cells. In addition, MRI, though a poor study did
not show any other possible explanations.
-Started treatment with cidofovir, patient tolerated probenecid and IVF
hydration very well
- Changed standing haldol to Zyprexa due to QTc prolongation, will
continue to monitor QTc
- ID and neuro following, appreciate recs
-f/u CSF viral PCRs and well as pending cxs
-started cidofovir 400mg and probenacid as directed by protocol
-avoid mind alternating medications
ativan, morphine, etc.
-started thiamine IV x 5 days and po folate,
-will f/u EEG from today
-continue broad antibiotic coverage with daptomycin and meropenem
pending further culture data
-continue micafungin for fungal ppx while on heavy immunosuppression
.
#Hypothermia-has been improving with warming blankets, thought to be
secondary to infection. Pt apparently displayed this physiology with
his prior viral infectious. Could also be secondary to an endocrine
source.
-thyroid studies: TSH and T4 mildly decreased, but in the context of an
acute illness are difficult to assess. Could consider cortisol stim
test if he remains hypothermic and no infectious etiology is found
-warming blankets.
-on daptomycin and meropenem in case of bacterial sepsis, as per ID
team
.
# s/p CLL with BMT c/b GVHD
-care per BMT team, discuss immunosuppressant and prophylactic
regimens.
-can d/c acyclovir with initiation of cidofovir
.
#GI:diarrhea, could be related to immunosuppression/medication effect,
GVHD.
- stool cultures NG thus far.
- iv fluids PRN
- replete lytes.
.
#Elevated LFTs/bili-chronic since around [**4-25**], per BMT thought to be
mainly due to GVHD, could be acutely worsened by viral infection. Will
continue to monitor and continue immune suppression regimen as per BMT
team.
-If worsens, consider RUQ u/s
.
#Anemia-baseline is chronic likely secondary to
immunosuppresion/infection/GVHD, but acute drop in HCT today likely due
to IVF administration, HCT fell below 21 today.
-Check a type and screen since he does not have an active one. F/U
transfusion threshold with BMT but will likely transfuse 1 unit PRBC
-Continue to monitor
.
#Thrombocytopenia-chronic as with anemia. Continue to monitor.
.
#Non gap metabolic acidosis-based on VBG looks like a primary
respiratory alkalemia likely due to hyperventilation from agitation,
and compensatory metabolic academia
-could also be related to diarrhea and IVF
.
#HTN-currently normotensive, will hold outpatient medications
.
#HL-currently holding statin given transaminitis
ICU Care
Nutrition:
Glycemic Control:
Lines:
PICC Line - [**2124-8-25**] 01:20 PM
Prophylaxis:
DVT: pneumo boots
Stress ulcer: IV PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU pending decreased nursing needs now that NGT is in
place
------ Protected Section ------
MICU Attending Addendum:
I examined the patient today, reviewed the history and laboratory data
and was present for the key portion of the services provided. I have
also reviewed Dr [**Last Name (STitle) 10627**]
s note above and largely agree with the
findings and plan of care. I have also discussed the patient
s status
with Dr [**Last Name (STitle) 383**]. Over the morning the patient has continued to be
unresponsive and yet is now starting to look agitated again.
Furthermore he has a rising lactate and a metabolic acidosis (7.27 on
VBG, compared to 7.42 earlier today). The possibility of sepsis is
high, including intra-abdominal with his GVHD. Given acidemia and
severely altered mental status, we feel intubation is in order, and Dr
[**Last Name (STitle) 383**] agrees and pt
s wife consents. If hemodynamically stable I
concur with abd CT later today. Overall prognosis is very guarded, but
for now we will continue max care.
[**First Name8 (NamePattern2) 1620**] [**Last Name (NamePattern1) 1621**], MD
45 min spent in the care of this critically ill pt.
------ Protected Section Addendum Entered By:[**Name (NI) 1620**] [**Last Name (NamePattern1) 1621**], MD
on:[**2124-8-26**] 13:55 ------
Additional MICU Attending Addendum 15:00hr
Repeat [**Year (4 digits) 573**] gases (abg
s) now show pH 7.42 and arterial lactate is
only 1+. Now that haldol, Zyprexa, and benadryl stopped, patient has
times when he follows simple commands. We will follow his clinical
trajectory closely and for now hold off on intubation though if he
becomes progressively acidotic or deeply obtunded we will have low
threshold for intubation then.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1621**], MD
------ Protected Section Addendum Entered By:[**Name (NI) 1620**] [**Last Name (NamePattern1) 1621**], MD
on:[**2124-8-26**] 15:28 ------
|
Physician
|
Classify the following medical document.
|
Trauma, s/p multiple stab wounds to head, chest, right arm & axilla,
abdomen, and right buttocks. Pt is s/p Exp Lap with repair of liver
laceration & repair of gastrotomy; and repair RUE brachial vein.
Assessment:
Pt sedated on propofol and Fentanyl infusion- not responding to noxious
stimulation, no cough, gag, corneal; PERRL @ 2mm. C-collar in place;
logroll precautions in effect. Vital signs stable and urine output
adequate. Impaired gas exchange per ABG; breath sounds clear &
diminished R>L. Bilateral chest tube in place without fluctuation or
leak & negative for crepitus; serosanginous drainage from both.
Abdominal incision is open with transparent dressing intact & 2 JP
drains with large s/s output. Bear hugger for temp of 96.9. Groin lines
for access placed in ED. Warm extremities with palpable pulses. +CSM in
UE which is more edematous than left.
Action:
Propofol lightened for neuro assessments and titrated for adequate
sedation; Fentanyl titrated for analgesia per nonverbal & vital sign
responses. Neuro checks Q 4 hours & prn. CT of head and neck done.
Neurosurgical consult obtained. Repeat head CT @ 1800 for reported
right temporal pneumocephalous &? bleed vs. artifact
Vent changes made
PEEP increased to 10cm, see metavision; ABG
assessed. ETT position adjusted per CXR findings; now at 23cm at teeth.
Access changed: LSC MLC placed & confirmed by CXR, and left radial
arterial line placed; groin lines removed with adequate hemostasis
achieved.
RUE wounds examined by ortho resident for reported tendon damage;
dressings changed. X-rays of right humerus were done. RUE elevated on
pillow. Right 5^th digit stab laceration was cleaned & sutured by
trauma resident.
Abdominal JPs placed to low constant wall suction for large output.
Serial HCTs Q 4 hours
Q 6 hour blood sugars monitored.
amp of D50W for blood sugar of 69.
Serum K+ 3.3: repleted.
Logroll status discontinued per trauma team.
Pt now normothermic @ 99.9
Response:
Pt MAE
s when light from sedation, but does not follow commands. Pt
appeared to nod his head to confirm that his name was [**Known firstname 4211**]. Cough, gag,
and corneal reflexes present but impaired, and pt localizes to nail bed
pressure. PERRL @ 2mm; sclera edema bilaterally. Pt also becomes
dysynchronous with vent, with RR>40 and clamping down on ETT;
generalized shaking observed each time sedation was lightened.
Repeat head CT results pending.
Breath sounds remain decreased R>L, clear & with scant secretions. ABG
and O2 saturations reveal adequate oxygenation improved on current O2
support. Mild permissive hypercapnea noted with pH wnl. Both chest
tubes continue to drain s/s fluid that is becoming more serous; no
fluctuations or air leaks noted. ? Crepitus on right where greater
edema is notable in right upper chest, shoulder, and arm. Also new is
air collecting under transparent dressing of upper arm laceration (ICU
resident notified). Right axillary JP drain has moderate s/s output.
RUE remains warm with palpable peripheral pulses; all stab lacerations
of RUE are stapled & clean with small to moderate s/s drainage.
Spontaneous movement of RUE noted against gravity with sedation
suspended; no grasp noted.
Abdominal drainage >500cc this shift, s/s fluid. HCT stable @ 35-36;
vital signs remain stable see Metavision; urine output remains
adequate.
C-collar remains in place; pt has been position with HOB @20 degrees
and is tolerating side to side positioning Bear hugger removed; now
with temp spike to 102 @ 1900; ICU resident aware. Pt is to receive
Tylenol.
Blood sugars 79-97.
Left hand noted to be cooler following placement of arterial line; +
but weaker radial pulse and normal skin coloring; ICU resident
notified.
