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Admission Date: [**2192-5-29**] Discharge Date: [**2192-6-7**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9152**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname 3968**] [**Known lastname 79941**] is a 90 woman with a history of a seizure
disorder
on Keppra. She is known to the neurology department from prior
admissions, most recently in [**2191-9-16**] when she presented
to the hospital with altered mental status and was found to be
in
status. Neurology has been today for concern of a similar
presentation.
The patient lives with son who does her ADLS. Per report, last
night he briefly left the home and on return he found her
unresponsive with her lips blue. EMS came and put her on
non-rebreather. Enroute to the hospital, she was documented as
having a GTC of unclear duration. She was given 5mg valium and
the seizure resolved by the time she reached the emergency room.
In the ED, EKG demonstrated ST elevations in V2-V4. It was
initially felt that the patient was CMO so she was treated only
with rectal aspirin and admitted to the medicine floor. However,
after discussion with her family it was felt the patient would
be
DNR/DNI and so she was started on a heparin drip, ordered for
rectal plavix (not yet given) and transferred to the cardiology
floor.
At present, the patient is arousable but not able to speak. She
has been noted to have flexure posture left UE but the RUE is
rhythmically contracting. LEs are quiet. The team is loading her
with 1g Keppra IV and continuous EEG has been ordered. Because
of
her DNR/DNI status, there is a goal to avoid sedating
medications.
Per her family, the patient has not had any recent illness.
They
deny any siezures since [**Month (only) 359**] and state they always bring her
to the hospital when she has a seizure. They have not noticed
any episodes of unresponsiveness at home. She has not had any
known head trauma or falls.
The patient is unable to offer any history at this time.
Past Medical History:
-Seizure disorder: Diagnosed 9/[**2188**]. Etiology uncertain.
Episodes of speech arrest with gaze deviation, occasional
generalized convulsion. Was initailly treated with
benzo/dilantin load which led to respiratory depression and
intubation. On Keppra since that time. Saw Dr. [**First Name (STitle) **] of [**Location (un) 2274**]
once in [**10/2191**] after discharge in [**2190**].
-Dementia NOS
-Hypertension
-Coronary artery disease
-Mild LV [**Year (4 digits) 7216**] dysfunction
-Mitral regurgitation
-Rheumatoid arthritis
-COPD/asthma on inh steroid/[**Last Name (un) **] (Advair) and PRN nebs
-Hypertension
-Coronary artery disease
-Mild LV [**Last Name (un) 7216**] dysfunction
-Mitral regurgitation ([**12-18**]+)
-Mild pulmonary artery systolic hypertension
-Rheumatoid arthritis
-h/o hospitalization for PNA [**4-24**], now [**5-26**]
Social History:
Immigrant from [**Country 38213**]; lived at home with son. At baseline, the
family says that she talks, eats purees, and walks with a
walker. Over the last few months, however, she has no longer
been able to go to the bathroom on her own. No [**Country **],
smoking, or ETOH use
Family History:
No family history of seizures.
Physical Exam:
< ON ADMISSION >
Afebrile BP 178/88 HR 80 RR 22 O2% 80% Non-rebreather
General: Laying in bed, seizing.
Head and Neck: Dried blood in the mouth. MMD.
Neck: Supple
Pulmonary: Rapid, shallow breaths, Lungs clear
Cardiac: regular rate and rhythm, could not appreciate a murmur
Abdomen: soft, non apparent tenderness
Extremities: warm, well perfused. Multiple [**Last Name (un) 2043**] deformities in
the hands and feet related to arthritis
Skin: no rashes or lesions noted.
Neurologic:
Pt is seizing- Unresponsive to verbal stim/commands. Does not
speak. Eyes are intermittanly deviated to the right. Pupils are
3mm and minimally reactive (has bilateral lense
opacities/cataracts). Right eye intermittently blinking, + lip
smacking. Right arm is flexed and contracting at the elbow,
wrist and shoulder. Right foot is occasionally extending at the
ankle. Tone is increased throughout, could not elicit reflexes.
Withdraws all limbs except the right upper extremity to noxious
stim.
< ON DAY OF DISCHARGE >
VS are stable/normal. Satting 92-97% on RA with HR in 60s-70s.
Gen: cachectic. Lying in bed in NAD.
HEENT: edentulous, MMM.
Pulm: increased air movement at the Right base, no wheezes or
rhonchi. Scattered dry crackles (?atalectasis with resolving PNA
on R and bilateral mild effusions on CXR). No wet crackles.
Decreased BS and dullness to percussion at both bases, R>L.
CV: HS are regular. No JVD. No [**Location (un) **]. Hand/wrist edema 3-4d ago
has since resolved.
Abd: Soft, flat, non-tender. +BS.
Neuro: eyes open. Tracks. Does not speak. Does not follow
commands, including son's commands in her native language. CN
exam unchanged with PERRL, conjugate EOMs, no nystagmus, +weak
blink to threat in all quadrants, +corneals, symmetric face.
Turns neck occasionally, but does not move arms or legs
spontantously, but withdraws briskly from pain in all four
extremities. Hands/wrists are flaccid (with profound RA
changes), while arms are contracted, but extendable. Patient can
hold arms up antigravity bilaterally, but does not follow
commands for sensory/motor testing. No movement in either leg.
On Discharge:
Lying in bed, NAD, op clear, rrr, cta, abd soft, ext
nonedematous, Awake, not speaking or following commands but
unclear if this is related to language barrier as patient
primarily speaks Albanian. PERRL, blinks to threat bilaterally,
EOMI, face symm, withdraws to noxious stim in all extremities.
Pertinent Results:
[**2192-6-7**] 05:18AM BLOOD WBC-7.2 RBC-4.32 Hgb-13.1 Hct-39.2 MCV-91
MCH-30.4 MCHC-33.5 RDW-13.6 Plt Ct-299
[**2192-6-6**] 05:00AM BLOOD WBC-7.7 RBC-4.52 Hgb-13.6 Hct-40.0 MCV-89
MCH-30.1 MCHC-33.9 RDW-13.7 Plt Ct-314
[**2192-6-5**] 05:55AM BLOOD WBC-6.7 RBC-4.36 Hgb-13.3 Hct-40.0 MCV-92
MCH-30.4 MCHC-33.1 RDW-13.7 Plt Ct-268
[**2192-6-4**] 10:00AM BLOOD WBC-UNABLE TO RBC-UNABLE TO Hgb-UNABLE
TO Hct-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO Plt Ct-UNABLE TO
[**2192-6-3**] 06:20AM BLOOD WBC-6.1 RBC-3.89* Hgb-12.0 Hct-36.0
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.4 Plt Ct-288
[**2192-6-2**] 09:30AM BLOOD WBC-4.9 RBC-3.87* Hgb-11.3* Hct-34.9*
MCV-90 MCH-29.3 MCHC-32.5 RDW-13.3 Plt Ct-261
[**2192-6-1**] 06:15AM BLOOD WBC-8.0 RBC-3.92* Hgb-11.9* Hct-35.2*
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.2 Plt Ct-230
[**2192-5-31**] 08:31AM BLOOD WBC-14.2* RBC-3.72* Hgb-11.1* Hct-33.1*
MCV-89 MCH-29.7 MCHC-33.5 RDW-13.2 Plt Ct-246
[**2192-5-30**] 03:59AM BLOOD WBC-13.3* RBC-4.16* Hgb-12.4 Hct-36.5
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.5 Plt Ct-283
[**2192-5-29**] 11:29AM BLOOD WBC-9.9 RBC-4.36 Hgb-13.2 Hct-39.1 MCV-90
MCH-30.2 MCHC-33.7 RDW-13.3 Plt Ct-285
[**2192-5-29**] 01:48AM BLOOD WBC-8.6 RBC-4.21 Hgb-13.1 Hct-38.7 MCV-92
MCH-31.1 MCHC-33.8 RDW-13.2 Plt Ct-348
[**2192-6-3**] 06:20AM BLOOD Neuts-84.1* Lymphs-11.1* Monos-4.2
Eos-0.2 Baso-0.4
[**2192-6-2**] 09:30AM BLOOD Neuts-82.9* Lymphs-13.1* Monos-3.7 Eos-0
Baso-0.2
[**2192-5-29**] 11:29AM BLOOD PT-12.2 PTT-25.8 INR(PT)-1.0
[**2192-5-29**] 01:48AM BLOOD PT-12.8 PTT-27.0 INR(PT)-1.1
[**2192-5-29**] 01:48AM BLOOD Fibrino-394
[**2192-6-7**] 05:18AM BLOOD Glucose-83 UreaN-11 Creat-0.5 Na-140
K-4.0 Cl-99 HCO3-34* AnGap-11
[**2192-6-6**] 09:02PM BLOOD Glucose-86 UreaN-12 Creat-0.4 Na-142
K-3.0* Cl-99 HCO3-34* AnGap-12
[**2192-6-6**] 05:00AM BLOOD Glucose-97 UreaN-15 Creat-0.4 Na-141
K-3.0* Cl-93* HCO3-41* AnGap-10
[**2192-6-5**] 05:55AM BLOOD Glucose-80 UreaN-17 Creat-0.5 Na-142
K-3.5 Cl-98 HCO3-32 AnGap-16
[**2192-6-4**] 10:00AM BLOOD Glucose-[**2180**]* UreaN-7 Creat-0.6 Na-LESS
THAN K-2.0* Cl-50* HCO3-19*
[**2192-6-3**] 06:20AM BLOOD Glucose-119* UreaN-16 Creat-0.6 Na-137
K-3.6 Cl-101 HCO3-29 AnGap-11
[**2192-6-2**] 09:30AM BLOOD Glucose-139* UreaN-18 Creat-0.5 Na-139
K-3.8 Cl-102 HCO3-28 AnGap-13
[**2192-6-1**] 06:15AM BLOOD Glucose-91 UreaN-12 Creat-0.5 Na-134
K-3.7 Cl-99 HCO3-27 AnGap-12
[**2192-5-31**] 08:31AM BLOOD Glucose-111* UreaN-17 Creat-0.6 Na-133
K-3.6 Cl-97 HCO3-28 AnGap-12
[**2192-5-30**] 03:59AM BLOOD Glucose-99 UreaN-12 Creat-0.5 Na-129*
K-4.1 Cl-93* HCO3-24 AnGap-16
[**2192-5-29**] 11:29AM BLOOD Glucose-84 UreaN-14 Creat-0.5 Na-130*
K-4.5 Cl-93* HCO3-26 AnGap-16
[**2192-5-30**] 03:59AM BLOOD CK(CPK)-68
[**2192-5-29**] 07:49PM BLOOD CK(CPK)-85
[**2192-5-29**] 11:29AM BLOOD CK(CPK)-60
[**2192-5-29**] 01:48AM BLOOD CK(CPK)-29
[**2192-5-30**] 03:59AM BLOOD CK-MB-6 cTropnT-0.17*
[**2192-5-29**] 07:49PM BLOOD CK-MB-9 cTropnT-0.19*
[**2192-5-29**] 11:29AM BLOOD CK-MB-11* MB Indx-18.3* cTropnT-0.27*
[**2192-5-29**] 01:48AM BLOOD CK-MB-5
[**2192-5-29**] 01:48AM BLOOD cTropnT-LESS THAN
[**2192-6-7**] 05:18AM BLOOD Calcium-8.7 Phos-2.0* Mg-1.8
[**2192-6-6**] 09:02PM BLOOD Mg-1.7
[**2192-6-6**] 05:00AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.9
[**2192-6-5**] 05:55AM BLOOD Calcium-8.9 Phos-1.9* Mg-1.8
[**2192-6-3**] 06:20AM BLOOD Calcium-8.6 Phos-1.9* Mg-2.0
[**2192-6-2**] 09:30AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1
[**2192-6-1**] 06:15AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.8
[**2192-5-31**] 08:31AM BLOOD Calcium-8.7 Phos-2.0* Mg-1.7
[**2192-5-30**] 03:59AM BLOOD Albumin-3.7 Calcium-9.0 Phos-2.5* Mg-1.7
[**2192-5-29**] 11:29AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8
[**2192-6-6**] 05:00AM BLOOD Osmolal-293
[**2192-6-3**] 08:50AM BLOOD Vanco-15.6
[**2192-6-2**] 09:30AM BLOOD Vanco-5.0*
[**2192-6-1**] 06:15AM BLOOD Digoxin-1.3
[**2192-5-29**] 01:48AM BLOOD Digoxin-0.4*
[**2192-6-7**] 05:18AM BLOOD Valproa-86
[**2192-6-6**] 05:00AM BLOOD Valproa-73
[**2192-6-5**] 05:55AM BLOOD Valproa-64
[**2192-6-3**] 06:20AM BLOOD Valproa-60
[**2192-6-2**] 09:30AM BLOOD Valproa-64
[**2192-6-1**] 06:15AM BLOOD Valproa-62
[**2192-5-31**] 08:31AM BLOOD Valproa-58
[**2192-6-1**] 10:00AM BLOOD Type-ART Temp-36.6 Rates-/36 O2 Flow-5
pO2-61* pCO2-42 pH-7.44 calTCO2-29 Base XS-3 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2192-6-1**] 10:00AM BLOOD Lactate-1.1 Na-132* K-3.2* Cl-97*
[**2192-5-29**] 01:55AM BLOOD Glucose-239* Lactate-5.2* Na-130* K-4.4
Cl-90* calHCO3-24
[**2192-6-1**] 10:00AM BLOOD freeCa-1.22
MOST RECENT AVAILABLE LTM-EEG 24h report [**6-3**]:
FINDINGS:
ROUTINE SAMPLING: Shows a mixed [**5-22**] Hz theta frequency and [**2-17**]
Hz delta
frequency background. In addition, there were frequent sharp
transients
seen broadly over the left hemisphere.
SPIKE DETECTION PROGRAMS: There were four entries in these files
which
do not include any epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There was one entry in these files
which
consists of lead artifact.
PUSHBUTTON ACTIVATIONS: There were no entries in these files.
SLEEP: The patient progressed from wakefulness into stages I-IV
of
sleep.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 70-80 bpm.
IMPRESSION: This is an abnormal continuous EEG due to the
presence of a
mixed [**5-22**] Hz theta and [**2-17**] Hz delta frequency background
consistent with
a mild diffuse encephalopathy. In addition, there are frequent
sharp
transients seen broadly over the left hemisphere; however,
compared to
the previous tracing, there are fewer definite interictal sharp
discharges. There were no electrographic seizures seen. Compared
to
the previous tracing, this tracing is slightly improved.
CXR [**5-30**]
IMPRESSION: AP chest compared to [**5-29**]:
A new large area of homogeneous opacification has developed at
the base of the right hemithorax, at least some of which is
pleural effusion. The rest could be a large area of pneumonia or
collapse, or a larger collection of pleural effusion. Upright
and right decubitus positioning for the subsequent radiographic
studies might be helpful in elucidating that. Left lung is
clear. Heart size is normal. No pneumothorax.
NCHCT [**5-30**]
FINDINGS: Study is limited by motion artifact. Within this
limitation, there is no evidence for acute intracranial
hemorrhage, large mass, mass effect, edema, or hydrocephalus.
Very prominent sulci and ventricles likely reflect age-related
involutional changes. White matter hypodensities are likely
secondary to sequela of chronic small vessel ischemic disease.
Visualized bones and soft tissues are grossly unremarkable. The
visualized portions of the paranasal sinuses and mastoid air
cells are grossly well aerated, although note is made of
under-pneumatization of the mastoid air cells bilaterally.
IMPRESSION: Limited study without evidence for an acute
intracranial process.
Brief Hospital Course:
Ms. [**Known lastname 79941**] was admitted initially to [**Hospital1 18**] Cardiology for ST
depressions and a mild (peak ~0.3) trop elevation. She was found
to be in NCSE with non-responsiveness and left-gaze deviation,
so she was transferred to the Neuro-ICU for seizure management.
Options for NCSE were limited by her DNR/DNI status and family
concerns over her [**2188**] experience in which she was intubated
after respiratory failure followed PHT/LZP for seizure.
Conservative measures were therefore taken with their permission
-- levetiracitam (Keppra) was increased (from home dose of
750bid) to 1500mg [**Hospital1 **]. Depakote (VPA) was added, and her seizure
frequency decreased gradually to zero with levels of VPA in the
60s. Goal VPA is 60-70. She was switched to PO sprinkles
Depakote on the day of discharge (prev IV 200q8 --> 150q6, now
250/375 [**Hospital1 **] PO dosing; goal 60-70 VPA trough level). She was
transferred to the hospital floor on the Epilepsy Neurology
service. She remained seizure free on these two AEDs (LEV and
VPA), and EEG leads were removed several days before discharge.
She took several days to awaken and track and start eating, but
has not yet recovered to her sons' stated baseline of talking
and following commands.
She arrived on the floor in respiratory distress with a RLL
pneumonia and COPD exacerbation. We continued Vancomycin and
Zosyn (plan = 10-day course) for PNA, and started q3h albuterol
/ q6h ipratropium nebs as well as qdaily 40mg methylprednisolone
for 5-day course (no taper), which she completed [**6-5**]. The nebs
were spaced to PRN:q6 by the following week (several days prior
to discharge and her respiratory status improved dramatically
with the aforementioned treatment regimen. She will complete the
IV abx on [**6-8**], and she is continued on her COPD home Rx regimen
(Advair [**Hospital1 **] and PRN nebs for wheezing / dyspnea). Her ASA and
dig were continued. Dig level was therapeutic (see above) on her
home 0.1mg dosing, which was given here by injection while NPO.
She was started on metoprolol 5mg q6hr IV (no BB in home med
regimen despite known MR [**First Name (Titles) **] [**Last Name (Titles) 7216**] CHF), which can be
switched to PO if she continues tolerating
She was deemed by S&S contult as tentatively safe for swallowing
with puree/honey-thick liquids, with the acknowledged risk that
she may aspirate. This was discussed with her sons, who agreed
that this is the best course for her and she would not want
artificial/invasive means of feeding (i.e. no PEG). On the day
of discharge, she was doing quite well with cautious feeds of
applesauce. Her Depakote was switched to PO sprinkles mixed with
the applesauce; her other medicines can be switched as well if
she continues tolerating PO feeds.
Medications on Admission:
- Keppra 1 gram qAM, 500mg qPM
- ASA 325mg daily
- Combivent 2 puffs by mouth 3-4 times daily
- Advair 250/50 [**Hospital1 **]
- Digoxin 0.125 (1 tablet daily Monday thru Friday, no Digoxin
on
Saturday and Sundays)
Discharge Medications:
1. aspirin 300 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever>100.5.
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): For DVT ppx.
6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for skin redness.
7. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing/respiratory distress.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing/respiratory distress.
9. metoprolol tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q4H (every 4 hours): Hold for HR < 60 or SBP < 90;
[**Month (only) 116**] switch to PO dosing as tolerated.
10. famotidine(PF) in [**Doctor First Name **] (iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours).
11. digoxin 250 mcg/mL Solution Sig: 0.1 mg Injection DAILY
(Daily).
12. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 gm
Intravenous Q6H (every 6 hours) for 2 days: Day 1 = [**2192-5-30**]
contine through [**6-8**] to finish 10day course.
13. levetiracetam 500 mg/5 mL Solution Sig: 1500 (1500) mg
Intravenous Q12H (every 12 hours): may switch to PO
levetiracitam as tolerated.
14. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) as needed for
RLL-pneumonia for 2 days: Day 1 = [**2192-5-30**]
contine THROUGH [**6-8**] to finish 10day course.
15. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
16. Depakote Sprinkles 125 mg Capsule, Sprinkle Sig: Three (3)
Capsule, Sprinkle PO qPM: 250mg in the morning (2caps); 375mg in
the evening (3caps).
17. Depakote Sprinkles 125 mg Capsule, Sprinkle Sig: Two (2)
Capsule, Sprinkle PO qAM: 250mg in the morning (2caps); 375mg in
the evening (3caps).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary diagnoses:
1. Non-convulsive status epilepticus
2. Pneumonia
3. COPD exacerbation
4. mild NSTEMI
Secondary diagnoses:
<see discharge summary, PMH>
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Awake and alert -- tracks and swallows
applesauce/purees, but does not speak or follow commands.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mrs. [**Known lastname 79941**], you were admitted initially to the Cardiology
service out of concern for your heart, which suffered a very
minor injury and seems to have recovered well. You were then
moved to the Neurology-ICU service due to seizures. Your Keppra
dose was increased to 1500mg (still twice per day). A new
anti-epileptic drug was added, called Depakote (sodium
valproate), and your seizures stopped, so you were transferred
to the hospital floor on the Epilepsy Neurology service, where
we have been caring for you for over a week. You did not have
any more seizures, so we removed the EEG monitoring leads.
When you arrived on the floor, you were in respiratory distress
for a pneumonia and COPD exacerbation. You were given IV
antibiotics for the pneumonia, and albuterol + ipratropium
nebulizer treatments with IV steroid x five days for the COPD
(reactive airways disease / bronchospasm). Your breathing
improved greatly over the next few days, and the antibiotics
will finish after a 10-day course. You should continue taking
your COPD medicines (Advair twice per day, every day, plus
albuterol whenever you are wheezing or short of breath). For
your heart, we continued your home medications (aspirin,
digoxin, and metoprolol, which you should continue after
discharge as before.
Finally, you took a long time to wake up from all the illnesses
you developed (mild heart attack, pneumonia, COPD exacerbation,
and seizures with new seizure medicines) and you were not safe
for swallowing due to the risk that you would aspirate water and
food into your lungs and worsen your pneumonia. At the end of
your hospital stay, our colleagues in SPEECH & SWALLOW evaluated
you, and suggested it would be OK to try eating pureed foods and
specially-thickend liquids, as long as you and your family
understand that you are at elevated risk for developing another
pneumonia. Your sons determined that you would not want a
feeding tube implanted into your abdomen/stomach, so this was
not pursued. You are initially doing well with very cautious
feeding with purees (e.g. applesauce, ground eggs).
It was a pleasure taking care of you and discussing your care
with your sons, Ms. [**Known lastname 79941**]! Best of luck to all of you in the
future; be well!
Followup Instructions:
1. With Neurologist. Please call if you need to reschedule your
appointment.
- Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Location (un) 2274**]: [**Telephone/Fax (1) 63931**] -- [**7-16**] ([**2191**])
at 1:00pm
-location: [**Location (un) 2129**] (2blks down [**Location (un) **], across the
street [**Hospital1 79945**]).
2. With your PRIMARY CARE PROVIDER [**Name9 (PRE) 2678**] after discharge from
Rehab facility. Please call for appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9153**]
Completed by:[**2192-6-7**]
|
[
"41071",
"486",
"4280",
"4019",
"41401",
"4240"
] |
Admission Date: [**2176-10-24**] Discharge Date: [**2176-12-7**]
Date of Birth: [**2176-10-24**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] was born by
emergency section due to brisk vaginal bleeding from a
placental abruption. He was born at 31 and 6/7 weeks
gestation, weighing [**2140**] grams. He was admitted to the NICU
for prematurity and respiratory distress.
MATERNAL HISTORY: Mother is a 35 year-old, Gravida I, Para
0, now I with an EDC of [**2176-12-20**]. Blood type 0 positive,
antibody negative, HBSAG negative, RPR nonreactive, GBS
unknown. Rubella immune. Mother had a 10 cm subchorionic
hematoma that resolved and she had P-PROM with clear fluid at
22 weeks gestation at a hospital in Bermuda. There was no
preterm labor or vaginal bleeding at that time. On [**2176-9-14**],
she presented with vaginal bleeding and spotting. She was
treated with betamethasone, Penicillin and transferred from
Bermuda to [**Hospital1 18**] on [**2176-9-16**] at 26 weeks gestation for further
management. She completed a course of betamethasone on
[**2176-9-17**], was treated with Ampicillin and Erythromycin also.
On arrival to [**Hospital1 18**], she had no active bleeding. There were
good fetal movements and no further complications until the
day of delivery when she began to have the brisk large
bleeding. In the delivery room, the infant was initially
limp and cyanotic but became more vigorous with a spontaneous
cry with just stimulation. He pinked centrally on his own.
He had good tone but did develop some respiratory distress
with increased retractions, requiring facial C-Pap in the
delivery room. The infant was transferred to the NICU for
further management. Apgars were 8 and 8 at 1 and 5 minutes.
Of significant note in the delivery room, the infant's
umbilical cord was found to be small and withered in
appearance with a greenish stain to it. No meconium stained
fluid. Large amount of bloody, amniotic fluid at delivery
with clot.
PAST MEDICAL HISTORY: Non contributory to the infant's
issues.
SOCIAL HISTORY: Non contributory to the infant's issues.
FAMILY HISTORY: The family lives in Bermuda.
PHYSICAL EXAMINATION: On admission to the NICU, birth weight
was [**2140**] grams. Head circumference was 30 cm. Length was 46
cm. Length was 90th percentile. Weight was 90th percentile.
The head circumference was 75th percentile. HEENT: Normal
head with mild molding. Eyes: Normal. Nose, ears, mouth
normal. Normal palate. Neck supple. No masses. Chest:
Decreased breath sounds equal bilaterally with some
retractions. CV: Normal heart sounds, no murmur, normal
pulse and perfusion. Abdomen: No masses. Nontender,
nondistended. Umbilical cord: Yellowish, green stain.
Genitourinary: Normal premature male, patent anus. Sac
normal. Extremities: Normal skin. Normal neuro
developmental. Active. Normal tone, normal strength.
HOSPITAL COURSE: Respiratory: The infant was intubated on
admission to the NICU and given Surfactant therapy, 2 doses.
Was placed on high frequency ventilation on admission to the
NICU as well. The infant remained on high frequency
ventilation and was actually found to have a
pneumomediastinum and a right pneumothorax on day of life 1
while on high frequency ventilation. The infant was weaned to
nasal cannula on that same day. The pneumomediastinum and
right sided pneumo, both resolved on their own without
intervention. The infant weaned to room air on day of life 4,
[**2176-10-28**] and has remained on room air since that time. The
infant has had rare apneic and bradycardiac episodes. Never
required methylxanthine therapy. He was noted to have occasional
bradycardia with or without desaturation whic was completely
resolved. He did not have any epsiode for 5 consecutive days
prior to discharge.
Cardiovascular: He was initially cardiovascularly stable, not
requiring any inotropic support but did develop a murmur on
day of life 25 which is [**2176-11-18**]. Echocardiogram was done at that
time which showed trivial left pulmonary artery stenosis, a small
PFO and no PDA. The infant has had no further cardiac
evaluations but it is recommended that follow-up with a
cardiologist takes place at some point for the PFO. Otherwise,
the infant at this present times does have a murmur but does
maintain normal heart rates and blood pressures.
Fluids, electrolytes and nutrition: IV fluids were initiated
on the newborn day. The infant had peripheral IV placed at
that time. Enteral feedings were initiated on day of life 2
and slowly advancing fine up until day of life 6 on [**2176-10-30**]
when the infant presented with a grossly bloody stool at that
time. The infant was then made n.p.o. IV fluids were
reinitiated. Prior to that taking place, the infant had
achieved almost full feedings, was up to 130 ml/kg per day of
enteral feedings. The feedings were then stopped. KUB was
done and there was concern for necrotizing enterocolitis but
non specific. There was no bowel perforation but concern for
pneumatosis. The CBC at that time was normal. Due to the
bloody stools, the infant was made n.p.o. and treated for a
14 day course for NEC. The infant had a PICC line placed on
[**2176-11-3**] for prolonged IV nutrition. The infant remained
n.p.o. for the full 14 day course and enteral feedings were
again initiated on [**2176-11-13**] and slowly advanced to full
feedings. Full feedings were achieved on [**2176-11-22**] and
calories were further advanced to 24 calories per ounce
breast milk or Special Care 24 cals per ounce which was weaned
down to 20 cal/oz on [**2176-12-5**] and she demonstrated god weight
gain. Infant is voiding and stooling normally on his own. Most
recent head circumference is 34 cm and the length is 50 cm
The discharge weight is 3220 gm.
Gastrointestinal: The infant was treated for the 14 days of
necrotizing enterocolitis as mentioned above. Also, the
infant developed hyperbilirubinemia with a peak bilirubin
level of 11.1 over 0.5. He received a total of 4 days of
phototherapy.
Hematology: Hematocrit at birth was 49; platelet count 56.
The infant has required no blood product transfusions and the
most recent hematocrit was 27.4 with a retic count of 2.3%
and that was on [**2176-11-21**]. The infant has required no blood
product transfusions. The infant's blood type is 0 positive,
DAP negative. The infant was started on elemental iron or
Ferinsol on [**2176-11-25**]. The infant is presently getting 0.2 ml
per day of Ferinsol.
Infectious disease: CBC and blood culture were screened on
admission to the NICU. The infant received a 36 hour rule out
of Ampicillin and Gentamycin which were subsequently
discontinued. When the clinical status improved, the blood
culture remained negative. The CBC was benign on admission to
the NICU. The infant was restarted on antibiotics when he
developed bloody stools on day of life 6, [**2176-10-30**]. The CBC
at that time was not shifted but within 12 hours from that
point in time, the CBC did then become shifted with a
bandemia. The blood culture that was drawn on [**2176-10-30**] did
grow gram positive cocci which was identified as staph epi.
The infant was started on Vancomycin and Gentamycin on
[**2176-10-30**] which was subsequently switched to Zosyn and
Vancomycin on [**2176-10-30**] shortly thereafter starting the
Gentamycin. The infant continued on antibiotics for a full
14 days from that point in time. The antibiotics were
subsequently discontinued on [**2176-11-12**]. There had been no
further issues with infectious disease.
Neurologic: Head ultrasound was screened on [**2176-10-31**] which
was found to be within normal range. A 1 month head
ultrasound was done on [**2176-11-27**] and the results are normal.
Sensory:
Hearing: A hearing screen was performed with automated
auditory brain stem responses and the result is .
Ophthalmology: The infant had 2 eye exams performed. One was
on [**2176-11-10**] which showed immaturity to zone 2. Follow-up was
[**2176-11-25**] which showed immaturity but in the zone 3 range.
Recommendation is for a repeat eye exam in 3 weeks from the
date of [**2176-11-25**].
Psychosocial: [**Hospital1 18**] social worker has been involved with the
family. There have been ongoing issues with returning the
infant back to home in Bermuda. If there are any psychosocial
issues or questions, the [**Hospital1 18**] social worker can be reached
at [**Telephone/Fax (1) 8717**].
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: Home with the parents to Bermuda on
commercial airline.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 69070**], telephone
number [**Telephone/Fax (1) 69071**].
CARE RECOMMENDATIONS: Ad lib p.o. feedings of 20 calorie,
either breast milk or Similac 20 calorie with iron and breast
feeds as well.
MEDICATIONS: Ferinsol .2 ml p.o. daily.
CAR SEAT SCREENING: Performed on [**2176-11-26**].
STATE NEWBORN SCREENS: Sent on [**9-4**] and [**11-7**]. The
initial state screen sent on [**10-27**] showed an elevated 17 OH.
Follow-up state screens both remained normal.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine was given on
[**2176-11-25**].
The initial Synagis dose was given on [**2176-11-26**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: (1) Born at less than
32 weeks; (2) Born between 32 weeks and 35 weeks with two of
the following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; (3) chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP: The infant should follow-up with the pediatrician
within 2 days of discharge from the NICU.
The infant should also have follow-up at an ophthalmologist
by the end of [**Month (only) **].
Follow-up with cardiologist for PFO.
Follow-up with early intervention.
DISCHARGE DIAGNOSES:
1. Prematurity born at 31 and 6/7 weeks gestation.
2. Respiratory distress syndrome resolved.
3. Pneumomediastinum resolved.
4. Right pneumothorax resolved.
5. Sepsis ruled out.
6. Necrotizing enterocolitis resolved.
7. Hyperbilirubinemia resolved.
8. Patent foramen ovale (PFO) murmur, L trivial PA stenosis
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2176-11-27**] 00:35:45
T: [**2176-11-27**] 05:46:38
Job#: [**Job Number 69072**]
|
[
"V053"
] |
Admission Date: [**2102-11-10**] Discharge Date: [**2102-11-17**]
Date of Birth: [**2025-1-20**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 77 year old male had an
abnormal electrocardiogram at a recent routine visit with his
primary care physician. [**Name10 (NameIs) **] had been having increasing
fatigue for greater than one year and dyspnea on exertion
also for greater than one year. His stress test was positive
after his abnormal electrocardiogram. He had a cardiac
catheterization performed at [**Hospital6 3872**] in
late [**2102-9-22**], which showed left anterior descending
coronary artery 90 percent lesion, diagonal two 90 percent
lesion, diagonal three 60 percent lesion, circumflex 90
percent lesion, right coronary artery 70 to 75 percent
lesion., posterior descending coronary artery 60 percent
lesion and an ejection fraction of 40 percent, a dilated
aortic root and mildly elevated left ventricular end
diastolic pressure. Cardiac catheterization done in [**2101-6-21**], showed an ejection fraction of 35 to 40 percent with
mild mitral regurgitation. The patient was admitted to the
hospital on [**2102-11-10**], in preparation for his surgery. He
was to be done electively but called complaining of shortness
of breath so the patient was admitted to the hospital.
PAST MEDICAL HISTORY: Murmur.
Myocardial infarction twenty years ago.
Hiatal hernia.
Gastroesophageal reflux disease.
History of atrial fibrillation twenty years ago.
PAST SURGICAL HISTORY: Cataract removal in [**2088**], and [**2089**].
PREOPERATIVE MEDICATIONS:
1. Toprol XL 100 mg daily.
2. IMDUR 30 mg p.o. daily.
3. Lisinopril 5 mg p.o. daily.
4. Reglan 10 mg p.o. daily.
5. Naproxen 250 mg p.o. twice a day but was stopped prior to
his admission.
6. Ecotrin 325 mg p.o. daily.
7. Glucosamine combination drug p.o. daily.
8. Prilosec p.r.n.
ALLERGIES: He had no known drug allergies.
PHYSICAL EXAMINATION: On examination, he was sitting up in
bed in no apparent distress. He was alert and oriented times
three and appropriate. He had crackles of his right base and
diminished breath sounds of his left base. His heart was
regular rate and rhythm with S1 and S2 and grade II/VI
systolic ejection murmur. His abdomen was soft, round,
nontender, nondistended with positive bowel sounds. His
extremities were warm and well perfused with trace edema
bilaterally. He had two plus bilateral radial, dorsalis
pedis and posterior tibial pulses.
LABORATORY DATA: His preoperative laboratories were as
follows: White blood cell count 7.3, hematocrit 46.7,
platelet count 419,000. Sodium 140, potassium 4.1, chloride
100, bicarbonate 29, blood urea nitrogen 19, creatinine 1.0
with a blood sugar of 61. His HbA1C was 4.9 percent.
Prothrombin time 12.3, partial thromboplastin time 27.7, INR
1.0. ALT 21, AST 24, alkaline phosphatase 90, total
bilirubin 0.6, albumin 4.6. Preoperative urinalysis was
negative. His preoperative chest x-ray showed no acute
cardiopulmonary process.
HO[**Last Name (STitle) **] COURSE: He was given intravenous Lasix for diuresis
prior to surgery. The next day, [**2102-11-11**], the patient
underwent coronary artery bypass grafting times four by Dr.
[**Last Name (Prefixes) **] with left internal mammary artery to the left
anterior descending coronary artery, saphenous vein graft to
the posterior descending coronary artery, saphenous vein
graft to the obtuse marginal and saphenous vein graft to the
diagonal. He was transferred to the Cardiothoracic Intensive
Care Unit in stable condition on Neo-Synephrine drip at 0.3
mcg/kg/minute, a Dobutamine drip at 3.0 mcg/kg/minute and a
Propofol drip at 10 mcg/kg/minute. On postoperative day
number one, the patient had been extubated overnight. He was
given volume, remained on Dobutamine drip at 3.0 and the Neo-
Synephrine drip had been weaned off. He was also on insulin
drip at 4 units per hour. Aspirin was restarted.
Postoperative white blood cell count was 12.1, hematocrit
27.0, potassium 4.4, blood urea nitrogen 15, creatinine 1.0.
He was hemodynamically stable with a blood pressure of 109/58
and in sinus tachycardia at 103. On postoperative day number
two, he had been transfused one unit of packed red blood
cells for a hematocrit of 24.0, remained in sinus rhythm with
no other significant events. He began intravenous Lasix
diuresis 20 mg twice a day. His examination was
unremarkable. His creatinine remained stable at 1.0. He
started his beta blocker. His Swan-Ganz was discontinued and
he was transferred out to the floor. On postoperative day
number three, the patient was ambulating independently on the
floor although complaining of a little bit of weakness. He
had a full evaluation done by physical therapy. He remained
stable. His hematocrit rose to 28.7. He had good blood
pressure. His examination was unremarkable with trace
peripheral edema. His incisions were clean, dry and intact.