Plan:
Continue with all above actions and monitoring. Follow neuro exam Q 4
hours & prn
Wean sedation as tolerated.
Monitor ABG to assess pH; follow saturations, breath sounds, and airway
pressure/plateau for developing respiratory distress associated with
injuries and multiple blood products transfused.
Follow CSM of UEs; elevate RUE.
Cont serial HCTs follow drainage of JP and wound sites.
Recheck serum K+; follow blood sugars & treat per sliding scale order.
Follow temps and culture for >102.
Pt remains unidentified at this time; their have been no inquiries
made. Police investigators called earlier today asking to speak with
patient if able. T/SICU social worker, [**Name (NI) 1746**] [**Name (NI) 363**] spoke with police
detective; little information was forwarded to us by police as their
investigation is ongoing at this time. Police have all pt belongings,
obtained in ED (see chain of custody papers).
ED MDs came by at end of this shift to see pt; they reported that pt
was alert on admission to ED but c/o of not being able to breathe. He
had minimal breath sounds. It was related that he was able to confirm
he had no allergies and no PMH. There was not time for additional
inquiries and his name or NOK contact information was not obtained.
|
Nursing
|
Classify the following medical document.
|
ADMISSION NOTE:
The patient is a 64-year-old female who began having crampy spasmodic
abdominal pain accompanied by nausea and dry heaves about three days
ago. She denies passage of flatus for 2-3 days, last BM was 3 days ago.
She denies fever and chills. The pain is remniscent of an episode of
food poisoning she had remotely. Pt was transferred from [**Hospital 713**] to [**Hospital1 1**]. Taken to OR for LOA and gastric tube placement.
+closed loop obstruction and peritonitis. Large amounts of foul
smelling gastric contents via g tube. Pt brought to T/SICU intubated
post op for further monitoring.
PSH:
s/p lap gastric bypass [**2160-5-27**] complicated by a bile leak at the
[**Hospital 714**] Hospital Group. She was taken back to the operating room for
a exploratory laparotomy which did not identify source of the bile leak
and a right colectomy and gastrostomy tube was performed. Her continued
to have biliary drainage from her peritoneal JP drains and she was
transferred to the [**Hospital1 715**] for further
management of her bilary leak. + open cholecystectomy, colonoscopy
(negative, [**2148**])
PMH:
morbid obesity (BMI 49), CHF, EBV syndrome, Bipolar
disorder/depression (followed by Dr. [**Last Name (STitle) 716**] in [**Location (un) 717**]),
hypertension, arthritis, chronic dyspnea on exertion, asthma,
bronchiti, DJD, plantar fasciitis, , obstructive sleep apnea (on CPAP
at home), urinary incontinence, chronic back/leg pain
SOCIAL HISTORY:
Smoked 1 PPD, quit in [**2148**]. Admits to [**7-9**] drinks per day, occasional
marijuana, and lives alone in a [**Hospital3 718**] in [**Location (un) 717**]. She is
a retired nurse and has two children in [**Location (un) **].
*please see nursing admission sheet for further details re:
medications, contact info etc.*
Bowel obstruction (intestinal obstruction, including volvulus,
adhesions)
Assessment:
Abdominal cramps, nausea and dry heaving, constipation at admission
Action:
Pt taken to OR for LOA due to closed loop obstruction and gastric tube
placement
Response:
Pt hemodynamically stable, active fluid recesitation and electrolyte
repletion, moderate amounts of foul smelling g tube contents after
placement
Plan:
Continue to monitor labs and fluid balance, abdominal assessments and g
tube monitoring
.H/O alcohol abuse
Assessment:
Pt stated she drinks 6-12 drinks/daily, family reinforced the fact that
pt has a high ETOH intake
Action:
Pt started on Midazolam infusion
Response:
No s/s of etoh w/d, pt calm when awake, vss
Plan:
Continue Midazolam gtt and monitor for s/s of withdrawal
Acute Pain
Assessment:
Pt nods
to pain when asked, points to abdomen (incision)
Action:
Pt started on Fentanyl gtt at 50mcgs/hr, titrating to effect
Response:
Pt nods
to pain when asked
Plan:
Continue Fentanyl gtt and titrate to effect
Respiratory failure, acute (not ARDS/[**Doctor Last Name 2**])
Assessment:
Pt intubated on CMV, abg wnl with POA2 300
s, lung sounds clear,
adequate TV. Pt on CMV TV 550 R 14 P5 100%
Action:
Weaned to PSV 10 peep 5 50%
Response:
Sats 100%, tidal volumes 400-500, rr low to mid teens
Plan:
Continue to wean vent as tolerated for extubation
Hypovolemia (Volume Depletion - without shock)
Assessment:
Sbp 90
s, low uop 20-30cc/hr
Action:
LR bolus 1 liter x2
Response:
Increase in UOP and SBP back to 120-130
Plan:
Continue to monitor fluid status
|
Nursing
|
Classify the following medical document.
|
Chief Complaint: hypoxia, change in mental status
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
66F with small cell lung ca diagnosed by biopsy of neck soft tissue
lesion with lesions in T7, with malignant lymphadenompathy, admitted
electively for chemo on [**6-29**]. initally did well but developed
neutrotpenic fever, started on abx broad spectrum. For
thrombocytopenia, received a plt transfusion developed hypoxia and
fever in the setting of plt transfusion. Some concern for TRALI,
treated with supportive care. Pt did a little better, but last night pt
became hypoxic; treated with lasix but persistent O2 requrirment. Also
reports small amount of hemoptysis intermittent with normal sputum.
furthermore, worsening anemia in the last few days. ddx on the floor
included trali, pe (less likley given prophylaxis). transferred to the
icu for further work-up monitoring.
Patient admitted from: [**Hospital1 54**] [**Hospital1 55**]
History obtained from Patient
Allergies:
Penicillins
Hives;
Demerol (Injection) (Meperidine Hcl)
Hives;
Iodine
itching;
Latex
itching;
Betadine (Topical) (Povidone-Iodine)
Unknown;
Last dose of Antibiotics:
Vancomycin - [**2102-7-14**] 10:15 AM
Infusions:
Other ICU medications:
Other medications:
vanco 1g q12, cefepime, flagyl; nebs; fondaparinux
Past medical history:
Family history:
Social History:
small cell lung ca - [**2101**]
paraneoplastic syndrome resulting in blurry vision and leg weakness
thrombocytopenia: h/o possibly hit, now post-chemo
copd, h/o heavy tob use
pvd, s/p aaa with stent; chronic stable angina
father died from stroke; sonw with dvt; mother with cad
Occupation:
Drugs: none
Tobacco: h/o tob use many yeasr
Alcohol: none
Other:
Review of systems:
Constitutional: No(t) Fatigue, Fever, No(t) Weight loss
Eyes: No(t) Blurry vision, No(t) Conjunctival edema
Ear, Nose, Throat: No(t) Dry mouth
Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)
Tachycardia, No(t) Orthopnea, relieved with nitro this am
Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral
nutrition
Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,
No(t) Diarrhea, No(t) Constipation
Genitourinary: No(t) Dysuria, No(t) Dialysis
Integumentary (skin): No(t) Jaundice, No(t) Rash
Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy
Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure
Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,
No(t) Daytime somnolence
Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine
Signs or concerns for abuse : No
Pain: No pain / appears comfortable
Flowsheet Data as of [**2102-7-14**] 01:02 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37.5
C (99.5
Tcurrent: 37.5
C (99.5
HR: 105 (105 - 114) bpm
BP: 114/57(68) {94/47(58) - 114/57(68)} mmHg
RR: 18 (18 - 21) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Height: 61 Inch
Total In:
213 mL
PO:
TF:
IVF:
213 mL
Blood products:
Total out:
0 mL
250 mL
Urine:
250 mL
NG:
Stool:
Drains:
Balance:
0 mL
-37 mL
Respiratory
O2 Delivery Device: Aerosol-cool
SpO2: 98%
ABG: 7.4/40/53 on ?
Physical Examination
General Appearance: Well nourished, No acute distress, No(t) Overweight
/ Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)
Endotracheal tube, No(t) NG tube, No(t) OG tube
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)
Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,
No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)
Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),
(Breath Sounds: Crackles : insp and exp)
Abdominal: Soft, Non-tender, No(t) Bowel sounds present, Distended,
No(t) Tender: , No(t) Obese
Extremities: Right: Trace, Left: Trace
Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, No(t) Sedated, No(t) Paralyzed, Tone: Not assessed
Labs / Radiology
32
22
8
1.2
28
24
106
4
139
9
[image002.jpg]
Other labs: PT / PTT / INR:1.3/31, Differential-Neuts:92, Band:0,
Lymph:6.3
Imaging: cxr: left perihilar consolidation; interstitial opacities
Microbiology: GRAM STAIN (Final [**2102-7-4**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): PLEOMORPHIC GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
ECG: sinus tach, no [**Last Name (un) **] changes
Assessment and Plan
66F with small cell lung ca, admitted for chemo, with hospital course
complicated by neurtopenic fever, now with new interstitial lung
infiltreates and worsening oxygenation despite broad-spectrum
antibiotics, with minimal response to lasix, and now with hemoptysis.
etiology of the infiltrates and hypoxia remains unclear. bacterial pna
seem unlikely given lack of response to antibiotics. however, patient
may be at risk for atypical infections, including pcp, [**Name10 (NameIs) **] well as
fungal infections (yeast in sputum). PE is much less likely given
thrombocytopenia, dvt ppx, and clear infiltrates on the cxr giving an
alternative explanation to the hypoxia. ANCA-associated vasculitis as
part of a paraneoplasic syndrome has been reported as well. TRALI from
platelet transfusion is possible:
hypoxia and interstitial infiltrates: with hemoptysis; maybe trali;
focal cancer may be contributing to the picture
-check anca
-continue to treat for bacterial infection for now
-expand coverage to include atypicals and pcp with azithromycin and
bactrim
-continue diuresis as tolerated; holding for now given incr creatinine
-cont suppl O2
-hold off on additional imaging for now
thrombocytopenia and anemia: due to recent chemo; possible HIT dx in
the past
-prn transfusion
-holding heparin
acute renal failure: in the setting of lasix use
-renal dose meds
-hold nephrotoxics and lasix; hold off on fluid challenge given
tenuous repospiratory status
cad/pvd:
-holding asa/plavix in the setting of hemoptysis and thrombocytopenia
goals of care
-dnr/dni
ICU Care
Nutrition:
Glycemic Control: Blood sugar well controlled
Lines / Intubation:
PICC Line - [**2102-7-14**] 10:30 AM
Comments:
Prophylaxis:
DVT: (fondaparinux)
Stress ulcer: PPI
VAP:
Comments:
Communication: Family meeting held , ICU consent signed Comments:
daughter [**Name (NI) 2123**] is the HCP
[**Name (NI) 66**] status: DNR / DNI
Disposition: ICU
Total time spent: 45 minutes
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
Chief Complaint:
24 Hour Events:
- LDH at 700
- PM Lytes: Lactate 3.4 (from 1.1), K 3.2, P 1.0
- HCT 33.6 from 38.1
- UOP to 30/hr from 60/hr
- Received 4 L of fluids
- Received: 14 g CaGluc, 60 KPhos, 2 Pkt Neutra Phos, 54 oral K Meq
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Morphine Sulfate - [**2141-5-23**] 07:20 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2141-5-23**] 07:53 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**43**] AM
Tmax: 37.5
C (99.5
Tcurrent: 37.2
C (98.9
HR: 122 (106 - 131) bpm
BP: 121/87(94) {88/54(63) - 154/101(112)} mmHg
RR: 24 (19 - 28) insp/min
SpO2: 96%
Heart rhythm: ST (Sinus Tachycardia)
Height: 63 Inch
Total In:
7,602 mL
1,144 mL
PO:
TF:
IVF:
4,602 mL
634 mL
Blood products:
Total out:
1,553 mL
380 mL
Urine:
1,018 mL
380 mL
NG:
Stool:
Drains:
Balance:
6,049 mL
764 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 96%
ABG: ///19/
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
88 K/uL
9.7 g/dL
95 mg/dL
0.4 mg/dL
19 mEq/L
4.1 mEq/L
4 mg/dL
103 mEq/L
130 mEq/L
30.7 %
12.3 K/uL
[image002.jpg]
[**2141-5-22**] 04:30 AM
[**2141-5-22**] 06:56 AM
[**2141-5-22**] 02:55 PM
[**2141-5-22**] 09:13 PM
[**2141-5-23**] 03:59 AM
WBC
13.2
12.3
Hct
38.1
33.6
33.7
30.7
Plt
108
88
Cr
0.4
0.5
0.4
0.4
TCO2
14
Glucose
116
163
117
95
Other labs: PT / PTT / INR:11.8/29.5/1.0, Amylase / Lipase:/372,
Differential-Neuts:86.5 %, Lymph:10.5 %, Mono:2.5 %, Eos:0.4 %, Lactic
Acid:3.4 mmol/L, Albumin:2.5 g/dL, LDH:722 IU/L, Ca++:5.7 mg/dL,
Mg++:1.9 mg/dL, PO4:2.5 mg/dL
Assessment and Plan
PANCREATITIS, ACUTE
ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)
ICU Care
Nutrition:
Glycemic Control:
Lines:
22 Gauge - [**2141-5-23**] 01:00 AM
20 Gauge - [**2141-5-23**] 01:00 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
|
Physician
|
Classify the following medical document.
|
Mrs [**Last Name (STitle) 12830**] is an 88 yr. old woman, who fell at home on [**1-14**]. she
underwent hip surgery on [**1-16**]. pt. also broke her humerous and uses a
sling when oob.
Pt. is very HOH and hears best from her left ear.
Pt. is alert and orientated.
She was sent to [**Hospital3 **] for rehab.
Today she was found to be hypoxic with sat in the 80
s. pt. also found
to be diaph. Brought to the ed and
02 sats 88-89% on RA. Placed on NRB with o2 sats in high 90
Placed on np at 6L. sats 95-97%. Given nebs in the ed. Pt. very wheezy
on adm.
Lactate 1.6. cxr showed pneumonia and bil pleural effusions. Pt. denies
sob.
Given levoquin and vanco prior to transfer to the micu. Foley placed.
u/a sent.
Pt. never hypotensive. Pt. slightly tachy in low 100
Pain control (acute pain, chronic pain)
Assessment:
Pt with recent l femur fx and l humerus fx . had surgical orif l hip.
Drsg [**Name5 (PTitle) **] [**Name5 (PTitle) **] hip d&i. l arm in splint. Denies pain when at rest and but
with any repositioning of pt she does yell out in pain.
Action:
Physical therapy consulted and worked with pt at the bedside. Pt
received Tylenol 1000mg po atc. Pt also medicated with 0.5 mg ivp
morphine . repositioned from side to side.
Response:
Pt continues to experience pt with any movement of left extremities but
pain free when left alone.
Plan:
Continue with Tylenol and prn morphine as needed for pain management .
continue to support l hip and arm with any repositioning
Diabetes Mellitus (DM), Type II
Assessment:
Pt with hx of t ype 2 dm and recently on metformin 500mg [**Hospital1 **]. Blood
sugars elevated as high as 200
Action:
Blood sugars cheked q 6 hrs as ordered ad treated with ssi as needed.
Medicated x1 with 4 units humalog insulin at 1230. pt ordered for heart
healthy diet but pt
s dentures are at [**Hospital3 **] so will need
family to pick them up when possible. Tolerating liqs and pill well but
aspiration precautions maintained.
Response:
As above
Plan:
Follow blood sugars as ordered and tx with ssi as needed. Maintain
aspiration precautions and advance diet when pt
s dentures are
available
Respiratory failure, acute (not ARDS/[**Doctor Last Name 11**])
Assessment:
Cxr concerning for bil pleural effusions and underlying infiltrate
though pt without leukocytosis or fever. Pt initially covered for cap
with vancomycin and levofloxacin but antibiotics d/c
d today. Received
pt on 70% face tent o2 but then changed TO 4L/M NC. L ungs essentially
clear on auscultation but diminished at the bases. her resp distress
aprrear predominantly due to mild chf . we suspect that her underlying
physiology limited bu kyphosis and lg intrathoracic hiatal hernia may
be contributing to her dyspnea though pt denies being sob. Pt diuresed
overnoc with a total of 40 mg iv lasix
none given today . rr in the
high teens to low 20
s and o2 sats> 95%
Action:
Resp status monitored closely. Fluid balance monitored as well. Given
nebs as ordered. Tte done at bedside
Response:
Pt needs less amt of o2 with adequate diuresis results of tte pending
Plan:
Antibiotics d/c
d. continue to follw pt
s resp status and fluid
balance. Goal for i%o is to be neg 1-2 liters and if necessary will
administer additional diuretics.