His pacing wires remained in place. His chest tubes had
minimal drainage. His chest tubes and pacing wires were
discontinued later in the day without incident. The patient
was encouraged to increase his p.o. intake and increase his
level of activity by increased amounts of ambulation. He was
receiving Percocet which gave him nausea, so this was
switched over to Tylenol number three for pain. On
postoperative day number four, the patient continued to
progress very well and was waiting to do a complete level
five prior to his discharge. His beta blocker was increased
to Lopressor 50 mg twice a day. He was receiving p.o.
Tylenol with Codeine for pain management. His lungs were
rhonchorous but his examination was otherwise unremarkable.
He was alert and oriented with a nonfocal neurologic
examination. On postoperative day number five, he was doing
very well but had some persistent tachycardia with a heart
rate in the 90 to 105 range. His Lopressor was discontinued.
He started Toprol 100 mg p.o. daily. He was alert and
oriented. This was changed at patient request for the
simplicity of once a day dosing. His creatinine remained
stable at 0.9. He had occasional premature ventricular
contractions with couplets and a six beat run of
supraventricular tachycardia at 11:00 p.m. on the evening of
[**2102-11-17**], without any symptoms whatsoever, was saturating
94 to 97 percent in room air with decreased breath sounds at
his bases. The following morning the day of discharge, he
was in sinus rhythm at 84 beats per minute with a temperature
maximum of 98.9, blood pressure 120/63. Laboratories the day
prior were white blood cell count 8.3, hematocrit 29.3,
platelet count 386,000, potassium 4.0, blood urea nitrogen
20, creatinine 0.9. He had small blisters on his right
distal leg incision. His examination was otherwise
unremarkable other than some rhonchorous sounds in his
bilateral lung bases but he was much improved with better
heart rate control and the patient was deemed able to go home
with VNA services and was discharged on [**2102-11-17**].
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting times four.
Myocardial infarction twenty years ago.
Hiatal hernia.
Gastroesophageal reflux disease.
History of atrial fibrillation twenty years ago.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. twice a day for ten days.
2. Potassium Chloride 20 mEq p.o. twice a day for ten days.
3. Colace 100 mg p.o. twice a day.
4. Enteric Coated Aspirin 81 mg p.o. once daily.
5. Protonix 40 mg p.o. once daily.
6. Reglan 10 mg p.o. once daily.
7. Sustained Release Metoprolol 100 mg one tablet p.o. once
daily.
8. Niferex 150/50 mg tablet, one capsule p.o. once a day for
one month.
9. Vitamin C 500 mg p.o. twice a day for one month.
10. Folic Acid 1 mg p.o. once a day for one month.
FO[**Last Name (STitle) 996**]P: The patient was instructed to follow-up with Dr.
[**First Name (STitle) **], his primary care physician, [**Name10 (NameIs) **] one to two weeks
postdischarge, to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1655**] in
approximately one to two weeks postdischarge and to follow-up
with Dr. [**Last Name (Prefixes) **], his surgeon, in the office for a
postoperative surgical visit in approximately three to four
weeks postdischarge.
DISCHARGE STATUS: He was discharged home with VNA services
in stable condition on [**2102-11-17**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2102-12-28**] 16:26:43
T: [**2102-12-30**] 09:06:11
Job#: [**Job Number 60201**]
|
[
"4280",
"41401",
"412",
"53081",
"2859",
"4019"
] |
Admission Date: [**2124-5-9**] Discharge Date: [**2124-5-24**]
Service: VASCULAR
HISTORY OF PRESENT ILLNESS: The patient was an 88-year-old
male with a history of cerebrovascular disease who presented
with signs and symptoms of peptic ulcer disease, but work-up
revealed the fact that the patient had postprandial abdominal
pain and was ultimately evaluated for mesenteric ischemia.
The patient's symptoms included intermittent abdominal pain,
as well as a description of an episode of diffuse abdominal
pain and "feeling lousy" after meals for the past several
months. The patient discouraged the patient from eating and
resulted in an [**7-1**] lb weight loss over the prior four months
before admission. Additionally, the patient noted a drastic
................., as well as an overall abdominal girth.
REVIEW OF SYSTEMS: He denied nausea or vomiting. He denied
diarrhea. No chills. Per the patient, he never had a [**Last Name 16423**]
problem "with his heart." He denied history of myocardial
infarction. No previous echocardiogram data. No prior
catheterization or rhythm disturbances. He did state that he
did have stress test long ago and could not remember exactly
what the nature or results of that were.
After being admitted for the work-up of mesenteric ischemia,
he did receive an arteriogram that showed significant
mesenteric vessel disease requiring likely operative
intervention. Prior to him going to the operating room, he
did get a cardiac consultation. Cardiology had seen the
patient, and given his multiple comorbidities, they
recommended work-up.
PAST MEDICAL HISTORY: Significant for diabetes times 30
years which is "labile." Prior history of stroke and
transient ischemic attacks. History of hypoglycemia from his
diabetes. Coronary artery disease with prior myocardial
infarction. History of hypertension. He denied tobacco. He
used alcohol occasionally.
SOCIAL HISTORY: He lived at home. He worked in a leather
factory. He repaired televisions and radios as his prior
occupations, but was retired on admission.
MEDICATIONS ON ADMISSION: Zestoretic q.d., Plavix 75 mg
q.d., Aspirin 325 mg q.d., Humulin N 15 q.a.m., Ambien 5 mg
q.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.0??????, pulse
101, respirations 18, blood pressure 150/80, oxygen
saturation 95% on room air. General: The patient was in no
acute distress. He was a well-developed, well-nourished
white male. HEENT: Pupils equal, round and reactive to
light and accommodation. Extraocular movements intact.
Normocephalic, atraumatic. Conjunctivae normal. Oropharynx
negative. Neck: Supple. Trachea midline. No palpable
lymphadenopathy. Lungs: Clear to auscultation but decreased
throughout. Heart: Regular, rate and rhythm. Normal S1 and
S2. Abdomen: Scaphoid. Minimally distended. Tympanitic.
Nontender. Rectal: Heme negative. Normal tone. No masses.
Musculoskeletal: Grossly intact. Pulse exam was 2+ femoral,
2+ dorsalis pedis, 2+ posterior tibial bilaterally. No
evidence of tissue loss.
HOSPITAL COURSE: The patient was admitted on [**2124-5-9**],
for his mesenteric ischemia work-up. He did receive a
preoperative carotid ultrasound that revealed no significant
hemodynamic lesions, either on the right or left carotid
bifurcation. [**Last Name (un) **] consultation was obtained for blood
sugar management while he was in-house. Ultimately he was
given prehydration Mucomyst for his in-house angiogram which
showed significant three-vessel disease. Additionally his
work-up included not only cardiac work-up but also PFT
evaluation.
On [**2124-5-14**], he was received preoperative work-up, and
his labs were notable for a white count of 10.6, hematocrit
39.1, and a platelet count 243, BUN and creatinine of 31 and
1.6; coags were with a PT and INR of 13.9 and 1.3, with a PTT
of 29.4. He had cardiac clearance. Carotid ultrasound as
previously stated was negative. Chest x-ray showed mild
congestive heart failure. Recheck showed some worsening
failure. Urinalysis was negative. He was placed on
perioperative beta-blocker.
On [**2124-5-15**], the patient went to the Operating Room
where he underwent aorto-SMA bypass with an 8 x 40 mm PTFE
graft under the assistance of Drs. [**Last Name (STitle) 1391**], [**Name5 (PTitle) **], and
Shan. At the time of operation, the findings were a
calcified aorta and occluded left CIA. The patient's blood
loss was 100 cc. He received 2200 cc of Crystalloid. Urine
output was 420 cc for the case. There were no complications.
He went to the PACU with palpable popliteals bilaterally, and
his feet were warm. He received Heparin 500 U/hr, as well as
Neo-Synephrine, and Dobutamine. The patient remained
intubated.
Cardiac consultation was required ..................
postoperative due to the patient's Dobutamine requirement and
low cardiac index. Initial index was 1.1 intraoperative with
a PA pressure of 61/30, and CVP of 14. Dobutamine had been
started intraoperatively empirically for hemodynamic
findings. Electrocardiogram postoperatively was unchanged
with left bundle branch block. Cardiology recommended
following cardiac outputs, as well as PA saturations and
aortic saturations. Echocardiogram was rechecked with a goal
wedge stated to be approximately 18. His enzymes were
ordered to be cycled accordingly.
At the time of postoperative check at 6:30 p.m. on [**2124-5-15**], he was still on Dobutamine drip at 2.5, Heparin drip at
500 U/hr, and epidural for pain. He remained intubated and
sedated. His temperature was 38.1??????C, 80, with frequent APCs,
blood pressure 110/50, CVP 15, PA pressure 52/24, wedge 24.
Fick Cardiac output index numbers were 4.07 and 2.31, with an
SVR of 1179. Non-Fick output index were 3.89 and 2.21. He
was on ................... with an SIMV, pressure support of
60%, 700 x 10, 5 and 5. Arterial blood gases on that were
7.32, 35, 158, 22, and 98%. He had a mixed mean of 70. He
received a total 2700 cc of fluids. Immediately
postoperatively he received 1 U packed red blood cells. His
postoperative hematocrit was 29.2, with a creatinine of 1.8,
and PTT of 85 on Heparin drip as noted. His CK was 90,
troponin less than 0.3.
Postoperative chest x-ray showed mild congestive heart
failure. Swan-Ganz catheter was in good position. There was
no evidence of pneumothorax. Electrocardiogram showed no
acute ischemia. No changes. Echocardiogram postoperatively
demonstrated an ejection fraction of 25%, with decreased
right ventricular motion, which was a new finding. Overall
echocardiogram findings showed global hypokinesis which drove
the service to rule the patient out for myocardial
infarction. Adequate oxygenation had to be ensured.
The plan was to keep the patient intubated over night, rule
him out serially, and support him hemodynamically. The
patient was therefore admitted to the [**Hospital Unit Name 153**] for postoperative
management.
By postoperative day #1, he was doing well hemodynamically,
although he did have a temperature to 101.3??????. He was in
sinus rhythm at 93, with a blood pressure of 111/49. CVP was
9, PA pressure 48/20, output index of 6.1 and 3.49, with an
SVR of 630. He remained vented and supported. He was doing
otherwise satisfactory. He was noted to have a postoperative
creatinine at this time of 2.5 which was markedly elevated.
Again this was thought to be secondary to his recent contrast
load and intraoperative fluid shift and questionable
transient hypotension and low index output.
Over the next several days, the patient was weaned from the
vent on postoperative day #3. He was reintubated for
respiratory distress. He was noted to have a troponin leak
as well. At this time, his hematocrit was 29.9, and his BUN
and creatinine were up to 112 and 4.3, falling into acute
postoperative renal failure. He remained intubated and
sedated. He was noted to have some cool cyanotic toes. He
had a left posterior tibialis present by Doppler. He was
being supported with Dobutamine and being diuresed with
Natrecor for his pulmonary edema which had occurred
postoperatively from fluid shifts. He had a lactate of 1.8
at this time. He was continued on Heparin drip. He was on
broad-spectrum antibiotics of Vancomycin and Flagyl.
Renal was consulted shortly thereafter for his management of
acute renal failure. He continued to have fevers and
ultimately developed thrombocytopenia. A combination of
thrombocytopenia, fevers, respiratory failure, and acute
renal failure, metabolic acidosis was ominous at best. He
ultimately ruled in for myocardial infarction
postoperatively. His .................. was decreased
serially. He was supported. His Dobutamine was switched to
Milrinone and Natrecor, and he was started on Amiodarone for
ventricular ectopy/atrial fibrillation.
By [**2124-5-21**], the patient continued to be managed for his
congestive heart failure. Cardiology at this time had noted
that he was begun on Amiodarone for supraventricular
tachycardia. His blood pressure was 108/57, pulse ranging
90-120 for supraventricular tachycardia. He was continued on
Vancomycin, Levofloxacin, and Flagyl, with Lopressor 2.5
.................., Natrecor, Milrinone drip 0.5, Versed
drip, and Protonix. His hematocrit was 30. His platelet
count was down to 44, and his BUN and creatinine were
119/4.1.
His Natrecor was increased serially to assist with his heart
failure, and he continued to go into renal failure.
Ultimately he developed, on postoperative day #6, some new
wide complex tachycardia with stable blood pressure. He was
continued on Amiodarone drip, and he was changed to Milrinone
earlier. His Natrecor was increased serially. He was noted
to have a cold cyanotic right lower extremity with decreased
pulses. His index at this time remained to be 2.
The patient was being covered by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as Dr.
[**Last Name (STitle) 1391**] was out of time. Overall his cardiac parameters
improved. Although his right leg was worrisome, there was
nothing they could do in light of the situation except for
heparinization. There was nothing that could be done in
terms of revascularization. This was all thought to be due
to his overall hypoperfused state.
Over the ensuing days, the patient's clinical status
deteriorated; renal function was worse. The family at this
time had discussed on [**2124-5-23**], that the patient be made
DNR. He was given a 48-hour trial. The patient clearly had
a poor prognosis. Cardiology at this time recommended
instead of continuing with Milrinone, to try to introduce
Hydralazine for afterload reduction to stop his Natrecor
drip, as it had no affect on his pulmonary edema management.
His antibiotics were continued accordingly. By postoperative
day #9, the patient continued on Vancomycin, Levofloxacin,
and Flagyl. At this time, the day was [**2124-5-24**]. He was
on Lopressor, Protonix, Levaquin, Aspirin, Flagyl, Milrinone,
Amiodarone, and Vancomycin. His weight was up 16 kg, and he
was being supported with total parenteral nutrition. He
remained intubated on full ventilatory support. Overall his
outlook was grim.
A family discussion was held, and the patient was CMO.
Shortly after the removal of support, the patient expired at
approximately 3:30 p.m. on [**2124-5-24**]. The family was
accordingly notified.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2124-8-28**] 15:26
T: [**2124-8-28**] 15:56
JOB#: [**Job Number 43132**]
|
[
"4280",
"42731",
"51881",
"5849",
"2762"
] |
Admission Date: [**2159-6-2**] Discharge Date: [**2159-6-5**]
Date of Birth: [**2082-10-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77-year-old male with diabetes mellitus type 2,
hypercholesterolemia, hypertension, status post porcine mitral
valve replacement in [**2137**],
diabetic nephropathy and retinopathy who presents w/ ? of
altered mental status. In [**2137**] patient had developed bacterial
endocarditis, having received a six week course of antibiotics
prior to mitral valve replacement. For the patient two years,
the patient has noted an increased symptom burden from heart
failure, with worsened dyspnea on exersion, 4 pillow orthopnea,
lower extremity edema. At present pt describes dyspnea with
minimal exertion (dressing himself, or toileting). The patient
has had ongoing conversations with his outpatinet cardiologist
regarding the necessity of valve replacement. Over the last
month the patient has an even more progression of his symptoms.
The patient was discharged from BIDNH 2 days prior to
presentation after a MVA [**3-3**] to a syncopal episode. The patient
reports prior synocopal epsides while standing from sleep. The
etiology of his LOC was attributed to hypotension in the setting
of increased BP meds in the setting of MS. The patient was
discharged with plans for cardiology follow up to plan for valve
replacement.
.....On the morning of presentation, the patient was awakening
from sleep, and for the first 1-2 minutes he was confused,
thinking he was in [**Country 9819**]. The patients family reports
recurrent episodes of acute, short-duration confusion while
awakening for the last few months. The patients family does not
feel that he is confused during day to day activities, but does
note that he is somnlanent throughout the day. In review of
systoms, the patient endoreses an englarging abdomen over the
last 2-4 weeks. He denies abdominal pain, blood in stool,
change in stool quality. He has no history of liver disease.
.....With this ? of altered mental status, the patinet was
brought into the ED for further evaluation. while there his BP
was 90/53, HR 70, 89% 2L, 97% on 3L. He was given an aspirin,
and admitted for further manegment.
Past Medical History:
1. Diabetes mellitus-2.
2. Hypercholesterolemia.
3. Hypertension.
4. Strangulated hernia, status post surgery in [**2158-10-30**].
5. Mitral valve replacement, porcine, [**2137**].
6. Diabetic retinopathy.
7. Diabetic nephropathy.
8. Gout.
9. Severe mitral regurgitation with chronic systolic heart
failure.
Social History:
The patient lives at home with his wife. Former computer
programer. No alcohol, tobacco or drugs.
Family History:
noncontributory.
Physical Exam:
Gen: WDWN middle aged male tachypnic slouched forward. Oriented
x3. Mood, affect appropriate. + RLS
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Difficultly
keeping eyes open.
Neck: Supple with [**Doctor Last Name **] V waves JVP at mandible.
CV: RRR, S1,S2, III/VI holosystolic murmur heard best at base.
+ S3
Chest: Wet crackles b/l heard 1/2 up lung fields
Abd: Soft, NT. + abdominal distension w/ + FW. No HSM or
tenderness. Surigcal vental scar noted.
Ext: 1+ - 2+ LE edema. 2+ dp/pt. No femoral bruits.
Pertinent Results:
[**2159-6-2**] 09:50AM BLOOD WBC-8.0 RBC-3.64* Hgb-12.0* Hct-36.0*
MCV-99* MCH-33.0* MCHC-33.4 RDW-18.5* Plt Ct-128*
[**2159-6-2**] 09:50AM BLOOD Neuts-83.1* Lymphs-9.4* Monos-5.0 Eos-2.1
Baso-0.4
[**2159-6-2**] 09:50AM BLOOD Glucose-217* UreaN-70* Creat-2.2* Na-144
K-3.9 Cl-106 HCO3-29 AnGap-13
[**2159-6-2**] 09:50AM BLOOD CK-MB-4 proBNP-[**Numeric Identifier **]*
[**2159-6-2**] 09:50AM BLOOD cTropnT-0.17*
[**2159-6-2**] 09:50AM BLOOD CK(CPK)-141
[**2159-6-2**] 11:31AM BLOOD Lactate-1.5
[**2159-6-2**] 09:50AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.8*
NCHCT: [**2159-6-2**]
1. No acute intracranial process.
2. Slight prominence of the right MCA, most likely represents
slight tortuosity. However, a small aneurysm cannot be excluded.
.
CXR ([**2159-6-2**]):
IMPRESSION: Subtle reticulonodular pattern in the lower lobes
bilaterally. In the absence of a prior chest radiograph this
could represents an atypical pneumonia or chronic changes. If
clinical suspicion for infection is high consider chest CT.
TTE ([**2159-5-30**]):
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-15mmHg. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). The right
ventricular cavity is mildly dilated There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The prosthetic mitral valve leaflets are
thickened. Motion of the prosthetic mitral valve leaflets/poppet
is abnormal. There is a question of flail leaflet motion There
is moderate valvular mitral stenosis (area 1.0-1.5cm2). Severe
(4+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension.
Brief Hospital Course:
Patient is a 76 year old male with history of MVR ('[**37**]), DM,
CRI, w/ known severe mitral regurgitation who presents with ?
AMS, found to be in acute heart failure.
On initial exam, there was clear evidence of volume overload,
with Lower Extremity edema, hypoxia, pulmonary edema, and
abdominal ascietes. No evidence of LV systolic dysfunction on
TTE. Patient's complaints of fatigue and SOB/DOE were thought
to be due to mitral valvular dysfunction, and patinet was
considered for MVR. CT surgery was consulted. On the afteroon
of [**2159-6-4**], the patient was sent for cardiac catheterization for
pre-operative evaluation. In the holding area the patient
became increasingly altered, hypotensive, and Short of breath.
Due to his worsened status, he was transferred to the CCU for
concern of sepis. Broad spectrum antibiotics were started prior
to transfer, he was placed on Vancomycin, Levofloxacin and
Meropenem. His respiratory and mental status continued to
decline and he was intubated. He became hypotensive and
required pressors. The family was notified and the wife decided
to make no further interventions, he was DNR/DNI. Pressors were
increased due to continued hypotension. Blood cultures came
back positive for gram + cocci. The patient went into cardiac
arrest and expired on the morning of [**2159-6-5**].
Medications on Admission:
1. Allopurinol 100 mg daily.
2. Iron 325 t.i.d.
3. Klor-Con at least 40 daily.
4. Procrit weekly.
5. Bumex 4 mg twice daily.
6. Avapro 75 mg daily.
7. Folic acid 1 mg daily.
8. Zetia 10 mg daily.
9. Januvia 50 mg daily.
10. Crestor 10 mg daily.
11. Glimepiride 2 mg daily.
12. Insulin 70/30 ten units in the morning.
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"5849",
"0389",
"99592",
"5859",
"4240",
"4280",
"40390",
"2720"
] |
Admission Date: [**2154-8-23**] Discharge Date: [**2154-8-29**]
Date of Birth: [**2097-11-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypoxia, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 yo M with widely metastatic renal cell CA on sutent
presenting with hypoxia and hypotension.
The patient states that approximately 2-3 days ago he awoke in
the middle of the night to go to the bathroom and noted
significant dyspnea on exertion. His shortness of breath was
persistent and slightly worsened until the time of admission. On
the day of admission, the patient was seen in oncology clinic
for a scheduled transfusion for anemia thought to be associated
with sutent myelosuppresion. The patient complained of SOB and
was found to be hypoxic to the 80's%. He was sent to the ED. The
patient denies any recent fevers, chest pain, pleuritic pain or
dizziness. He notes a non-productive cough over this time period
with increased RLE swelling more than LLE swelling. The
patient's wife notes that his RUE also was transiently swollen.
The patient describes a small amount of increased shortness of
breath when supine. He notes possible sick contacts.
In the ED, the patient was hypoxic to 80s% improved on 4L NC
with sbp 80. He received approximately 1.5L NS and 1U PRBC (for
Hct 22 down from 29 1 month prior). Lactate was noted to be 2.8.
CXR revealed a multifocal infiltrate and he received 1 dose of
levofloxacin. The patient was felt not stable for CTA and he was
admitted to the ICU for further care.
Past Medical History:
--Metastatic RCC diagnosed [**7-/2152**] after developing hematuria.
S/p debulking nephrectomy in 10/[**2151**]. His disease progressed,
and he received radiation to the lumbar spine, left chest wall,
and left humerus. Mets also to R temporal bone, T10 vertebral
body with compression and extension into epidural space. He
developed a left humeral pathologic fracture in [**12/2152**]
requiring an IM nail procedure. S/p laminectomy and poterior
T3-L1 fusion for back pain from spinal met. He started high-dose
interleukin-2 therapy in [**2-/2153**], but his disease continued to
progress. He entered the Avastin and sorafenib trial on
[**2153-4-18**] and has had a decrease in size of his lesions.
Sorafenib had to be held for four weeks because of weight loss.
His sorafenib was restarted after gaining some weight but at a
reduced dose on [**2153-7-25**]. His Avastin was held because of
excessive proteinuria. He was withdrawn from the study on
[**2153-11-28**] because of osseous metastases. Started Sutent
[**2153-12-26**], discontinued soon after that and then restarted on
[**2154-5-15**] at reduced doses due to myelosuppression. Cord
compression at T10 [**2154-3-8**]. He underwent spinal embolization on
[**3-9**] followed by transpedicular decompression at T10, total
laminectomy for excision of tumor at T11, and T3-L1 fusion on
[**3-12**]. He then received radiation therapy to T10-T11 and T5-T6,
completed [**5-3**].
-- HTN
-- GERD
-- Bilateral knee replacements
Social History:
The patient lives in [**Location **] with his wife. [**Name (NI) **] is retired, but
previously worked as a combat engineer in the military for 15
years and as a post officer in the post office for 30 years. He
smokes approximately 1 pack over the span of 3 days. He reports
having smoked one pack per day since the age of 15. He drinks
very occasionally. He is married. He has two daughters.
Family History:
Brother w/ early heart disease. DM in both mom and dad. Mother
and daughter both have "thyroid problems."
Physical Exam:
97.8 101 94/53 63 22 98% 4L NC 71.3kg, desats to 80's% with
minimal movement.
Gen: Cathectic, pale. NAD.
Integumentary: No rashes or lesions.
HEENT: PERRL.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Bilateral crackles R>L.
Abd: Soft, nontender, nondistended.
Ext: RLE edema 2+, LLE edema 1+.
Back: Large thoracic spinal surgical scar.
Neuro: A&Ox3.
Pertinent Results:
[**2154-8-23**] CTA -
1. No evidence of pulmonary embolism or aortic dissection.
2. New extensive multifocal bilateral ground-glass opacity with
septal thickening and increase of size of preexisting pulmonary
nodules. These findings are most likely secondary to pneumonia,
less likely CHF. Recommend evaluation of pulmonary nodules
following resolution of these opacities.
3. Extensive bony metastatic disease within the spine, ribs and
sternum.
[**2154-8-23**] CT Head -
1. New right cerebellar enhancing 1 cm lesion concerning for a
metastatic focus.
2. Worsening right frontal bone expansile lytic lesion
consistent with bony metastasis.
[**2154-8-23**] US RUE/RLE - No evidence of acute deep venous thrombosis
in the right upper or right lower extremity.
Brief Hospital Course:
56 yo M with metastatic renal cell CA on palliative chemo and
XRT with mets to spine with hypoxia and hypotension.
# Hypoxia. The patient was hypoxic to 80s% on admission to the
ED but improved on 4L NC. Also hypotensive to SBP 80's. He
received approximately 1.5L NS and 1U PRBC (for Hct 22 down from
29.1 month prior). Lactate was noted to be 2.8. CXR revealed a
multifocal infiltrate and he received 1 dose of levofloxacin. A
CTA was negative for PE, but showed multifocal infiltrates
consistent with PNA. His antibiotics were broaden upon
admission to the ICU to vancomycin, ceftazidime, and
levofloxacin. The patient continued to deteriorate during the
next few days with increasing oxygen requirements. He was
started on bactrim to cover for possible bactrim given his
relative [**Name (NI) 28729**]. A family meet was held given his
worsening respiratory status that was felt to be a combination
of infection, worsening metastatic disease, and bilateral
pleural effusion. He and his family decided on CMO and all
medications were discontinued. He passed away on [**2154-8-29**] at
11:01am. His wife was with him at this bedside. His family
declined autopsy.
Medications on Admission:
IBUPROFEN 800 mg--1 tablet(s) by mouth twice a day as needed for
pain
LISINOPRIL 40 mg--1 tablet(s) by mouth once a day
METOPROLOL SUCCINATE 50 mg--1 tablet(s) by mouth daily
OXYCODONE 5 mg--1 tab by mouth every 4 hours as needed for pain
OXYCONTIN 80 mg--2 tablet(s) by mouth twice a day
PROTONIX 40MG--Take one pill each day
VITAMIN B-6 100 mg--3 tablet(s) by mouth once a day
SUTENT 12.5 mg--3 capsule(s) by mouth once a day
TUMS 500 mg--[**11-20**] tablet(s) by mouth four times a day as needed
Discharge Medications:
The patient passed away on [**2154-8-29**] at 11:01am.
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
The patient passed away on [**2154-8-29**] at 11:01am.
Discharge Instructions:
The patient passed away on [**2154-8-29**] at 11:01am.
Followup Instructions:
The patient passed away on [**2154-8-29**] at 11:01am.
|
[
"51881",
"486",
"4280",
"2762",
"2761",
"5119",
"4019"
] |
Admission Date: [**2186-5-4**] Discharge Date: [**2186-5-10**]
Date of Birth: [**2120-4-21**] Sex: F
Service:
ADMITTING DIAGNOSIS: Diabetic ketoacidosis.
HISTORY OF PRESENT ILLNESS: This is a 66 year old female
with a history of Stage 2 breast cancer, hypertension,
hypercholesterolemia where family found her on the day of
admission unresponsive. Per the Triage, she did not complain
of any chest pain, shortness of breath, fever or chills. Per
family a few days ago, she was feeling weak, slurred speech
but had not been eating. She was back to herself the day
before admission until, on the day of admission, she had
mental status changes per her grandson upon arrival to the
Emergency Department. Denies any nausea or vomiting. In the
Emergency Room, she had abdominal pain, cool extremities,
hypotensive in the 70s over 30s systolic and diastolic,
started on Levophed but weaned after intravenous fluid
hydration which improved her blood pressure. She was
intubated for a questionable concern of tiring with arterial
blood gas of 7.09, 18, and 400 O2. Post intubation, she was
transferred to the Medical Intensive Care Unit for further
treatment.
PAST MEDICAL HISTORY:
1. Stage 2 breast cancer, invasive, ductal cell, diagnosed
in [**2183**], status post Radiation therapy and chemotherapy.
2. Hypertension.
3. Hypercholesterolemia.
4. Spinal stenosis.
5. Myoclonus in bilateral lower extremities.
6. History of B12 deficiency.
HOME MEDICATIONS:
1. Aspirin.
2. Lipitor.
3. Klonopin.
4. Ibuprofen.
5. Lisinopril.
6. Os-Cal.
7. Triamterene.
8. Vitamin B12.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No history of diabetes mellitus or other
history in siblings or other family members.
SOCIAL HISTORY: No tobacco, no ethanol. Lives alone.
Independent of all activities of daily living. Daughter
calls and visits frequently every day.
PHYSICAL EXAMINATION: On admission in the Emergency Room,
vital signs were temperature 96.4 F.; blood pressure 74/37;
pulse 110; respiratory rate 18; saturation of 85% on room air
and then afterwards was intubated on AC-500, 14, FIO2 of 80%,
tidal volume 700 to 800. On examination, generally was
intubated and sedated. Skin dry. HEENT: Pupils equally
round and reactive to light and accommodation. No
lymphadenopathy. Mucous membranes were moist.
Cardiovascular with tachycardia with a regular rhythm; no
murmurs, rubs or gallops. Pulmonary clear to auscultation
bilaterally. Abdomen with decreased bowel sounds but
present. Positive tenderness per Emergency Room diffusely.
Positive guaiac. No masses appreciated. Extremities with no
cyanosis, clubbing or edema. Fingers and toes were cool with
decreased capillary refill greater than two seconds.
Neurologic is sedated with occasional myoclonic jerking.
LABORATORY: On admission, white blood cell count 16.2,
hematocrit 31.4, platelets 241, MCV 90. Sodium 138,
potassium not logged; chloride 85, bicarbonate 7, BUN of 113
and creatinine of 8.3. Glucose of 1034.
Chest x-ray showed no failure; line in place. D-Dimers were
27 and 53, fibrinogen 604. CEA 13.
Urinalysis showed many bacteria with 6 to 10 epithelials,
large blood, moderate leukocyte esterase, negative nitrites,
250 glucose, 15 ketones, 11 to 20 red blood cells, greater
than 50 white blood cells.
HOSPITAL COURSE: The patient is a 66 year old female with a
history of Stage 2 invasive ductal cancer who now presents
with new onset diabetes mellitus and in diabetic ketoacidosis
with questionable urosepsis, admitted to Medical Intensive
Care Unit.
Per Medical Intensive Care Unit summary, the patient was
intubated after course as dictated. Had done well; was
extubated. Her diabetic ketoacidosis was treated with
insulin drip and intravenous fluids aggressively and the gap
was closed two days prior to transfer to the floor.
The patient extubated the day prior to transfer to the [**Hospital1 139**]
Medicine Floor and did well. Hypotension resolved with
intravenous fluid boluses. She was also ruled out for
myocardial infarction. She was transferred then to [**Hospital1 139**]
Medicine and extubated on the day prior to the transfer to
the Medicine Floor, doing well, and weaned off of her O2
nasal cannula, at which point on the day prior to discharge
the patient was educated about diabetic medication through [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consultation recommendations. Also, multiple
educational summaries were given by the nursing staff and
physicians of how to use insulin at home and how to check
blood glucose levels. The family was involved.
The patient was able to self administer insulin and will have
education by [**Hospital **] Clinic later on this afternoon on
discharge date. She is to follow-up with [**Hospital **] Clinic and
also with Dr. [**Last Name (STitle) 4844**] with whom she has an appointment in two
weeks.
Otherwise the patient is discharged in good condition.
Pulmonary status was all recovered and no other issues.
For her urinary tract infection she was to complete a 14 day
course. She has remained afebrile since transfer back to the
floor. She is continuing eight more days of Levaquin q. day.
She is to follow-up again with Dr. [**Last Name (STitle) 4844**].
DISPOSITION: The patient was discharged to home with
[**Hospital6 407**] services.
DISCHARGE INSTRUCTIONS:
1. She was told to seek medical attention as soon as
possible if symptoms return or new symptoms arise.
2. She has appointment with [**Last Name (un) **] Diabetes Center today at
02:00 o'clock and get educated on what to further follow-up
with [**Hospital **] Clinic.
3. Also appointment with Dr.[**Name (NI) 4864**] office, with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8271**], on [**2186-5-24**], at 03:00 p.m.
4. Other recommended follow-ups as noted.
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis.
2. Diabetes mellitus.
3. Urinary tract infection.
There were no major surgical or invasive procedures except
intubated in the unit.
CONDITION AT DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Ipratropium p.r.n.
2. Levofloxacin 500 mg p.o. q. day.
3. Aspirin 325 mg p.o. q. day.
4. Protonix 40 mg p.o. q. day.
5. Insulin 70/30, 18 units q. a.m. and 70/30, 10 units q.
p.m.
The patient and family are aware of diagnosis, treatment and
frequency as indicated and managed by primary care physician.
Diet: Diabetic, low carbohydrate, low cholesterol diet.
Arranging home health services with Physical Therapy and
[**Hospital6 407**] to teach medications and
administration and checking blood glucose at home. Home
Health Service, again, as discussed above, Physical Therapy
with weight bearing, activity as tolerated with caution.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 6307**]
Dictated By:[**Name8 (MD) 12818**]
MEDQUIST36
D: [**2186-5-10**] 14:25
T: [**2186-5-11**] 18:38
JOB#: [**Job Number 12819**]
|
[
"5849",
"51881",
"5990",
"2762"
] |
Admission Date: [**2195-11-30**] Discharge Date: [**2195-12-25**]
Date of Birth: [**2118-5-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
carotid stenosis
Major Surgical or Invasive Procedure:
rt. CEA with patch [**2195-12-1**]
PEG placement [**2195-12-11**]
Trach placement [**2195-12-11**]
History of Present Illness:
77y/o male s/p left CEA, known to Dr. [**Last Name (STitle) 1391**] with followup
carotid u/s q6months.
Hospitalized [**10-19**] with stroke . manfested by left hemiparesis,
visual changes OS ( neglect) and difficulty swallowing with
aspiration. Swallowing has impproved with speech thearphy.
Presents for rt. crotid endarectomy. Has been wheel chair bound
since stroke.
ROS: hx cad with arrythmia
hx aspiration
hx c. diff treated with flagyl x 1 week
hx BPH with nocturnal frequency
denies: headaches, seizzures, syncopy, PND<Orthopnea,
palpa,pneumonia, asthma, claudication or DVT
now admitted for elective CEA
Past Medical History:
CVA [**2183**], [**10-19**]
CAD ,s/p IWMI
hx GI bleed [**8-19**] s/p EGD/colonoscopy @ [**Last Name (un) 11560**] Gen. results??
BPH
cardiomyopathy ef 30%
hx VT
s/p left CEA [**2190**]
CAGB"Sx4 [**2184**]
AICD [**2193**]
Social History:
retired [**Doctor Last Name **]
married lives with spouse
wheel chair bound
Habits: smoking d/c [**2187**] previous 2ppd x years
ETOH: denies
Family History:
unknown
Physical Exam:
Vital signs: 96.0-71-20 b/p 110/70 oxygen saturatiion 93% room
air Wt.: 85.5 Kg
general: oriented x3 mild dysarthia
HEENT:normal cephalic tongue midline
Lungs: clear to ausculattion >a/P chest diameter
Heart: regular rate rythmn. no mumur
abd: begnin
rectal: enlagred prostate smooth. guiac negative stool
PV: feet pink warm pulses 2+ symmetrical intaact
Neuro: oriented x3 CN intact, Motor sensory intact. strength
5+/5+ bilaterally upper and lower. hand grasp rt.5+/5+, lt.
hand grasp 4+/5+
Romberg not tested
DTR"S 2= plantar rt. down, let up
wt. 85.5 KG
Pertinent Results:
[**2195-11-30**] 11:56PM WBC-6.9 RBC-4.65 HGB-13.8* HCT-41.2 MCV-89
MCH-29.6 MCHC-33.5 RDW-13.5
[**2195-11-30**] 11:56PM PLT COUNT-180
[**2195-11-30**] 11:56PM PT-12.8 PTT-32.0 INR(PT)-1.0
[**2195-11-30**] 08:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2195-11-30**] 08:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2195-11-30**] 11:56PM GLUCOSE-89 UREA N-23* CREAT-0.9 SODIUM-144
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-27 ANION GAP-13
[**2195-11-30**] 11:56PM CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-1.9
Brief Hospital Course:
[**2195-11-30**] admitted and prepared for surgery.