Demographics
Attending MD:
[**Doctor Last Name 1111**] [**Location (un) **]
Admit diagnosis:
PNEUMONIA
Code status:
Height:
Admission weight:
46.9 kg
Daily weight:
47.6 kg
Allergies/Reactions:
No Known Drug Allergies
Precautions:
PMH: Diabetes - Oral [**Doctor Last Name 121**]
CV-PMH: CHF
Additional history: pt. is HOH.
hx of diverticulosis
hx of anxiety. , hx of dyslipdiemia. osteroporosis,
hx of aortic insufficiency
hx of benign cystic pancreatic lesion.
hx of spinal stenosis
s/p fx of left hip ( with surgery on [**1-14**]).
also fx of left humerous on [**1-14**] (using sling).
Surgery / Procedure and date: [**1-16**] open reduction with internal
fixation of the left hip.
Latest Vital Signs and I/O
Non-invasive BP:
S:108
D:67
Temperature:
97.3
Arterial BP:
S:
D:
Respiratory rate:
20 insp/min
Heart Rate:
92 bpm
Heart rhythm:
SR (Sinus Rhythm)
O2 delivery device:
Nasal cannula
O2 saturation:
98% %
O2 flow:
4 L/min
FiO2 set:
70% %
24h total in:
550 mL
24h total out:
1,765 mL
Pertinent Lab Results:
Sodium:
135 mEq/L
[**2187-1-23**] 03:03 AM
Potassium:
4.0 mEq/L
[**2187-1-23**] 03:03 AM
Chloride:
98 mEq/L
[**2187-1-23**] 03:03 AM
CO2:
28 mEq/L
[**2187-1-23**] 03:03 AM
BUN:
41 mg/dL
[**2187-1-23**] 03:03 AM
Creatinine:
0.6 mg/dL
[**2187-1-23**] 03:03 AM
Glucose:
165 mg/dL
[**2187-1-23**] 03:03 AM
Hematocrit:
32.2 %
[**2187-1-23**] 03:03 AM
Finger Stick Glucose:
200
[**2187-1-23**] 12:00 PM
Valuables / Signature
Patient valuables: none
Other valuables:
Clothes: Sent home with:
Wallet / Money:
No money / wallet
Cash / Credit cards sent home with:
Jewelry: none
Transferred from: [**Hospital Ward Name **] 409
Transferred to: 11 [**Hospital Ward Name **]
Date & time of Transfer: [**2187-1-23**] 1600
|
Nursing
|
Classify the following medical document.
|
TITLE:
History of Present Illness
- gave 2 units PRBC, IVF (750 cc)
- held all antii-hypertensives
- HR initially 110s atrial tachycardia, fell to 70s and sinus with
fluids, alternating between these two rhythms with stable BP
Medications
Unchanged
Physical Exam
BP 90-112/53-82, HR 69-134, RR 13, O2 Sat 100% on 4L by NC
Tmax C last 24 hours: 36.3 C
Tmax F last 24 hours: 97.3 F
T current C: 35.6 C
T current F: [**Age over 90 **] F
Previous day:
Intake: 3,500 mL
Output: 1,400 mL
Fluid balance: 2,100 mL
Today:
Intake: 1,608 mL
Output: 150 mL
Fluid balance: 1,458 mL
Gen: elderly woman lying in bed, appears uncomfortable
HEENT: dry mucous membranes
Neck: could not visualize neck veins
Cardiac: tachycardic, irregular, no audible murmur
Lungs: clear anteriorly
Ext: DP and PT pulses dopplerable bilaterally, R femoral site without
hematoma, bruit, or tenderness, L femoral site with ~8 cm diameter
hematoma exapanded by ~1 cm since last marking 2 hours previously
Neuro: A&O x 3
Skin: no rashes
Labs
267
9.1
169
0.6
26
4.4
14
104
136
26.8
9.4
[image002.jpg]
[**2155-2-26**] 11:20 PM
WBC
9.4
Hgb
9.1
Hct (Serum)
26.8
Plt
267
INR
1.7
PTT
43.6
Na+
136
K + (Serum)
4.4
Cl
104
HCO3
26
BUN
14
Creatinine
0.6
Glucose
169
ABG: / / / 26 / Values as of [**2155-2-26**] 11:20 PM
Assessment and Plan
HEMORRHAGE/HEMATOMA, PROCEDURE-RELATED (E.G., CATH, PACEMAKER, ICD
BLEED)
77 year old woman with paroxysmal atrial
fibrillation/flutter and atrial tachycardia admitted to the ccu after
an ablation procedure for monitoring of a groin hematoma.
.
#. Hematoma: Iatrogenic after catheterization. Apparently still
increasing in size. Hct has now fallen from 34.7 to 26.8, albeit with
5+ L crystalloid. No sign of arterial compromise or fistula. CT shows
no extension intra- or retro-peritoneally.
- 2 units pRBC
- aggressive fluid resuscitation
- serial Hct
- maintain active clot
- hold coumadin
- hold sotalol, losartan, HCTZ
.
#. Atrial tachycardia: patient has a history of afib/flutter, and
recently diagnosed atrial tachycardia. Now s/p ablation procedure and
alternating between sinus and atrial tachycardia. Currently, she is
hemodynamically stable and asymptomatic.
- holding sotalol until acute bleeding stops
- no anticoagulation for now; will restart after bleeding
.
#. Hypotension: Patient was hypotensive to SBP 90 after procedure,
responded to IVF. Likely secondary to blood loss and general
anesthesia with possible additional contribution from arrhythmia
(although pt has apparently been hemodynamically stable while in and
out of this rhythm for at least the past month.)
- aggressive fluid resusucitation.
- blood
- hold antihypertensives
.
FEN: cardiac diet, replete lytes PRN
ACCESS: PIV's
PROPHYLAXIS:
-
CODE: full
.
DISPO: CCU
.
Contact: [**Name (NI) 160**] [**Name (NI) 5221**] (brother): [**Telephone/Fax (1) 5222**] (notified of ccu
admission [**2-26**])
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2128-3-19**] Discharge Date: [**2128-4-9**]
Date of Birth: [**2050-6-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
77 y.o. male with two weeks of RLE claudication, Two days of RLE
rest pain, with a feeling of colness in his RLE.
Major Surgical or Invasive Procedure:
RLE angiography
Revision of right femoral to peroneal bypass graft using vein
graft
Angioplasty from left cephalic vein
Exploration of distal GSV
Cardiac Catherization with stenting of left main
Intubation post op for resp failure
PA catheter placed
echocardiogram EF 35-40%
History of Present Illness:
77 y.o. male with two weeks of RLE claudication, Two days of RLE
rest pain, with a feeling of colness in his RLE. Pt has a hx of
a fem - peroneal bypass graft [**Last Name (un) **] a vein graft. On [**8-19**] pt had
a percutaneous revision of the graft site for stenosis. Pt
re-evaluated for graft patency on [**11-19**]. The graft was found to
patent at that time.
Past Medical History:
L AKA
s/p failed LE bypass
s/p R fem peroneal bypass
HTN
CAD
Social History:
Herbal therapies
neg smoker, quit in past 15 yrs ago
neg alcohol
neg recreational drugs
OTC meds - sinus allergy medicine, ES tylenol
Family History:
non contributory
Physical Exam:
AFVSS
HEENT - NCAT, PERRL
Neg lesions nares, oral pharnyx, auditory
Supple, FAROM
Neg lymphandopathy
LUNGS - CTA B/L with sligtht crackles bases
CARDIAC - RRR without murmers, Palpable PMI
ABD - Soft, Pos BS, NTTP, neg Bruits, neg organomegaly, neg
AAA
NUERO - A/O x3
NAD
EXT - LLE AKA / palpable femoral pulse
RLE Slight edema noted
Graft 2 plus
Pertinent Results:
[**2128-4-8**] 04:01AM BLOOD WBC-12.1* RBC-3.38* Hgb-9.5* Hct-29.5*
MCV-87 MCH-
[**2128-3-27**] 02:24AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.021
[**2128-3-19**] 06:00PM BLOOD Neuts-60.9 Lymphs-29.6 Monos-5.9 Eos-3.2
Baso-0.4
[**2128-4-8**] 04:01AM BLOOD Plt Ct-437
[**2128-4-8**] 04:01AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
[**2128-4-3**] 03:19AM BLOOD freeCa-1.17
Brief Hospital Course:
Pt had a difficult hospital stay
Pt admitted on [**2128-3-19**] for a right leg ischemia
Pt underwent the following procedures on [**2128-3-19**]
1. Thrombectomy of right femoral to peroneal artery in-situ
saphenous vein graft.
2. Revision vein graft with vein patch angioplasty using left
arm cephalic vein.
3. Harvest of upper arm extremity vein.
After procedure pt admitted to PACU then VICU, early post up pt
experienced EKG changes, specifically for ST depression V3-V5,
had Brief runs NSVT and also complained of some chest pain. A
cardiology consult was obtained. Pt R/I for NSTEMI.
On [**2128-3-21**] Pt experienced with resp. failure. Pt was transferd to
the SICU for observation. Later in the day pt condition became
worse. Pt had to intubated and at this time pt recieved a R IJ
CVL. A chest X-Ray showed resp. failure. Pt dalso experienced
ARF secondary to hypotensive episode experienced with his
NSTEMI.
During this time pt was aggressively treated for both CHF and
ARF, both which resolved during his stay in the SICU.
On [**3-22**] pt underwent Cardiac catherization. The catherization
showed:
1. Selective coronary angiography revealed a right-dominant
system with
left-main and 3-vessel coronary disease.
2. The LMCA had a hazy proximal
95% stenosis and a distal tapering 50% stenosis.
3. The LAD was diffusely diseased with serial proximal and
mid-vessel 60% stenoses and an 80% long tubular stenosis in the
distal vessel.
4. The LCx had severe diffuse disease and a 70% stenosis in the
mid-vessel involving the origin of the OM1 branch. The RCA had
severe diffuse disease up to 50-60% throughout with a focal 80%
stenosis of the RPL branch.
5. Echo showed an ejection fraction of 35% with anterior
hypokinesis. He is thus referred for cardiac catheterization
for
evaluation of coronary anatomy
Cardiology decided to do an intervention which consisted:
1. Successful stenting of the ostial Left Main with a 3.5x13mm
Cypher
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] with a 4.5x12mm Quantum MAverick at 16 atms.
Pt remained intubated, tolerated the procedure and transfered
back to the SICU in stable condition
On [**3-25**] pt experienced new onset A-Fib. Pt was treated
aggressively, the A-Fib has resolved. Pt extubated the same day.
Pt remained in the SICU untill [**2128-4-1**]. During this time frame
he was treated for the variety of ailments mentioned above. On 3
/18 pt transeferd back to the VICU in stable condition.
Pt remianed in the VICU untill [**4-7**], then transfered to the
floor.
Pt screened by PT / Case management. Pt discharged from the
hospital in stable condition.
Medications on Admission:
Captopril
Atenolol
Paxil
Lipitor
Colace
Nueurontin
Aprazolam
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
2. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Clopidogrel Bisulfate 75 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily) for 30 days: after thirty days, decrease plavix to
75 mg for 9 months.
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed.
9. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
10. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
12. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Clonidine HCl 0.2 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-18**]
Drops Ophthalmic PRN (as needed).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
Occluded Right femoral peroneal graft, had revision to correct
Respiratory failure p/o requiring intubation
Non Specific Ventricular Tachycardia - R/I for MI - requiring
left main stent
Afib post op, now RRR
Acute Renal Failure post op
EF 35-40%
HTN
Hypercholesteralemia
LAKA
Failed Left LE bypass
Known L CIA/EIA occlusion
CAD
LBP S?P laminectomy
Discharge Condition:
stable
Discharge Instructions:
Check for fevers and chills - if have evaluate
Look at surgical wounds - if drainage, erythematous or swelling
please call Dr [**Last Name (STitle) 22423**] office
F/U cardiology as directed
F/U Dr [**Last Name (STitle) **] as directed below
Per PT OOB with asst [**Hospital1 **]
Ambulate pt PRN
Followup Instructions:
Follow up with Cardiology in 12 weeks from the date of stent
[**2128-3-23**]
Please call [**Telephone/Fax (1) 22424**]
Follow up with Dr [**Last Name (STitle) **] in two weeks, please call [**Telephone/Fax (1) 22425**]
Completed by:[**2128-4-9**]
|
Discharge summary
|
Classify the following medical document.
|
[**2151-2-2**] 2:32 PM
ABDOMINAL AORTA Clip # [**Clip Number (Radiology) 56800**]
Reason: SMA aneurysm identified in the CT angio of abdomen.For coil
Contrast: OPTIRAY Amt: 55
********************************* CPT Codes ********************************
* [**Numeric Identifier 39**] EMBO NON NEURO -59 DISTINCT PROCEDURAL SERVICE *
* [**Numeric Identifier 2871**] INITAL 2ND ORDER ABD/PEL/LOWER -59 DISTINCT PROCEDURAL SERVICE *
* [**Numeric Identifier 43**] TRANCATHETER EMBOLIZATION -59 DISTINCT PROCEDURAL SERVICE *
* [**Numeric Identifier 822**] F/U STATUS INFUSION/EMBO -59 DISTINCT PROCEDURAL SERVICE *
* [**Numeric Identifier 1044**] VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *
* [**Numeric Identifier 55610**] IV CONSCIOUTIOUS SEDATION PRO -59 DISTINCT PROCEDURAL SERVICE *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
54 year old man with
REASON FOR THIS EXAMINATION:
SMA aneurysm identified in the CT angio of abdomen.For coil embolization.
______________________________________________________________________________
FINAL REPORT
INDICATION: A 54-YEAR-OLD MALE WITH PSEUDOANEURYSM ADJACENT TO THE SUPERIOR
MESENTERIC ARTERY SEEN ON CONTRAST CT SCAN. PLEASE EMBOLIZE.
RADIOLOGISTS:
ATTENDING RADIOLOGIST: Dr. [**First Name (STitle) 34437**] [**Name (STitle) 34432**]. INTERVENTIONAL RADIOLOGY FELLOW: Dr.
[**First Name (STitle) 35591**] [**Name (STitle) **].
TECHNIQUE: Informed consent was obtained prior to the procedure. Dr. [**Last Name (STitle) 34432**]
was present for the entirety of the procedure.
The right common femoral artery was accessed using a micropuncture access
system and a 5 Fr. vascular sheath was placed into the common femoral artery.
The SMA was catheterized with a 5 FR Cobra glide catheter and a superior
mesenteric angiogram was performed. The catheter was withdrawn into the ostium
of the superior mesenteric artery, and another superior mesenteric artery
angiogram was performed. A .035 angled Glidewire was used to place the
catheter into the pseudoaneurysm under fluoroscopic guidance. Multiple macro
coils were placed under fluoroscopic observation including 10 mm x 5 cm coils,
and 10 mm x 8 cm coils. Subsequently, due to residual flow in the
pseudoaneursym, 1500 units of thrombin mixed with saline and contrast were
injected slowly under fluoroscopic control into the pseudoaneurysm while the
catheter was pulled back from the apex of the aneurysm to the neck of the
aneurysm very slowly. When the catheter tip was in the SMA, it was aspirated.
The catheter was positioned again in the origin of the superior mesenteric
artery and a superior mesenteric artery angiogram was performed. The sheath
and catheter were removed and manual pressure applied at the right groin
though hemostasis was achieved. Sterile dressing was applied.
MEDICATIONS: Local anesthesia consist of 1% Lidocaine. Under continuous
monitoring, small divided doses of Fentanyl totaling 200 mcg was administered.
COMPLICATIONS: No complications were evident.
(Over)
[**2151-2-2**] 2:32 PM
ABDOMINAL AORTA Clip # [**Clip Number (Radiology) 56800**]
Reason: SMA aneurysm identified in the CT angio of abdomen.For coil
Contrast: OPTIRAY Amt: 55
______________________________________________________________________________
FINAL REPORT
(Cont)
FINDINGS: Superior mesenteric artery angiogram with the tip of the catheter
approximately 3 cm from the origin demonstrate a normal superior mesenteric
angiogram. However, when the catheter was retracted to the origin of the
superior mesenteric artery, an angiogram performed, an approximately 3 x 2 cm
pseudoaneurysm was seen arising from the proximal superior mesenteric artery
just to the right side of the origin. Post procedure angiogram after
embolization and thrombin injection demonstrated no flow within the
pseudoaneurysm and patent SMA.