[**12-1**] s/p rt. CEA with patch, neck rexploration and carotid
exploration with intraoperative angiogram. Acute stroke. Neuro
consulted.
[**2195-12-2**] POD#1 speech and swallow consluted. recommended NPO .
[**2195-12-3**] POD#2 hypoxic unresponsive intubated and transfered to
ICU. head CT rt, MCA stroke. sapiration?? began on Vanco ,levo
flagyl.
[**2195-12-5**] POD# 4 sputum c/s gram postive organisms and gran
negative organisms. Zosyn began for aspiration pneumonia.
VANCO?LEVO?Flagyl discontinued. Failed extubation secondary to
secreations re in;tu;bated. TPN began.
[**2195-12-9**] POD# 6 u/s of left arm for swelling negative for DVT.
[**2195-12-11**] POD# 8 c diff sent, positive flagyl restarted. PEG
placed. Tracheostomy with #8 portex placed. Zosyn d/c'd.
[**2195-12-13**] POD# [**10-17**] TPN discontinued. tube feeds began. Trach
mask all day!! sputum culture for persistant temp. GNR levo
restarted/ Vancomyci for blood c/s of GPC.CVL d/c'd
[**2195-12-16**] POD# 13/5 Transfered to VICU. PT/OT consults
[**2195-12-21**] POD# 18/10 o2 weanening began. tolerating tube feeds.
[**2195-12-22**] POD# 19/11 continues to progress. await rehab. bed
[**2195-12-24**] POD# 21/13 still with secreations and could not be
evaluated by speech and swallow at this time. Will need eval at
rehabilitation.
[**2195-12-25**] POD# 22/14 discharged to rehabilitation stable
Medications on Admission:
asa 81mgm
plavix 75mgm
iron 325mgm
toporl xl 50mgm
proscar 5mgm
folic acid 2mgm
beconase NU
cozaar 50mgm [**Hospital1 **]
combivent MDi pudd 2 [**Hospital1 **]
zeta 10mgm HS
Discharge Medications:
1.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal QD ().
3. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-16**]
Drops Ophthalmic PRN (as needed).
8. Acetaminophen 160 mg/5 mL Elixir Sig: 325-360 mgm PO Q4-6H
(every 4 to 6 hours) as needed for fever.
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Insulin Reg (Human) Buffered 100 unit/mL Solution Sig: as
directed Injection every six (6) hours: glucoses <70 [**1-16**] amp
D50%
glucoses 71-120/no insuin
glucoses 121-140/2u
glucoses 141-160/4u
glucoses 161-180/6u
glucoses 181-200/8u
glucoses 201-220/10u
glucoses 221-240/12u
glucoses 241-260/14u
glucoses 261-280/16u
glucoses 281-300/18u
glucoses 301-320/20u
glucoses 321-340/22u
glucoses 341-360/24u
glucoses 361-380/26u
glucoses 381-400/28u
glucoses > 400 [**Name8 (MD) 138**] Md.
15. Tears Naturale Drops Sig: One (1) gtts Ophthalmic four
times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
carotid stenosis rt. s/p RT. CEA
postoperative rt. MCA stroke
respiratory failure s/p trach
aspiration s/p PEG
aspiration pneumonia , treated with Zosyn
C. diff, treated
rt. neck hematoma, resolved
Discharge Condition:
improved, stable
Discharge Instructions:
trach care per routine
Followup Instructions:
4 weeks Dr. [**Last Name (STitle) 1391**]. call for appoiontment. [**Telephone/Fax (1) 1393**]
Completed by:[**2195-12-25**]
|
[
"5070",
"4280",
"4019",
"2720",
"V4581"
] |
Admission Date: [**2140-8-6**] Discharge Date: [**2140-8-10**]
Date of Birth: [**2065-1-7**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
woman with diabetes, hypertension, hyperlipidemia, and
hypothyroidism who presented to [**Hospital3 1280**] Hospital for [**7-18**]
chest pressure, facial pain, shortness of breath, and
diaphoresis after skipping her evening medications.
She was given 81 mg of aspirin, sublingual nitroglycerin
times three, and 4 mg of morphine by Emergency Medical
Service in the field. An electrocardiogram was done that
revealed ST elevations in the inferior leads. She was given
3000 units of heparin, a nitroglycerin drip, Lasix 40 mg, and
started on Integrilin. She was premedicated with Solu-Medrol
and Benadryl due to a suspected allergy to contrast and sent
to [**Hospital1 69**] for cardiac
catheterization.
The patient denied any previous myocardial infarction but
states she was hospitalized once for congestive heart
failure. A transthoracic echocardiogram on [**2139-6-26**]
demonstrated an ejection fraction of 65% with 1+ mitral
regurgitation and delayed relaxation of left ventricular
inflow. She currently denies orthopnea and paroxysmal
nocturnal dyspnea. She has used a walker for a number of
years and currently gets short of breath with minimal
exertion.
Her current chest pressure had completely resolved upon
arrival to [**Hospital1 69**] where she was
taken straight to the catheterization laboratory. Cardiac
catheterization showed normal left main coronary artery with
20% ostial left anterior descending artery, normal right
coronary artery, 30% proximal left circumflex, 30% first
obtuse marginal. The obtuse marginal and left posterior
descending artery demonstrated cutoffs consistent with
embolism and spontaneous thrombolysis. No interventions were
made.
Of note, during the cardiac catheterization the femoral
artery was unable to be cannulated, and a right radial
approach was necessary.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes.
3. Pulmonary hypertension.
4. Urinary incontinence.
5. Anemia.
6. Osteoarthritis.
7. Hypothyroidism.
8. Congestive heart failure.
PAST SURGICAL HISTORY:
1. Left shoulder replacement.
2. Varicose vein surgery.
3. T12-L2 arthrodesis with pedicle screw fixation.
FAMILY HISTORY: Family medical history was significant for
mother who died of a myocardial infarction in her 80s.
SOCIAL HISTORY: The patient denies tobacco or alcohol use.
She lives at home with her husband in [**Name (NI) 47**]. Five of
her children are living in the area. She is a retired
receptionist.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature of 98,
blood pressure of 162/82, heart rate of 81, respiratory rate
of 12, and oxygen saturation of 99% on 2 liters nasal
cannula. In general, the patient was obese and talkative, in
no apparent distress. Head, eyes, ears, nose, and throat
revealed jugular venous pressure was not appreciated. Pupils
were equal, round, and reactive to light. Extraocular
movements were intact. Possible 3-cm X 3-cm goiter on the
left lobe of the thyroid. Chest was clear to auscultation
bilaterally and anteriorly; unable to assess posterior lung
fields. Cardiovascular examination revealed a regular rate.
Normal first heart sound and second heart sound. Positive
fourth heart sound. No murmurs. The abdomen was obese,
soft, nontender, and nondistended. Normal active bowel
sounds. Extremities revealed 2+ pitting edema bilaterally to
the knees. Good dorsalis pedis pulses bilaterally.
Neurologically, alert and oriented times three, nonfocal.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed a white blood cell count of 11.9,
hemoglobin of 11.9, hematocrit of 33.9, platelets of 140.
Chemistry revealed a sodium of 140, potassium of 4.9,
chloride of 102, bicarbonate of 20, blood urea nitrogen
of 49, creatinine of 1.9, blood glucose of 23, with an anion
gap of 18. PT of 14.8, PTT of 150, INR of 1.5. Initial
arterial blood gas was 7.39/43/66/23.
RADIOLOGY/IMAGING: Electrocardiogram done on admission pain
free revealed 2-mm to 3-mm ST elevations in the inferior lead
with ST depressions in V2 through V4, aVL; all new compared
to electrocardiogram dated [**2139-6-30**].
IMPRESSION: The patient is a 76-year-old female status post
inferior myocardial infarction with spontaneous thrombolysis.
HOSPITAL COURSE:
1. CARDIOVASCULAR: (a) Coronary artery disease: The
patient was transferred to the Coronary Care Unit and was
started on aspirin, Plavix, Integrilin drip, and Lipitor.
The Integrilin drip was stopped prematurely, approximately
eight hours after staring, status post catheterization due to
concern over bleeding from central venous site as well as a
femoral sheath.
Cardiac enzymes were cycled and showed a peak creatine
phosphokinase at 7 a.m. after admission at 1306, CK/MB of 84,
and an index of 6.4, with a troponin of greater than 50. All
cardiac enzyme markers trended downward for the remainder of
the hospital course.
Lipids were checked on hospital day four, and the patient was
found to have an low-density lipoprotein of 95; and therefore
Lipitor was stopped.
(b) Pump: The patient was on six antihypertensive
medications at home. On admission, she stated she was
compliant with all.
Status post catheterization, her medications were started and
titrated up slowly, and she was discharged on an
antihypertensive regimen of metoprolol 100 mg p.o. b.i.d.,
enalapril 40 mg p.o. q.d., Lasix 40 mg p.o. b.i.d. The
patient's blood pressure at the time of discharge was 130/78.
A repeat echocardiogram was performed on [**2140-7-10**] which
showed an ejection fraction of 35%, hypokinesis of basal
inferolateral walls consistent with systolic dysfunction,
moderate pulmonary hypertension.
(c) Rate and Rhythm: The patient had a 10-beat run of
ventricular tachycardia on hospital day two; presumed due to
reperfusion.
2. HEMATOLOGY: The patient was transfused 2 units of packed
red blood cells during her hospital course for a hematocrit
fall from a hematocrit of 31 with concern over excessive
bleeding from central line sites.
3. ENDOCRINE: The patient was started on her outpatient
regimen of glyburide 2.5 mg and a regular insulin
sliding-scale. Synthroid 175 mcg, believed to be the correct
outpatient dose, was started. The patient's glucose was well
controlled during her hospital course with a maximum
fingerstick not greater than 150. No signs of hypothyroidism
were noted during her hospital course.
4. GASTROINTESTINAL: On hospital day four, the patient had
four loose stools in the morning due to concern for
Clostridium difficile toxin, an assay was sent which came
back negative. The patient's diarrhea resolved by hospital
day five.
5. REHABILITATION: The patient was seen and evaluated by
Physical Therapy who believed that the patient was back to
baseline and safe for discharge back to home. The patient's
family did not feel it was necessary for [**First Name (Titles) 1587**] [**Last Name (Titles) **] nurse assistance at this time.
CONDITION AT DISCHARGE: Condition on discharge was much
improved and stable.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 100 mg p.o. b.i.d.
2. Enalapril 40 mg p.o. q.d.
3. Enteric-coated aspirin 325 mg p.o. q.d.
4. Lasix 40 mg p.o. b.i.d.
5. Plavix 75 mg p.o. q.d. (times 30 days).
6. Glyburide 2.5 mg p.o. q.d.
7. Synthroid 175 mcg p.o. q.d.
8. Paxil 20 mg p.o. q.d.
DISCHARGE DIAGNOSES:
1. Diabetes.
2. Hypothyroidism.
3. Hypertension.
4. Acute inferior myocardial infarction.
5. Congestive heart failure.
DISCHARGE FOLLOWUP:
1. Follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) 1968**] ([**Hospital3 1280**] Hospital
Cardiology); appointment scheduled for [**2140-8-19**].
2. Follow up with Dr. [**First Name4 (NamePattern1) 2411**] [**Last Name (NamePattern1) 17103**] ([**Hospital 27252**] Medical),
primary care physician; to be scheduled by the patient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D:
T: [**2140-8-11**] 11:38
JOB#: [**Job Number 33117**]
cc:[**Telephone/Fax (1) 33118**]
|
[
"4280",
"41401",
"4019",
"25000",
"2720",
"2449",
"2859"
] |
Admission Date: [**2131-5-16**] Discharge Date: [**2131-5-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Bradycardia, hypotension
Major Surgical or Invasive Procedure:
Intubation
Thoracentesis
History of Present Illness:
Pt is an 88 yo male with h/o CHF (EF 45%), CAD, CKD, TIIDM
admitted to the MICU from rehab with hypotension, junctional
bradycardia, and mental status change [**2131-5-16**]. The patient was
admitted to [**Hospital3 1196**] [**Date range (1) 39358**] after a
mechanical fall and treated for UTI and CHF exacerbation. He was
discharged to [**Hospital 18979**] rehab on [**2131-5-5**]. For the past few days he
complained of worsening weakness and fatigue. He was noted to be
bradycardic and metoprolol was held as of [**2131-5-15**]. On the day of
admission he was found to be hypotensive (SBP 90s), bradycardic
(HR 30s), and with mental status changes; he was sent to [**Hospital1 18**]
ED.
.
In the ER the pt was in a junctional rhythm with a rate in the
30s and was treated with atropine. He was treated for
hyperkalemia and also given glucagon due to beta-blockade. He
reverted to NSR with rate in the 60s. The patient was intubated
in the ER for mental status changes and airway production in
setting of uremia and patient vomiting. He was seen by
cardiology who thought the bradycardia was secondary to
hyperkalemia, which was secondary to renal failure, and
recommended dialysis. Renal was consulted and did not believe
dialysis was indicated at this time.
Past Medical History:
Type II diabetes mellitus
CKD with baseline creat 2.0 in [**1-/2131**], thought secondary to
diabetic nephropathy
CAD s/p CABG 13yrs ago, s/p NSTEMI with PCI x3 ~2 months prior
CHF (EF 45% echo [**2131-4-25**] with inferior hypokinesis, left atrial
enlargement)
Chronic 02 requirement of 2.5 L NC for CHF
Hypothyroidism
h/o Proteus UTI
Vertigo
Left eye blindness s/p childhood accident
HOH R ear
s/p recent mechanical fall
Social History:
Lives with wife. [**Name (NI) **] three daughters, two that live in the area
and visit twice a week.
Family History:
Mother died of MI at 67.
Physical Exam:
Wt 82.2kg T 96.6 HR 59 BP 119/67 RR 14 99%
A/C Tv 550 RR 14 FiO2 40% PEEP 5
Gen: intubated, sedated male in NAD
HEENT: right pupil reactive, left opacified, anicteric, MMM
Neck: supple, JVP nondistended
Cardio: bradycardic with reg rhythm, nl S1 S2, no m/r/g
Pulm: occasional bilateral wheeze, o/w CTA
Abd: soft, NT, distended with fluid wave, + BS, no masses, no
HSM
Ext: 2+ peripheral edema (R>L); decreased DP and PT pulses B
Pertinent Results:
[**5-21**] chest ct:
1. No evidence of that moderate to large right pleural effusion
is anything other than a transudate. Relaxation atelectasis
probably responsible for collapsed right middle and lower lobe.
2. Mild mediastinal adenopathy could be due to congestive heart
failure.
3. Severe atherosclerosis, predominantly in coronaries, also in
the aorta, innominate artery, and upper abdomen.
4. Probable pulmonary arterial hypertension. Mild cardiomegaly.
Aortic valvular calcification, hemodynamic significance
uncertain.
5. Ascites.
6. No evidence of sternotomy complications.
ecg:
Normal sinus rhythm with left anterior fascicular block. Cannot
exclude prior
inferior myocardial infarction. Compared to the previous tracing
of [**2131-5-18**] no
diagnostic interval change.
Brief Hospital Course:
A/P: 88yo male with h/o TIIDM, CAD, CHF, CKD p/w hyperkalemia,
bradycardia, hypotension, and acute on chronic renal failure.
Admitting diagnoses improved on discharge. Pt discharged to
rehab for PT/OT.
.
1) Bradycardia/hypotension/hyperkalemia: Likely multifactorial
due to hyperkalemia in the setting of beta-blocker and
amiodarone in addition to the recent diagnosis of
hypothyroidism. Initial rhythm was junctional bradycardia in 40s
which improved to sinus rhythm/sinus brady with atropine,
treatment of hyperkalemia, and increase of levothyroxine. Blood
pressure also improved with treatment of bradycardia. The pt had
no further episodes of bradycardia after his initial
stabilization. Amiodarone and metoprolol were restarted in the
intensive care unit prior to transfer to the floor.
.
2) Renal Failure: Current presentation likely acute on chronic
renal failure due to overdiuresis (and subsequent CHF
precipitated by volume load to treat hypovolemia). Etiology of
CKD most likely diabetic nephropathy. Nephrology believes he
will need dialysis within the year. [**Last Name (un) **] discontinued during
hospitalization and was not restarted on discharge. Recent creat
2.0-2.6 at OSH; 2.2 on discharge. Pt was followed in house by
nephrology, who by discharge recommended: discontinuing renagel,
decreasing calcium to 500mg tid, decreasing lasix to 40mg po qd
to decrease risk of hypovolemia, and continuing epogen 10,000u
qmwf. Pt discharged with caudet catheter and is scheduled for
follow-up with urology. Pt will follow-up with nephrology
locally as he will need close observation.
.
3) CHF: Diastolic dysfunction with EF 60% and home O2
requirement of 2.5L. Pt diuresed with lasix IV and po.
Outpatient regimen of ASA, metoprolol, statin continued; [**Last Name (un) **]
discontinued because of ARF. At dry weight and baseline O2
requirement on discharge. Lasix 40mg po qd on discharge with
care not to overdiurese. Pt will follow-up with his cardiology
at [**Hospital1 **].
.
4) Right pleural effusion: The pt received a
therapeutic/diagnostic thoracentesis for non-resolving right
pleural effusion the day prior to discharge. 2L fluid removed,
with subjective improvement in dyspnea. The effusion was found
to be transudative and is most likely secondary to heart
failure. The effusion is less likely secondary to infection in
this pt who remained afebrile and appear nontoxic. Gram stain
negative, although cultures pending. Also of concern is
malignant effusion in setting of ascites. Pleural fluid culture
and cytology will need follow-up.
.
5) Ascites/liver function: Likely secondary to right heart
failure; RUQ showed no liver pathology. Repeat US showed mild
ascites. Improved with diuresis. Repeat LFTs showed resolved
transaminases with alk phos 192, GGT 147, total bili 0.3. Pt
without symptoms of biliary disease. Recommend follow-up LFTs
for resolution within one month of discharge.
.
6) CAD: Pt denied CP during admission. Outpatient regimen of
ASA, lipitor, and metoprolol continued; as above, [**Last Name (un) **] held for
ARF.
.
7) TIIDM: QID FS's, RISS. Glyburide held in house with adequate
blood sugar control; consider restarting as outpatient as
needed.
.
8) Communication: Wife
.
9) Code status: Full
Medications on Admission:
RISS
Tylenol 650 PO q 3 hrs
milk of magnesia PRN
dulcolax PRN
lasix 80 mg qd
prilosec 20 mg PO BID
glyburide 2.5 mg
colace 100 mg PO BID
folic acid 1 mg qd
vitamin B12 500 mg qd
Vitamin B6 50 mg PO qd
Ambien 5 mg qhs PRN
Lopressor 50 mg PO BID ( d/c'd [**5-15**])
ASA 325 mg PO qd
Plavix 75 mg qd
Amiodarone 200 mg PO qd
Lipitor 40 mg qd
Metolazone 2.5 PO qd
Losartan 50 mg PO
Levothyroxine 25 mcg qd
Flomax 0.4 PO BID
Remeron 15 mg PO qhs
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) 10,000
Injection QMOWEFR (Monday -Wednesday-Friday).
13. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Haloperidol Lactate 5 mg/mL Solution Sig: 2.5 mg Injection
Q4H (every 4 hours) as needed for agitation.
17. Insulin Regular Human 100 unit/mL Solution Sig: as directed
units Injection ASDIR (AS DIRECTED): sliding scale is attached.
18. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Vitamin B-6 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Bradycardia
Congestive heart failure
Acute on chronic renal failure
Right pleural effusion
Discharge Condition:
On 2.5L O2 as per outpatient, afebrile, vital signs stable
Discharge Instructions:
Please contact a physician if you have shortness of breath that
does not improve.
.
Please contact a physician if you have chest pain that does not
resolve.
.
Please take your medications as prescribed.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4027**]
Please follow-up with you cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 39359**]
Please follow-up with a renal physician in your area or you may
call the renal clinic at [**Hospital1 18**] ([**Telephone/Fax (1) 773**] for an
appointment- you should see them within 1 month of discharge
Please f/u with urology on [**2131-6-1**] at 10:15 am on [**Hospital Ward Name **] 3
([**Hospital1 18**])
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"5849",
"2767",
"5119",
"4280",
"42789",
"41401",
"412",
"5859"
] |
Admission Date: [**2147-10-27**] Discharge Date: [**2147-11-10**]
Date of Birth: [**2096-9-24**] Sex: F
Service: CT [**Doctor First Name 147**]
ADMISSION DIAGNOSIS:
Coronary artery disease requiring revascularization.
HISTORY OF PRESENT ILLNESS: This is a 51-year-old female
with a history of increasing fatigue, increasing dyspnea on
exertion and chest discomfort with known rheumatic fever, who
was admitted for cardiac catheterization on [**2147-10-27**]. This
demonstrated 80% left main coronary artery with moderate
mitral regurgitation and mitral stenosis.
PAST MEDICAL HISTORY: The past medical history was
significant for noninsulin dependent diabetes mellitus,
hypertension and rheumatic fever.
MEDICATIONS ON ADMISSION: Her medications on admission
included Diovan, atenolol, Glucophage, Glucotrol, aspirin,
Lasix, Flonase, iron sulfate and Claritin.
ALLERGIES: The patient had an allergy to Tylenol #3.
PHYSICAL EXAMINATION: On physical examination, the patient
was a 51-year-old obese female in no apparent distress.
Neurologically, she was grossly intact. The lungs were clear
to auscultation bilaterally. The cardiac examination was
significant for an S1 and S2 and a grade II/VI systolic
ejection murmur. The abdomen was obese and soft with active
bowel sounds. The extremities were warm with palpable
dorsalis pedis pulses bilaterally and no peripheral edema
noted.
PLAN: The plan was to perform coronary artery bypass
grafting and mitral valve replacement, which was scheduled
tentatively with Dr. [**Last Name (STitle) 1537**] for [**2147-10-30**].
HOSPITAL COURSE: The patient was admitted to the medicine
service. She stated that she needed a root canal for two
broken teeth. The oromaxillofacial surgery service was
called and the patient underwent a tooth extraction on
[**2147-10-28**]. She developed chest discomfort that she
associated with the stress of surgery. Given what appeared
to be angina, she was started on heparin drip.
The patient was taken to the operating room by Dr. [**Last Name (STitle) 1537**] on
[**2147-10-30**], where coronary artery bypass grafting times two
was performed as follows: left internal mammary artery to
left anterior descending artery and radial artery to obtuse
marginal artery as well as mitral valve replacement with a
#29 Carbomedics. The patient was maintained on nitroglycerin
postoperatively in the cardiac surgery recovery unit, given
her radial artery bypass graft. She did well and was
extubated without complications. Lasix, Lopressor, aspirin
and Imdur were begun. Her chest tubes were removed and she
was transferred to the floor.
The patient was doing well on the floor until postoperative
day #2, when she developed rapid atrial fibrillation with a
heart rate in the 160s, requiring intravenous Lopressor for
rate control. She was also begun on amiodarone. She was
relatively well rate controlled in a rhythm that alternated
between atrial fibrillation and atrial flutter when, on
postoperative day #4, it was noted that the patient had a
long, approximately 4.2 second, pause in which there was no
ventricular response to her atrial flutter. The cardiology
service was consulted and she subsequently had two further
episodes with syncopal symptoms.
At this time, her amiodarone was decreased and her Lopressor
was stopped. She was started on a heparin drip, given her
persistent atrial flutter/fibrillation. Coumadin had also
been started. The cardiology consultant recommended that the
patient would benefit from pacemaker placement; however, the
patient requested if there were any alternative treatments
and was informed that cardioversion would be an appropriate
second choice to try to disrupt the atrial fibrillation and
see if the patient had persistent pauses post cardioversion.
A transesophageal echocardiogram was obtained to ensure that
there was no clot in the left atrium. At that time, a
significant clot was found in the left atrial appendage,
which contraindicated cardioversion. Hence, the patient was
scheduled for pacemaker placement. Her Coumadin was held.
Once her INR dropped to below 1.8, the patient underwent dual
chamber pacemaker placement with a Medtronics bipolar pacing,
bipolar sensing pacemaker. She tolerated the procedure well
and was restarted immediately on her Coumadin as well as on a
heparin drip.
CONDITION ON DISCHARGE: The patient was doing well and on
postoperative day #11, given the fact that she was afebrile
with a relatively well controlled heart rate and she was
doing well despite being in persistent atrial
fibrillation/flutter with excellent rate control, that she
would be stable for discharge. On the day of discharge, the
patient was clear to auscultation and in a regular rhythm.
Her sternum was stable and dry. Her abdomen was soft. Her
extremities were well perfused with minimal edema.
DISCHARGE DIET: The patient was discharged on a cardiac
diet.
DISCHARGE MEDICATIONS:
Lopressor 50 mg p.o. t.i.d.
Lasix 20 mg p.o. b.i.d. times ten days.
Potassium chloride 20 mEq p.o. b.i.d. times ten days.
Colace 100 mg p.o. b.i.d.
Imdur 30 mg p.o. q.d.
Glucophage 1000 mg p.o. b.i.d.
Glucotrol 10 mg p.o. b.i.d.
Aspirin 81 mg p.o. q.d.
Motrin 600 mg p.o. every six hours p.r.n.
Zantac 150 mg p.o. b.i.d.
Sliding scale insulin.
Coumadin 2 mg p.o. q.d.
Heparin intravenous drip at 700 units per hour.
Percocet.
DISCHARGE INSTRUCTIONS: The instructions for anticoagulation
were that a target INR of 3 to 3.5 should be attained. Until
that occurs, heparin should be maintained with a target
partial thromboplastin time of 60 to 80.
FOLLOW UP: The patient is scheduled for a follow up
appointment with Dr. [**Last Name (STitle) 1537**] in one month and a pacemaker clinic
follow up in one week. The phone number for the clinic is
[**Telephone/Fax (1) 59**].
The patient was instructed
DISCHARGE DIAGNOSES:
1. Noninsulin dependent diabetes.
2. Hypertension.
3. Rheumatic fever.
4. Rheumatic mitral valve disease, status post mitral valve
replacement.
5. Coronary artery disease, status post coronary artery
bypass grafting.
6. Atrial fibrillation/atrial flutter, status post pacemaker
insertion.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2147-11-10**] 14:57
T: [**2147-11-10**] 17:22
JOB#: [**Job Number 95534**]
|
[
"41401",
"4019",
"25000"
] |
Admission Date: [**2149-10-7**] Discharge Date: [**2149-10-20**]
Date of Birth: [**2103-6-23**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Amoxicillin / Blood-Group Specific Substance /
Adhesive Tape
Attending:[**Doctor First Name 3290**]
Chief Complaint:
productive cough
Major Surgical or Invasive Procedure:
ORTHOPEDIC:
1. Removal implant deep left fibula.
2. Open biopsy bone deep left medial malleolus
CARDAIC:
Cardiac Catherization ([**10-17**])
History of Present Illness:
Per report patient was in USOH when began experiencing cough
productive of clear sputum with nausea worse than baseline. (She
felt sx were related to left ankle infection; as it was not
chararacteristic of CHF excerbation which includes PND,
orthopnea) Called EMS and admitted to [**Hospital1 34**]. On initial
presentation febrile to 100.1 BP: 80/50, tachycardiac,
leukocytosis to 10.7. Initial CXR: flash pulmonary edema vs PNA.
She was admitted to ICU, initially requiring 100% Fio2, started
on stress dose steriods, IV vanc and levofloxacin 750mg QD and
diuresis with IV lasix 20mg. Notable OSH labs: influenza A and
B: neg, urine legionella neg, urine strep pneum antigen neg.
Urine cx neg. Blood cx positive 2/4 bottles for gram + cocci in
clusters (coag neg staph) - deemed contaminant by ID
(levofloxacin stop date per notes [**10-8**]). Creatinine at time of
transfer: 2.0 (1.4 admission -> 2.0; per renal recs at OSH stop
Lasix). Vancomycin had been stopped and patient continued on
Levofloxacin (750mg IV q48hrs) for atypical PNA vs brochitis
Per report initially hyperglycemic neccisitating insulin gtt on
night of admission b/c of mild DKA which resolved and pt
transitioned to SQ inusulin. Prior to transfer transitioned to
home regime. At time of transfer she was saturating well on 3L
NC, BG controlled.
.
Of note, patient with history of left ankle fracture in
[**2148-10-1**] status post ORIF, c/b complicated by failure of
healing of the medial malleolar wound and medial malleolar
hardware-associated osteomyelitis with coag-negative staph. Drs.
[**Name5 (PTitle) **] ([**Name5 (PTitle) 1957**]), [**Doctor Last Name **] (ID), and [**Last Name (un) 3407**] (vascular) have been
following. She is s/p wash out and 2 courses of prolonged IV
vanco (6weeks) currently on doxycycline suppression therapy
(100mg PO BID). In the last 1-2 weeks (while on doxy), her
infection has returned with increased drainage and tenderness of
medial malleolar wound as well as rising inflammatory markers
(CRP: 3 ->100). Per [**Last Name (un) **] plan is to return to the OR with Dr.
[**Last Name (STitle) **] for a repeat wash out in effort to treat this
infection. After she no longer has an infectious source and she
is no longer as deconditioned, then she may be considered for
MVR to prevent her recurrent CHF.
.
On arrival, initial vital signs were 98.8 118/57 87 18 3L
NC. Overall patient in no distress. Reports persistent wet cough
but denies SOB, PND, orthopnea, peripheral edema. Complains of
left ankle pain as well as pain in right hip (at baseline).
Reports abdominal pain, blaoting and minimal nausea (again
baseline sx). Denies any fevers, chills, weight loss or gain.
Denies chest pain, palp. Denies diarrhea, constipation, dysuria.
Past Medical History:
PAST MEDICAL HISTORY:
# CAD and MI, s/p CABG:
- LIMA to LAD, SVG to OM, SVG to Diagonal, and SVG to PDA. SVG
to
the OM and diagonal occluded
# Diastolic Heart Failure
# Peripheral vascular disease c/b chronic heel ulcers
# Hypertension
# Diabetes Mellitus-type I c/b retinopathy (legally blind) and
neuropathy, gastroparesis
# osteoporosis
# Sarcoid, reported lung nodule
# depression
# s/p right tibial fracture
# s/p right leg fracture (cast), [**2147**]
# s/p left wrist fracture, [**2147**]
# s/p fall and intracranial bleed, [**2147**]
# Blood group specific substance. Blood products (red cells and
platelets) should be leukoreduced.
Past Surgical History
.
Cardiovascular:
# CABG [**5-1**]- LIMA to LAD, SVG to OM, SVG to Diagonal, and SVG to
PDA. SVG to the OM and diagonal occluded
# s/p right femoropopliteal bypass and left SFA drug-eluting
[**Last Name (LF) **],
[**2147-5-2**]
RENAL:
# s/p living-related kidney transplant [**2140-10-31**] (baseline Cr
1.2-1.3 over the last year)
[**Year (4 digits) **]:
# s/p Open Reduction Internal Fixation of Left Bimalleolar
Fracture
([**2148-10-15**])
# s/p left patella open reduction and fixation, [**2147**]. Hardware
removed [**2148-10-15**]
# s/p left ankle washout and hardware removal ([**3-/2149**])
GI:
# s/p cholecystectomy
Social History:
Patient lives with her mother who is her primary care giver.
Ambulates with assistance
-Tobacco history: smokes half a [**4-3**] cig/day
-ETOH: none
-Illicit drugs: smokes marijuana several times per week to help
with nausea and appetite
Family History:
There is no history of diabetes or kidney disease. Her father
had an MI at 74 and mother has hypertension. Grandfather had
leukemia and hypertension.
Physical Exam:
Vitals: 97.9 151/69 (primarily: 120-130s/50-80s) 69 (70s) 99%
RA
FS: 91, 108, 118, 126
General: Chronically-ill appearing, sitting upright in bed, NAD.
HEENT: Legally blind. Scleral anicetric. Moist mucous membranes.
OP without exudates or lesions
Neck: supple, no LAD
Heart: RRR, II/VI systolic ejection murmur best heard at LSB, no
appreciable carotid bruit, no peripheral edema
Lungs: CTA-B, no wheezes, no crackles, good aeration b/l, no
accessory muscle use
Abdomen: soft, NT, ND +BS, no guarding
Extremities: warm, well perfused, no clubbing, cyanosis.
#Left ankle: medial and lateral ankle with gauze: dressing with
serosangious drainage; non-tender, FROM,
# Right toe: quarter size eschar on tip of toe with mild
erythema, non-tender, no drainage.
Neuro: Alert and oriented x3; moving all extremities with no
focal deficits, decreased sensation on b /l LE.
T/L/D
- PICC line: R arm: dressing c/d/i, no surrounding tenderness or
erythemia
Pertinent Results:
OSH labs and imaging:
Trop negx3.
[**10-6**] BMP: 134/4.698/17/31/1.4
.
Imaging:
CXR ([**10-5**]) OSH
Minimal interstitial edema compatible with mild CHF, no focal
alveolar opacity or pleural effusion
.
[**Hospital1 18**] labs:
Trop neg
CRP: 15.3
ESR: 57
.
CBC at discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
4.7 3.17* 9.5* 28.7* 91 29.9 33.1 14.5 467*
BMP at discharge:
Glucose UreaN Creat Na K Cl HCO3 AnGap
152 23* 1.9* 134 4.2 98 27 13
.
IMAGING:
.
RENAL US ([**10-8**])
RENAL TRANSPLANT ULTRASOUND: The right lower quadrant renal
transplant is
identified. There is no hydronephrosis or perinephric fluid. The
urinary
bladder is decompressed around a Foley catheter, and therefore
not well
visualized.
DOPPLER EXAMINATION: The main renal artery and vein are patent
with
appropriate waveforms. Resistive indices of the upper, mid, and
lower pole of the transplant kidney are 0.64, 0.71 and 0.60
respectively. Arterial
waveforms are appropriate, with sharp systolic upstrokes and
preserved flow through diastole.
IMPRESSION:
1. Normal renal transplant ultrasound.
2. Normal renal transplant Doppler examination
.
TTE ([**10-10**])
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with inferolateral hypokinesis.
The remaining segments contract normally (LVEF = 45%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. No masses or vegetations are seen on the aortic valve.
The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No vegetations seen (adequate-quality study). Mild
regional left ventricular systolic dysfunction, c/w CAD. Normal
global and regional biventricular systolic function. In presence
of high clinical suspicion, absence of vegetations on
transthoracic echocardiogram does not exclude endocarditis.
.
CXR ([**10-16**])
FINDINGS: Interval removal of endotracheal and nasogastric tube.
Right PICC position stable with tip in the mid SVC. No
pneumothorax. Sternotomy sutures are midline and intact.
Improved aeration of the left retrocardiac space. The three
faint rounded opacities first demonstrated in the left lung on
[**2149-10-9**] chest x-ray are less conspicuous than prior. The
cardiac silhouette is top normal. The mediastinal and hilar
contours are unremarkable.
IMPRESSION: Improved aeration of retrocardiac space. Less
conspicuous
rounded opacities in left lung, recommend continued radiographic
followup.
.
Cardiac Cath ([**10-17**])
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 8-
6A) SEPTAL-1 NORMAL
7) MID-LAD DISCRETE
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 DISCRETE 90
11) INTERMEDIUS NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
17) LEFT PDA NORMAL
17A) POSTERIOR LV NORMAL
**ARTERIOGRAPHY RESULTS TO SEGMENTS MORPHOLOGY % STENOSIS
LOCATION
**BYPASS GRAFT
28) SVBG #1 NORMAL
29) SVBG #2 NORMAL
30) SVBG #3 NORMAL
31) SVBG #4 NORMAL
32) LIMA NORMAL
33) RIMA NORMAL
.
COMMENTS:
1. Coronary angiography in this right dominant system revealed
diffuse
multivessel multivessel disease. The LMCA had no
angiographically significant disease. The LAD had an 80%
proximal stenosis. The large D1 had no angiographically
apparent disease. The
small D2 had 90% stenosis, as in prior angiographic images. The
prior
PTCA site in the Cx was patent with normal flow. THe RCA was
known to
be occluded. The SVG-RCA was patent. THE LIMA-LAD was patent.
2. Resting hemodynamics revealed normal right-sided filling
pressures
and pulmonary capillary wedge pressures. The cariac index was
preserved.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease with patent SVG to PDA,
LIMA to
LAD and patent PTCA site to the LCx.
2. Normal right-sided filling pressures.
.
MICRO:
[**2149-10-9**] 10:55 pm URINE Source: Catheter.
**FINAL REPORT [**2149-10-11**]**
URINE CULTURE (Final [**2149-10-11**]): NO GROWTH.
.