IMPRESSION:
1. Successful coil and thrombin embolization of superior mesenteric artery
pseudoaneurysm.
|
Radiology
|
Classify the following medical document.
|
[**2166-11-17**] 12:54 PM
BILIARY CATH CHECK Clip # [**Clip Number (Radiology) 46741**]
Reason: r/o biliary obstruction
Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM
Contrast: OPTIRAY Amt: 20
********************************* CPT Codes ********************************
* [**Numeric Identifier 6610**] CHALNAGIOGRAPHY VIA EXISTING C -78 RELATED PROCEDURE DURING POSTOPE *
* [**Numeric Identifier 6611**] TUBE CHOLANGIOGRAM *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
70 year old man s/p PTC placement with rising bilirubins
REASON FOR THIS EXAMINATION:
r/o biliary obstruction
______________________________________________________________________________
PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb MON [**2166-11-17**] 5:39 PM
Percutaneous biliary drain well positioned and patent.
______________________________________________________________________________
FINAL REPORT
INDICATION: 70-year-old male with pancreatic head mass and biliary
obstruction, status post right percutaneous biliary drain placed on
[**2166-10-24**]. Now has rising bilirubin, evaluate for biliary obstruction.
COMPARISON: PTBD, [**2166-10-24**].
RADIOLOGISTS: Drs. [**Last Name (STitle) 517**] and [**Name5 (PTitle) 65**] performed the procedure. Dr. [**Last Name (STitle) 65**],
attending radiologist, was present throughout the procedure.
PROCEDURE/FINDINGS: After the risks, benefits, and alternatives of the
procedure were explained to the patient, written informed consent was
obtained. The patient was brought to the angiography suite and placed supine
on the angiographic table. A timeout and huddle were performed to confirm
patient identity and the procedure being performed. The indwelling right
percutaneous biliary drain was prepped and draped in standard sterile fashion.
A single supine scout view of the abdomen demonstrates a biliary drain to be
well positioned, with the pigtail in the duodenum with multiple scattered
surgical abdominal clips again identified. Contrast was slowly hand injected
through the percutaneous biliary drain under constant fluoroscopic guidance.
This demonstrated patency of the biliary drain without evidence for dilatation
of the extra-hepatic ducts. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 89**] and Glidewire were advanced through the
catheter to confirm patency. The patient tolerated the procedure well, and
there were no immediate complications.
IMPRESSION: Percutaneous biliary drain well positioned and patent.
(Over)
[**2166-11-17**] 12:54 PM
BILIARY CATH CHECK Clip # [**Clip Number (Radiology) 46741**]
Reason: r/o biliary obstruction
Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM
Contrast: OPTIRAY Amt: 20
______________________________________________________________________________
FINAL REPORT
(Cont)
|
Radiology
|
Classify the following medical document.
|
24 Hour Events: 79y F presenting with large L frontal and occipital
intraparenchymal hemorrhage
No major events overnight
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Ciprofloxacin - [**2148-12-8**] 02:23 AM
Vancomycin - [**2148-12-9**] 08:38 AM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2148-12-9**] 07:28 PM
Heparin Sodium (Prophylaxis) - [**2148-12-9**] 10:13 PM
Other medications:
Flowsheet Data as of [**2148-12-10**] 07:07 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 38.1
C (100.5
Tcurrent: 37.1
C (98.7
HR: 80 (77 - 105) bpm
BP: 126/92(96) {113/51(70) - 156/92(96)} mmHg
RR: 12 (12 - 20) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 65.2 kg (admission): 60 kg
Height: 63 Inch
Total In:
1,572 mL
440 mL
PO:
TF:
1,200 mL
354 mL
IVF:
372 mL
85 mL
Blood products:
Total out:
1,975 mL
585 mL
Urine:
1,975 mL
585 mL
NG:
Stool:
Drains:
Balance:
-403 mL
-145 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 476 (332 - 476) mL
PS : 8 cmH2O
RR (Spontaneous): 12
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 45
PIP: 13 cmH2O
SpO2: 98%
ABG: ///30/
Ve: 4.6 L/min
Physical Examination
General Appearance: sedated, intubated
Eyes / Conjunctiva: anicosocoria at baseline
Head, Ears, Nose, Throat: Endotracheal tube, OG tube
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,
Diminished: at bases)
Abdominal: Soft
Extremities: Right lower extremity edema: Trace, Left lower extremity
edema: Trace
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,
Tone: Not assessed
Labs / Radiology
313 K/uL
8.9 g/dL
127 mg/dL
0.5 mg/dL
30 mEq/L
4.0 mEq/L
19 mg/dL
103 mEq/L
140 mEq/L
27.5 %
9.4 K/uL
[image002.jpg]
[**2148-12-5**] 01:30 PM
[**2148-12-5**] 07:26 PM
[**2148-12-6**] 04:11 AM
[**2148-12-6**] 04:01 PM
[**2148-12-7**] 01:12 AM
[**2148-12-7**] 02:17 PM
[**2148-12-8**] 02:15 AM
[**2148-12-8**] 02:07 PM
[**2148-12-9**] 01:58 AM
[**2148-12-10**] 03:17 AM
WBC
11.6
8.7
8.1
8.3
9.4
Hct
27.2
26.8
27.1
27.3
27.5
Plt
152
184
185
236
313
Cr
0.5
0.5
0.5
0.5
0.5
0.4
0.4
0.4
0.4
0.5
Glucose
156
148
147
133
132
136
129
136
130
127
Other labs: PT / PTT / INR:11.3/24.2/0.9, Lactic Acid:0.9 mmol/L,
Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL
Assessment and Plan
INTRACEREBRAL HEMORRHAGE (ICH)
79y F presenting with large L frontal and occipital intraparenchymal
hemorrhage
Neurologic: L Frontal/occipital IPH with poor prognosis for
neurological recovery. On Propofol for sedation. Prn fentanyl. Not
following commands. Moving bilat LE and LUE, withdraws to noxious
stimuli.
-weaning down on keppra
Cardiovascular: Goal sbp 120-160. Prn hydralazine/lopressor.
Autoregulating.
Pulmonary: Intubated for airway protection. On CPAP/PS.
Gastrointestinal/Abdomen: Full bowel regimen. PEG if family elects to
continue care.
Nutrition: NPO. TF at goal via OGT
Renal: Foley in place. Auto-diuresing. UTI on UA , on vanc for
enterococci and cont fever, await sensitivities.
Hematology: Stable.
Endocrine: RISS. Goal SBP < 150
ID: Enterococci UTI on vancomycin follow up sensitivities for abx.
Lines / Tubes / Drains: PIV, foley, ETT, left subclavian TLC.
Wounds: none
Fluids: kvo
Consults: neurosurg, neuro
Communication: Family meeting on monday [**12-9**] - family requests another
meeting for wed [**12-11**], this time with palliative care team present.
Billing Diagnosis: IPH
DVT: boots, HSQ
Stress ulcer: h2b
VAP bundle: +
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2148-12-10**] 05:59 AM 50 mL/hour
Glycemic Control:
Lines:
Multi Lumen - [**2148-12-3**] 01:43 PM
Code status: DNR
Disposition:SICU
Total time spent: 30 min
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2131-3-21**] Discharge Date: [**2131-4-12**]
Date of Birth: [**2082-11-8**] Sex: F
Service: PLASTIC
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 36263**]
Chief Complaint:
left thigh infection
Major Surgical or Invasive Procedure:
[**2131-3-21**] Debridement of left thigh necrotizing soft tissue
infection.
.
[**2131-3-22**]: Incision and debridement 25 x 40 cm left thigh
full-thickness skin, fat, fascia. Excision of the
Sartorius muscle.
.
[**2131-3-24**]: 1. Incision and drainage of wound and change of wound
V.A.C. of medial thigh. 2. Incision and drainage of the left
lateral thigh.
.
[**2131-3-27**] Incision and drainage of necrotizing fasciitis
with vacuum-assisted closure change, wound surface
area 375 cm2
.
[**2131-3-30**] Incision and drainage of necrotizing fasciitis
and application of VAC dressing
.
[**2131-4-2**]
1. Irrigation and debridement of the skin, subcutaneous tissue
of right groin (20 x 20 cm). 2. Delayed primary closure of left
lateral thigh wound (10cm). 3. Application of a vacuum-assisted
closure dressing (20 x 20 cm).
.
[**2131-4-5**] Split-thickness skin reconstruction of left groin
(30x16cm)
History of Present Illness:
48F with 4 days of left thigh erythema, induration, pain.
Presented to [**Hospital3 **] 2 days prior. L thigh was
observed, found to be getting worse. Was evaluated by surgery
there (Dr [**Last Name (STitle) 110791**] who felt an emergent debridement was
necessary but felt it should be done at a tertiary care center
so transfer to the [**Hospital1 18**] MICU was arranged. On transport, she
was hypotensive requiring a single pressor. On arrival, she was
hemodynamically stable and quite fluid responsive and pressors
were no longer needed. She was awake and alert on arrival,
though confused about whether her leg has worsened or improved
the past 48 hours. She has no other symptoms, just L thigh/hip
pain.
Past Medical History:
PMH: hypertension
tobacco abuse
obesity
alcohol abuse
dyslipidemia
hypothyroidism
depression
IBS
.
PSH: C-section
Social History:
- Tobacco: [**3-22**] cig/ day
- Alcohol: daily, 4 drinks daily, last drink was on [**3-19**]
- Illicits: patient denies
Family History:
non-contributory
Physical Exam:
Admission Exam (upon arrival/evaluation in MICU)
Vitals: T 100.4 P 104 BP 98/46 RR 20 O2 98% 2L
GEN: A&O, NAD, anxious
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, obese, nondistended, nontender, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: right lower extremity normal. Left foot/leg normal with
good
pulses and normal sensation. L thigh with significant
circumferential erythema. blistering on anteromedial proximal
thigh. indurated primarily on lateral portion. moderate pain
with
flexing knee and hip joint.
Pertinent Results:
OSH: Na 133, K 3.6, CO2 15, BUN 323, Cr 1.7, Gluocse 187, WBC
17,
Hgb 11, Hematocrit 31, Plt 185, Band 22, Bcx [**2131-3-19**]: no growth.
Troponin 0.01, CK 105, 78, 91. Cortisol 31, AST 27, ALT 24.
[**2131-3-21**] [**Hospital1 18**] Labs -
CBC - 15.2 > 30.6 < 189
N:98 Band:0 L:1 M:1 E:0 Bas:0
137 112 34
----------------< 161
3.4 14 1.4
Ca: 5.6 Mg: 1.3 P: 2.7
AST: 20 ALT: 27 AP: 84 Tbili: 0.7 Alb: 2.0 Vanco: <1.7
PT: 16.1 PTT: 29.6 INR: 1.5
Fibrinogen: 731 UA: mod positive
.
[**2131-4-3**] Creat-2.2*
[**2131-4-9**] Creat-1.3*
.
IMAGING:
CT LOW EXT W/O C BILAT [**2131-3-21**] IMPRESSION: Extensive changes of
cellulitis and subcutaneous edema. No specific features to
suggest necrotizing fasciitis such as soft tissue gas.
.
TTE (Portable) [**2131-3-22**] The left atrium is normal in size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is mildly depressed (LVEF= 40-50%). The number of
aortic valve leaflets cannot be determined. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. Moderate [2+]
tricuspid regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality due to body habitus. Mild
global LV systolic dysfunction. Moderate TR with normal PASP. RV
function is difficult to evaluate on this study
.
Radiology Report RENAL U.S. Study Date of [**2131-4-4**] 8:43 AM
IMPRESSION:
1. No hydronephrosis.
2. Difficult imaging of the left kidney with apparent greater
than 3-cm size discrepancy. Correlate for details of prior
medical history/reflux.
.
MICROBIOLOGY:
[**2131-3-21**] 6:52 pm SWAB LEFT INNER THIGH.
**FINAL REPORT [**2131-3-23**]**
GRAM STAIN (Final [**2131-3-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND IN SHORT
CHAINS.
WOUND CULTURE (Final [**2131-3-23**]):
BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 110792**] is a 48F which was transferred from [**Hospital3 **]
after a left thigh was evaluated by surgery there (Dr. [**Last Name (STitle) 110791**]
and felt an emergent debridement was necessary. Surgery was
consulted upon arrival to the MICU. At that time she had an
obvious severe left thigh infection. After obtaining an
operative-planning CT scan, she was immediately taken to the
operating room for debridement. Please see the operative report
from [**3-21**] for further details. Patient had a large amount of
necrotic tissue in the anterior and medial areas of her left
thigh, not extending to the knee or up above the inguinal
ligament. She was transferred to the ICU post-op and left
intubated given her profound sepsis, tachypnea, and planned
return to the operating room for further debridement the
following day. Patient returned to the OR on 5 more occassions
for further debridement and vac changes (see op note for [**3-22**],
[**3-24**], [**3-30**], 4,16) and then finally for skin graft to her left
thigh wound defect on [**2131-4-5**] with Plastic Surgery.
.
Her further course is outlined below by organ system:
Neurologic: She was given intermittent Dilaudid IV for pain
control, then was transferred to PO pain meds when tolerating
diet. She was begun on Seroquel for agitation and delerium HD 3.
She had been placed on a CIWA scale for concern for alcohol
withdrawal but did not require significant doses of Ativan.
Patient had occassional episodes of anxiety, relieved with
redirection and treated with Ativan.
.
Cardiovascular: She was initially showing signs of hemodynamic
instability but by HD 2 she had been weaned off pressors. She
had an episode of chest pain HD 4 but EKG and enzymes showed no
myocardial change. Her hematocrit decreased from baseline of 29
to 21 which was attributed to the repeated surgical explorations
and she received 2 units RBCs on HD13 with adequate increase in
hematocrit and again 2 units in HD 18.
.
Pulmonary: She has baseline OSA which was treated with CPAP at
night. Narcotics were minimized when possible to sustain her
respiratory drive.
.
Gastrointestinal: She was maintained on famotidine IV while
intubated, then transitioned to oral Zantac for stress ulcer
prophylaxis.
.
Nutrition: She was advanced to a regular diet [**3-25**] which she
tolerated well.
.
Renal: She initially had acute kidney injury from sepsis, but
that had resolved by HD 4. Patient had increased Cr again on
HD17 and at first it was attribute to AIN from a betalactam as
patient had +eos in urine and a morbilliform rash. The
antibiotics were discontinued and patient Cr remained elevated.
A Renal consult was placed and it was thought the [**Last Name (un) **] was
secondary to a low flow state given fluid losses. Renal
recommended Calcium Acetate 667 mg PO/NG TID. A foley
catheter was used to monitor urine output until HD 13. Patient
voided without difficulty. Foley was replaced on HD17 after
grafting, given location of injury and concern for contamination
of wound. Patient's foley was discontinued on HD21 after VAC
dressing was removed and patient was able to get out of bed to
use commode safely. Cr was monitored and by the time of
discharge, patient's creatinine continued to recover and was
1.3.
.
Endocrine: Her blood sugar was controlled by an insulin sliding
scale and she was maintained on her thyroid medication through
an IV equivalent until tolerating POs.
.
Infectious Disease: She presented in septic shock from left
thigh cellulitis. She was treated with broad spectrum
antibiosis: Vanc, Clinda, Zosyn ([**Date range (1) 19644**]) then transitioned to
Augmentin for 2 days. Her wound cultures from the first
debridement showed Group A streptococcus. The antibiotics were
then discontinued as the primary surgical team felt the
debridement had been completed. Patient's blood cultures and
urine cultures remained negative.
.
Patient was discharged to rehab facility on hospital day 23. The
patient was doing well, afebrile with stable vital signs,
tolerating a regular diet, voiding without assistance, and pain
was well controlled.
Medications on Admission:
Synthroid 175mcg daily
Diovan 360mg daily
HCTZ 12.5mg daily
Prozac 60 mg daily
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
3. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours)
as needed for pain.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. cetirizine 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH
MEALS).