[**2149-10-14**] 11:30 am TISSUE Site: ANKLE LT LATERAL ANKLE.
GRAM STAIN (Final [**2149-10-14**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2149-10-17**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2149-10-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2149-10-15**]):
NO FUNGAL ELEMENTS SEEN.
[**2149-10-14**] 11:30 am TISSUE Site: ANKLE
MEDIAL LEFT ANKLE TISSUE.
GRAM STAIN (Final [**2149-10-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2149-10-17**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2149-10-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2149-10-15**]):
NO FUNGAL ELEMENTS SEEN.
.
Blood Cx ([**10-8**], [**10-9**]): NGTD
Brief Hospital Course:
Ms [**Known lastname 19419**] is a 46yo female with h/o poorly controlled
diabetes type 1, CAD, MI status post CABG and PCI, end-stage
renal disease status post living-related renal transplant in
[**2140-10-31**] on tacrolimus and prednisone immunosuppression,
transferred from OSH for continued treatment of URI/atypical PNA
and CHF exacerbation; hospital course c/b aspiration event
requiring intubation, transferred back to the floor for
continued mgmt of CHF, chronic osteo of L. ankle and coronary
artery disease.
.
# CHF. Patient with multiple prior admissions to [**Hospital1 **] and OSH with
CHF exacerbations. On this admission to it was thought that
possible URI/atypical PNA/bronchitis triggered mild CHF
exacerbation. Initial presentation at OSH notable for low-grade
fever, leukocytosis to 10.6. CXRs from OSH consistent with
pulmonary edema: interstitial edema and Kerley B lines, no focal
consolidations noted. On admission to [**Hospital1 **] patient afebrile with
normal WBC. She was diuresised with improvement in respiratory
symptoms. Finished 7day course of levofloxacin for coverage of
atypical PNA. Initially, patients underlying CAD causing
ischemia in setting of hypertension thought to account for
tendency to flash. However, patient was taken for cardiac
catherization on [**10-17**] which was clean. Question if recurrent
flashes simply resulted from med and diet noncompliance. At time
of discharge patient hemodynamically stable, without need for
supplemental oxygen. Lasix dose at time of discharge 80mg PO
daily with blood pressures and fluid status well controlled.
.
# Episode of respiratory failure thought to be secondary to an
aspiration event. Patient was found cyanotic on floor with
evidence of recent emesis. A code blue was called, patient
intubated and transferred to ICU. Of note patient was never
pulseless. The patient was able to be extubated after one day in
the unit. She rapidly improved and was able to tolerate nasal
cannula oxygen without difficulty. A speech and swallow eval
was done and she passed without difficulty. She was restarted on
her home meds, full diet and transferred back the floor with no
further aspiration events.
.
# Wall motion abnormality. After the episode of respiratory
distress requiring intubation TTE was ordered to assess for any
cardiac cause. TTE demonstrated a new inferior wall motion
abnormality when compared to most recent echo in [**Month (only) 958**]. Trops
cycled and neg. Initially, no further cards work-up was
performed prior to orthopedic wash-out of left ankle. Cardiac
cath performed later in hospitalization was clean.
.
# Medial malleolus osteomyelitis - On admission oral suppressant
regimen of doxycyline stopped per ID request to optimize yield
of bone biopsy. Due to increasing concern over recurrent
infection, evident by increased inflammatory markers, patient
started on IV vancomycin. She was taken to OR on [**10-14**] for Left
ankle wash-out. Tissue and bone biopsies were obtained during
the procedure: no growth to date. Patient to follow-up with ID
and [**Month/Year (2) **] as outpatient. Plan to continue likely 6wk course of
IV antibiotics. Will follow-up in [**Month/Year (2) **] clinic in 2-3wk for
suture removal. At time of discharge, medial and lateral
incision sites clean, dry, intact with no surrounding erythema
or stigmata of infection. Patient discharged on vancomycin 750mg
IV QD. Regarding pain patient discharged on outpatient percocet
regimen as well as lidocaine patch and small supple (30tablets)
of dilaudid 2mg PO for breakthru pain in the post-operative
period.
.
# Diabetes Mellitus with gastroparesis - Blood sugars difficult
to control in house. Initial hyperglycemia likely aggravated by
stress dose steriods that were received at outpatient hospital
and again in our ICU, Insulin was dosed as [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recommendations. At time of discharge lantus 10u [**Hospital1 **], ISS.
Metoclopramide and Zofran used to control nausea secondary to
gastroparesis while hospitalized.
.
# ESRD s/p post living-related renal transplant in [**2140-10-31**]
on tacrolimus and prednisone immunosuppression. Baseline
creatinine in recent months: 1.2 - 1.8. [**10-7**] OSH labs: creatinine
2.0. Concern for acute on chronic kidney failure as admission
creatinine elevated slightly above base at 2.2. Renal ultrasound
ordered to assess transplant kidney; dopplers were normal with
no sign of rejection. Tacrolimus levels were monitored daily and
at time of discharge patient on 2.5mg PO BID with plan to follow
level with outpatient labs. Patient continued on prednisone 4mg
daily. Creatinine at time of discharge 1.9. Elevated creatinine
at time of discharge thought secondary to both elevated
tacrolimus level as well as recent dye insult from cardiac cath
(though patient pre-hydrated and received mucomyst pre and post
procedure)
.
# HTN: Patient with history of labile BP. During this admission
pressures oscilated between asymptomatic hyper and hypotension.
Most accurate read taken in left thigh. Patient continued on
home regimen with strict holding parameters. In days leading up
to discharge, blood pressures well controlled on labetalol,
lasix, nifidipine; deferred re-initiation of ACEI to PCP and
cardiologist.
.
# PVD/CAD s/p MI, s/p CABG. Trops negx3 at OSH, neg x5 at [**Hospital1 **].
Plavix and ASA continued in house, held in peri-operative
period. Cardiac catherization performed due to concern of
worsening of CAD, valvular disease. Cardiac cath clean. No
intervention required. Patient discharged on Plavix; ASA dose
decreased from 325 -> 81 to decrease risk of bleed.
.
# Normocytic Anemia: Likely secondary to chronic kidney disease
and iron deficiency.
Patient received 1u pRBC with appropriate bump in HCT. Stable at
time of discharge.
Iron supplementation continued
.
# Depresssion. Appropriate affect in house. Continued Bupropion,
Citalopram
.
# Insomnia. Continue Trazadone 100mg qhs
.
Code: Full
Medications on Admission:
Active Medication list as of [**2149-10-3**]:
.
Medications - Prescription
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day
BUPROPION HCL - 75 mg Tablet - 1 Tablet(s) by mouth daily
CITALOPRAM - 40 mg Tablet - one and one half Tablet(s) by mouth
in a.m.
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
COMPAZINE - 25 mg Suppository - 1 Suppository(s) rectally three
times a day as needed for nausea
DOXYCYCLINE MONOHYDRATE - 100 mg Capsule - 1 Capsule(s) by mouth
twice a day
FUROSEMIDE - 40 mg Tablet - 2 Tablet(s) by mouth twice a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times
a
day
GLUCAGON (HUMAN RECOMBINANT) [GLUCAGON EMERGENCY] - 1 mg Kit -
ASDIR once as needed for for hypoglycemia PATIENT USES 2 PER
MONTH
HEPARIN FLUSH (PORCINE) IN NS - 100 unit/mL Kit - 3cc heparin
once a day per protocol post infusion
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider:
[**Name Initial (NameIs) 10088**]) - 100 unit/mL Cartridge - 9 units Twice a Day
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider:
[**Name Initial (NameIs) 20522**]) - 100 unit/mL Cartridge - per sliding scale
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol
Inhaler - 2 puffs inh q6 hours as needed for coughing
LABETALOL - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 200 mg Tablet - 2 Tablet(s) by mouth three times a day
hold for SBP<100 or HR<60
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - ASDIR once apply 15
min before drawing blood
METOCLOPRAMIDE - 10 mg Tablet - 1 (One) Tablet(s) by mouth daily
do not take more than 5 - 6 times per week
NIFEDIPINE - 90 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth once a day
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**2-1**] Tablet(s) by
mouth q8hr as needed for ankle pain
PANTOPRAZOLE - (Dose adjustment - no new Rx) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth qeday
POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17
gram/dose Powder - by mouth PRN
PREDNISONE - 1 mg Tablet - 4 Tablet(s) by mouth daily
SODIUM CHLORIDE 0.9 % [SALINE FLUSH] - 0.9 % Syringe - as
directed once a day 3-5cc saline flush pre and post infusion
TACROLIMUS [PROGRAF] - 1 mg Capsule - 3 Capsule(s) by mouth
twice
a day brand name medically necessary, no substitution
TALKING SCALE - - Use once daily for use with CHF protocol
TRAZODONE - 100 mg Tablet - one Tablet by mouth at bedtime
VANCOMYCIN - 750 mg Recon Soln - infuse 750 mg once a day
.
Medications - OTC
ASPIRIN - (OTC) - 325 mg Tablet - One Tablet(s) by mouth daily
BLOOD SUGAR DIAGNOSTIC [PRECISION XTRA TEST] - Strip - use to
monitor your blood sugar up to 10 times per day or as directed
CALCIUM CARBONATE-VITAMIN D3 - 600 mg-400 unit Tablet - 1
Tablet(s) by mouth twice a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - [**2-1**] Capsule(s) by
mouth twice a day
FERROUS SULFATE - 325 mg (65 mg) Tablet - 1 Tablet(s) by mouth
twice a day
NUT.TX.GLUC.INTOL,LAC-FREE,SOY [GLUCERNA] - Liquid - 1 can by
mouth six times per day Diabetes Mellitus Type I Gastroperisis
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (OTC; Dose adjustment - no
beverage and drink daily as needed for as needed for
constipation
.
Discharge Medications:
1. Outpatient Lab Work
REQUIRED LABORATORY MONITORING:
LAB TESTS: CBC, BUN, Crea, ESR, CRP, Vanco trough
FREQUENCY: Qweekly
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
3. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
4. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q8H (every 8 hours) as needed for pain.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
13. Tacrolimus 1 mg Capsule Sig: 2.5 Capsules PO Q12H (every 12
hours).
Disp:*150 Capsule(s)* Refills:*2*
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
SOB/wheeze.
Disp:*1 bottle* Refills:*2*
15. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
16. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) u subQ
Subcutaneous twice a day.
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Sig:
Three (3) ml every eight (8) hours: Sodium Chloride 0.9% Flush
3 mL IV Q8H:PRN line flush
.
Disp:*30 flush* Refills:*2*
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Sig:
Heparin Flush (10 units/ml) 2 mL IV PRN line flush flush Qday
and prn.
Disp:*30 flush* Refills:*2*
20. Humalog 100 unit/mL Solution Sig: per sliding scale u/mL
Subcutaneous with meals, at bedtime: PLEASE HOLD AM HUMALOG
UNTIL AFTER BREAKFAST - if able to eat, dose per AM scale; if
nausea prevents eating, dose per BEDTIME SCALE.
21. SLIDING SCALE
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-150mg/dL 0u 0u 0u 0Units
151-250mg/dL 6u 6u 6u 0Units
251-300 mg/dL 8u 8u 8u 4Units
301-350mg/dL 10u 10u 10u 6units
351-400mg/dL 12u 12u 12u 8Units
22. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
23. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
24. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
25. Calcium Carbonate-Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
26. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
27. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO once a
day: Do not take more than 5-6x/week.
28. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO once a
day.
29. Citalopram 40 mg Tablet Sig: one and one half tablet Tablet
PO QAM.
30. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation every six (6) hours as needed for cough.
31. Vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous once a day: Will complete 6 week course of
vancomycin. tentative stop date: [**11-25**].
Disp:*30 bags* Refills:*2*
32. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three
times a day.
33. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
PRIMARY:
CHF exacerbation
Chronic osteomyelitis
.
SECONDARY:
End-stage kidney disease
Diabetes Mellitus
Coronary Artery Disease
Peripheral Vascular Disease
Discharge Condition:
Mental status: clear and coherent
Ambulates with assistance' weight bearing activity as tolerated.
Discharge Instructions:
Dear Ms [**Known lastname 19419**] it was a pleasure taking care of you.
.
You were initially transferred to [**Hospital1 18**] for continued treatment
of an upper respiratory infection and CHF exacerbation. During
your stay you were actively diuresised, continued on antibiotics
and your respiratory symptoms improved.
.
Unfortunately you had an episode of respiratory distress
necessitating ICU transfer and intubation. The episode was
thought secondary to an aspiration event. Shortly after transfer
to the ICU you were extubated, your respiratory status improved
and you were transferred back to the floor.
.
While hospitalized the infectious disease, orthopedic, renal,
and cardiology services participated in your care. There was
concern for recurrent osteomyelitis of your left ankle. Your
doxycyline was stopped and you were restarted on IV vancomycin
to complete a 6wk course. On [**10-14**] you were taken to the OR by
Dr. [**Last Name (STitle) **] for a wash-out of your left ankle. Biopsies were
taken of bone and soft tissue during the procedure and at time
of discharge had demonstrated no bacterial growth. You will need
to follow-up with both infectious disease and [**Last Name (STitle) **] for
continued care of this infection as an outpatient. Until
follow-up you will continue taking IV vancomycin 750mg daily for
likely 6wk course. Your sutures will be removed in [**Last Name (STitle) **] clinic
in 2-3wks. Until that time be sure to keep incision sites,
clean and dry. You may ambulate with assistance with weight
bearing activities as tolerated.
.
While hospitalized your underlying coronary artery disease was
evaluated. You had a cardiac catherization done on [**10-17**] which
was clean with no interventions necessary. You will follow-up
with Dr. [**Last Name (STitle) 20523**] as an outpatient.
.
Regarding your renal function, you were followed by the renal
service. An ultrsound of your transplanted kidney was obtained
which was negative for any signs of rejection. You were
continued on tacrolimus and prednisone to prevent rejection.
.
CHANGES TO YOUR MEDICATIONS:
--We DECREASED your Aspirin from 325mg -> 81mg by mouth daily
--We DECREASED your LASIX to 80u by mouth to once daily
--We STOPPED your DOXYCYLINE.
--We STARTED VANCOMYCIN , 750mg IV every day (6week course:
Start date: [**2149-10-14**] Stop date: [**2149-11-25**]) You levels will be
checked with weekly lab draws.
--We DECREASED your dose of TACROLIMUS to 2.5mg twice daily.
--YOUR HOME INSULIN REGIMEN WAS CHANGED TO THE FOLLOWING: LANTUS
10u twice daily with insulin sliding scales with meals and
bedtime.
Regarding sliding scale: Check sugar and administer AM humalog
AFTER breakfast - if you have eaten full meal use AM sliding
scale, if nausea has made it difficult to eat use BEDTIME
sliding scale to avoid hypoglycemia.
--PAIN REGIMEN: We continued your PERCOCET; We added daily
LIDOCAINE patchs, we discharged you with 30 pills of DILAUDID
2mg for breakthough pain as needed every 4-6hrs (please do not
take more than 4 pills daily to avoid over-sedation)
--We also added an albuterol inhaler to use as needed to help
with your breathing.
.
Followup Instructions:
[**Last Name (un) **] FOLLOW-UP
Wednesday @ 9am with Dr [**Last Name (STitle) 10088**]
[**Name (STitle) **] Center [**Location (un) **], [**Location (un) **]
.
Department: [**Hospital3 249**]
When: TUESDAY [**2149-10-28**] at 10:00 AM
With: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
DEPT: ORTHOPEDICS - suture removal
Tuesday [**10-28**] at 1120
[**Location (un) **] [**Hospital Ward Name 23**] Center [**Location (un) **]
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2149-11-3**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2149-12-1**] at 9:30 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2149-11-19**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2149-10-21**]
|
[
"51881",
"5849",
"40391",
"V4581",
"412",
"V5867",
"4280",
"4240",
"3051"
] |
Admission Date: [**2137-11-8**] Discharge Date: [**2137-12-3**]
Date of Birth: [**2085-9-12**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old
female with a history of advanced human immunodeficiency
virus/acquired immunodeficiency syndrome for 10 to 15 years
complicated by human immunodeficiency virus nephropathy,
human immunodeficiency virus cardiomyopathy (with an ejection
fraction of 15% to 20%), acquired immunodeficiency syndrome
related dementia and encephalopathy for the past who presents
with a history of lactic acidosis while taking proteus
inhibitors.
The patient was admitted to the hospital with lactic acidosis
presumed to be due to proteus inhibitors while on highly
active antiretroviral therapy. She was admitted to the
Medical Intensive Care Unit with hypoglycemia, hypothermia,
and hypotension.
The patient's blood pressure was stabilized without pressors.
Her hypoglycemia resolved. The patient revealed evidence of
hepatic failure with liver function tests in the 100s, and a
total bilirubin of 26, and coagulopathy with an INR of
greater than 5. This occurred after all her ACE inhibitors
and highly active antiretroviral therapy were discontinued.
The patient was initially made comfort measures only, and
after mentating better the patient was made do not
resuscitate/do not intubate, cardiopulmonary resuscitation
not indicated, due to her severe illness. However, the
patient continued to receive full treatment of all of her
issues.
The patient was transferred to the floor for further
management by the medical team under the care of Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. The patient's liver function tests did not improve
greatly; however, the patient was occasionally mentating and
was occasionally able to take oral intake; although, never
adequate for her poor nutritional status.
On [**2137-12-1**] the patient had a subsequent event of
hypoglycemia, hypotension, and bradycardia into the 30s. A
code was called. The patient was given atropine and her
heart rate rebounded. Her blood pressure increased and
continued to increase with aggressive intravenous fluid
hydration. The patient was given multiple ampules of
dextrose 50 every hour to maintain her glucose greater than
70. It was presumed that the patient had no glycocin stores
and severe hepatic dysfunction prohibiting proper
gluconeogenesis.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's blood
pressure was maintained with a systolic blood pressure in the
110s with intravenous fluid boluses. The patient was felt to
be severely dehydrated. The patient was also persistently
hypothermic with a temperature of 96 degrees Fahrenheit
regularly, increasing to 97 degrees Fahrenheit rectally with
warming blankets. Her heart rate was 50 to 74. Her
respiratory rate was 22 to 27. The patient's oxygen
saturation was 97% on room air. In general, the patient was
a very thin and frail woman breathing deeply. She had her
eyes closed and was not responding well. Head, eyes, ears,
nose, and throat examination revealed the patient's sclerae
were icteric. Her pupils were reactive. The oropharynx was
clear with no evidence of thrush. On cardiovascular
examination, the patient had a regular rate and rhythm.
There was a 3/6 systolic murmur and third heart sound. No
rubs. Radial and dorsalis pedis pulses were 1+ bilaterally.
The lungs were clear with crackles halfway up bilaterally.
There was good air movement. The patient's abdomen had
hypoactive bowel sounds. The abdomen was distended and
nontender. There was no organomegaly was appreciated. The
patient's extremities were cool and dry with no edema. The
patient's sacrum had erythema on the perineum. Skin revealed
tinting on the forehead. The patient had a right midline
peripherally inserted central catheter line placed with no
erythema or swelling. She had a left fistula site on her
wrist that was bandaged due to subsequent spontaneous
bleeding.
IMPRESSION: Our impression was that the patient was a frail
50-year-old female with advanced human immunodeficiency
virus/acquired immunodeficiency syndrome, multiple
complications, with poor cardiac function, renal function
dependent on dialysis, and hepatic failure unlikely to
improve.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
for further management, and a family meeting was called to
discuss the patient's code status.
On the evening prior to the family meeting, the patient had
11 beats of nonsustained ventricular tachycardia with
electrocardiogram changes. The patient ruled out for a
myocardial infarction and was maintained on aspirin, and beta
blocker, and oxygen through nasal cannula.
Due to the spontaneously bleeding arteriovenous fistula site,
the patient was given multiple units of fresh frozen plasma
as well as packed red blood cells. Over that night, the
patient's hematocrit dropped to 12%.
In the morning, the patient was not responding well. A chest
x-ray was done because of agonal breathing. The patient was
found to have total white out of the left lung. It was
unclear if this due to an isolated effusion or spontaneous
pulmonary hemorrhage in the setting of a hematocrit drop.
It was also clear that over the past two days the patient had
low fibrinogen, an elevated prothrombin time and partial
thromboplastin time, an elevated lactate dehydrogenase, and a
haptoglobin of less than 20 which would also be consistent
with hemolysis and possible disseminated intravascular
coagulation; however, a full disseminated intravascular
coagulation panel was never checked, and it was thought to be
uninterpretable in the setting of liver failure. The patient
was maintained on a D-10 drip to keep her glucose level above
70.
Up until this point, the patient had been receiving
hemodialysis every other day with ultrafiltration due to an
inability to take much off because of blood pressure demands.
The patient was also known to have chronic hypercalcemia due
to hyperparathyroidism from her renal failure which was
managed with hydration.
During the patient's hospitalization, she was off of highly
active antiretroviral therapy but was maintained on
Pneumocystis carinii pneumonia and Mycobacterium
avium-intracellulare prophylaxis with azithromycin and
Bactrim.
For nutrition, it was very difficult to give the patient
proper nutrition as she would not tolerate tube feeds. She
pulled out her postpyloric tube and could not mentate long
enough to take in oral intake adequate enough to improve her
nutritional status.
A family meeting was held. The patient's primary nurse,
intern hospital attending (Dr. [**First Name (STitle) **], and the patient's
primary care provider over the 15 years (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7626**])
were all present. As the patient's sister and health care
proxy ([**Name (NI) **]) as well as her sister [**Doctor First Name **], and daughter.
It was discussed that the patient's health was extremely
poor. It was unclear if the patient would ever survive to
discharge. The patient's family still wanted all treatment
to be pursued but understood that it would extremely
difficult to resuscitate or ventilate her should she need
cardiopulmonary resuscitation or mechanical ventilation. It
was determined that the patient would be do not
resuscitate/do not intubate.
One hour after signing this order, the patient had agonal
breathing. She continued to have bradycardia in the 20s
which responded to atropine. However, her respiratory status
worsened until full respiratory arrest. The patient died on
[**2137-12-3**] due to respiratory failure secondary to a
pulmonary effusion and possible pulmonary hemorrhage
secondary to coagulopathy and liver failure, secondary to
human immunodeficiency virus and acquired immunodeficiency
syndrome. The patient's family and primary care provider
(Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7626**]) were all made aware. An autopsy was
refused.
[**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**]
Dictated By:[**Last Name (NamePattern1) 6374**]
MEDQUIST36
D: [**2137-12-9**] 14:33
T: [**2137-12-13**] 08:43
JOB#: [**Job Number 109899**]
|
[
"0389",
"2762",
"4280",
"2875"
] |
Admission Date: [**2130-9-20**] Discharge Date: [**2130-9-26**]
Service: MICU
ADMISSION DIAGNOSIS:
1. Respiratory distress.
2. Respiratory failure.
3. Pneumonia.
4. COPD exacerbation.
HISTORY OF PRESENT ILLNESS: Patient is a 79 year old with
multiple medical problems including a history of chronic
obstructive pulmonary disease, atrial fibrillation who was
recently discharged from [**Doctor First Name **]-[**Country **] on [**2130-9-8**] for a
history of cellulitis who presented to the Emergency Room on
[**2130-9-20**] with increasing dyspnea times one day. The
morning of admission the patient was without complaints per
the nursing home staff, however having increasing shortness
of breath throughout the day. Patient noted to be
unresponsive at 1:45 p.m. and vital signs recorded at the
time were 96.9, 88, 102/66, 22. Patient became more
responsive with an O2 sat of 85% prior to transfer to the
Emergency Room. Wheezes at the time were noted which
decreased with Combivent nebulizer treatment in the Emergency
Room.
In the Emergency Room patient noted to be in moderate
respiratory distress. O2 sats were noted to be in the 80s on
face mask. Patient also noted to have periorbital cyanosis
at nursing home. Patient was intubated in the Emergency Room
secondary to decreased O2 saturations and persistent
respiratory distress. An arterial blood gas performed at the
time demonstrated a pH of 7.27, 54, 98 on 60% FIO2, AC 12 x
600. Patient was transferred to the Medical Intensive Care
Unit for continued care.
PAST MEDICAL HISTORY:
1. COPD, prior intubations three times on home O2 two liters
to three liters. No pulmonary function tests available.
2. Atrial fibrillation. MAT EF of 50% on last TTE in [**2128**].
3. Hypertension.
4. Anemia.
5. Status post left kidney donation.
6. Prostate cancer status post radiation.
7. Peptic ulcer disease status post Billroth.
8. Venous insufficiency.
9. Left leg cellulitis 09/[**2129**].
10. Osteopenia status post multiple compression fractures, on
chronic opiates.
11. History of VRE.
12. Decreased thyroid.
13. History of thigh burns.
14. History of DVT in [**2129**].
MEDICATIONS ON LAST DISCHARGE:
1. Protonix 40.
2. Synthroid 100.
3. Oxycodone 10.
4. Miconazole
5. Oxazepam
6. Albuterol.
7. Flovent.
8. Atrovent.
9. Fentanyl.
10. Levofloxacin 250 mg p.o. q.d.
11. CACO3.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient is a former smoker who currently
lives at the [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **].
PHYSICAL EXAMINATION: Vital signs: 98.6, blood pressure
105/63, irregular, respiratory rate 12, heart rate around 60,
O2 sats 88% preintubation, 99% post intubation, FIO2 post
intubation, vent AC 12 x 600 FIO2 of 60%, general intubated,
sedated, no spontaneous movement, not in acute distress.
HEENT: Pupils 2:1 bilateral. Neck: Supple; jugulovenous
pressure flat. Cardiovascular: Irregularly irregular; no
murmurs, rubs, or gallops. Respiratory: Decreased breath
sounds throughout. Cardiovascular: Midline sternotomy scar.
Abdomen: Midline surgical scar left transverse upper
abdomen; positive bowel sounds; nontender, nondistended.
Extremities: Left shin erythema and warmth; 1+ edema.
Neuro: Sedated; pupils 2:1; 1+ deep tendon reflexes.
Rectal: Guaiac positive.
SOCIAL HISTORY: Lives in [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **]. Former smoker; quit
two years ago.
LABORATORY DATA: White blood cell count 17, differential
neutrophils 75, lymphs 21, monocytes 2. Urinalysis: Large
blood, positive protein, greater than 50 red blood cells, 0
to 2 white blood cell count. Electrolytes 142/3.1, 107/19;
BUN 27/2.2, baseline is 1.2-1.5; glucose 162, INR 3.7; ABG
7.27, 54, 98; troponin 0.14; lactate 1.2.
Chest x-ray: Diffuse patchy linear infiltrates, question
loculated effusion.
EKG: MAT at 99, 0.5 mm ST segment depressions in V4, V5, low
voltage in limb leads, Q-waves in 3.
HOSPITAL COURSE:
1. Respiratory failure: Patient presented to the Emergency
Room with respiratory failure requiring intubation. Patient
was extubated on [**2130-9-22**]. Patient's respiratory failure
was considered secondary to COPD flare up versus secondary to
possible pneumonia. Patient was continued on Levofloxacin.
Patient was also provided with Vancomycin. Patient's sputum
subsequently grew up Staph aureus. Staph aureus is likely a
colonization. Patient's x-ray reportedly is baseline.
Patient was continued on Albuterol and Atrovent. Patient's
white blood cell count subsequently decreased to 10.6 by
[**2130-9-26**].
2. Troponin: Patient presented with troponin 0.14.
Patient's enzymes were cycled. Patient's troponin decreased
in nature. There was likely secondary to demand ischemia.
Patient showed no EKG changes.
3. Renal failure: Patient with elevated creatinine from
baseline. Patient's creatinine responded to volume.
Patient's creatinine was 1.5 on [**2130-9-26**].
4. Cellulitis: Patient with a history of cellulitis.
Patient's cellulitis was actually improved on presentation.
However, given possible decompensation, Vancomycin was
initiated.
5. MAT atrial fibrillation: Patient with history of MAT
atrial fibrillation. Blood pressures not provided given
history of COPD. Patient is on Coumadin; initially held,
then reintroduced throughout his hospitalization. Patient's
Coumadin level should be checked as outpatient INR.
6. Heme: Patient with baseline anemia. Patient anemic in
physical exam. Patient transfused two units on [**2130-9-22**]
after hematocrit of 24. Patient responded appropriately.
Patient with history of guaiac-positive stools. Patient
should likely receive an outpatient colonoscopy per primary's
team.
7. Patient with a history of opiate use. Secondary to
chronic back pain, multiple fractures.
8. Cellulitis: Further assessed with a CT. A CT performed
demonstrated a fluid density along the anteromedial skin
surface which was most consistent with edema. However, the
possibility of a fluid conduction could not be excluded by
Radiology. The patient, however, subsequently resumed
refusing MRI. The patient's symptoms improved, and it was
felt that an MRI would be low yield, and the patient did
refuse the test.
9. Muscle: Patient complained of shoulder pain. Therefore,
an x-ray was performed on [**2130-9-25**]. The [**2130-9-25**] x-ray
of the left shoulder showed diffuse osteopenia
catheter-imposed humeral diaphysis most likely representing a
PICC line. No fractures noted. The humeral head was
subluxed superiorly consistent with the chronic rotator cuff
tear. Access midline was placed on [**2130-9-25**] in the left
arm, code full.
10. Gastrointestinal: Of note, patient during his
hospitalization, developed possible epididymitis. Urology
was consulted. Patient's symptoms resolved.
11. Infectious Diseases: Patient with diarrhea. Patient's
C. difficile titer was sent. First one was negative.
Additional two should be sent. Patient was empirically
initiated on Metronidazole. Patient's symptoms have
improved.
DISPOSITION: To [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **].
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subq q. 12 hours.
2. Vancomycin 1000 mg IV q. day dose with trough levels.
3. Aspirin 325 mg p.o. q.d.
4. Fentanyl patch 150 mcg q. 72 hours.
5. Pantoprazole 40 mg p.o. q.d.
6. Levothyroxine sodium 100 mcg p.o. q.d.
7. Trazodone HCL 25 mg p.o. h.s. p.r.n.
8. Ipratropium bromine nebulizer, one nebulizer IH q. six.
9. Loperamide HCL 2 mg p.o. t.i.d. p.r.n.
10. Oxycodone 5 mg p.o. q. 4 to 6 hours p.r.n.
11. Prednisone 20 mg p.o. q.d. times five days.
12. Metronidazole 500 mg p.o. q. 8 hours times seven days.
13. Levofloxacin 250 mg p.o. q.d. times 10 days.
14. Hydromorphinol 2 mg p.o. q. 4 to 6 hours p.r.n.
15. Miconazole powder 2%, one application topical, b.i.d.
p.r.n.
DISCHARGE INSTRUCTIONS:
1. Physical Therapy, Occupational Therapy: Assistance with
activities of daily living.
2. Cardiac-healthy diet.
3. Keep leg raised and wrapped.
4. Coumadin monitoring.
5. Vancomycin monitoring.
RECOMMENDATIONS:
1. Colonoscopy possible per outpatient team.
2. Follow-up leg [**Hospital 4338**] Clinic should all symptoms deteriorate.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 201**]
Dictated For [**Doctor Last Name 40957**], Intern
MEDQUIST36
D: [**2130-9-26**] 15:42
T: [**2130-9-26**] 16:20
JOB#: [**Job Number 40958**]
|
[
"51881",
"486",
"42731",
"5849",
"V5861",
"4019"
] |
Admission Date: [**2103-5-6**] Discharge Date: [**2103-5-18**]
Date of Birth: [**2021-2-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
fevers, leukocytosis
Major Surgical or Invasive Procedure:
IR percutaneous drainage of left perinephric fluid collection
_____
History of Present Illness:
82M with multiple medical comorbidities s/p sigmoid colectomy
with end transverse [**Hospital 47427**] transfered from OSH for further
management of a retroperitoneal abscess. Pt initially presented
from his nursing home to [**Hospital3 **] [**2103-5-4**] with fever to
102.6 and increasing leukocytosis. He was found to be
hypotensive
to SBP 85, which improved with resuscitation, and WBC 33. CXR
revealed a LLL pneumonia and UA was consistent with a UTI, for
which he was started on empiric Vanc/Zosyn and admitted to the
ICU. He underwent CT A/P which was interpreted as showing left
hydronephrosis with a 16x10x8cm peri-nephric / retroperitoneal
abscess with air, along with a LLL pneumonia. Given the lack of
interventional radiology capabilities at the OSH, the pt was
directly transfered to [**Hospital1 18**] TSICU for anticipated percutaneous
drainage pf the per-nephric abscess.
Past Medical History:
Past Medical History:
-Hypertension, GERD, Atrial fibrillation, Hx positive PPD,
Urinary retention, BPH, Hx basal cell CA, SIADH, Hypothyroidism,
glaucoma, Insomnia, Constipation
Past Surgical History:
-Sigmoid colectomy w/ Hartmann's / end transverse colostomy
-Cataract surgery
-Total thyroidectory [**2091**]
Social History:
Lives in a nursing home. Denies tobacco, EtOH, illicits.
Family History:
NC
Physical Exam:
GEN: elderly male, frail appearing, shovel mask w/ humidified
air in place, oriented to self and medical center, intermittent
weak cough with thick secretions
HEENT: oropharynx clear
CV: S1, S2 regular rhythm, normal rate, no murmurs
LUNG: rhonchi bibasilarly, decreased BS right base
ABD: soft, non-tender, non-distended, drain w/ yellow fluid,
ostomy with brown stool
EXT: warm, distal pulses intact, [**1-15**]+ edema, RUE > LUE, picc in
place in RUE
Neuro: face w/ right sided droop, asymmetry w/ smile, tongue
midline, EOMI, moves toes bilaterally
Pertinent Results:
Laboratory:
10.2
21.9 >------< 425
34.0
PT: 14.6 PTT: 29.5 INR: 1.4
154 123 31
-------------< 102
3.6 21 0.5
Ca: 7.7 Mg: 2.3 P: 2.9
Imaging:
CT A/P (OSH [**2103-5-6**]):
1. Obstructed left kidney with a large perirenal/RP abscess
(16x10x8cm) with air, involving psoas muscle and extending to
the
lower pelvis to just above the acetabulum.
2. RLL consolidation with air bronchograms
3. Extensive atherosclerotic disease of the abdominal aorta
without aneurysm
4. Aneurysmal dilitationof the common left iliac artery with the
lumen narrowed.
5. Bladder calculi
Brief Hospital Course:
This is an 82 M who initially presented to [**Hospital3 **]
[**2103-5-4**] with fever, leukocytosis, and hypotension found to have
16x10x8cm peri-nephric / retroperitoneal fluid collection and
pneumonia he was started on vancomycin and zosyn and transferred
to [**Hospital1 18**] surgery service for further management
.
#PSOAS / PERINEPHRIC ABSCESS: The etiology was unclear although
most likely from complication of GU infection in patient with
chronic indwellling foley catheter. He was initially admitted to
surgery service but was not a surgical candidate. Patient
underwent IR guided drainage on [**2103-5-8**] with removal of 400cc of
fluid resulting in partial decompression of hydronephrosis.
There was evidence that the collecting system was communicating
with the fluid collection during the procedure. Subsequently
fluid from the drain was found to have elevated creatinine c/w
urine. Likely he developed GU infection with nephric/ureter
abscess with loss of collecting system integrity and spread to
perinephric/psoas. Unclear if calculi (bladder calculi seen on
imaging) or ureter mass (not found on imaging) predisposed to
rupture. He was startd on vancomycin and zosyn. Urine culture
and fluid collection culture returned with no growth (although
had already been on antibiotics for several days. Urine and
drain cytology returned without evidence of malignant cells.
Infectious disease was consulted. Repeat abdominal imaging on
[**5-15**] showed a well placed drain and signficant improvement in
fluid collection. Plan for percutaneous nephrostomy tube and
eventual removal of abdominal drain was was discussed with the
son [**Name (NI) 382**]. However, the patient continued to slowly decline and
there was concern about his ability to tolerate the procedure
and whether it was consistent with his overall goals of care
given his poor overall prognosis. In coordination with the son,
it was decided to not pursue further procedures, such as
nephrostomy tube placement. At [**Doctor First Name 391**] Bay, in discussion with
the son, if the abdominal drain were to accidentally come out
the, then he would not be rehospitalized to replace it. Zosyn
was stopped on [**2103-5-17**] as, in consultation with the son, it was
felt to not aid in patient comfort.
.
#HYPERNATREMIA: Patient's sodium was 137 at OSH and on admission
to [**Hospital1 18**] was found to be 154. The most likely etiology is
over-resuscitation with normal saline in setting of reduced
access to free H20. His sodium continued to remain slighly
elevated in the setting of decreased access to free water. He
was given D5W at a rate of 75-125cc/hr while he was NPO. Per
discussion with the son, he wants to continue the PICC line and
continue D5W (rate of 75cc/hr) for hydration at this time to
have family members the opportunity to come in this weekend and
see the patient.
.
#HCAP: Patient is nursing home resident found to have fever,
increased secretions and cough, and radiographic evidence with
opacity in the right lung base of pneumonia with differential
icluding aspiration vs HCAP. During his hospital stay he was
noted to have a weak cough with difficulty managing secretions.
He completed an 8 day course of vanc/zosyn on [**5-15**]. Legionella
negative.
.
#NUTRITION: The patient has failed several speech/swallow
evaluations and was determined to be high risk of aspiration.
This was discussed with the HCP, who was not interested in NG
tube placement. We held off on oral nutrition initially in the
hope that his condition may improve. At discharge, the risk of
aspiration was again addressed with the HCP and the options to
either continue NPO status or have the patient be allowed to
have nectar thick liquids for comfort if he verbalizes. The HCP
felt that it could be ok for him to eat/drink for comfort
knowing that this might lead to the patient's demise. Please
continue aspiration precautions.
.
#RUE SWELLING: He was found to have a PICC associated
non-occlusive subacute-to-chronic right subclavian thrombus.
PICC functining appropriately. He was discharged with the PICC
line given his healthcare proxy wanted the pt to continue
hydration during the weekend so family could come and see him.
.
#HEMATOCRIT DROP: His hematocrit trended down on [**5-16**] from mid
twenties to 18. He was transfused four units of blood with
improvement up to 26. His hematocrit trended down to 23 on [**5-17**]
and he was given another unit of blood. The etiology of blood
loss was unclear. GI bleed considered, particularly stress
ulcer, although no melana or bright red blood in ostomy. He was
evaluated by the GI service. RP bleed considered but CT abdomen
negative. No evidence of hemolysis on labs.
.
GOALS OF CARE: Addressed with [**Doctor Last Name **], the healthcare proxy,
[**Name (NI) 6028**] the hospitalization. We discussed that even with
standard medical care in this situation that he has a poor
prognosis. The HCP informed us that his father would not want
extraordinary measures and would want to focus more on comfort
in this situation. [**Doctor Last Name **] agreed with stopping antibiotics at
discharge, as well as no additional transfusions, or further lab
testing, or re-hospitalization. If the abdominal drain were to
fall out he would not want his father rehospitalized for more
procedures. He wanted to keep the PICC line in place and
continue IV hydration over the weekend so that family members
could visit him. Would readdress whether continuing IVF after
this weekend is c/w goals of care.
.
.
CHRONIC ISSUES:
.
#HYPERTENSION: Blood pressure ranged from 100-130. His home
antihypertensives were held during this hospitalization.
.
#ATRIAL FIBRILLATION: He has a history of atrial fibrillation,
managed with rate control with beta blocker. His beta blocker
was changed to IV during the hospitalization given he was NPO.
Aspirin was held. Beta blocker not continued due to goals of
care.
.
#FACIAL DROOP: Patient noted to have facial droop on admission
with garbled speech and right sided weakness. The [**Hospital1 2519**] note also reported that his speech was not clear. I
spoke w / [**Doctor First Name 391**] Bay Skilled Nursing who confirmed that the
unclear [**Name2 (NI) 16019**] was chronic.
.
#INSOMNIA: His ambien was held
.
#GLAUCOMA: His Methazolamid 25mg [**Hospital1 **] (hold while NPO) was held.
.
#HYPOTHYROID: The levothyroxine daily was changed from PO to IV
while hospitalized and NPO. It was stopped at discharge as not
c/w goals of care change to comfort focused care.
.
#URINE RETENTION: The oxybutynin was held
.
This was prepared by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D.(cell phone [**Telephone/Fax (1) 47428**] if
any questions)
Medications on Admission:
Brimonidine Tartrate 5ml solution 0.15% OP
Protonix 40mg daily
Amlodipine 5mg daily
Levothyroxine 0.1mg daily
Artificial tear solution 2 gtt [**Hospital1 **] PRN
tylenol 650mg Q6H PRN pain
ambien 5mg HS PRN insomnia
Vitamin B-12 Inj 1000 mcg IM q3 months
Methazolamid 25mg [**Hospital1 **]
ASA 325mg daily
Lactulose 30ml daily
Metoprolol Tartrate 25mg [**Hospital1 **]
Oxybutynin Chloride 5mg TID
Levofloxacin 500mg daily
Flagyl 250mg TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
3. Senna 1 TAB PO BID:PRN constipation
4. Intravenous fluid order -> D5W at 75cc per hour for three
days
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
Psoas / Perinephric abscess
Healthcare Associated Pneumonia
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Mental Status: Confused - sometimes.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname **]. You
were admitted with a fluid collection near your kidney and a
pneumonia.
For the fluid collection, a drain was placed to remove the
fluid. The fluid appears to be urine from a rupture in your
kidney or ureter. You were treated for an infection with
antibiotics. You were followed by the urology and infectious
disease services.
For the pneumonia, you were treated with antibiotics and your
condition improved.
Your blood counts were low and you were given a transfusion.
Followup Instructions:
-
|
[
"5070",
"0389",
"2760",
"2851",
"486",
"4019",
"53081",
"42731"
] |
Admission Date: [**2175-7-25**] Discharge Date: [**2175-7-26**]
Date of Birth: [**2112-2-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name13 (STitle) **] presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for dyspnea on exertion,
lower extremity edema, 2 days of worsening productive cough.
Also with PND, nausea, denies chest pain. He is scheduled for
MVR/TVR and CABG with Dr. [**Last Name (STitle) **] on [**2175-7-31**].
.
He reports that he has had a cough which is productive of white
sputum which has been very persistent for the past day and did
not improve with NyQuil. The patient reports that he thought he
had pneumonia so he came to the ED. He feels like he has "a
tickle in my throat" that he can't clear. He also reports that
he has a tightness in his back, which is C7-T2 area, which he
reports is a "tightness" and feels different from the back pain
that he had during his presentation during the last
hospitalization, which was sharper. The patient does endorse
paryoxysmal nocturnal dyspnea and orthopnea, but he cannot
clarify it is due to discomfort from lying where his neck hurts
him or if it is because he feels SOB. He says he has been
compliant with his medications. He also reports DOE but this is
unchanged from his baseline and is felt to be due to his severe
MR/TR. As well, he does not endorse LE edema.
.
In the ED, initial vitals were 98.4 93-125/46-73 82-88 20 100%
RA 108.6kg.
Labs and imaging significant for a BNP of 336, negative
troponins and WBC of 22. CXR without acute cardiopulmonary
process and UA was negative.
Patient given Lasix 20mg IV once and dextromethamorphan,
Tessalon Perles, he felt that his cough improved with these
interventions.
.
On arrival to the floor, patient had ongoing productive cough,
did endorse ongoing "tightness" in the superior aspect of his
back and otherwise felt well.
.
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 chest pain,
palpitations, syncope or presyncope.
Past Medical History:
severe MR/TR
CAD with small LAD
EF 50-55%
atrial fibrillation (paroxysmal)
alcohol abuse
chronic leukocytosis (WBC 15-16)
Hypertension
Hyperlipidemia
Psoriasis
Diverticulitis
s/p sigmoid resection [**2175-5-19**]
Social History:
lives with girlfriend in [**Name (NI) **]. Maintenance worker.
-Tobacco history: quit 7 yrs ago. [**11-20**] ppd for 40 yrs
-ETOH: [**3-24**] drinks nightly, wine/beer/liquor, no history of
withdrawal symptoms. last drink Sunday [**7-9**]
-Illicit drugs: none
Family History:
Mother, died of lymphoma age 81. Father, with DM died of
alzheimers ag 84. Broather, throat cancer age 64.
No family history of heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.9 BP 104/60 HR 77 RR 12 O2 sat 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CN II-XII intact.
NECK: no cervical lymphadenopathy, no thyroid nodules or
thyromegaly appreciated. Neck veins not appreciated due to body
habitus. No carotid bruits.
CARDIAC: irregularly irregular. No m/r/g.
LUNGS: CTAB, no crackles, wheezes or rhonchi. Resp were
unlabored, no accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace edema in LE bilaterally. No c/c. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right:DP 1+ PT 1+
Left: DP 1+ PT 1+
DISCHARGE PHYSICAL EXAM:
afebrile, tachycardia to 100 with atrial fibrillation which
resolved spontaneously to HR of 80s-90s. BP 98-113/56-66.
No pericardial rub appreciated. No crackles or wheezes in the
lungs bilaterally.
No LE edema.
Pertinent Results:
ADMISSION LABS:
[**2175-7-25**] 05:20PM BLOOD WBC-16.9* RBC-3.84* Hgb-10.9* Hct-32.6*
MCV-85 MCH-28.5 MCHC-33.5 RDW-14.6 Plt Ct-328
[**2175-7-25**] 05:20PM BLOOD PTT-47.2*
[**2175-7-25**] 05:20PM BLOOD Plt Ct-328
[**2175-7-25**] 05:20PM BLOOD Glucose-101* UreaN-16 Creat-1.2 Na-141
K-5.0 Cl-104 HCO3-28 AnGap-14
[**2175-7-25**] 05:20PM BLOOD Calcium-9.6 Phos-5.5* Mg-2.4
PERTINENT LABS AND STUDIES:
CXR [**2175-7-25**]: In comparison with study of [**7-19**], the cardiac
silhouette may be slightly larger without definite pulmonary
vascular congestion. Probable mild pleural effusion and
atelectatic changes at the bases on the left. The increasing
cardiac size with little change in pulmonary vascularity raises
the possibility of pericardial effusion
ECHOCARDIOGRAM: [**2175-7-25**]: Focused study to assess pericardial
effusion.
There is a small to [**Month/Day/Year 1192**] sized pericardial effusion. There
are no echocardiographic signs of tamponade.
Compared with the prior study dated [**2175-7-14**] (images reviewed),
the amount of pericardial effusion has increased (previously
trivial). It appears circumferential, but predominantly located
along the infero-lateral wall of the LV.
DISCHARGE LABS:
[**2175-7-26**] 06:00AM BLOOD WBC-18.1* RBC-3.75* Hgb-10.7* Hct-31.7*
MCV-85 MCH-28.5 MCHC-33.7 RDW-14.2 Plt Ct-392
[**2175-7-26**] 06:00AM BLOOD Glucose-115* UreaN-17 Creat-1.1 Na-137
K-4.9 Cl-103 HCO3-25 AnGap-14
[**2175-7-26**] 06:00AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.2
Brief Hospital Course:
63yo male with past medical history of severe MR [**First Name (Titles) **] [**Last Name (Titles) **] who is
scheduled for surgery on [**2175-7-31**], here with productive cough for
1-2 days and pressure in his scapulae.
.
ACUTE ISSUES:
# Cough: productive of white sputum, patient is afebrile. CXR
without signs of pneumonia. Treated with
dextromethamorphan-guiafenesin, tessalon perles for symptomatic
control and had improvement of symptoms with this.
.
# Pericardial effusion: the patient has worsening positional
back pain, which is potentially consistent with pericarditis,
among other etiologies, including MSK. No cardiac rub
appreciated. He has a known pericardial effusion which was
considered to be insignificant, he did not undergo
pericardiocentesis during the prior hospitalization.
Cardiomegaly has worsened on his CXR (3cm difference), which is
concerning for worsening pericardial effusion. No signs of
tamponade--blood pressure stable, no JVD appreciated (pulsus not
assessed as patient looked very stable). Repeat echocardiogram
performed and showed that the effusion had increased but was
still small. The cardiac surgery team was updated on the new
finding.
.
# Leukocytosis: seen during prior hospitalization and stable
from prior hospitalization at 15-20. ID saw him during prior
hospitalization and cleared him for surgery. The patient's UA
was negative, his CXR was not concerning for pna, and bacterial
blood and urine cultures were pending at time of discharge.
.
CHRONIC ISSUES:
# CORONARIES: patient with known CAD in the LAD. Questionable
plan for CABG during MR/TR on Monday [**2175-7-31**]. Continued on
simvastatin, lisinopril, ASA, metoprolol.
.
# PUMP: borderline CHF 50-55%, appears euvolemic at this time.
Maintain on home dose of Lasix 20mg Daily. Discussed at length
the importance of fluid restrictions to 1500mL per day, taking
Lasix.
.
# RHYTHM: paroxysmal afib, on dabigatran. Rate control on
metoprolol succinate and diltiazem, patient does become
tachycardic with heart rate to low 100's but remains
asymptomatic and will return to atrial fibrillation in the
70-80s. No cardioversion scheduled because of plan for cardiac
surgery next week ([**2175-7-31**]).
.
# History of alcohol abuse, last drink prior to previous
hospitalization on [**2175-7-9**]. Continued on thiamine, B12, folic
acid, MVI
ISSUES OF TRANSITIONS IN CARE:
PENDING STUDIES:
- blood cultures x2
- urine culture
CODE STATUS: FULL CODE (CONFIRMED)
CONTACT: [**Name (NI) **] [**Name (NI) 91703**] (girlfriend) [**Telephone/Fax (1) 91702**]
Medications on Admission:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
3. aspirin 325 mg Tablet daily
4. furosemide 20 mg Tablet daily
5. multivitamin One tablet PO DAILY
6. folic acid 1 mg Tablet 1 Tablet PO DAILY
7. thiamine HCl 100 mg Tablet One Tablet PO DAILY
8. metoprolol succinate 100 mg Tablet ER DAILY
9. cyanocobalamin (vitamin B-12) 50 mcg Tablet PO DAILY
10. Diltzac ER 240 mg Capsule once a day.
11. dabigatran etexilate 150 mg Capsule PO twice a day.
12. trazodone 25 mg Tablet PO HS as needed for insomnia.
.
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
9. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
12. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*100 ML(s)* Refills:*0*
13. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*15 Capsule(s)* Refills:*0*
14. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
primary: viral upper respiratory infection; paroxysmal atrial
fibrillation
secondary: severe mitral valve regurgitation; severe tricuspid
valve regurgitation; pericardial effusion; coronary artery
disease; dyslipidemia; hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Name13 (STitle) **],
You were admitted to the hospital for a cough. It is felt that
this cough is most likely just a simple virus. You do not have a
pneumonia. Reasons to return to the hospital would include
development of a fever, which is a temperature of greater than
100.5 degrees. You have also complained of some back
pressure/tightness, and this current pain is not because of your
heart. It is most likely due to a muscle strain because you have
been lying down so much recently. If you cannot tolerate this
pain, you may take Tylenol. Do not take Advil, Ibuprofen, Motrin
or other NSAIDs as they will interfere with your Aspirin, which
is very important for you.
It is of the utmost importance that you DO NOT DRINK ALCOHOL. DO
NOT SMOKE CIGARETTES.
Please note that the following changes have been made to your
medications:
- NO major changes, however, you may use Tessalon Perles,
Dextromethomorphan-guaifenesin (which is Mucinex) as needed for
your cough.
- Please continue to take your medications as directed during
your last hospitalization. The following medications you MUST
take daily: Aspirin, Simvastatin, Lisinopril, Lasix, Metoprolol,
Diltzac, Dabigatran. Your multivitamin, thiamine, B12, folic
acid, and trazadone are very important too.
Followup Instructions:
Your cardiac surgery is on [**2175-7-31**] at 6 am with Dr. [**Last Name (STitle) **].
|
[
"2767",
"42731",
"4240",
"41401",
"2724",
"4019",
"V1582"
] |
Admission Date: [**2175-3-10**] Discharge Date: [**2175-5-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Aspiration
Major Surgical or Invasive Procedure:
Intubation, repostitioning G-Tube, change of G-tube to G-J tube
History of Present Illness:
Mr. [**Known lastname 4476**] is a [**Age over 90 **] year old man with a long history of
end-stage dementia for at least 10 years with recurrent
aspiration pneumonias and pressure ulcers who presents to the
[**Hospital1 18**] ED from [**Hospital **] Rehab with an aspiration. He was recently
discharged from [**Hospital1 18**] [**3-3**] after he had an aspiration and had a
prolonged intubation. He was treated with vanc/zosyn for a two
week course which was completed [**3-5**]. Today, nursing at [**Hospital1 **]
noted that his abdomen was somewhat distended. A KUB was
performed that showed the feeding tube was coiled in his stomach
in a different position. Tube feeds were restarted and the
feeding tube was noted to be further displaced with the phlange
out of place. The patient was turned and began vomiting and
gagging and was suctions. His VS when he was evaluated there
were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM.
.
The patient was brought to the [**Hospital1 18**] ED evaluation. In the ED,
he was immediately intubated, and started on
levaquin/vanc/flagyl for presumed aspiration pneumonia. He
transiently dropped his blood pressure to a systolic of 80's
over 30's and was started on levophed.
Past Medical History:
End-stage Alzheimers
Atrial fibrillation
Recurrent aspiration pneumonias
h/o MRSA and VRE colonization
Myoclonus
Social History:
Recently discharged from [**Hospital1 18**] to [**Hospital **] rehab.
Has been cared for by his daughter for the past three years.
Family History:
Noncontributory
Physical Exam:
VS: (on arrival to the MICU) T 98.9 HR 100 BP 75/33 RR 21 Sat
98%
Vent: AC Tv 500 RR 14 PEEP 8 FiO2 60%
GEN: unresponsive, intubated man on a intubated and sedated on a
ventilator
HEENT: Dry MM, sclerae anicteric, pinpoint pupils.
CV: Distant heart sounds, irregular
PUL: Coarse rhonchi throughout
ABD: Distended, no rebound or guarding.
EXT: 1+ edema
Pertinent Results:
ADMISSION LABS
[**2175-3-9**] 11:00PM BLOOD WBC-9.6 RBC-3.73* Hgb-10.9* Hct-33.8*
MCV-91 MCH-29.2 MCHC-32.3 RDW-18.5* Plt Ct-314
[**2175-3-9**] 11:00PM BLOOD Neuts-69.8 Lymphs-21.3 Monos-4.6 Eos-4.2*
Baso-0.2
[**2175-3-9**] 11:00PM BLOOD PT-13.3* PTT-25.6 INR(PT)-1.2*
[**2175-3-9**] 11:00PM BLOOD Glucose-128* UreaN-32* Creat-1.0 Na-139
K-4.4 Cl-97 HCO3-30 AnGap-16
[**2175-3-9**] 11:00PM BLOOD ALT-26 AST-41* AlkPhos-159* Amylase-66
TotBili-0.5
[**2175-3-9**] 11:00PM BLOOD Lipase-63*
[**2175-3-9**] 11:00PM BLOOD Albumin-3.6 Calcium-10.0 Phos-3.6 Mg-2.3
[**2175-3-9**] 11:00PM BLOOD Cortsol-26.2*
[**2175-3-9**] 11:00PM BLOOD CRP-158.4*
[**2175-3-10**] 04:13AM BLOOD Type-ART pO2-68* pCO2-38 pH-7.49*
calHCO3-30 Base XS-5
[**2175-3-9**] 11:00PM BLOOD Lactate-2.0
LAB TRENDS
CBC
[**2175-3-10**] 11:00AM BLOOD WBC-13.9* RBC-3.22* Hgb-9.6* Hct-29.1*
MCV-90 MCH-29.9 MCHC-33.1 RDW-19.1* Plt Ct-259
[**2175-3-13**] 04:28AM BLOOD WBC-10.7 RBC-3.01* Hgb-8.8* Hct-27.5*
MCV-92 MCH-29.4 MCHC-32.1 RDW-19.6* Plt Ct-274
[**2175-3-16**] 03:18AM BLOOD WBC-11.5* RBC-2.90* Hgb-8.9* Hct-26.8*
MCV-92 MCH-30.5 MCHC-33.1 RDW-19.3* Plt Ct-286
[**2175-3-20**] 04:52AM BLOOD WBC-10.0 RBC-2.79* Hgb-8.4* Hct-25.3*
MCV-91 MCH-30.3 MCHC-33.4 RDW-19.9* Plt Ct-380
[**2175-3-22**] 03:00AM BLOOD WBC-9.7 RBC-2.88* Hgb-8.6* Hct-26.3*
MCV-91 MCH-29.8 MCHC-32.7 RDW-19.9* Plt Ct-410
[**2175-3-26**] 03:49AM BLOOD WBC-11.9* RBC-2.68* Hgb-8.1* Hct-24.6*
MCV-92 MCH-30.2 MCHC-32.9 RDW-20.4* Plt Ct-283
[**2175-4-1**] 05:00AM BLOOD WBC-15.0* RBC-2.69* Hgb-8.2* Hct-25.4*
MCV-94 MCH-30.3 MCHC-32.2 RDW-21.6* Plt Ct-299
[**2175-4-3**] 04:10AM BLOOD WBC-15.1* RBC-2.87* Hgb-8.8* Hct-27.3*
MCV-95 MCH-30.8 MCHC-32.4 RDW-22.0* Plt Ct-349
[**2175-4-7**] 05:27AM BLOOD WBC-9.8 RBC-2.50* Hgb-7.5* Hct-23.8*
MCV-95 MCH-30.1 MCHC-31.6 RDW-21.8* Plt Ct-334
[**2175-4-13**] 03:24AM BLOOD WBC-8.1 RBC-3.00* Hgb-9.5* Hct-28.2*
MCV-94 MCH-31.5 MCHC-33.6 RDW-19.7* Plt Ct-263
[**2175-4-18**] 03:42AM BLOOD WBC-7.7 RBC-2.89* Hgb-8.7* Hct-27.5*
MCV-95 MCH-30.1 MCHC-31.7 RDW-19.7* Plt Ct-329
CHEMISTRY
[**2175-3-11**] 02:42AM BLOOD Glucose-124* UreaN-23* Creat-0.9 Na-141
K-3.1* Cl-105 HCO3-24 AnGap-15
[**2175-3-14**] 03:51AM BLOOD Glucose-103 UreaN-32* Creat-1.0 Na-144
K-4.5 Cl-110* HCO3-24 AnGap-15
[**2175-3-17**] 03:52AM BLOOD Glucose-118* UreaN-41* Creat-0.9 Na-141
K-4.2 Cl-107 HCO3-25 AnGap-13
[**2175-3-18**] 04:07AM BLOOD Glucose-710* UreaN-38* Creat-1.0 Na-137
K-5.5* Cl-103 HCO3-26 AnGap-14
[**2175-3-20**] 04:52AM BLOOD Glucose-87 UreaN-46* Creat-0.9 Na-138
K-3.7 Cl-104 HCO3-27 AnGap-11
[**2175-3-23**] 05:15AM BLOOD Glucose-105 UreaN-54* Creat-0.9 Na-142
K-3.7 Cl-111* HCO3-21* AnGap-14
[**2175-3-27**] 03:58AM BLOOD Glucose-127* UreaN-72* Creat-1.1 Na-143
K-4.1 Cl-112* HCO3-21* AnGap-14
[**2175-3-30**] 02:18AM BLOOD Glucose-125* UreaN-76* Creat-1.2 Na-147*
K-4.0 Cl-113* HCO3-22 AnGap-16
[**2175-4-3**] 04:10AM BLOOD Glucose-122* UreaN-55* Creat-1.2 Na-143
K-4.2 Cl-110* HCO3-23 AnGap-14
[**2175-4-8**] 01:28AM BLOOD Glucose-139* UreaN-32* Creat-1.3* Na-144
K-4.2 Cl-111* HCO3-21* AnGap-16
[**2175-4-15**] 01:55AM BLOOD Glucose-103 UreaN-40* Creat-1.3* Na-138
K-3.5 Cl-103 HCO3-23 AnGap-16
[**2175-4-18**] 02:03PM BLOOD Glucose-128* UreaN-39* Creat-1.4* Na-142
K-3.9 Cl-104 HCO3-28 AnGap-14
COAGS
[**2175-3-11**] 02:42AM BLOOD PT-17.4* PTT-31.4 INR(PT)-1.6*
[**2175-3-16**] 03:18AM BLOOD PT-15.2* INR(PT)-1.4*
[**2175-3-18**] 04:07AM BLOOD PT-14.6* INR(PT)-1.3*
[**2175-3-31**] 12:38PM BLOOD PT-16.6* PTT-29.4 INR(PT)-1.5*
[**2175-4-8**] 01:28AM BLOOD PT-17.1* PTT-31.2 INR(PT)-1.6*
[**2175-4-18**] 03:42AM BLOOD PT-15.5* PTT-30.6 INR(PT)-1.4*
~
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~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
RADIOLOGY
CHEST (PORTABLE AP) [**2175-3-9**] 10:48 PM
IMPRESSION: Bilateral pleural effusions with perihilar haze and
upper zone redistribution present. A focal opacity is present in
the left mid lung zone. Findings may represent CHF/volume
overload with concern for concomitant infection.
CHEST (PORTABLE AP) [**2175-3-19**] 3:49 PM
IMPRESSION: Mild-to-moderate pulmonary edema has developed since
[**3-16**], partially obscuring multifocal consolidation, and
accompanied by increasing moderate right pleural effusion. Large
cardiac silhouette is stable. No pneumothorax. ET tube and right
central venous line are in standard placements. No pneumothorax.
CHEST (PORTABLE AP) [**2175-3-21**] 9:51 AM
IMPRESSION: Worsening of the left upper lobe and left lower lobe
consolidations vs. left pleural effusion. 2) Improvement of the
right lower lobe consolidation.
CHEST (PORTABLE AP) [**2175-4-2**] 1:02 PM
FINDINGS: There is a frontal and a view dedicated to the right
lateral chest. The tracheostomy tube is unchanged. The right IJ
line with tip in the superior vena cava is unchanged. There
continue to be patchy areas of opacity in both lower lungs and
in the perihilar regions suggesting multifocal pneumonia. There
could also be an element of CHF
C1894 INT.SHTH NOT/GUID,EP,NONLASER [**2175-4-5**] 1:24 PM
CHANGE G-TUBE TO G-J TUBE
IMPRESSION: Successful placement of a MIC gastrojejunostomy tube
with the tip of the tube in the small bowel loop. This catheter
is ready to use
CHEST (PORTABLE AP) [**2175-4-6**] 12:33 PM
Right pleural effusion is again demonstrated grossly unchanged
as well as pleural effusion on the left. The position of the
various lines and tubes is unaltered and the left lower lobe
consolidation is again demonstrated
CHEST (PORTABLE AP) [**2175-4-11**] 5:59 AM
Moderately severe pulmonary edema and moderate left and small
right pleural effusion have increased over the past five days.
More discrete region of consolidation seen in the left perihilar
lung is now partially obscured but has not cleared and other
areas of pneumonia could be obscured by the effusions and edema.
Heart size is top normal. Tracheostomy tube and left subclavian
central venous catheter are in standard placements. No
pneumothorax.
CHEST (PORTABLE AP) [**2175-4-13**] 1:12 PM
IMPRESSION: Mild improvement of previously described pulmonary
edema
CHEST (PORTABLE AP) [**2175-4-17**] 4:48 AM
Elevation of the right lung base which has progressed slowly
since early [**Month (only) 547**] is probably due to a combination of lower lobe
atelectasis and moderate right pleural effusion. Left perihilar
consolidation and hazy opacification of most of the left lung is
probably due to a combination of mild pulmonary edema and
increasing moderate left pleural effusion. Although the heart is
not grossly enlarged, there is persistent mediastinal venous
engorgement. More intense consolidation in the left upper lung
is consistent with a coexistent pneumonia, unchanged since [**4-14**].
~
~
~
~
~
~
~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CARDIOLOGY
ECG Study Date of [**2175-3-10**] 3:51:00 AM
Atrial fibrillation with rapid ventricular response
Left axis deviation - anterior fascicular block
Ant/septal+lateral ST-T changes may be due to myocardial
ischemia
Repolarization changes may be partly due to rate/rhythm
Incomplete right bundle branch block
Since previous tracing, right bundle branch block now incomplete
ECHO Study Date of [**2175-3-11**]
Conclusions:
The left atrium is normal in size. There is symmetric left
ventricular
hypertrophy. Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. Overall left ventricular
systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated. Right ventricular systolic function is normal.
The aortic root is moderately dilated. The ascending aorta is
mildly dilated. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are thickened. There is
probably mild aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension.
ECG Study Date of [**2175-3-19**] 12:11:06 PM
Atrial fibrillation. Axis to the left. T wave inversion in lead
aVL.
QR complexes in leads VI-V2. Non-specific T wave inversion in
lead aVL and low amplitude T waves in lead I. Right
bundle-branch block. Anteroseptal myocardial infarction. Left
axis deviation. Atrial fibrillation. Non-specific T wave
abnormalities. Compared to the previous tracing of [**2175-3-10**]
atrial fibrillation with tachycardia is no longer present.
Quality of tracing does not permit further assessment.
~
~
~
~
~
~
~
~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MICROBIOLOGY
Sputum: Pseudomonas multidrug resistant. Sensitve to Tobra,
intermediate to [**Last Name (un) **] and Gent.
KLEBSIELLA PNEUMONIAE
MRSA
C.Diff positive last on [**4-2**]
Brief Hospital Course:
CC:[**CC Contact Info 4477**].
HPI:
Mr. [**Known lastname 4476**] is a [**Age over 90 **] year old man with a long history of
end-stage dementia for at least 10 years with recurrent
aspiration pneumonias and pressure ulcers who presents to the
[**Hospital1 18**] ED from [**Hospital **] Rehab with an aspiration. He was recently
discharged from [**Hospital1 18**] [**3-3**] after he had an aspiration and had a
prolonged intubation. He was treated with vanc/zosyn for a two
week course which was completed [**3-5**]. Today, nursing at [**Hospital1 **]
noted that his abdomen was somewhat distended. A KUB was
performed that showed the feeding tube was coiled in his stomach
in a different position. Tube feeds were restarted and the
feeding tube was noted to be further displaced with the phlange
out of place. The patient was turned and began vomiting and
gagging and was suctions. His VS when he was evaluated there
were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM.
.
The patient was brought to the [**Hospital1 18**] ED evaluation. In the ED,
he was immediately intubated, and started on
levaquin/vanc/flagyl for presumed aspiration pneumonia. He
transiently dropped his blood pressure to a systolic of 80's
over 30's and was started on levophed.
Surgery was consulted
.
[**Age over 90 **]M with end-stage dementia noncommunicative for last 10 years
and inability to be weaned off vent p/w recurrent aspiration
pneumonias and likely aspiration. On IV flagyl for +c diff.
+Sputum cx pseudamonas on [**4-3**] in setting of hypotn, elevated
WBC and low grade fevers. s/p Tracheostomy [**3-31**].
.
# Pseudomonas pneumonia: Initially admitted with hypoxia, fevers
and hypotension with ?aspiration pneumonia however CXR unchanged
and started on vancomycin/zosyn ([**Date range (1) 4478**]) for coverage of
nosocomial peumonia. Subsequently abx d/c'd [**1-19**] +c diff in
stool. On [**3-24**] and [**3-26**] sputum cx grew resistant pseudamonas
([**Last Name (un) 36**] tobra, zosyn, meropenum) and pansensitive klebsiella
however clinically stable and no clear indication of pna on CXR.
s/p trach on [**3-31**]. [**Date range (1) 4479**] increasing WBC, hypotn and low
grade temp. Initially started on zosyn. Sputum again +for
pseudamonas and pt. started on meropenem, tobra. On [**4-11**]
meropenem was d/c and on [**4-14**] pt. grew pseudomonas out of sputum
- ID recommended only starting again if clinical picture
worsened. Pt's clinical picture did not worsen after this. Ctx
sensitive to zosyn and question if pt. was infected vs.
colonized as pt. w/ stable white count and not spiking
temperatures so decision was made to switch to single coverage.
The decision was made to start Zosyn on [**4-23**] and was scheduled to
complete a 14 day course. Because of the proximity of the end
date to the projected date of discharge, vanco and zosyn were
continued through the date of discharge. These antibiotics
should be discontinued 1-2 days after the patient is transferred
to his long term treatment facility.
## C. Diff Colitis: Pt. was also found to have C. diff colitis
during hospitalization likely [**1-19**] antibiotics. Pt. initially
started on vanco and flagyl. Per ID recs, pt. only needs single
coverage for this, so vanco was d/c and flagyl continued. It is
imperative that the patient continue flagyl for 14 days AFTER
the last dose of Zosyn. Hence, this would correspond to 16 days
after transfer from [**Hospital1 18**].
.
## Hypotension: likely due to sepsis originally, but responsive
to fluid boluses. In SICU, pt. was started on pressors, but
stopped on [**3-13**]. Pt. maintained goal MAPs. IN the MICU pt.
likely remained hypotensive due to poor forward flow. - given
total clinic pictures decision was made that pressors were not
indicated and the goal MAP was b/t 50-60. Throughout stay in
MICU, pt. w/ stable BP w/ occassional fluid boluses for
decreasting MAPS. and infection responsive to fluid boluses. It
was decided by the MICU team, other medical and subspecialty
teams directly involved w/ pt's care, ethics committee that CPR
was not medically indicated in this pt
.
## Acute renal failure: Pt. w/ acute renal failure during his
stay at [**Hospital1 **]. Renal was consulted and this was felt to be
secondary to poor forward flow. Pt. appears to have pre-renal
failure in the setting of total volume overload. Per renal,
this is not reversible and therefore the decision was made that
dialysis was not medically indicated. Pt. w/ increasing
creatinine throughout stay. Renal followed and pt. was startd
on bicarb.
.
# Atrial fibrillation: was in good control until arrival to
floor but developed some RVR. Stable throughout SICU and MICU
stay. Pt. was rate controlled on his own.
.
# Decubitus ulcers: Pt. w/ sacral decubitus - stage 1 and right
heel stage 1. Pt. also w/ multiple skin tears from tape. Pt.
w/ hip wound. Wound care following. Pt. w/ wet to dry
dressings.
.
## G/J Tube - Pt. had a G/J tube placed by IR. During MICU
stay, there was a question of increased leakage around tube and
surgery was consulted. An IR study was done that showed that
tube was in place w/ no evidence of obstruction. On [**5-4**], it
was decided to feed the J portion of the tube and suction the G
portion as there was no surgery indicated. On [**5-5**], there was a
hole noted at the distal portion of the feeding tube. Pt. was
taken back to IR and a G tube was placed at daughter's
insistence despite the strong recommendation by the MICU team
and IR team to have G/J tube replaced.
.
# F/E/N: Pt. was originally on TPN because of aspiration event.
When pt. was in the MICU he was on TF. At the end of MICU stay,
pt. was tolerating Vivonex.
.
# Ppx: Throughout hospital stay, pt. was on PPI and Heparin
prophylaxis.
Medications on Admission:
Vancomycin 1gm q24h until [**3-5**]
Zosyn 2.25gm q8h until [**3-5**]
Docusate liquid 150 twice daily
ASA 325mg daily
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops
Ophthalmic PRN
Magnesium Hydroxide 15mg daily
Heparin 5000u sc bid
Albuterol neb q6h
Atrovent neb q6h
Lansoprazole 30mg daily
Donepezil 10mg qhs
Lasix 20mg daily
Milk of Magnesia 15cc daily
Lopressor 6.25 mg [**Hospital1 **]
Tylenol elixir prn
Tube feeds: Nepro 0.45% @ 70cc/hr
Discharge Medications:
1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please give 5000 units
subcutaneous heparin tid.
13. Potassium Iodide 1 g/mL Solution Sig: Ten (10) Drop PO TID
(3 times a day) as needed for via J tube.
14. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily) as needed for down J-tube.
15. Artificial Tears Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection ASDIR (AS DIRECTED).
17. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
(3 times a day).
18. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
19. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours).
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: Please use 10 mL NS
followed by 2 ml of 100units/ml heparin (200 units heparin) each
lumen daily and PRN.
21. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): please give 40 mg solution
IV q 24 hours.
22. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams
Recon Solns Intravenous Q 12H (Every 12 Hours) for 2 days:
Please give 2.25 g IV q 13 hours.
23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg IV Intravenous Q12H (every 12 hours) for
15 days: Please give 500 mg IV q 12 hrs .
24. Wound Care
25. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 gram
Recon Soln(s)IV Intravenous Q8H (every 8 hours).
26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram (200ml piggyback) Intravenous Q48H (every 48 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Aspiration Pneumonia
Acute Renal Failure
Hypotension
Alzheimers
Discharge Condition:
Stable
Discharge Instructions:
IT IS VERY IMPORTANT THAT THIS PT'S TRACH BE HUBBED AT ALL TIMES
AS IT SLIPS SOME DUE TO GRANULATION TISSUE IN TRACT.
Patient should follow up with your primary care physician in the
next week. Please take all the medications as directed. Pleas
continue wound care as outlined.