12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
13. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
14. diphenhydramine HCl 25 mg Capsule Sig: [**12-18**] Capsules PO Q6H
(every 6 hours) as needed for pruritus.
15. Prozac 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP < 110 or HR< 60 .
17. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
18. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
19. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
20. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
21. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
1. Necrotizing fasciitis of the left thigh
2. Septic shock
3. Acute renal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with necrotizing fasciitis of
your left thigh. You were taken to the operating room multiple
times to have the area of infection debrided. The wound defect
was then covered with a skin graft. Please follow these
discharge instructions.
.
Followup Instructions:
-You should continue taking your current medications.
-If the area of your skin graft in your left groin/thigh area
begins to worsen after discharge with an acute increase in
swelling or pain or redness, please call Dr.[**Name (NI) 2989**] office at
([**Telephone/Fax (1) 36264**]
- You should keep your right thigh donor site open to air and
leave the yellow xeroform dressing in place to dry out. Do not
get this area wet.
- Your left groin/thigh skin graft and repair sites will be
dressed with a xeroform dressing to graft areas, fluffed gauzes
covered with
kerlix and then ace wrap.
- Continue on oral antibiotics until you are seen in [**Hospital 702**]
clinic by Dr. [**First Name (STitle) 1022**]
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]. Please call his office to
schedule a follow up appointment in 1 week: ([**Telephone/Fax (1) 36264**].
.
Please follow up with your PCP to review the details of your
hospitalization. You were treated for necrotizing fasciitis
(beta streptococcus group A), septic shock and acute renal
insufficiency). You have completed your course of antibiotic
therapy and your creatinine is normalizing. You should have a
set of repeat electrolytes drawn at your PCP appointment to be
sure your kidney function continues to improve.
.
You should also schedule a follow up appointment with Nephrology
in [**12-18**] months after this hospitalization. Call for an
appointment:
([**Telephone/Fax (1) 10135**]
Completed by:[**2131-4-12**]
|
Discharge summary
|
Classify the following medical document.
|
TITLE:
Chief Complaint:
24 Hour Events:
- three way foley placed for continuous bladder irrigation. Some clots
came out, was pink tinged, then completely clear.
- CT scan, got versed with it; somnolent afterwards; also got zyprexa
yesterday am
- Neuro feels large posterior infarct may be in last day or so; OK to
restart heparin gtt if we really feel necessary
- Delirium, waxing and [**Doctor Last Name 533**] mental status
- UA sent --> positive -- starting ceftriaxone
- had a few beats of NSVT, frequent ectopy
- 17:40 wanted to have restraints taken off, became agitated ; given
zyprexa-zydis 5mg x2; drawing lytes/cr b/c of decreased urine output
- does not appear to have Left side neglect
- holding heparin gtt ; started subq heparin
- EKG showed worsening TWIs similar to EKG when he first presented, but
cardiac enzymes showed CK [**Last Name (LF) 13334**], [**First Name3 (LF) **] did not restart heparin gtt
; redraw cardiac enzymes at midnight (added on to AM labs b/c difficult
stick)
- considered PE b/c of tachycardia and hypoxemia but EKG and Echo (from
[**2-19**]) showed no signs of RH strain
- gave 10mg IV lasix for hypoxia (to which he had responded very well
in ED) ; put out about 400cc of urine
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Ceftriaxone - [**2179-2-21**] 09:15 PM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2179-2-21**] 10:00 PM
Furosemide (Lasix) - [**2179-2-21**] 10:00 PM
Lorazepam (Ativan) - [**2179-2-22**] 06:30 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2179-2-22**] 06:54 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**81**] AM
Tmax: 38.2
C (100.7
Tcurrent: 37
C (98.6
HR: 115 (91 - 120) bpm
BP: 137/84(94) {109/60(72) - 151/117(121)} mmHg
RR: 30 (14 - 33) insp/min
SpO2: 94%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
1,100 mL
97 mL
PO:
350 mL
30 mL
TF:
IVF:
750 mL
67 mL
Blood products:
Total out:
0 mL
420 mL
Urine:
420 mL
NG:
Stool:
Drains:
Balance:
1,100 mL
-323 mL
Respiratory support
O2 Delivery Device: Face tent
SpO2: 94%
ABG: ///27/
Physical Examination
Gen:
HEENT:
Chest:
Abd:
Ext:
Skin:
Neuro:
Labs / Radiology
Head CT [**2179-2-21**]
Large hypodensity in the right occipital lobe, of
undetermined age, could be of subacute nature. Periventricular white
matter
densities, likely due to chronic small vessel ischemic changes. No
acute
hemorrhage.
Please note that CT is not sensitive for acute ischemia, and if there
is
clinical concern, MRI can be done.
181 K/uL
10.5 g/dL
158 mg/dL
1.9 mg/dL
27 mEq/L
3.9 mEq/L
24 mg/dL
109 mEq/L
144 mEq/L
31.8 %
12.4 K/uL
[image002.jpg]
[**2179-2-20**] 09:13 PM
[**2179-2-21**] 06:38 AM
[**2179-2-21**] 05:57 PM
[**2179-2-22**] 02:45 AM
WBC
15.4
12.4
Hct
37.3
31.8
Plt
243
181
Cr
1.8
1.7
1.9
TropT
8.29
4.94
2.54
2.61
Glucose
156
158
Other labs: PT / PTT / INR:12.9/29.4/1.1, CK / CKMB /
Troponin-T:357/10/2.61, ALT / AST:51/178, Alk Phos / T Bili:98/,
Ca++:8.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.3 mg/dL
Microbiology: urine Eosinophils Negative
Assessment and Plan
72 year old man with HTN, HL, DM, CKD, non-verbal from schitzophrenia
and mental retardation presenting with NSTEMI and hyperglycemia.
# Subacute Stroke:
Large hypodense area on CT in Right occipital lobe. Neurology
consulted and prefers not to use heparin gtt though states that it is
OK if absolutely necessary for ACS. Patient appears to have some
visual defects in Left eye; does not appear to have left-sided
hemineglect. Neuro exam limited due to patient
s schizophrenia and
difficulty participating in exam.
- Repeat Head CT if neuro exam changes
- Holding heparin gtt for now
# NSTEMI:
EKG and cardiac enzymes consitent with NSTEMI on presentation.
Difficult to assess patient in terms of pain, so checked EKG last night
which showed larger T wave inversions, similar to on presentation;
concern for restarting heparin gtt for coronary reperfusion, medical
management of NSTEMI. Cardiac enzymes trending down, so heparin gtt
not restarted. He is not consentable for cardiac catheterization, but
presumably full code. He does not appear to have signs of cardiogenic
shock, but will be gentle with beta-blockade for concern of worsening
heart failure. Social work involved and found guardian
s phone number;
message left for guardian by social worker and CCU team.
- continue ASA, plavix, statin, ACE
- low-dose beta-blocker for HR goal < 90
- make all attempts to reach guardian again today
- appreciate social work help in contacting guardian
- appreciate ethics recommendations
# HYPOXEMIA: [**Month (only) 51**] be secondary to fluid overload from MI. Less likely
to have PE b/c no signs of RH strain on EKG or Echo. Attempted
diuresis with lasix overnight, responded moderately well w urine
output; difficult to assess whether oxygenation improved because he was
on more O2 than required. Oxygenation worsens with agitation.
- repeat cxr if not improving
# HYPERTENSION:
Weaned of nitroglycerin gtt yesterday and BPs stable on valsartan and
beta blocker.
- continue valsartan
- beta blocker
# UTI:
Not using ciprofloxacin b/c getting antipsychotics as well which could
prolong QT.
- started Ceftriaxone last night
# HYPERGLYCEMIA: Likely precipitated by NSTEMI and UTI on top of
diabetes.
- F/U HbA1c.
- restart home regimen and start insulin gtt if not controlled
- hold sulfonurea
#Distended bowel on CXR: continue to follow clinically.
#Hematuria
continue continuous bladder irrigation.
# SCHIZOPHRENIA:
Unclear if home zyprexa dose is accurate. Will continue to try to
confirm information; PCP will be in office today.
- zyprexa 5mg daily for now
# CHRONIC RENAL INSUFFICIENCY: at baseline Cr 1.8-2.0
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2179-2-20**] 05:45 PM
Prophylaxis:
DVT: subq heparin
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full (Presumed)
Disposition: CCU
|
Physician
|
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