Followup Instructions:
You should follow up with your primary care physician in the
next week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"5070",
"42731",
"4280",
"0389",
"99592",
"5849"
] |
Admission Date: [**2145-5-5**] Discharge Date: [**2145-5-10**]
Date of Birth: [**2083-8-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niacin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
asymptomatic.abnormal stress test on routine yearly physical
exam
Major Surgical or Invasive Procedure:
[**2145-5-6**]
1. Coronary artery bypass grafting x4, with left internal
mammary artery to left anterior descending coronary
artery; reversed saphenous vein single graft from the
aorta to the first diagonal coronary artery; reversed
saphenous vein single graft from the aorta to the first
obtuse marginal coronary artery; as well as reversed
saphenous vein single graft from the aorta to the distal
right coronary artery.
2. Epiaortic duplex scan.
3. Exploration of right atrial appendage to rule out or
rule in atrial septal defect.
4. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
61 yo male with HTN, dyslipidemia and diabetes recently seen
for routine physical. Referred for nuclear stress test on [**4-19**]
due to risk factors for CAD- showing medium area of moderate
stress induced ischemia in the PDA territory and diagonal
artery,
NL LV function. Pt now presents for cardiac catheterization to
further evaluate.
Past Medical History:
Hypertension
Dyslipidemia
Diabetes (type II with retinopathy)
BPH
Colon Polyps s/p polypectomy
Lung Nodule (right side- stable)
Basal cell CA
Diverticulosis
Social History:
Lives with: married with two adult children.
Occupation: Retired. Previously employed with [**Company 22957**].
Tobacco: Quit 30 years ago
ETOH: 10 beers per week
Family History:
Mother and father died of CAD in their 60's
Physical Exam:
Pulse:48 SB Resp:16 O2 sat: 99% RA
B/P Right: 117/50 Left:
Height: 5' 7" Weight: 225#'s
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: cath site Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit Right: None Left:None- s/p CEA
Pertinent Results:
[**2145-5-8**] 06:02AM BLOOD WBC-14.6* RBC-3.12* Hgb-9.2* Hct-27.4*
MCV-88 MCH-29.7 MCHC-33.7 RDW-13.5 Plt Ct-205
[**2145-5-6**] 01:46PM BLOOD PT-13.5* PTT-21.9* INR(PT)-1.2*
[**2145-5-8**] 06:02AM BLOOD Glucose-121* UreaN-23* Creat-0.9 Na-137
K-4.1 Cl-102 HCO3-26 AnGap-13
Pre-CPB:
No mass/thrombus is seen in the left atrium or left atrial
appendage.
No inter-atrial flow could be demonstrated with doppler or
bubble studies.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
An epi-aortic scan showed no significant disease at the aortic
cannulation site.
Post-CPB:
The patient is AV-Paced, on low dose phenlephrine.
Preserved biventricular systolic fxn. No MR, no AI.
Aorta intact.
No interatrial flow.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2145-5-6**] where the patient underwent coronary
artery bypass x 4. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Cefazolin was
used for surgical antibiotic prophylaxis. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. [**Last Name (un) **] was consulted for assistance with
blood glucose management. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Rehab in good condition with appropriate
follow up instructions.
Medications on Admission:
atenolol 37.5mg
HCTZ 25mg
lisinopril 10mg
metformin 1000mg [**Hospital1 **]
Actos 15mg daily
Simvastatin 80mg
ASA 325mg
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for PAIN.
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
13. Repaglinide 2 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals.
14. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig:
One (1) Subcutaneous four times a day: dose prn for
BG>200mg/dL, per sliding scale.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
16. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks.
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
18. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
coronary artery disease, s/p CABG [**2145-5-6**]
PMH:
Hypertension
Dyslipidemia
Diabetes (type II with retinopathy)
BPH
Colon Polyps s/p polypectomy
Lung Nodule (right side- stable)
Basal cell CA
Diverticulosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] I. [**Telephone/Fax (1) 17794**] in [**12-12**] weeks
Cardiologist Dr. [**First Name (STitle) **],[**First Name3 (LF) 2922**] S. [**Telephone/Fax (2) 2258**]in 1-2 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2145-5-10**]
|
[
"41401",
"4019",
"2724",
"2859"
] |
Admission Date: [**2131-12-26**] Discharge Date: [**2132-1-17**]
Date of Birth: [**2087-6-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
SOB and R arm swelling
Major Surgical or Invasive Procedure:
R AV fistula ligation
History of Present Illness:
Pt. is a 44 y/o with a hx of ESRD on HD (Tu, Th, Sat), Type II
DM, who p/w SOB x 2 day and R arm pain x 2 weeks. Pt. reports
she has had SOB with exertion since returning from HD on
Tuesday. Reports she has been getting a cold for the last week,
with rhinorrhea and cough productive of yellow sputum. Denies
HA, CP, fevers, reports chronic chills. Says she has had similar
episodes of SOB in the past "when I get fluid overloaded from
dialysis" but that she has been regular about HD so doesn't know
why she would be fluid overloaded now.
.
Pt. also reports getting a R AV fistula placed 1 month ago. She
reports her arm has been becoming painful and swollen for the
past 2 weeks. Says occasionally she'll get pain shooting from
elbow to R thumb, and sometimes her R hand goes numb if she
sleeps on her R, but otherwise denies weakness or numbness in R
hand.
.
In ED: A/A Nebs, ASA, Blood Cx x 2. Transplant surgery asked to
eval R arm fistula, Renal asked to eval for HD.
Past Medical History:
Type II DM, +retinopathy
ESRD on HD
HTN
Hx Pre-eclampsia
CHF- EF unknown, pt. reports "leaky valves"
Sleep Apnea -> CPAP, Home O2 PRN
CVA [**8-19**] with residual L arm and leg weakness
Social History:
No EtOH, hx tobacco quit 1 year ago, used to smoke 3 ppd x 33
years. Lives with cousin, [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 26707**], on
disability
Family History:
Adopted, unknown
Physical Exam:
VS: 96.8 116 167/93 18 99% on 2L
Gen: A+O, sitting on stretcher in NAD
HEENT: EOMI, PERRL
CV: tachycardic, regular rhythm, harsh 4/6 systolic murmer
Lungs: decreased BS at bases bilat, mild bibasilar crackles
Abd: obese, soft, NTND, +BS
Ext: fistula in R forearm, +thrill, R arm markedly swollen from
elbow to shoulder, TTP in this area. + radial pulse bilat
Pertinent Results:
CTA Chest [**2131-12-26**]: 1) No evidence of pulmonary embolism.
2) Congestive heart failure with mild bilateral pleural
effusions.
3) Nonspecific borderline mediastinal lymphadenopathy.
4) Tiny ill defined alveolar opacities in the anterior left
upper lobe
anteriorly, nonspecific; possibly infectious in nature; these
should be
reassessed to ensure resolution.
.
Right upper extremity venous ultrasound and Doppler examination,
[**2131-12-26**]:
Examination of the right internal jugular, right subclavian,
right axillary, paired brachial and basilic veins shows no
evidence of deep vein thrombosis. A very limited evaluation of
the fistula suggests that it is patent.
.
Fistulogram [**2131-12-28**]: Central subclavian occlusion. Limited
outflow of the AV fistula through multiple collaterals in the
arm, shoulder and thoracic wall. The AV anastomosis is patent.
Recommend MR venogram to determine central end of occlusion.
Based on MRI, decision to attempt further venous recanalization
under anesthesia could be considered.
.
MRI/MRA Chest [**2132-1-2**]: MRA of the thorax shows normal pulmonary
arteries bilaterally without central filling defects to suggest
pulmonary embolus. Pulmonary veins are patent and have a normal
appearance. The left ventricle wall appears mildly thickened
raising the question of left ventricular hypertrophy. Chamber
size is within normal limits for all four [**Doctor Last Name 1754**] of the heart.
The ascending and descending aorta have a normal appearance
without aneurysmal dilatation, ulcer, or large amount of
atherosclerosis. Bilateral common carotid arteries are widely
patent proximally and patent to their bifurcations. Bilateral
subclavian arteries are also widely patent giving rise to
respective vertebral arteries. The left vertebral artery appears
slightly dominant. No concerning lesions within the arteries.
.
There is marked narrowing of the right subclavian vein a few
centimeters
central to the right chest wall that extends over the entire
more central
portion of the right subclavian vein and right brachiocephalic
vein. The
caliber of the vessel at this level measures between 3 and 9 mm
with multiple areas of stenosis. PICC does extend through the
stenoses and into the superior vena cava. The right jugular vein
is completely thrombosed.
.
The left subclavian vein is markedly irregular with moderate
stenoses but
remains patent to the left brachiocephalic vein. Within the left
lateral
subclavian vein are some filling defects that could represent
chronic thrombus that are nonocclusive. The patient's
double-lumen dialysis catheter enters through the central left
subclavian vein and into the brachiocephalic vein and SVC. There
is minimal contrast around the dialysis catheter throughout its
course within the brachiocephalic vein and superior SVC, which
is narrowed superiorly, however there is slow flow around the
catheter. The left jugular vein is completely thrombosed.
.
Large number of venous collaterals shunting venous blood from
the neck and bilateral upper extremities around the bilateral
subclavian vein and
brachiocephalic vein stenoses. Collaterals are seen within
anterior chest
walls bilaterally, left much greater than right, within the
posterior thorax including the intercostal veins and within the
supraclavicular veins bilaterally. Early on after the injection,
contrast is seen to flow more through these collaterals than
through the bilateral subclavian veins, right brachiocephalic,
and proximal left brachiocephalic vein. The two largest central
collaterals are the azygos vein and the left superior
intercostal vein.
.
There are multiple bilateral enlarged axillary lymph nodes,
which are
nonspecific and were seen on the recent CT scan. Clinical
correlation to
explain this lymphadenopathy is recommended.
.
No definite abnormalities are seen within the upper abdomen on
limited
evaluation. Within the right latissimus dorsi muscle is a 8.6 x
3.6 x 4.0 cm lesion with predominantly fat within it, though
there is some central soft tissue with intermediate T1 and T2
signal. This is not definitely a simple lipoma and therefore
dedicated MRI is recommended to better characterize.
.
IMPRESSION:
1. Multifocal high-grade stenosis within the right subclavian
vein centrally and right brachiocephalic vein. These vessels are
patent though there is slow flow through them with large venous
collaterals.
.
2. Moderate stenoses within the left subclavian vein and minimal
flow through the left brachiocephalic vein about the patient's
dialysis catheter as well as in the superior SVC which is
slightly narrowed. These lumens are patent, however there is
decreased flow as evidenced by delayed filling and the extensive
collaterals.
.
3. Bilateral jugular vein occlusion inferiorly.
.
4. 8.6 cm fat-containing lesion within the right latissimus
dorsi does
contain soft tissue elements and therefore is not definitely a
simple lipoma. Dedicated MRI is recommended to better
characterize.
.
5. Right greater than left axillary lymphadenopathy is
non-specific and
clinical correlation is recommended
.
CTA Chest [**2132-1-6**]: 1. No evidence of pulmonary embolism.
2. Findings most consistent with congestive heart failure.
3. New bibasilar opacities, probably atelectases.
4. Prominent axillary lymph nodes.
Brief Hospital Course:
SOB: CTA showed findings c/w CHF. Pt. was aggressively
dialyzed with improvement in her SOB. After HD #3 she did not
require O2 during the day to maintain O2 sats. A TTE was
checked and showed and EF of 75% with moderate LV outflow
obstruction, [**12-17**]+ MR, and mild PA hypertension, and high outflow
CHF [**1-17**] her AV fistula was thought to contribute to SOB.
Pulmonary was consulted re: PA HTN contributing to SOB and
recommended PFTs, which showed a restrictive defect, as well as
a RA ABG, which showed a pH of 7.39, PO2 73, PCO2 46, HCO3 29.
She was continued on her CPAP at night. PA HTN was also thought
to contribute to her SOB. PE was considered on admission,
however CTA was negative for PE. It was considered again when
pt. was transferred to the MICU on [**1-5**] for hypotension and
hypoxia, especially given known UE thrombi, however repeat CTA
was negative for PE.
.
CHF: As mentioned above pt. was found to have high output CHF,
making her pro-load dependant. On [**1-5**] she became hypotensive
and hypoxic, and was transferred to the MICU for further
management. She briefly required pressors, but responded to
fluid resuscitation (3L NS), and briefly required BiPAP for
management of hypoxia, though she was quickly weaned to O2 by
NC. All blood cultures were negative, so this episode was
thought be be [**1-17**] decreased pre-load from decreased PO intake
and fluid removal at HD, and not sepsis. She was continued on
ASA QD throughout her hospitalization, as well as her BB (though
this was held during her episode of hypotension) She was
started on an ACE at the beginning of her hospitalization,
however this was stopped during her hypotensive episode and was
not restarted in order to maintain a higher basal BP. This was
later restarted at the time of discharge.
.
Arm Swelling: RUE dopplers were checked on admission and were
negative for DVT. Transplant evaluated pt in ED and reviewed
dopplers, and concluded that no intervention was necessary.
However given clinical concern for thrombosis, this was followed
up with an AV fistulogram which showed central subclavian
occlusion. Pt. was started on Heparin gtt. Transplant was
reconsulted and again recommended no intervention. Therefore
interventional radiology was consulted re: recanalization of R
subclavian vein. They recommended an MRI/MRV prior to
intervention, and this was obtained (see results above) and
showed bilateral thrombi and stenoses. While these studies were
being obtained pt. also developed LUE swelling, due to L sided
clots. On [**1-9**] recanalization of R subclavian clot was
attempted by IR, but was unsuccessful. Pt. was transferred to
the MICU for infusion of tPA overnight, and recanalization was
attempted again on [**1-10**], again unsuccessfully. Transplant was
contact[**Name (NI) **] again after these procedures, and on [**1-12**] they ligated
her R AV fistula.
.
ESRD: Renal was consulted, and pt. was continued on HD through
her L subclavian HD catheter. Her PhosLo was d/ced as her Phos
was WNL, and her Epogen at HD was continued. She was started on
Nephrocaps.
.
Type II DM: Actos was held given concern for fluid retention,
pt. was covered with RISS, with good blood glucose control over
admission.
.
Dispo: At the time of discharge the patient INR was to be drawn
at dialysis and followed up by Dr. [**First Name8 (NamePattern2) 26708**] [**Name (STitle) **]. The patient
would later be transitioned to the coumadin clinic at [**Hospital 6308**].
Medications on Admission:
Metoprolol 100 mg [**Hospital1 **]
Lansoprazole 30 mg [**Hospital1 **]
Pioglitazone 30 mg QD
Diltiazem Er 360 mg QD
Calcium Acetate 667 mg TID with meals
Reglan 10 mg TID
ASA 325 mg QD
Epogen with HD
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Lansoprazole 30 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*
4. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
PRN.
Disp:*qs inhaler* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED): Will be given at dialysis.
8. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*5 Bottles* Refills:*2*
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-17**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*qs bottles* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
12. trazadone Sig: 25mg at bedtime.
Disp:*30 pills* Refills:*2*
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Patient needs INR level monitored on Tuesday, Thursday and
Saturday.
Please report value to Dr. [**First Name8 (NamePattern2) 26708**] [**Name (STitle) **] [**Numeric Identifier 26709**]
[**Hospital 191**] clinic
16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis
Bilateral Upper Extremity Thrombus
.
Secondary Diagnosis
Type II DM, retinopathy
ESRD on HD
HTN
Pre-eclampsia
CHF: EF 75%
Sleep Apnea: CPAP
CVA [**8-19**] with L arma and leg weakness
Discharge Condition:
Good, vitals stable, patient ambulating and eating,
Discharge Instructions:
Seek medical services immediately if you should have any fevers,
chills, worsening upper extremity swelling or any other
worrisome sympmtom. Please take your medications as prescribed.
Please restrict your sodium intake to 2g per day.
.
Your INR will be checked at dialysis. They will report the
results to me. Do not take your Coumadin tonight. Take it on
Friday. I will contact you on Saturday as to whether or not you
need to take it.
.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-1-22**]
4:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-2-5**]
1:30
Completed by:[**2132-1-22**]
|
[
"40391",
"4168",
"32723"
] |
Admission Date: [**2174-3-30**] Discharge Date: [**2174-4-6**]
Date of Birth: [**2109-1-7**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Cortisone
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
L facial rash and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 65 yo woman with MG on immunosuppression who presents
with zoster ophthalmicus and a possible bacterial
superinfection. Her symptoms started two weeks ago when she
noted sharp shooting pain on the [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of her face and scalp.
The following day she developed marked swelling and vesicular
rash around her left eye. Because of the swelling she could not
see through the left eye. She contact[**Name (NI) **] her ophtholmologist who
diagnosed her with shingles and referred her to her PCP. [**Name10 (NameIs) **] was
prescribed po valacyclovir and took it for 3 days. As her
symptoms failed to improve, she contact[**Name (NI) **] her neurologist Dr.
[**Last Name (STitle) 1206**] who urged her to present to [**Hospital1 18**] for IV acyclovir
treatment.
.
In the ED she received IV acyclovir and was admitted to
neurology for further management ([**2174-3-30**]). Initially stable
w/o complaints. On [**4-1**] patient was noted to be weak and did
poorly on her respiratory testing (NIF 24, FVC 0.9). She was
subsequently transferred to the ICU amid concerns of myasthenia
flare and related respiratory distress. On admission to ICU
patient was stable with repeated NIF -50 and FVC 2.4. She did
not require intubation and was started on IVIg for myasthenia.
Patient was transferred to medicine on [**4-2**] for further
management.
.
On the floor, she denies any facial pain or headache. Notes some
difficulty seeing w her left eye because of the swelling. Denies
recent fevers, chills, night sweats, sore throat, cough, SOB.
Denies chest pain, palpitations. Denies abdominal pain, N/V/D.
Denies new vessicles or any rashes at other parts of her body.
Denies sick contacts but notes distant history of chickenpox as
a child. Notes fatigue w repeated physical activity unchanged
from her baseline MG.
Past Medical History:
myasthenia [**Last Name (un) 2902**]
osteoporosis
breast calcifications
mitral valve prolapse
Social History:
Married lives with husband, works this past year, part-time,
teaching [**Location (un) 1131**]. No tob, etoh or drugs.
Family History:
breast cancer, emphysema, cardiac arrest
Physical Exam:
PHYSICAL EXAM:
VS: Tc:97.8 Tmax:98.2 BP:122/68 HR:95 RR:20 O2 sat: 98% @ RA
GEN: NAD.
HEENT:
- EOMI, PERRL bilaterally; vision intact bilaterally. Resolving
edema/erythema in CN V1 distribution with crusted areas medially
w/o new vessicles.
- R ear tympanic membrane non-inflammed with intact light reflex
and no pooling of fluid; mild edema/erythrema of the external
ear epithelium inferiorly; No vessicles noted. No pus or
drainage noted. L ear exam unremarkable.
- OP clear without lesions. MMM. No sinus tenderness.
NECK: Supple; No LAD; no JVD appreciated
CV: RRR, nl S1, S2. No m/r/g.
CHEST: CTAB, no crackles/wheezes/rhonchi; unlabored respiration
w/o accessory muscle use
ABD: +BS, Soft, NT/ND, no masses or organomegally appreciated
EXT: WWP, No c/c/e
SKIN: Erythematous rash with crusted edges and central resolving
area contained within left CNV1 dermatome; Minimal edema of
surrounding skin and eyelid, now resolving. No vessicles
appreciated. No puss production or drainage noted; Resolving
left conjunctival injection with scant viscous drainage. No
other lesions or rashes appreciated.
NEURO: A&O x 3. CN II-XII intact. Normal bulk, strength and tone
throughout. Sensation intact. No nystagmus, dysarthria,
intention or action tremor. Downgoing Babinski bilaterally.
Pertinent Results:
[**2174-4-3**] 05:35AM BLOOD WBC-8.9 RBC-3.41* Hgb-10.3* Hct-31.0*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.8 Plt Ct-279
[**2174-4-4**] 04:45AM BLOOD WBC-7.6 RBC-2.99* Hgb-9.1* Hct-26.7*
MCV-89 MCH-30.6 MCHC-34.2 RDW-14.8 Plt Ct-281
[**2174-4-2**] 02:49AM BLOOD WBC-10.7 RBC-3.36* Hgb-10.2* Hct-29.8*
MCV-89 MCH-30.3 MCHC-34.2 RDW-14.7 Plt Ct-235
[**2174-3-30**] 04:02PM BLOOD WBC-9.4 RBC-3.66* Hgb-11.5* Hct-32.6*
MCV-89 MCH-31.5 MCHC-35.3* RDW-14.7 Plt Ct-253
[**2174-4-1**] 08:00AM BLOOD Neuts-88.5* Lymphs-7.3* Monos-4.0 Eos-0.1
Baso-0.1
[**2174-3-30**] 04:02PM BLOOD Neuts-90.4* Lymphs-6.6* Monos-2.8 Eos-0.1
Baso-0.1
[**2174-4-2**] 02:49AM BLOOD PT-13.3 PTT-30.1 INR(PT)-1.1
[**2174-3-31**] 05:26AM BLOOD PT-13.0 PTT-23.2 INR(PT)-1.1
[**2174-4-4**] 04:45AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-138
K-3.4 Cl-102 HCO3-31 AnGap-8
[**2174-4-3**] 05:35AM BLOOD Glucose-99 UreaN-12 Creat-0.6 Na-138
K-3.3 Cl-101 HCO3-31 AnGap-9
[**2174-4-2**] 02:49AM BLOOD Glucose-97 UreaN-8 Creat-0.5 Na-137 K-3.5
Cl-100 HCO3-32 AnGap-9
[**2174-4-1**] 08:00AM BLOOD Glucose-144* UreaN-7 Creat-0.5 Na-135
K-3.5 Cl-93* HCO3-36* AnGap-10
[**2174-3-31**] 05:26AM BLOOD ALT-37 AST-18 LD(LDH)-282* AlkPhos-47
TotBili-0.4
[**2174-4-4**] 04:45AM BLOOD Calcium-8.8 Iron-38
[**2174-4-1**] 08:00AM BLOOD Albumin-3.9 Calcium-7.5* Phos-3.4 Mg-2.0
[**2174-3-31**] 05:26AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.0*
[**2174-4-4**] 04:45AM BLOOD calTIBC-267 Ferritn-49 TRF-205
[**2174-4-1**] 08:00AM BLOOD IgG-425* IgA-47* IgM-56
[**2174-4-1**] 11:15PM BLOOD Type-ART pO2-94 pCO2-45 pH-7.45
calTCO2-32* Base XS-6
[**2174-4-1**] 07:34PM BLOOD Type-ART FiO2-20 pO2-76* pCO2-41 pH-7.48*
calTCO2-31* Base XS-6
[**2174-4-1**] 07:34PM BLOOD Lactate-1.6
.
CHEST X-RAY: The lungs are clear without infiltrate or effusion.
On prior chest x-ray, there is a history of a lung nodule, but
this is not evident on today's study. Compared to the prior
exam, there has been no significant interval change.
.
CULTURES: Blood, urine, MRSA, and C. diff cultures negative
Brief Hospital Course:
65 year old female with myasthenia [**Last Name (un) 2902**] on prednisone,
CellCept and IVIg immunosuppression presenting with zoster
ophthalmicus and superimposed cellulitis.
.
1.) MICU Course:
Pt was transferred from floor to MICU for concern of respiratory
fatigue secondary to myasthenia [**Last Name (un) 2902**]. On the floor NIF -> -24
and FVC 900cc, however there was concern this low value may have
been related to anxiety. In the MICU the patient remained
stable and not show signs of respiratory fatigue. ABG showed
normal pCO2. NIF overnight was -44 with an FVC of 2.4L. NIF in
the AM ([**4-2**]) was -50. The patient tolerated room air for the
majority of the night. She was given IVIg for treatment of
possible myasthenia crisis.
.
2.) ZOSTER OPTHALMICUS:
Zoster opthalmicus in L CNV1 distribution with associated
cellulitis. Patient completed seven days of IV acyclovir and 7
days of IV Unasyn while inpatient. Discharge on 14 days of
valacyclovir 1g PO TID and on augmentin 875 mg PO BID for total
on 10 days as per ID recs. Continue with topical bacitracin and
polymyxin B. Continue lidocaine and gabapentin PRN pain;
.
2.) MYASTHENIA [**Last Name (un) **]:
Following ICU stay, patient remained stable and in no
respiratory distress. NIF remained around -50 and FVC at 1.7.
She completed 5 days of IVIg with last dose on [**4-4**]. She was
continued on home prednisone, Cellcept, pyridostigmine. She was
insructed to start on dapsone 100mg PO QD for PCP prophylaxis
until prednisone < 20mg per day on discharge. Also started on
Calcium and Vitamin D.
.
3.)R EAR PAIN: Patient complained of ear pain contralateral to
zoster 2 days prior to discharge. On exam, no evidence of
vesicles but possible dullness of TM c/w viral infection.
Patient was already on antibiotics. Her symptoms improved the
next day.
.
4.) ANEMIA:
Patient has baseline anemia and has had history of iron
deficiency in the past reuqiring supplemental iron. Iron labs
significant for normocytosis, low-normal Fe (38), low-normal
TIBC (267) and normal ferritin (49). This data suggests mixed Fe
deficiency and ACD, as her ferritin would be expected to be much
higher in the setting of acute infection and inflammation. No
evidence of hemolysis on exam or from history. No evidence of
acute bleeding and gastrocult negative on admission.
- Futher outpatient eval if symptomatic.
.
5.) HYPOTHYROIDISM: Stable. Continue home synthroid.
Medications on Admission:
Medications (at home):
Levothyroxine 25 mcg
Cellcept [**Pager number **] mg [**Hospital1 **]
protonix 40 mg daily
Prednisone 20 daily
Pyridostigmine 90 mg [**Hospital1 **] and 60 mg qhs
Forteo (takes 1 shot per day, has not been taking past 1-2 weeks
while sick with GI bug)
Cholestyramine prn for loose stools
Discharge Medications:
1. Valacyclovir 1 g Tablet Sig: One (1) Tablet PO three times a
day for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
2. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Dapsone 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: 7.5 ml PO BID (2
times a day).
9. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: Five (5) mL PO
QHS (once a day (at bedtime)).
10. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
11. Neurontin 300 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for pain.
Disp:*90 Capsule(s)* Refills:*0*
12. Trifluridine 1 % Drops Sig: One (1) Drop Ophthalmic Q4H
(every 4 hours).
Disp:*QS 1 month * Refills:*0*
13. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic
Q2-4H () as needed for eye comfort.
Disp:*QS 1 month * Refills:*0*
14. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical TID (3 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ZOSTER OPTHALMICUS
BACTERIAL SUPERINFECTION
.
Secondary:
myasthenia [**Last Name (un) 2902**]
Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for Zoster opthalmicus, a reactivation of the
chicken pox virus in one of the nerves of your face. You were
treated with IV acyclovir. Given you myasthenia [**Last Name (un) 2902**] and
concern for your respiratory status, you were treated with IVIG.
You were also treated with antibiotics for a possible bacterial
infection that may have occured in the skin that had broken down
from the viral infection. You should complete the course of
prescribed medications and follow up with the doctors as below.
You were started on dapsone for prophylaxis against an infection
called PCP. [**Name10 (NameIs) **] should take this medication while you are on
high doses of prednisone.
If you have new fevers, increasing pain, or any other concerning
symptoms, please seek medical attention.
Followup Instructions:
You should follow up with Dr. [**First Name (STitle) **] from opthomology. Date/Time:
[**4-26**] at 3PM in the [**Last Name (un) **] diabetes center. You may need to get
a referral from your PCP prior to this appointment. You can
call [**Telephone/Fax (1) 28100**] if you need to change this.
Infectious disease: Fri [**5-13**] at 10:00 AM with Dr. [**First Name (STitle) **] [**Last Name (NamePattern1) 12939**] (basement)
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2174-6-8**] 1:00
Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) 162**] [**Telephone/Fax (1) 40969**].
Date/Time: [**2174-4-12**] 2:15 PM
You have an appointment scheduled with your neurologist, Dr.
[**Last Name (STitle) 1206**]. Phone: [**Telephone/Fax (1) 44311**] Date/Time: [**2174-4-14**] 11:00 AM.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2174-4-12**]
|
[
"2859",
"2449",
"4240"
] |
Admission Date: [**2137-9-7**] Discharge Date: [**2137-9-12**]
Date of Birth: [**2099-9-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracyclines / Succinylcholine / Clozaril /
Calcium Channel Blocking Agents-Benzothiazepines /
Beta-Adrenergic Blocking Agents
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
MICU admission
Hemodialysis
History of Present Illness:
37 year old female with schizoaffective d/o, depression, seizure
d/o, ESRD from IGA nephropathy, very poor access with
transhepatic HD catheter on coumadin; now admit with UGIB
(melena, hematemesis). Patient denies past history of
hematemesis but noted to have some in last DC summary, no EGD at
that time. States hematemsis started today, melena last night.
STR notes of dark bloody stool x 3 incontinent episodes. SBP
111 at STR. Patient was receiving coumadin for line as detailed
below; also started on fondaparineux 7.5 daily (appears to have
received 3 doses only) for subtherapeutic INR.
Past Medical History:
ESRD [**3-9**] IgA nephropathy
Schizoaffective disorder
Depression
Chronic anemia
GERD
Cardiomyopathy: ECHO [**2137-8-6**] EF >65%, hyperdynamic, LVH, no
valvular disease
Hypothyroidism
GI bleed
RLE DVT
Seizure disorder
tracheal stenosis s/p trach, on TM at 7L/min at rehab
malignant hypothermia
Surgical History:
s/p L upper and lower extremity AV fistulae(failed),
s/p R upper extremity AV fistula (basilic vein
transposition(failed),
s/p R forearm AV graft (failed),
s/p attempted insertion of a peritoneal dialysis catheter
(failed), central venous stenosis,
Innominate venous stenosis,
s/p R brachioarterial->axillary AV graft, nonfunctional,
status post multiple thrombectomies and angioplasties,
s/p tracheostomy,
s/p thrombectomy of AV graft x5,
s/p Transhepatic HD catheter placement
Social History:
Currently living at [**Hospital **] rehab. No tobacco, EtOH, illicit
drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T98.5, 95/46, 105, 21, 100% on 50% TM
General: Alert, conversant, flat affect, NAD
HEENT: NC/AT, PERRL, MM moist, small dried blood in nares.
Neck: Trach, no adenopathy
Lungs: coarse but clear, somewhat poor effort
Heart: slightly tachy, regular, no murmur appreciated
Abdomen: Soft, NT/ND. R lateral transhepatic HD line.
Extrem: Warm, no edema, L femoral line in place.
Neuro: Alert and oriented to place
Pertinent Results:
[**2137-9-7**] 10:07PM HCT-17.8*
[**2137-9-7**] 10:07PM PT-16.6* PTT-31.9 INR(PT)-1.5*
[**2137-9-7**] 03:21PM GLUCOSE-108* UREA N-45* CREAT-4.1* SODIUM-139
POTASSIUM-5.4* CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2137-9-7**] 03:21PM ALT(SGPT)-10 AST(SGOT)-13 LD(LDH)-150 ALK
PHOS-80 TOT BILI-0.3
[**2137-9-7**] 03:21PM ALBUMIN-2.7* CALCIUM-7.6* PHOSPHATE-3.0
MAGNESIUM-1.4*
[**2137-9-7**] 03:21PM VANCO-16.6
[**2137-9-7**] 03:21PM WBC-8.3 RBC-2.16* HGB-6.9* HCT-20.3* MCV-94
MCH-31.8 MCHC-33.7 RDW-17.2*
[**2137-9-7**] 03:21PM PLT COUNT-333
[**2137-9-7**] 11:15AM cTropnT-0.10*
[**2137-9-7**] 11:15AM CK(CPK)-15*
Brief Hospital Course:
#UGIB. The patient has had a history of GIB, with last EGD in
[**2134**]. During her last admission previous to this, she again had
a small amount of bleeding but was not scoped. This admission,
the patient again complained of hematemesis in the setting of
anticoagulation with fondaparinaux (however, normal INR due to
prophlactic doses of 1mg Coumadin daily to keep her transhepatic
vein patent) Given her ESRD and recent fondaparinux doses which
is renally cleared, the patient was at particulary high risk of
bleeding. A discussion with heme-path was had and it was
confirmed that there was no specific antidote for fondaparinux.
Therefore, the patient was monitored closely in the ICU due to
her GIB and on [**9-8**] the patient underwent an EGD. At that time,
a bleeding vessel was identified, possibly arterial in source,
and the vessel was clipped and injected with epinephrine.
Following the EGD, the patient had no clinical signs of active
rebleeding and no further investigative radionuclear scans were
needed. Of note, the patient recieved a large amount of FFP and
also recieved ~15 units PRBC this admission. The patient was
maintained on an IV PPI during this admission, which was
switched to sucralfate after several days, and now is being
considered for transfer back to [**Hospital **] rehab after several
days of no hematemesis and stable Hct.
.
# Hypotension. At baseline, pt has a low blood pressure with
SBP's running in the 80's - 100's. During this admission, the
patient had episodes of hypotension below her baseline that were
likely related to hypovolemia/blood loss from her large GIB. BP
was maintained with aggresive therapy with blood products.
Underlying infection/sepsis was considered but there was no
evidence of active infection or this admission. The patient
had two blood cultures on [**9-7**] that were drawn from a left
femoral line, and one of the two bottles showed gram negative
and gram positive rods. The patient had been in the ICU for
several days when these results were received, and was improving
clinically, without an elevated white count, so after discussion
with the team, it was thought that this was most likely a
contaminant. Blood cultures redrawn [**9-11**] are pending. The
patient was continued on treatment with Vancomycin that had been
started during a previous admission for a MRSA bactermia in the
past, with the plan to continue it with dialysis until [**9-15**]. will tolerate SBP in the 80s-use HR as indicator for
volume status as pt was tachycardic originally w acute bleed and
has not been since. In addition, Midodrine was stopped (had
been on 5 mg TID prn for SBP < 90), can consider restarting in
future.
.
# Thrombocytopenia: New development this admission, platelets
have continued to decrease but stabilized and recovered to the
130K range, 104 on discharge. Effect was suspected to be
medication related as fondaparineaux not usually associtaed with
thrombocytopenia, and PPI was switched to Carafate after which,
an improvement in the patient's thrombocytopenia was noted.
.
# ESRD on HD. HD M/W/F. History of extremely difficult access;
currently accessed via transhepatic catheter. On low dose
Coumadin 1mg daily for this with NO GOAL INR.
Pt was dialyzed during this admission without complication.
.
# History of line sepsis. Pt continued to recieve Vanco with HD
while here and recieved an extra 500mg dose early during the
admission secondary to her large volume blood loss and low
Vancomycin levels at that time. The course of Vancomycin
therapy was confirmed with ID and the patient is to continue
Vancomycin with HD through [**2137-9-15**].
.
# History of respiratory failure s/p trach. The patient's
respiratory status was stable during this admission, she was
continued on her trach mask at 40-50% FiO2 with no issues while
in the ICU.
.
# Hypothroidism. Patient was continued on her Synthroid.
.
# Schizoaffective disorder/depression: Patient was continued on
her fluphenazine.
.
# GERD: on Sucralfate, now off PPI/H2 blockers.
.
Medications on Admission:
Albuterol MDI 2 puffs QID
Calcium Acetate 667 mg TID with meals
Cinacalcet 90 mg daily
Fluphenazine 2.5 mg [**Hospital1 **], and 10 mg HS
Fondaparinux 7.5 mg daily (started [**9-4**])
Levothyroxine 100 mcg daily
Midodrine 5 mg TID for SBP <90
Pantoprazole 40 [**Hospital1 **]
Vancomycin 1 gram with HD (reportedly complete on [**9-6**])
Warfarin 3 mg daily
APAP prn
Miconazole prn
Alteplase prn to HD cath
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluphenazine HCl 2.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for wheeze.
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Vancomycin 1000 mg IV HD PROTOCOL
Give one dose after hemodialysis session
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Upper Gastro-intestinal Bleed secondary to bleeding esophageal
vessel and esophagitis
Discharge Condition:
Stable, trach in place
Discharge Instructions:
You were admitted to the hospital with a concern for bleeding.
You underwent a procedure called an EGD to control the bleeding.
You also received blood transfusions to keep your blood level
stable.
.
There were changes made to your medications. You will only
take coumadin 1mg daily and not adjust this for your INR. In
addition, you were started on Sucralfate 1 g four times per day.
This is to help protect your stomach given the recent bleed.
Your Fondaparineux was stopped.
.
If you have any further bleeding, coughing up of blood,
abdominal pain, shortness of breath, or other concerning
symptoms, please return to the ER.
.
You should follow up with your primary care doctor in the next
2-3 weeks.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-9-19**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2137-9-24**] 9:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"40391",
"0389",
"311",
"53081",
"2449",
"V5861",
"2875"
] |
Admission Date: [**2125-1-22**] Discharge Date: [**2125-1-29**]
Date of Birth: [**2098-6-30**] Sex: F
Service: MEDICINE
Allergies:
Famotidine
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Acetaminophen intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 26 year old female with history of anxiety,
depression and multiple past suicide attempts who is transferred
to [**Hospital1 18**] from the OSH for the management of the acetaminophen
overdose. Per report, patient ingested approximately 7.5g of
acetaminophen in a suicude attempt on [**1-19**]. Patient presented to
the [**Hospital3 **] ED on [**1-20**] with acetaminophen level of 132. She
received 20 hour course of IV n-acetylcysteine. The 16-hr
component of the infusion was repeated due to evolving liver
failure. Her AST and ALT levels were 4500 and 7400,
respectively, with INR 1.8. She was transferred to [**Hospital1 18**] for
further management.
On presentation at [**Hospital1 18**], patient was in no distress. She had no
specific complaints except headache. She denied any nausea,
vomiting, abdominal pain, diarrhea, fever, chills, confusion.
Past Medical History:
-Hypothyroidism: on levothyroxine
-Amenorrhea secondary to low body weight: s/p recent 10-day
course of medroxyprogesterone 10 mg po daily to stimulate
ovulation ([**Date range (1) 89743**]), not successful
Past Psychiatric History:
-Depression with chronic thoughts of suicidality and self-harm:
history of prior suicide attempt at age 16 via Tylenol overdose.
Two prior hospitalizations at age 16 for Tylenol overdose and at
age 20 in context of severe SI.
-Anorexia: diagnosed at age 12, no prior hospitalizations
related to anorexia, currently with stable weight, working with
new nutritionist.
Social History:
Lives with parents, grandmother and older sister in [**Name (NI) 38**],
middle of 3 girls. Graduated [**Doctor Last Name **] undergrad and grad school
LCSW. Recently working as social worker at [**Hospital3 **] Mental
Health. She has a few friends, does not date. Exercise
'fanatic'. No known hx of abuse or trauma.
Family History:
Paternal grandmother and father with depression, both sisters on
antidepressants.
Physical Exam:
VS: 100.8 54 114/65 16 100% RA
Gen: NAD, sad affect, appropriate
Neuro: no focal deficit, no aterixis
HEENT: No icterus, oropharynx moist, without exudate, no LAD, no
thyromegaly
CV: RRR, S1S2, no mur
pulm: CTA b/l
abdom: soft, ND/NT, + BS, no hepatomegaly
extremities: no edema, no cyanosis, well perfused
Pertinent Results:
ADMISSION LABS
[**2125-1-22**] 06:50PM PT-20.1* PTT-36.0* INR(PT)-1.8*
[**2125-1-22**] 06:50PM PLT COUNT-112*
[**2125-1-22**] 06:50PM NEUTS-78.6* LYMPHS-15.8* MONOS-1.9* EOS-3.4
BASOS-0.3
[**2125-1-22**] 06:50PM WBC-5.0 RBC-3.54* HGB-12.2 HCT-33.8* MCV-96
MCH-34.5* MCHC-36.1* RDW-13.3
[**2125-1-22**] 06:50PM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-2.0*#
MAGNESIUM-1.8 IRON-25*
[**2125-1-22**] 06:50PM LIPASE-23 GGT-37*
[**2125-1-22**] 06:50PM ALT(SGPT)-6860* AST(SGOT)-4114* LD(LDH)-2390*
ALK PHOS-65 AMYLASE-41 TOT BILI-0.7
[**2125-1-22**] 07:28PM LACTATE-1.3
[**2125-1-22**] 07:28PM TYPE-ART PO2-42* PCO2-36 PH-7.42 TOTAL CO2-24
BASE XS-0
.
DISCHARGE and PERTINENT LABS
[**2125-1-27**] 04:50AM BLOOD WBC-4.0 RBC-3.44* Hgb-11.8* Hct-33.1*
MCV-96 MCH-34.1* MCHC-35.6* RDW-13.2 Plt Ct-259
[**2125-1-27**] 04:50AM BLOOD Gran Ct-1780*
[**2125-1-27**] 04:50AM BLOOD ALT-[**2079**]* AST-104* AlkPhos-76 TotBili-0.2
[**2125-1-27**] 04:50AM BLOOD Albumin-3.7 Calcium-8.9 Phos-4.5 Mg-2.2
[**2125-1-26**] 04:35AM BLOOD WBC-2.7* RBC-3.45* Hgb-11.7* Hct-33.1*
MCV-96 MCH-33.7* MCHC-35.2* RDW-13.0 Plt Ct-201
[**2125-1-26**] 04:35AM BLOOD Neuts-35* Bands-0 Lymphs-51* Monos-5
Eos-7* Baso-2 Atyps-0 Metas-0 Myelos-0
[**2125-1-25**] 06:59AM BLOOD Fibrino-329
[**2125-1-25**] 06:59AM BLOOD VitB12->[**2113**] Folate->20
[**2125-1-23**] 01:43AM BLOOD TSH-2.0
[**2125-1-22**] 10:29PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HBc-NEGATIVE
.
IMAGING:
[**2125-1-22**] Abdominal U/S With Dopplers: FINDINGS: The liver is
normal in echogenicity and contour. No focal liver lesions are
seen. No intra- or extra-hepatic biliary dilation is identified.
The CBD measures 2 mm. Note is made of a small amount of
ascites. The gallbladder is mildly distended. There is
asymmetric gallbladder wall edema with the wall measuring up to
1 cm. Views of the pancreas are unremarkable, though the distal
tail is obscured by overlying bowel gas. Normal hepatic arterial
and venous waveforms are seen. Normal portal venous flow is
seen.
IMPRESSION:
1. No focal liver lesions. Small amount of intra-abdominal
ascites and
gallbladder wall edema likely related to acute liver
failure/hepatitis.
2. Patent hepatic vasculature with normal waveforms.
.
[**2125-1-23**] Chest X-ray (PA and Lat): No evidence of acute
cardiopulmonary disease. No pneumonia, vascular congestion, or
pleural effusion.
.
[**2125-1-23**] Trans-thoracic Echocardiogram: The left atrium is
elongated. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Normal study. No structural heart disease or
pathologic flow identified. Normal estimated pulmonary artery
systolic pressure.
Brief Hospital Course:
Mrs. [**Known firstname **] [**Known lastname 89742**] is a 26 year-old woman with history of prior
suicide attempts with overdose of multiple medications
(including acetaminophen), depresion, anorexia, anxiety and
hypothyroidism who comes after a suicidal attempt with 150
tablets of extre-strength tylenol on [**1-19**] at about 2pm on
[**2125-1-19**].
.
#. Tylenol induced Hepatitis: The patient was treated per
tylenol overdose protocol with NAC. AST and ALT peaked at 7575
and 3777 and have since improved significantly. The most
worrisome makers for high-risk are INR >6.5 and pH <7.3, which
she did not have. Normal protocol recommends 16 hours of NAC and
she got it for longer until her INR was <1.5 x2 days. Currently
her LFTs are improving up to ALT of 1572, AST 74 with INR of
1.1. She is out of the danger window and we would only expect
improvement in those values within the next weeks. She most
likely will recover 100% of her liver function. The albumin is
low, most likely as a negative stress reactant, but may be low
secondarily to the hepatitis or anorexia.
.
#. Depression / Suicidal attempt: Pt severly depressed and given
current and past episodes of SI/SA she is at high risk for
recurrence. She was placed on a 1:1 sitter, evaluated by
pscyhiatry, and discharged to inpatient psychiatry [**Hospital1 **].
.
#. Leukopenia: The patient developed leukopenia with a nadir of
2.2 WBC, which was thought to be secondarely to
stress/famotidine. This is also corroborated by the anemia with
low-reticulocyte count (see below). There was also a temporal
relationship with starting famotidine, which was stopped her
absolute neutrophil count is 1500. We expect the WBC to continue
improving back to her baseline. We should encourage good PO
intake. There is no need to trend this lab.
.
#. Anemia: Normocytic, normochromic anemia with normal RDW. She
has an iron/TIBC <15 (8%) with a ferritin of ~600 (most likley
falsely elevated given stress). Her MCV is in the high level of
normal (90s). Reticulocyte count was inappropriately low likely
due to bone marrow suppression from severe illness. B12 and
folate levels were normal.
.
#. Elevated INR: The patient's INR is downtrending and nearly
normal at 1.1. It is now to expected to remain normal.
.
#. Anorexia - Pt's BMI is 17.2 with a weight of 49.9 kg (80% of
her IBW of 60.2 Kg). She is tolerating diet well and her
electrolytes are within normal limits. Her WBC are low as
described above. She should be evaluated by nutrition and
psychiatry during her inpatient psychiatry stay. She should
have bone mineral density testing as an outpatient and receive
daily vitamin and mineral (neutra-phos) supplementation.
.
#. Hypothyroid - The patient is hypothyroid. She was continued
on her home dose of levothyroxine 88 mcg daily. A TSH was
checked and found to be wnl at 2.0.
.
#. Code - Full code
.
#. Contact: mother: [**Telephone/Fax (1) 89757**]
.
#. Transition of Care: The patient should be set-up with an
outpatient psychiatric provider and also have primary care
follow-up after her inpatient psychiatric course.
Medications on Admission:
Levothyroxine 88mcg daily
N-acetylcystine 310mg/hr
Famotidine 20mg PO BID
Discharge Medications:
1. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. potassium & sodium phosphates 280-160-250 mg Powder in Packet
Sig: One (1) Powder in Packet PO DAILY (Daily).
4. Outpatient Lab Work
Please check CBC with Diff, AST, ALT, and INR on [**2125-1-29**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: Tylenol Induced Hepatitis, Depression
Secondary Diagnoses: Anorexia, Leukopenia, Anemia,
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for tylenol overdose. You
were treated with a medication to decrease the toxicity from
tylenol. You were monitored in the ICU and then transferred to
the medical liver service. You were seen by psychiatry who
recommended inpatient psychiatric treatment for depression. You
are discharged to an inpatient psychiatric hospital.
.
The following changes were made to your medications:
You should START taking Vitamin D.
You should START taking Neutra-Phos.
.
It was a pleasure taking care of you.
Followup Instructions:
Please follow-up with your PCP 2-4 weeks after you are
discharged.
|
[
"2449",
"311",
"2859"
] |
Admission Date: [**2109-12-20**] Discharge Date: [**2110-1-5**]
Date of Birth: [**2045-2-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Quinine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2109-12-20**] Right posterolateral thoracotomy, replacement of the
proximal descending thoracic aortic aneurysm using a 26mm
Vascutek Dacron interposition tube graft
[**2109-12-20**] Diagnostic bronchoscopy pre-aortic reconstruction and
bronchoscopy with toilet aspiration of secretions post aortic
reconstruction
[**2109-12-23**] Right Bronchial Y-stent placement
[**2109-12-23**] Flexible bronchoscopy and Therapeutic aspiration of
secretions
[**2109-12-27**] Flexible bronchoscopy through endotracheal tube,
Therapeutic aspiration of secretions, Bronchoalveolar lavage of
the right middle lobe
History of Present Illness:
64 y/o female with complex past medical history (see below) who
has had intermittent bouts of dyspnea on exertion and hoarseness
(along with wheezing and dysphagia) over the past several years.
Underwent coronary artery bypass graft x 1 with respiratory
function continuing to decline. Further work-up revealed right
sided arch with aberrant takeoff of left subclavian and dilated
aorta. Also noted to have right mainstem bronchus compression.
Has already underwent 2 surgical procedures with vascular
surgery (Dr. [**Last Name (STitle) **] and now presents for surgical
replacement of her descending aorta.
Past Medical History:
Descending thoracic aortic aneurysm with aberrant left
subclavian artery and Kumeral's diverticulum with aortic sling
compressing the right main stem bronchus, s/p Left Carotid to
Subclavian bypass [**7-7**], s/p Amplatzer plugging of Aberrant left
subclavian [**9-6**], Coronary artery bypass graft x 1 (LIMA to LAD),
Connective tissue disorder with features of Lupus, Sjogren's and
raynaud syndrome, Stroke, Interstitial lung disease,
Hypothyroidism, Gastroesophageal Reflux disease, Right kidney
cyst, s/p cholecystectomy, s/p carcinoid tumor removal during
colonoscopy, s/p right lung resection?wedge
Social History:
She is a retired administrative assistant. She quit smoking 15
years ago and has wine daily with dinner. She is currently
living with her husband.
Family History:
She has a noncontributory family history.
Physical Exam:
At Discharge:Expired
Pertinent Results:
[**12-20**] Echo: PREBYPASS: 1. The left atrium is mildly dilated. 2.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal. 4. The descending thoracic aorta is moderately dilated.
The patient has a known right sided arch. 5. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. 6. The mitral valve
appears structurally normal with trivial mitral regurgitation.
7. There is no pericardial effusion. 8. Dr. [**Last Name (STitle) 914**] was notified
in person of the results during the surgical procedure.
POSTBYPASS: Patient is on an phenylephrine infusion and is in
sinus rhythm 1. Biventricular function is preserved. 2.
Descending thoracic graft not clearly appreciated. 3. Other
findings are unchanged.
[**Known lastname 44356**],[**Known firstname 3049**] [**Age over 90 44357**] F 64 [**2045-2-20**]
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2109-12-31**]
8:43 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2109-12-31**] SCHED
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # [**Clip Number (Radiology) 44358**]
Reason: elevated lft's, not tolerating tube feeds, elevated INR
not
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman s/p right sided descending aorta repair
REASON FOR THIS EXAMINATION:
elevated lft's, not tolerating tube feeds, elevated INR not
on coumadin. Please
do chest and abdominal CT WITH PO contrast
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: AJy TUE [**2109-12-31**] 6:33 PM
PFI:
1. The feeding tube appears to be coiled within the stomach and
is not
post-pyloric. Remainder of the supporting and monitoring lines
and tubes
appear in adequate position.
2. Bilateral lower lobe focal consolidation with air
bronchograms consistent
with pneumonia. Aspiration should be considered given location.
Further
interstitial and ground-glass opacities likely reflect a
combination of
atelectasis and fluid overload.
3. Ascites and diffuse anasarca suggest fluid overload.
4. Borderline fatty infiltration of the liver, but no biliary
dilatation or
mass lesions to explain patient's liver function test
abnormalities.
5. Status post repair of descending thoracic aortic aneurysm,
without
evidence for immediate complication.
Final Report
HISTORY: 64-year-old female, status post repair of descending
thoracic aortic
aneurysm. Referred for evaluation of persistent fever, elevated
LFTs and INR,
and poor tolerance of tube feedings.
COMPARISON: CT of the chest dated [**2109-5-10**].
TECHNIQUE: MDCT axial imaging of the chest and abdomen was
performed
following the administration of oral but not IV contrast.
Sagittal and
coronal reformatted images were reviewed.
CT CHEST: An endotracheal tube terminates approximately 2.5 cm
from the
carina. Tracheal Y-stent is seen with branches extending into
the right and
left main stem bronchi. Two right-sided central venous lines,
one subclavian
and one internal jugular, terminate in the distal SVC. There is
an NG tube
terminating in the stomach. A Dobbhoff-type feeding tube is also
seen
extending into the stomach and is coiled extensively, not
extending post-
pylorically. A right-sided chest tube courses along the
posterior margin of
the lung and terminates adjacent to the superior mediastinum.
Right-sided aortic arch is again noted. Patient is status post
repair of
descending thoracic aortic aneurysm, with graft anastomoses seen
at the level
of the arch and inferiorly. The graft appears to extend
approximately 10 cm
in the craniocaudal direction, and has a diameter of 2.9 cm at
the level of
the carina. There is no significant mediastinal hematoma. The
heart and
pulmonary vessels appear unremarkable. Coronary vascular
calcifications are
appreciated.
There are diffuse reticular and ground-glass opacities in both
lungs, left
greater than right, and more pronounced at the lung bases, where
there are
also areas of focal consolidation and air bronchograms
appreciated. The
crowding of vessels and bronchi suggests a component of
atelectasis, and
generalized anasarca indicates that a degree of fluid overload
is also likely
involved. However, an underlying pneumonia cannot be excluded;
dependent
location would suggest aspiration as possible etiology. There is
no
significant pleural effusion on the right. Pleural effusion on
the left is
small.
There is no mediastinal lymphadenopathy appreciated. There is no
axillary or
supraclavicular lymphadenopathy.
CT ABDOMEN: Oral contrast is seen in the stomach only.
Evaluation of intra-
abdominal organs is limited in lack of IV contrast. There is
moderate amount
of ascites present. The liver is of somewhat low attenuation,
suggesting
fatty infiltration. Liver is otherwise unremarkable without
focal lesions or
intra-/extra-hepatic biliary dilatation. Patient is status post
cholecystectomy. The pancreas, spleen, and adrenal glands appear
normal. The
left kidney is unremarkable. There is a large 5 x 6 cm cystic
structure
arising from the superior pole of the right kidney and has the
density of
simple fluid and is likely a simple cyst. This is unchanged
compared to [**Month (only) 547**]
of [**2109**]. There is no soft tissue stranding or significant
lymphadenopathy
present. There is no free air. Vascular calcifications are seen
without
aneurysmal dilatation.
IMPRESSION:
1. The feeding tube is coiled in the stomach. The remainder of
the
supportive and monitoring devices appear in adequate position.
2. Status post repair of descending thoracic aortic aneurysm,
with no
evidence for immediate post-surgical complication.
3. Diffuse interstitial and ground glass opacities in the lungs,
left
greater than right, with focal consolidations at the bilateral
bases. While
atelectasis and fluid overload are present, underlying pneumonia
cannot be
excluded. The location suggests aspiration as possible etiology.
4. Mild ascites and soft tissue anasarca suggests fluid
overload.
5. Stable large right renal cyst.
6. Borderline fatty infiltration of the liver, without evidence
for focal
liver lesions, biliary dilatation, or masses. Patient is status
post
cholecystectomy.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: WED [**2110-1-1**] 10:03 AM
Imaging Lab
[**Known lastname 44356**],[**Known firstname 3049**] [**Age over 90 44357**] F 64 [**2045-2-20**]
Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
Study Date of [**2109-12-29**] 4:57 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2109-12-29**] SCHED
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL Clip #
[**Clip Number (Radiology) 44359**]
Reason: evaluate flow, increased LFT ? obstruction
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with s/p descending aorta replacement
REASON FOR THIS EXAMINATION:
evaluate flow, increased LFT ? obstruction
Wet Read: KYg SUN [**2109-12-29**] 7:13 PM
limited exam. no e/o bil dil. patent hepatic vasculature.
Final Report
CLINICAL HISTORY: 64-year-old female with lupus, status post
descending aorta
surgery, with increased LFTs. Evaluate for obstruction.
COMPARISON: None.
ABDOMINAL ULTRASOUND: Limited exam as indwelling chest tubes
limits acoustic
windows. The liver is somewhat heterogeneous in appearance. No
focal hepatic
lesion is identified. There is no intra- or extra-hepatic
biliary dilatation.
The common duct measures 5 mm. There is no ascites.
DOPPLER ULTRASOUND: With the exception of the left portal vein,
which could
not be interrogated, the main/right portal veins and hepatic
veins are patent
with appropriate waveforms. The main, right and left hepatic
arteries show
normal flow.
IMPRESSION:
1. Limited exam as patient with indwelling chest tubes which
limits acoustic
windows. No focal hepatic lesion or evidence of biliary
dilatation.
2. Patent hepatic vasculature. The left portal vein was not
interrogated.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
Approved: MON [**2109-12-30**] 10:40 AM
Imaging Lab
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit and on [**12-20**] was brought to the
operating room where she underwent a right posterolateral
thoracotomy, replacement of the proximal descending thoracic
aortic aneurysm using a 26-mm Vascutek Dacron interposition tube
graft and bronchoscopy. Please see operative report for complete
surgical details. Post-surgery bronchoscopy revealed right
mainstem bronchus to still be collapsed. Following surgery she
was transferred to the CVICU for invasive monitoring in stable
condition. On post-op day one she was weaned from sedation,
awoke neurologically intact and extubated. Pulmonary medicine
was consulted for stent placement on post-op day two.
Post-operatively she required several blood transfusions d/t
anemia. Lumbar drain was removed on post-o p day two. Also on
this day she had episode of atrial fibrillation and was treated
appropriately. She continued to have bouts of atrial
fibrillation during post-op course. On post-op day three she was
brought to the operating room where she underwent Y-stent
placement by interventional pulmonology. Later this day she
required a bronchoscopy which found significant mucus retention
and mucus plug in the lumen of the Y-stent. And had successful
therapeutic aspiration. Later on this day she was again weaned
from sedation and extubated. Aggressive pulmonary therapy/toilet
were performed but she continued to require several
bronchoscopies and increasing oxygen requirements over next
several days. Overnight on post-op day six Mrs. [**Known lastname **] was
progressively getting more dyspneic and was in respiratory
distress the morning of post-op day seven, requiring intubation
and mechanical ventilation. Respiratory distress and hypoxia
seemed to be from developing pneumonia (Chest x-rays were
consistent with pneumonia and acute lung failure with ground
glass opacities) and acute respiratory distress syndrome. Blood
cultures taken on post-op day seven were positive for
Enterobacter Aerogenes and COAG negative Staphylococcus.
Bronchoalveolar Lavage and Urine cultures were positive as well
and she was started on broad-spectrum antibiotics until final
sensitivities were performed. Also on this day she had
increasing metabolic acidosis and hypotension (d/t septic shock)
and required multiple pressor support. She received similar
medical care over the next several days (including multiple
pressors and antibiotics) and infectious disease was consulted
on post-op day 11.
The patient remained intubated and her condition worsened with
the family asking that the patient be made comfort measures
only. The patient was extubated and expired shortly thereafter.
Medications on Admission:
Atenolol 12.5mg qd, Lipitor 10mg qd, Restasis, Plaquenil 400mg
qd, Synthroid 100mcg qd, Protonix 80mg qd, Effexor 75mg qd,
Zolpidem 10mg qd, Spiriva, Advair, Albuterol
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Descending thoracic aortic aneurysm with aberrant left
subclavian artery and Kumeral's diverticulum with aortic sling
compressing the right main stem bronchus s/p Right
posterolateral thoracotomy, replacement of the proximal
descending thoracic aortic aneurysm [**12-20**] and Right Bronchial
Y-stent placement [**12-23**]
Post-op Pneumonia
Post-op Sepsis
Post-op Acute Respiratory Distress Syndrome
Post-op Atrial Fibrillation
Post-op Anemia
PMH: s/p Left Carotid to Subclavian bypass [**7-7**], s/p Amplatzer
plugging of Aberrant left subclavian [**9-6**], Coronary Artery
Disease s/p Coronary artery bypass graft x 1 (LIMA to LAD),
Connective tissue disorder with features of Lupus, Sjogren's and
raynaud syndrome, Stroke, Interstitial lung disease,
Hypothyroidism, Gastroesophageal Reflux disease, Right kidney
cyst, s/p cholecystectomy, s/p carcinoid tumor removal during
colonoscopy, s/p right lung resection?wedge
Acute lung injury and respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2110-1-28**]
|
[
"99592",
"51881",
"2851",
"2449",
"53081",
"V4581"
] |
Admission Date: [**2193-8-25**] Discharge Date: [**2193-8-31**]
Date of Birth: [**2117-2-10**] Sex: M
Service: MEDICINE
Allergies:
Procainamide / Niacin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
PRBC
FFP
EGD
History of Present Illness:
76 yo man with CML on gleevec, CHF EF 25%, CAD, ?CKD (baseline
1.1-1.7) p/w fatigue, lightheadedness. Patient went to the Va on
tuesday to receive what sounds to be neupogen (per wife, for
'low white blood count'). He then became progreesively more
tired, lightheaded and short of breath with light activity. He
also reports feeling more cold. Given his increasing fatigue, he
presented today to the ED. He had 1 glass of wine today, but
otherwise denies NSAIDS, steroids, alcohol, recent antibiotics.
.
In ED, VS HR 82, BP 106/36 (baseline) , RR 13, O2 Sat 96% RA.
Hct down drom baseline around 30 to 15.6, INR 6.0, rest of CBC,
Chem 7 unremarkable. TroT negative. cross match sent, ~600cc NS
given, 2 PIV placed, Tx to MICU for further management.
.
ROS: (+) melena, fatigue
(-) N/V/SOB/CP/abd apin/diarrhea
Past Medical History:
chronic myelogenous leukemia on Gleevec
s/p ICD implantation [**10-28**] as cannot take quinidine with Gleevec
CKD - baseline Cr 1.7
MI late [**2155**]'s - was asymptomatic
bilateral hearing aides
Lumbar disc disease
Depression
[**2177**] CVA d/t LV thrombus - no residual deficits
[**2183**] Cath - RCA 90% proximal, totally occ distally, akinetic
inferoposterior segment, EF 25-30%
[**10-28**] ECHO - LVEF 25%, severe global LV hypokinesis, 2+ MR, 2+
TR, mild pulmonary hypertension
Social History:
Married x48 years. Lives with his wife. Quit smoking 25 yrs
ago, smoked 1 ppd x 20-25 years. ETOH 1 glass wine/day. No
IVDU. Worked in construction, worked only part-time after CVA
in [**2178**], now retired. Was in the military, worked with
automatic weapons.
Family History:
(-) FHx CAD
no leukemia/lymphoma
Physical Exam:
Vitals - T 97.5, BP 99/60, HR 69, RR 16, O2 100%RA;
General - awake, alert, in NAD
HEENT - PERRL, EOMI, MMM, OP clear, pale conjunctiva
Neck - no JVD
CV - RRR, no r/m/g
Lungs - on ant exam CTA b/l
Abd - S/NT/ND/+BS
Ext - no e/c/c
Neuro- AOx3, grossly intact
Pertinent Results:
[**2193-8-25**] 10:15PM GLUCOSE-95 UREA N-35* CREAT-1.2 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-11
[**2193-8-25**] 10:15PM estGFR-Using this
[**2193-8-25**] 10:15PM CK(CPK)-53
[**2193-8-25**] 10:15PM cTropnT-<0.01
[**2193-8-25**] 10:15PM CK-MB-NotDone
[**2193-8-25**] 10:15PM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-1.8
[**2193-8-25**] 10:15PM WBC-5.9 RBC-1.37*# HGB-5.1*# HCT-15.6*#
MCV-113* MCH-37.5* MCHC-33.1 RDW-18.9*
[**2193-8-25**] 10:15PM NEUTS-74.5* LYMPHS-19.4 MONOS-4.8 EOS-1.2
BASOS-0.2
[**2193-8-25**] 10:15PM PLT COUNT-317#
[**2193-8-25**] 10:15PM PT-50.6* PTT-34.6 INR(PT)-6.0*
Brief Hospital Course:
76 M with CML on gleevec, CHF EF 25%, CAD, chronic renal disease
(baseline Cr 1.1-1.7), presents with fatigue, lightheadedness,
and Hct 15 from slow GI bleeding.
.
# GI Bleeding:
EGD performed on [**8-29**] showed old blood in stomach with fresh
blood in duodenum but no source of bleeding. Serial Hcts were
checked, showing a slow GIB. Hct was maintained at >28 for
cardiac ischemia. He was guaiac positive in the ED with stable
VS throughout. His baseline hematocrit was 30, attributed to CML
and gleevec therapy. In the MICU, he received 5U PRBC. Iron
studies were consistent with anemia of chronic disease, with
normal B12 and folate. INR was unremarkable at 1.3, likely from
nutrition. Patient was placed on PPI [**Hospital1 **]. Plan is for patient to
follow up for Hcts intermittently, to monitor whether periodic
pRBC transfusions will be required. For cardiac ischemia, goal
Hct would be >28.
.
# Elevated INR:
INR on admission was 4.9, was brought down to <1.5 for EGD.
Patient is on coumadin, likely for severe left global
hypokinesis (apex was not commented) and history of CVA.
Coumadin was held during admission. Plan is to follow up with
PCP as outpatient regarding whether Coumadin should be
restarted.
.
# CML:
Follows with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**], and has been seen by Dr. [**Last Name (STitle) **] in
the past. Gleevec was continued throughout admission. In
response to Gleevec, patient had vomiting when he was not able
to eat meals, but he tolerated Gleevec well with no vomiting
when he was able to take his med with meals.
.
# CAD:
Patient was maintained on metoprolol, but not on ASA inhouse
because of possible interaction with Gleevec. Statin was
continued. Issue of restarting ASA should be addressed with his
PCP.
.
# CHF:
He has an EF 25% in [**2190**] with ICD in place. Repeat ECHO showed
unchanged LV function but worsening mitral regurgitation. He was
euvolemic on exam throughout admission.
.
# Depression:
Effexor was continued during admission.
Medications on Admission:
1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. Fluvastatin 80 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Imatinib 400 mg Tablet Sig: One (1) Tablet PO daily ().
7. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: GI bleeding
Secondary diagnosis: CML on Gleevec, CHF with ICD
Discharge Condition:
VSS, feels well, no dizziness, walks well.
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please return to the emergency room if you experience
increased gastrointestinal bleeding such as black or bright red
blood in stool, dizziness, lightheadedness, or fatigue.
3. Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5762**], if you
have questions regarding your medical care.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2193-11-25**] 8:00
.
2. Please have your hematocrit checked on [**Last Name (LF) 766**], [**9-2**],
and have the results faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**]. Or have your
hematocrit checked on Tues, [**9-3**] at your appointment with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**].
Completed by:[**2193-8-31**]
|
[
"4280",
"5859",
"5119",
"4240"
] |
Admission Date: [**2163-3-11**] Discharge Date: [**2163-3-15**]
Date of Birth: [**2094-1-20**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 69 year old female with an acute onset of
midepigastric abd pain, radiating to the flanks and back and
progressive in nature. She presented to an OSH after the pain
continued to worsen. She reported + nausea and vomiting, no
flatus, no diarrhea/constipation, no dysuria. She was found to
have elevated Amylase and Lipase ([**Telephone/Fax (1) 72249**]). She was made NPO
with IVF. A CT was obtained and showed a small amount of air in
the pancreatic head.
Past Medical History:
NIDDM, HLD, HTN, CRI (baseline Cr 1.4)
Social History:
Lives with husband
Reports [**Name (NI) **] tobacco
[**1-15**] drinks/week
Family History:
No history of pancreatitis or malignancies
Physical Exam:
98.6, 91, 160/55, 14, 96% RA
Gen: A+O x3, NAD
CV: RRR
Pulm: lungs clear bilat., slight decrease at the bases
Abd: Soft, ND, currnetly nontender, no rebound or guarding.
Ext: Trace LE edema
Pertinent Results:
CT ABD W&W/O C [**2163-3-12**] 4:07 PM
IMPRESSION:
1. Pancreatitis, without pancreatic pseudocyst or necrosis.
2. Sigmoid diverticulosis.
3. Cholecystectomy.
.
CHEST (PORTABLE AP) [**2163-3-14**] 8:55 AM
IMPRESSION:
Improvement in the pulmonary vascular congestion and bilateral
pleural effusions since the prior examination.
.
[**2163-3-14**] 03:15AM BLOOD WBC-9.0 RBC-3.11* Hgb-9.9* Hct-28.8*
MCV-92 MCH-31.8 MCHC-34.4 RDW-14.3 Plt Ct-199
[**2163-3-14**] 03:15AM BLOOD Glucose-180* UreaN-26* Creat-1.0 Na-144
K-3.1* Cl-108 HCO3-25 AnGap-14
[**2163-3-14**] 01:18PM BLOOD K-4.0
[**2163-3-14**] 09:20AM BLOOD ALT-23 AST-29 AlkPhos-111 Amylase-92
TotBili-0.5
[**2163-3-14**] 09:20AM BLOOD Lipase-114*
[**2163-3-14**] 09:20AM BLOOD Lipase-114*
[**2163-3-14**] 01:18PM BLOOD CK-MB-2 cTropnT-0.05*
[**2163-3-14**] 03:15AM BLOOD Calcium-8.8 Phos-1.8* Mg-2.2
[**2163-3-14**] 03:15AM BLOOD TSH-3.7
Brief Hospital Course:
She presented from an OSH on [**2163-3-11**] after concern for
necrotizing pancreatitis.
She went to the ICU for observation.
A CT on [**3-12**] showed Pancreatitis, without pancreatic pseudocyst
or necrosis; Sigmoid diverticulosis; Cholecystectomy.
Pain: She had good pain control with a PCA initially. She was
switched to PO meds and was using them sparingly.
GI: She was made NPO with IVF. Her Amylase/Lipase on admission
were 216 and 138. On [**2163-3-15**], they were 92 and 114, respectively.
She remained NPO for several days, on HD 3 she was started on
clears and then advanced to regular diet on HD 4. She tolerated
a PO diet without pain or an increase in her enzymes.
Cardiology: Cardiology was consulted for question of Atrial
fibrillation.
..Tachycardia: She was found to have a HR in the 150's on
[**2163-3-13**]. She had no complaints of chest pain, SOB. She reported
palpitations and telemetry is c/w intermittent episodes of
Aflutter. No 12-lead performed. She received Lopressor IV which
helped to bring the HR to <100. Her enzymes were cycled and
negative. She did have some short (2-3 seconds) runs of
A-flutter, but nothing sustained. Cards recommended a Echo,
which was pending at time of discharge. She will continue with
Lopressor and Diltiazem at home. She is currently in SR. If
recurrent A-flutter obtain 12-lead and consider ablation if
appears amenable as an outpt.
..Hypertension: She was hypertensive with a BP of 200/44. She
received Diltiazem, and Lopressor. An EKG showed no ST changes.
Hypokalemia: Her Potassium was 3.1, this was repleated and her K
was WNL.
Low Urine Output/Hypovolemia: On [**2163-3-15**], she was low UOP. She
received a 500cc bolus. A FENA was 0.2. After the fluid bolus,
her output began to increase.
Medications on Admission:
Asprin, Lipitor, Avandia, Tricor
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
6. Banana Daily
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis, without pancreatic pseudocyst or necrosis.
Sigmoid diverticulosis.
Hypokalemia
Hypovolemia
Tachycardia
Hypertension
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Please take all meds as ordered. You are being discharged on
Metoprolol and Diltiazem for HR and BP control.
.
Continue to ambulate several times per day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in [**1-15**] weeks. Call ([**Telephone/Fax (1) 27730**] to schedule an appointment.
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**12-14**] weeks to adjust your HR
and BP medications if needed. If recurrent A-flutter, obtain
12-lead and consider ablation if appears amenable as an outpt.
Completed by:[**2163-3-15**]
|
[
"5859",
"40390",
"25000"
] |
Admission Date: [**2187-4-10**] Discharge Date: [**2187-4-16**]
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Chest pain
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
gentleman with a history of cerebrovascular accident with
residual right hemiparesis who reported a six month history
of chest discomfort. He described it as a dull pain over his
left breast not related to exertion and lasting only about a
minute at a time. It is happening everyday. He has had
recent hospital admissions for chest pain, the first in
[**Month (only) 404**] where he ruled out for a myocardial infarction.
Echocardiogram at that time revealed an ejection fraction of
60%, moderate AS with a mean gradient of 22 mmHg with a peak
41 mmHg. He was admitted to [**Hospital 1474**] Hospital on [**2187-3-17**] for chest pain. He ruled out for a myocardial
infarction, but a Persantine Myoview revealed moderate large
inferior fixed defect with no ischemia. Ejection fraction
was noted to be 39% with global hypokinesis and moderate left
ventricular dilatation. Aside from the chest pain, he
otherwise feels generalized fatigue and leg heaviness as the
day progresses. He denied any claudication, orthopnea,
paroxysmal nocturnal dyspnea and lightheadedness. He now
presents to [**Hospital6 256**] for
evaluation of cardiac catheterization and the cardiothoracic
team for possible coronary artery bypass graft.
PAST MEDICAL HISTORY:
1. Hypertension
2. Hypercholesterolemia
3. Diabetes mellitus.
4. Status post cerebrovascular accident with right sided
hemiparesis
5. Glaucoma
PAST SURGICAL HISTORY:
1. Status post left CEA
2. Status post leg surgery
ADMISSION MEDICATIONS:
1. Aspirin 81 mg po qd
2. Protonix 40 mg po qd
3. Glyburide 1.25 mg po qd
4. Lipitor 10 mg po qd
5. Hydrochlorothiazide 12.5 mg po qd
6. Captopril 25 mg po tid
7. Toprol 50 mg po qd
8. Betoptic 1 GGT right eye [**Hospital1 **]
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is married, retired bricklayer.
PHYSICAL EXAM:
VITAL SIGNS: The patient is 5'4", weighs 190 pounds.
Temperature is 98.9??????, heart rate of 83, blood pressure 161/70
with 100% O2 saturation on room air. Blood glucose was 190.
HEAD, EARS, EYES, NOSE AND THROAT: Neck is supple, no
jugular venous distention, no lymphadenopathy.
CHEST: Clear bilaterally. The patient has a 3/6 systolic
ejection murmur which radiates to the carotids.
ABDOMEN: Soft, obese, nontender.
EXTREMITIES: No peripheral edema. The patient has 5/5
strength in the left upper and lower extremity. The patient
has 3 to 4/5 strength of the upper and lower extremities on
the right.
ADMISSION LABORATORIES: White count of 5.5, hematocrit of
42.6, platelets of 165. Sodium 139, potassium 3.9, chloride
105, bicarbonate 25, BUN 29, creatinine of 1.5, glucose 274.
INR was 0.94.
IMAGING: Carotid artery duplex studies bilaterally was
significant for right with less than 40% carotid stenosis and
no evidence of stenosis on the left. Electrocardiogram shows
sinus rhythm at a rate of 60 with a first degree and right
bundle branch block.
HOSPITAL COURSE: The patient, prior to admission, had
undergone cardiac catheterization. The results were
significant for right dominant system with three vessel
coronary artery disease. The left main was mildly diffusely
diseased. The left anterior descending artery had disease up
to 40%. Mid LAD had discrete 80% lesion prior to the major
bifurcation. Diagonal 1 had stenosis of 80%.
Circumferential artery had a 90% stenosis. The old one had a
discrete 50% stenosis. The RCA had a 90% stenosis. There
was a calculated ejection fraction of 25%. Mild aortic
stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 1.3 cm squared and an aortic valve
gradient of 9 mmHg. The patient on the day of admission was
taken to the Operating Room where he underwent a coronary
artery bypass graft x3. The grafts were left internal
mammary artery to LAD, saphenous vein graft to OM1, saphenous
vein graft to RCAPD. The patient tolerated the procedure
well and was transferred to the Cardiothoracic Intensive Care
Unit in stable condition and intubated on Neo drip.
The patient postoperatively remained hemodynamically stable.
All drips were weaned. The patient was extubated without
difficulty. The patient was making adequate urine. Total
for the first postoperative night was 455. It was
appropriately decreased. On postoperative day #1, the
patient remained hemodynamically stable. The chest tube was
discontinued without incident. The patient was transferred
to the floor for the remainder of the recovery. On the
floor, the patient did have occasional PVC seen on the
monitor. Otherwise, the patient remained in sinus rhythm.
He has remained afebrile, hemodynamically stable. Wires were
discontinued on postoperative day #2 without incident. The
patient has been evaluated by physical therapy and has been
ambulating with assist. It should be noted that prior to
surgery the patient's ambulation including using a right leg
brace to prevent foot drop and also a walker. The patient
has achieved a level 2 to 3 using a walker and close contact
guarding. The patient is tolerating a regular diet. The
patient's blood glucose levels have been controlled with
glyburide and sliding scale insulin. The patient's
hematocrit remained stable at 25. The patient's BUN and
creatinine remained stable at 42 and 1.4 respectively. The
patient's Foley was discontinued, required to be reinserted
on postoperative day #3 and the patient underwent a second
voiding trial in which he was able to do so without a
problem. The patient is stable and now ready for discharge.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft x3
2. Hypertension
3. Diabetes mellitus
4. Status post cerebrovascular accident with residual right
hemiparesis
5. Hypercholesterolemia
6. Glaucoma
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg po bid
2. Lasix 20 mg po bid
3. KCL 20 milliequivalents po bid
4. Colace 100 mg po bid
5. Enteric coated aspirin 325 mg po qd
6. Glyburide 1.25 mg po qd
7. Lipitor 10 mg po q hs
8. Protonix 40 mg po qd
9. Betoptic 1 GGT right eye [**Hospital1 **]
10. Percocet 5/325 1 to 2 po q4h prn
11. Captopril 25 mg po tid
DISCHARGE CONDITION: Stable
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 70**] in
six weeks and follow up with Dr. [**Last Name (STitle) 16004**] in two weeks, who is
his primary care physician.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2187-4-14**] 23:06
T: [**2187-4-16**] 11:50
JOB#: [**Job Number 41127**]
|
[
"41401",
"4241",
"25000",
"4019",
"2720"
] |
Admission Date: [**2100-10-28**] Discharge Date: [**2100-11-2**]
Date of Birth: [**2033-6-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
shortness of breath, fevers to 103, increased cough with sputum,
diffuse sharp chest pain
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The patient is a 67 year old female with a history of
long-standing mycobacterium avium intracellulare and
bronchiectasis who recently had a pneumonia in late [**Month (only) 216**] and
more recently a bronchoscopy on [**2100-10-20**] as preparation for a
planned right pneumonectomy, who presented to the ED early this
morning with sharp pains in her chest, shortness of breath and
fevers up to 103 over the last several weeks at home. The
patient was diagnosed with [**Doctor First Name **] over 20 years ago and was
initially treated with antibiotics including clarithromycin,
ethambutol and rifampin but eventually became resistant to
clarithromycin. In [**2094**], she underwent a right middle lobectomy
with right upper lobe pleural tent. For the last 6 months she
has been taking ehtambutol, rifampin, streptomycin and in [**Month (only) 216**]
she took Levaquin for 10 days for a pneumonia. She stopped the
streptomycin because she was tired of going to the hospital for
infusions and medicare would not pay for infusions at home.
Prior to that, she went off all medications for about 18 months
and per the patient felt "alright." The patient's family reports
that her disease has taken a significant turn for the worse
about a year and a half ago. She has had difficulty maintaining
weight, going as low as 88 pounds from her baseline of 110.
Right now she is around 100lbs. She reports that over the last
few weeks she has been spiking fevers up to 103 at home, has
been having a cough without blood that is productive of yellow
green sputum. She had the bronchoscopy on [**2100-10-20**] and a note from
a telephone call with Dr. [**Last Name (STitle) **] on [**2100-10-27**] advised the
patient to come to the ED if she felt worse and to start
amoxicillin-clavulanate 500/125/qid. She took two doses and by
2am on [**2100-10-28**] felt sharp pains all over her chest that lasted
for about one hour and then came to the ED wehre the pain
subsequently resolved.
.
In the ED the patient's vitals were notable for a temperature of
99, a HR of 120, a BP of 82/53, a RR of 36 and an oxygen
saturation of 84 percent of room air. She was given 2L of NS,
vancomycin and zosyn. Labs were sent. WBC was 10.6, Hct 35.7,
electrolytes were within normal limits, urine was clear,
moderate blood, trace protein, [**4-15**] RBC, 305 WBC, few bacteria
and 0-2 epis. Her chem showed a bicarb of 26 and a creatinine of
0.8. LFTs were WNL. Chest CT compared to a prior showed many
new opacities, particularly in the left lung, most suggestive of
bronchopneumonia with a strong component of airway inflammation,
probably due to infection with suggestion of superinfection. CT
also showed chronic-appearing fibro-cavitary disease bilaterally
in keeping with known diagnosis of mycobacterium avium complex.
Chest x ray in the ED showed a large right apical cavity with
thickening of irregular border, unchanged from her x ray on
[**2100-10-25**].
.
On the floor the patient reports that she no longer feels chest
pain, is still coughing up sputum but no blood, she denies
nausea, reports that she sometimes vomits when she coughs a lot,
denies lightheadedness, dizziness, palpitations, dysuria, or
diarrhea. She is anxious to leave the hospital.
Past Medical History:
.
Past Surgical and Medical History
Her past medical history is notable for Mycobacterium Avium
Intracellulare and bronchiectasis
.
Her past surgical history includes right middle lobectomy with
right upper lobe pleural tent and 3 cesarian sections.
Social History:
She denies tobacco use or illicit drug use but did smoke only
socially in her younger years. She does report significant
second hand smoke exposure from her parents. She haspreviously
been employed at the airport and reports expsoure to
jet fumes. She denies significant exposure to asbestos or
silica. She has not traveled recently. She lives with her
husband and children and currently doese not work. She is the
leader of a support group for [**Doctor First Name **].
Family History:
non contributory
Physical Exam:
Physical exam on admission
VS: T98.1 BP 100/52 HR 81 RR 18 O2 90% on 2L NC
General: NAD, sitting in bed talking comfortable on oxygen
HEENT: PERRL, oropharynx clear, MM slightly dry, no LAD, JVP not
visible
CV: RRR, no MRG S1 S2
Pulmonarly: wheezes and rhonchi bilaterally
Abdomen: soft, non tender, active bowel sounds, no rebound, no
guarding,
Skin: intact, no rashes, no cyanosis, no edema
Extremities: no edema
Neuro: AAOx3
Pertinent Results:
CT chest [**2100-10-28**]
IMPRESSION:
1. No PE.
2. Compared to the reference CT, there are many new opacities,
particularly in the left lung, most suggestive of
bronchopneumonia with a strong component of airway inflammation,
probably due to infection. Superinfection is suggested and
correlation with clinical symptoms is suggested.
3. Chronic-appearing fibro-cavitary disease bilaterally in
keeping with known diagnosis of mycobacterium avium complex.
CXR [**2100-10-28**]
There is a large right apical cavity with thickening of
irregular
border, unchanged. The lungs show markedly decrease
transparency, with partially nodular, partially small cavitary
and partially interstitial pattern of opacities. The right
costophrenic sinus remains obliterated. The left costophrenic
angle is free. Heart size is noral. Left-sided Port-A-Cath in
situ.
CXR [**2100-10-25**]
The most remarkable abnormality is a large right apical cavity
with
a thickened and irregular border. Additional cavity contents
cannot be excluded. The non-cavitary remaining right and the
entire left lung show markedly decreased transparency, with
partly nodular, partly small cavitary and partly interstitial
patterns of opacities. The right costophrenic sinus is
obliterated, likely caused by a small pleural scar, several
surgical clips project over the right costophrenic sinus. On the
left, the costophrenic sinus is unremarkable. Overall, mild
overinflation is present. The size of
the cardiac silhouette is unremarkable. Right-sided Port-A-Cath
in situ.
Microbiology
[**2100-10-28**] 11:28 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2100-10-29**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Preliminary):
[**2100-10-28**] 03:15AM BLOOD WBC-10.6 RBC-4.29 Hgb-11.4* Hct-35.7*
MCV-83 MCH-26.7* MCHC-32.1 RDW-14.3 Plt Ct-338
[**2100-10-28**] 03:15AM BLOOD Neuts-86.4* Lymphs-8.4* Monos-3.6 Eos-1.3
Baso-0.3
[**2100-10-28**] 03:15AM BLOOD Plt Ct-338
[**2100-10-28**] 04:20AM BLOOD PT-17.5* PTT-28.8 INR(PT)-1.6*
[**2100-10-28**] 03:15AM BLOOD Glucose-108* UreaN-19 Creat-0.8 Na-138
K-4.1 Cl-101 HCO3-26 AnGap-15
[**2100-10-28**] 03:15AM BLOOD estGFR-Using this
[**2100-10-28**] 03:15AM BLOOD ALT-7 AST-27 CK(CPK)-43 AlkPhos-70
TotBili-0.4
[**2100-10-28**] 03:15AM BLOOD Lipase-36
[**2100-10-28**] 03:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
Brief Hospital Course:
Ms. [**Known lastname 70938**] is a 68 yo female with long-standing history of
[**Doctor First Name **] who was admitted with pneumonia which was complicated by
acute respiratory failure and sepsis.
The patient has a known 20 year history of [**Doctor First Name **] and has had
significant decline over the last year and half prior to
admission as well as a recent pneumonia and had a scheduled
bronchoscopy as an outpatient on [**2100-10-20**] as part of preparation
for a planned right pneumonectomy to treat her [**Doctor First Name **]. In the
emergency room Chest CT compared to a prior showed many new
opacities, particularly in the left lung, most suggestive of
bronchopneumonia with a strong component of airway inflammation,
probably due to infection with suggestion of superinfection. CT
also showed chronic-appearing fibro-cavitary disease bilaterally
in keeping with known diagnosis of mycobacterium avium complex.
Infectious disease, pulmonary and thoracics were all consulted
upon admission. She was started on multiple antibiotics for her
pneumonia.
In the morning on [**2100-10-29**], the patient's breathing had markedly
worsened, requiring 4.5-5L NC to stay in the low 90s oxygen
saturation (at baseline she required 2 L occasionally). In the
afternoon of [**2100-10-29**], the patient's oxygen saturation continued
to decline going as low as 75% on 5L when she went to the
bathroom. The ICU was called and the patient agreed to be
transferred to be put on bipap. She repeatedly expressed her
wishes not to be intubated should she fail on bipap. Prior to
the tranfser to the unit she had reverse her original DNR/DNI
code status, stating that if she needed to be intubated for a
short time that was okay, but she did not want long term
intubation. She was intubated the morning of [**7-30**] due to
persistent hypoxia.
Her course was complicated by several epsidoes of hypotension
which were initially responsive to fluids. She remained febrile
and eventually required pressor to maintain her blood pressure.
She continued to clinically worsenin (persistent hypotension,
tachycardia, hypoxia, and new coagulopathy). Repeat CTA showed
no PE but did show progression of her parenchymal opacities. On
[**11-2**] a family meeting was held with Dr. [**Last Name (STitle) **] in attendance.
The family decided to make the patient CMO and the patient was
removed from the ventilator and died.
Medications on Admission:
ethambutol, rifampin, intravenous streptomycin (all stopped
about a week and a half ago), and albuterol/ipratropium inhaler
-patient has been taking ethambutol, rifampin, streptomycin
and/or clarithromycin for many years for [**Doctor First Name **] with little effect
recently and went back on these medications in [**2100-2-11**] for
a planned right pneumonectomy this fall which she still hopes to
have
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Sepsis
Hypoxic respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2101-10-27**]
|
[
"51881",
"0389",
"99592",
"78552",
"53081"
] |
Admission Date: [**2178-11-11**] Discharge Date: [**2178-12-3**]
Date of Birth: [**2102-8-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypoxic respiratory distress
Major Surgical or Invasive Procedure:
Endotracheal intubation
Arterial line placement
Tracheostomy
PEG placement
History of Present Illness:
76 yo F w/ h/o emphysema initially admitted to ICU [**2178-11-11**] for
hypoxic respiratory failure due to CAP w/ mucous plugging
causing acute desat that led to urgent intubation.
Past Medical History:
emphysema
macular degeneration
EF 75-80%, mod pulm htn, 2+ TR
Social History:
Alcohol: 2 drinks/night.
Tobacco: 50 pack-years. Currently still smoking.
Drugs: Denies.
Currently retired. Lives alone without assistance. Daughters in
the area. Used to work as a secretary at a lumber mill.
Family History:
CAD father and brother 50s. Mother with cardiac history.
Physical Exam:
On initial MICU admission:
Afebrile, normotensive with normal pulse.
Gen: well appearing elderly woman sitting upright in chair,
conversing comfortably. Alert and oriented.
HEENT: Pupils reactive, irregular. + cataract over right eye.
CV: RRR. Nl S1, S2. S4 present. No murmurs or rubs.
Lungs: Diminished breath sounds throughout. Exp wheezing in
upper lobes. Prolonged expiratory phase.
Abd: Soft. NT. ND. Normoactive bowel sounds.
Ext: Warm. Trace pitting edema. Thin extremities. DP 2+ b/l.
Neuro: Moves extremities well.
Rectal: Deferred but guaiac positive at OSH.
Pertinent Results:
CT ABDOMEN W/O CONTRAST [**2178-11-17**] 5:00 PM
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with new free air seen under diaphragm. Has
been on chronic steroids.
HISTORY: Free intraperitoneal air. On chronic steroids. Evaluate
bowel after administration of gastrografin.
COMPARISON: CT of the abdomen and pelvis from [**2178-11-17**]
at 14:16.
TECHNIQUE: MDCT acquired contiguous axial images from the lung
bases to the pubic symphysis were acquired following the
administration of oral gastrografin. IV contrast had been
administered earlier for the previous CT examination. Coronal
and sagittal reconstructions were obtained.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Again demonstrated within
the lung bases are bibasilar atelectasis and bilateral pleural
effusions, right greater than left.
There has been no significant interval change in the large
amount of free intraperitoneal air noted. Contrast is
demonstrated within the stomach and small bowel, and there is no
evidence of contrast extravasation. Within the left lower
quadrant, there is a focal segment of small bowel which
demonstrates mild bowel wall thickening, which on the prior exam
appeared to be normal. The significance of this bowel wall
thickening is uncertain, however ischemia cannot be fully
excluded. There is no evidence of pneumatosis.
The remainder of the examination is stable.
CT OF THE PELVIS WITHOUT IV CONTRAST: Pelvic loops of bowel
appear unremarkable. Again no evidence of contrast extravasation
is noted. Again noted, there is a large calcified fibroid uterus
with large bilateral adnexal cysts. There is no evidence of
pneumatosis.
CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were
essential in confirming the above findings.
IMPRESSION:
1. No evidence of oral contrast extravasation.
2. Focal area of bowel wall thickening involving a loop of the
mid small bowel within the left lower quadrant. Previously, this
loop of bowel appeared unremarkable on the examination from
three hours earlier. The significance of this bowel wall
thickening is unclear and it may be due to under filling of this
loop, however ischemia cannot be fully excluded.
3. Otherwise, stable appearance of the abdomen and pelvis with a
large amount of free intraperitoneal air again demonstrated.
Echo:
1. The left atrium is normal in size.
2.There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Left ventricular
systolic function is hyperdynamic (EF>75%). A mid-cavitary
resting gradient is identified.
3.Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
6.Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension.
6.There is no pericardial effusion.
E:A ratio: 0.50
CXR ([**11-22**]):
CHEST, SINGLE AP VIEW.
There is upper zone redistribution, without overt CHF. Again
seen is a small-to-moderate right pleural effusion with
underlying collapse and/or consolidation. This is probably
slightly larger than on the film obtained one day earlier. There
is also atelectasis at the left base, with some blunting of the
costophrenic angle, slightly improved in the interim.
CHEST (PORTABLE AP) [**2178-11-27**] 6:35 AM
PORTABLE AP CHEST: As compared to [**11-26**], moderate bilateral
pleural effusions have increased in size, allowing for
differences in patient positioning. Increasing airspace opacity
within the right mid lung could represent atelectasis, but
pneumonia have a similar appearance. Endotracheal tube and
enteric tube remain in stable position.
IMPRESSION:
1. Interval increase in size of now moderate bilateral pleural
effusions.
2. Atelectasis within the right midlung versus pneumonia.
CHEST (PORTABLE AP) [**2178-11-28**] 3:52 AM
IMPRESSION: AP chest compared to [**11-27**] and 3rd:
Left pleural effusion has resolved. No pneumothorax. Moderate
sized right pleural effusion has improved and atelectasis in the
right lower lobe decreased. Hyperinflation indicates severe
emphysema. The heart is normal size. Feeding tube passes into
the stomach and out of view while an ET tube is in standard
placement.
CHEST (PORTABLE AP) [**2178-11-30**] 3:52 AM
An endotracheal tube and feeding tube remain in place. Cardiac
and mediastinal contours are stable. There remains evidence of a
small-to- moderate right pleural effusion with adjacent
atelectasis. There may be a very minimal pleural effusion on the
left, but this is significantly smaller than on pre-
thoracentesis radiographs.
MICROBIOLOGY:
[**11-25**] urine cx, [**11-30**] urine cx: yeast
[**11-27**] sputum: MRSA (vanc-sensitive)
Brief Hospital Course:
Sputum cx grew out sparse Strep pneumo and OP flora. CXR c/w
atypical PNA. Patient tx w/ levo and then started on steroids
[**11-14**] for failure to wean from vent (tachypneic and
hypercarbic)/concern for COPD flare. She was ultimately able to
be extubated on [**11-14**] but required suction assistance w/ copious
secretions. S/p extubation, she passed a swallow eval. She was
transferred to the floor on [**11-16**] and was managed w/ a steroid
taper. Of note, on [**11-17**] CXR, patient noted to have free air
under the diaphragm. Abd CT showed large amount of free
intraperitoneal air w/ LLQ small bowel thickening - ? ischemia
but exam unremarkable w/o peritoneal signs. Surgery was
consulted but the patient remained clinically stable with benign
abdominal exam and antibx were expanded to pip/tazo. On [**11-19**]
the patient then developed acute hypercarbic and hypoxic
respiratory failure with O2 sat 59% off face mask thought [**2-25**]
combination of pneumonia, RLL collapse [**2-25**] mucous plug, and
COPD, and was transferred back to the MICU. In the MICU,
patient's respiratory status improved on BiPaP. She was then
transitioned to face mask. Her ABG improved to 7.35/64/73 at the
time of transfer to floor on [**11-20**].
.
The patient was doing well on the floor until one afternoon,
when she was found by a nurse sitting on the edge of her bed,
trying to get out of bed, disoriented, her O2 disconnected from
the wall. She c/o nausea. She was hypoxic to 57% after being
placed on 4L NC. She was then placed on 100% NRB and sats
improved to 90s. She was tachypneic to RR in high 30's and
somnolent. She was treated w/ atrovent neb and placed on Venturi
mask. Suctioning productive of moderate amount of thick white
sputum. ABGs as follows (baseline 7.44/56/92->7.23/87/71->? VBG
7.20/100/39->7.25/91/72). At the time of transfer back to MICU,
the patient oriented to self and hospital, somnolent, mildly
increased work of breathing. She initially did well on BiPAP but
had increasing work of breathing despite nebulizers and
suctioning and agreed to an elective intubation [**2178-11-25**]. A chest
CT showed large pleural effusions; the left side was tapped
(800cc of transudative fluid) and the right improved as well
with diuresis. Despite diuresis and the thoracentesis she
persistantly remained vent-dependant with copious secretions
and, after discussion with her family, agreed to a trach & PEG
on [**12-1**].
.
1. Hypercarbic respiratory failure:
- s/p Trach [**12-1**]
- Etiology potentially multifactorial but likely secondary to
underlying severe COPD with mucous plugging. S/p left chest
thoracentesis [**11-26**].
- continue nebulizer treatments, spiriva upon extubation
- continue frequent pulmonary toilet
- Influenza and pneumococcal vaccine given
- sputum: [**11-25**] sparse yeast; [**11-27**] MRSA; R midlung atelectasis
vs. pneumonia, on Vancomycin ([**11-27**]) for MRSA (suspect
tracheobronchitis rather than PNA)
- continue prednisone taper (day 2 at 15mg [**12-2**])
- OOB to chair as much as possible
- maintain on PS as tolerated; has had some apneic episodes at
night requiring MMV
.
2. ID: Fever and leukocytosis without obvious source, although
given increased secretions in an intubated patient, likely
pulmonary. completed course of Zosyn ([**Date range (1) 41492**]) for ?PNA on
admission. Prev had free air under diaphragm, followed by
surgery without any evidence ofr infection or surgical
indication. Abdominal exam remains benign with resolution of
previously visualized free air. Continue to monitor abdominal
exam and contact surgery with any change in exam. LFTs within
normal limits (consideration towards acalculous cholecystitis in
ICU patient). - patient started on Vancomycin (start [**11-27**]) for
increasing MRSA in sputum cultures and temp spike [**11-26**]. C. Diff
sent and neg x 3. Had course of cipro for UTI.
- Blood cultures pending, no growth to date
- vanco 7 day course for tracheobronchitis ([**11-27**] to [**12-3**])
- PICC placed [**11-30**]
- d/c foley [**12-2**]
.
3. HTN/CHF: Continue diltiazem, avoid beta blockers given
possibility of associated bronchial constriction
.
4. PPX: SQ Heparin, PPI, bowel regimen
.
5. FEN:
- replete lytes PRN
- PEG [**12-1**] with TF
.
6. Code: Full code (confirmed [**11-24**]; pt would not want long-term
vent but did want intubation)
.
7. Access: R PICC ([**11-30**])
- d/c foley today
.
8. Communication: patient
Son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 62302**](h) [**Telephone/Fax (1) 62303**](w)
Daughter [**Name (NI) 1439**] Cell [**Telephone/Fax (1) 62304**]
Grandson [**Name (NI) **] cell [**Telephone/Fax (1) 62305**]
Medications on Admission:
unknown eye drops
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Disp:*[**Numeric Identifier 31034**] units* Refills:*0*
2. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) for 1 months.
Disp:*1200 ML(s)* Refills:*0*
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
Disp:*1 bottle* Refills:*0*
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day) for 1
months.
Disp:*60 Disk with Device(s)* Refills:*0*
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) for 1 months.
Disp:*120 nebulizer* Refills:*0*
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) for 1 months.
Disp:*180 nebulizer* Refills:*0*
11. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily) for 1 months.
Disp:*30 Cap(s)* Refills:*0*
13. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100)
mg PO BID (2 times a day) for 1 months.
Disp:*6000 mg* Refills:*0*
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
15. Pantoprazole 40 mg IV Q24H
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
Disp:*1 container* Refills:*0*
17. Vancomycin HCl 1000 mg IV Q 12H
please D/C after [**2178-12-3**] dosing
18. Morphine Sulfate 1-2 mg IV Q4H:PRN
19. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): [[**2178-12-2**] 15mg]
[[**2178-12-3**] 15mg]
[[**2178-12-4**] 10mg]
[[**2178-12-5**] 10mg]
[[**2178-12-6**] 10mg]
[[**2178-12-7**] 5mg]
[[**2178-12-8**] 5mg]
[[**2178-12-9**] 5mg.
Disp:*QS Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Hypercarbic respiratory failure
MRSA+ sputum
emphysema
macular degeneration
Moderate pulmonary hypertension
Tricuspid regurgitation
Discharge Condition:
Stable
Discharge Instructions:
You should tell your nurse [**First Name (Titles) **] [**Last Name (Titles) **] if you have worsening
pains, fevers, chills, nausea, vomiting, shortness of breath,
chest pain, or other concerns.
It is important you take medications as directed. The physicians
at the rehabilitation center will adjust them as necessary
Followup Instructions:
Call your primary care [**Last Name (Titles) **] for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment
within 1 week after you leave the rehabilitation center.
|
[
"4280",
"5119",
"5990",
"2761",
"4019",
"3051",
"4168"
] |
Admission Date: [**2141-11-11**] Discharge Date: [**2141-11-16**]
Date of Birth: [**2068-6-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
MI instent restenosis
Major Surgical or Invasive Procedure:
Percutaneous coronary intervention/drug eluting stent x2
History of Present Illness:
73 yom s/p CABG [**2125**], PCI/LCX (01), instent restenosis
w/brachytherapy balloon cutting ([**3-11**]) and instent restenosis
x2 stents ([**4-13**]) now with instent restnosis to LCx s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (Prefixes) 10157**] to LCx and elevated right sided pressure on cath (PCWP
30). Patient also has extensive LAD disease -> LIMA-D1/LAD
(occluded proximally and subtotally occluded after LIMA
touchdown), RCA: SVG to RCA/PDA all occluded. LMain 60%. Has
previous EF 30-35% ([**4-13**]). No significant h/o arhythmia.
Patient reports approx 2 days of intermittent SSCP, squeezing
and [**12-11**] DOE. Denies orthopnea, PND, palpitations or syncope.
Of note, patient hasn't seen his PCP [**Last Name (NamePattern4) **] 4 yrs. Initially refused
taking statin and took only 30 days of Plavix after most recent
stent ([**4-13**]).
Past Medical History:
1. Hyperlipidemia
2. HTN
3. R CEA
4. CAD (CABG [**25**], stent [**36**], ballon cutting/brachy 02, stent
[**4-13**])
Social History:
15py tobacco history (quit at age 35)
no ETOH
lives with wife
Family History:
Fhx + for DM.
Physical Exam:
VS T 98.6 BP 130/70 HR 70 RR 16 O2sat 98%2L
NC
GEN: lying in bed
HEENT: PERRL, mmm, OP clear, no carotid bruit
CV: nl S1, S2 no murmurs/rubs/gallops appreciated
LUNG: CTA ant/lat
ABD: soft, NT, +BS
GROIN: no R femoral bruit or hematoma
EXT: 1+ DPP, nonedematous
NEURO: AOx3, nonfocal
Pertinent Results:
[**2141-11-11**] 12:25PM BLOOD WBC-8.9 RBC-3.53* Hgb-11.3* Hct-32.1*
MCV-91 MCH-32.0 MCHC-35.3* RDW-13.5 Plt Ct-177
Neuts-86.2* Bands-0 Lymphs-9.9* Monos-3.6 Eos-0.1 Baso-0.3
PT-14.5* PTT-27.1 INR(PT)-1.4
[**2141-11-11**] 12:25PM BLOOD Glucose-149* UreaN-49* Creat-2.3* Na-139
K-4.6 Cl-103 HCO3-23 AnGap-18
ALT-22 AST-17 AlkPhos-56 TotBili-0.8 Triglyc-98 HDL-36
CHOL/HD-3.4 LDLcalc-68
[**2141-11-11**] 12:25PM BLOOD CK(CPK)-99 cTropnT-1.08*
[**2141-11-12**] 02:56PM BLOOD CK-MB-13* MB Indx-7.3* cTropnT-1.18*
[**2141-11-12**] 10:08PM BLOOD CK-MB-13* MB Indx-6.6* cTropnT-1.19*
Calcium-9.2 Phos-3.9 Mg-2.3 freeCa-1.12
Iron-35* calTIBC-242* Ferritn-116 TRF-186*
CHEST (PORTABLE AP): Small vague density overlying the posterior
left 8th rib. Follow up with PA and lateral views is
recommended.
[**2141-11-11**] Cardiac Cath
COMMENTS:
1. Selective coronary angiography in this right dominant
circulation
demonstrated three vessel native coronary artery disease. The
LMCA had
diffuse 60% stenosis. The LAD with totally occluded proximally
and
subtotally occluded after the touchdown of the LIMA. The D1 was
without
any angiographically apparent flow limiting disease. The LCx had
a
proximal 80% instent restenosis. The more distal part of the
proximal
LCx stents were patent. OM1 and OM2 were without any flow
limiting
disease. The RCA was not engaged because it was known to be
previously
occluded.
2. The LIMA was without any flow limiting disease. The SVG was
not
engaged because it was known to be previously occluded.
3. Resting hemodynamics from right heart catheterization
demonstrated
moderately elevated right sided filling pressures (RVEDP
19mmHg). The
mean PCWP was severely elevated to 37mmHg and the tracing had
large v
waves. There was moderate to severe pulmonary arterial
hypertension. The
calculated cardiac output via the Fick method was 2.8 L/min with
a
cardiac index of 1.6.
4. successful prdilation using 2.5 X 20 mm Voyager balloon,
stenting
using 3.0 X 32mm and 3.0 X 12 cypher stents and post dilating
using 3.5 X 28 High sail ballon with lesion reduction from 90%
to 0% in
the mid CX and from 60% to 0% in the LMCA. The final angiogram
showed
TIMI III flow with no residual stenosis, no dissection or
embolisation.
(see PTCA comments)
FINAL DIAGNOSIS:
1. Severe three vessel native coronary artery disease.
2. Severely elevated PCWP with large v waves.
3. Severely depressed cardiac output.
4. Successful stenting of the CX/LMCA lesion.
[**2141-11-11**] ECHO
The left ventricular cavity is dilated. There is moderate to
severe regional left ventricular systolic dysfunction. Overall
left ventricular systolic function is moderately to severely
depressed with septal and apical hypokinesis although views are
technically suboptimal. The anterior wall may be hypokinetic but
is not fully visualized. Estimated LV ejection fraction ?30%.
Right ventricular chamber size and systolic function is probably
normal. The apex is not well seen; no apical thrombus seen but
cannot exclude. The aortic valve leaflets are mildly thickened.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-11**]+) mitral
regurgitation is seen. There is an anterior space which most
likely represents a fat pad, though a loculated anterior
pericardial effusion cannot be excluded.
Compared with the prior study (tape reviewed) of [**2141-4-25**],
there is no
definite change (although current study is technically
suboptimal for
comparison.
[**2140-11-11**] EKG
Atrial fibrillation. Inferolateral wall myocardial infarction,
age
indeterminate. Probable left ventricular hypertrophy. Compared
to the previous tracing no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 0 104 364/[**Telephone/Fax (2) 93154**]
Brief Hospital Course:
Mr. [**Known lastname 93155**] is a 73-year-old man with hypertension, peripheral
vascular disease, and coronary artery disease status post CABG
(`90), stent (`01 and `05), balloon/bracytherapy [**2137**] for
restenosis LCx now s/p 2 [**Year (4 digits) **] to restenosis site of LCx and
elevated filling pressures this admission.
.
##CARDIAC:
#Ischemia - 2 [**Year (4 digits) **] to LCx restenosis. Continue ASA, Plavix 75mg x
9 months. Restart Metoprolol XL 100 mg PO DAILY. Followed serial
EKGs and CE's. Started Lipitor 80mg. [**2141-11-12**]: Patient with 3/10
CP in AM, EKG showed 0.5-[**Street Address(2) 4793**] elevation isolated in V3.
Patient was started on heparin gtt for concern of ACS. Relieved
with Nitro gtt, CE's did not trend up, no further intervention
recommended.
.
#Pump - PCWP 30 indicating fluid overload, needing aggressive
diuresis. Patient received 100mg IV lasix s/p cath lab. Urgent
echocardiogram showed mod MR and no obvious flail leaflet. Nitro
ggt was titrated off and hydralazine was discontinued [**11-14**].
Patient was continued on imdur and started on lisinopril 10mg PO
QD.
.
#Rhythm - Patient is without history of afib. Patient went into
afib HR 89-90's, asymptomatic. Patient on IV heparin and started
on coumadin. Continued telemetry and serial EKG's.
.
##ARF: baseline 1.3, 2.3 on admission. likely [**1-11**] to decreased
perfusion. continue to reduce afterload, treat heart failure.
.
##Anemia: Baseline 38-40, 32.1->28.9. MCV 91. B12 wnl and iron
studies consistent with anemia of chronic disease. guiac'd
stool. No acute issues and no transfusions required. Deferred to
outpatient management.
.
##FEN: cardiac healthy 2g Na diet, replete lytes
.
##PPx: IV heparin, bowel regimen, PT consult
.
##Code: full
Medications on Admission:
1. ASA 325
2. amlodipine 5mg QD
3. metoprolol 50mg [**Hospital1 **]
4. captopril 25mg TID
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please start evening of [**2141-11-17**].
Disp:*60 Tablet(s)* Refills:*2*
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5 minutes: Please take 1 tablet as needed for chest
pain. [**Month (only) 116**] repeat dose after 5 minutes as needed up to 3 total
doses in 15 minutes.
Disp:*1 bottle* Refills:*2*
9. Outpatient Lab Work
Please go to [**Hospital3 **] admitting desk on Monday [**2141-11-20**]
between 9am-6pm to get your labs (INR/PT) drawn. Please have
results faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**] Fax [**Telephone/Fax (1) 66123**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. STEMI/LCx restenosis
2. CHF
Secondary:
3. Hypertension
4. Hypercholesterolemia
5. Former tobacco use
Discharge Condition:
Good
Discharge Instructions:
Please take medications as prescribed. Continue to take aspirin
and plavix for AT LEAST 3 MONTHS. Please follow-up with your
cardiologist/PCP regarding any adjustment to your medications.
Please keep you follow-up appointments.
Please go to [**Hospital3 **] admitting and pick up lab slip on
Monday [**2141-11-20**] between 9am-6pm and get your labs drawn. Please
have your INR/PT results sent to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**] Fax
([**Telephone/Fax (1) 93156**].
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: 1500cc.
Followup Instructions:
Please go to [**Hospital3 **] admitting and pick up lab slip on
Monday [**2141-11-20**] between 9am-6pm and get your labs drawn. Please
have your INR/PT results sent to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**] Fax
([**Telephone/Fax (1) 93156**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**], MD Phone:([**Telephone/Fax (1) 68572**] Date/Time:
[**2141-11-23**] 2:30pm Location: [**Street Address(2) **] [**Apartment Address(1) **], [**Hospital1 **], MA
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**] Date/Time:
[**2140-12-18**] 4:15pm Location: [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
Completed by:[**2141-11-19**]
|
[
"41071",
"41401",
"V4581"
] |
Admission Date: [**2121-12-2**] Discharge Date: [**2121-12-5**]
Date of Birth: [**2063-8-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
bile leak s/p cholecystectomy requiring transfer for [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] [**2121-12-2**] with plastic stent placement
History of Present Illness:
58-year-old man with history of HTN, hyperlipidemia, now s/p
laparoscopic cholecystectomy on [**2121-12-1**] at OSH complicated by
major bile leak, was transferred to [**Hospital1 18**] for [**Hospital1 **].
The patient presented to [**Hospital 498**] [**Hospital 2725**] Hospital on [**11-29**] with
RUQ pain, nausea, vomiting, was diagnosed with cholecystitis,
started on levoflox and metronidazole. His WBC was 9.2, Hct 47,
plt 254. Tbili 1.4, AST 270, ALT 270, amylase 271. His abx
regimen was then changed over to ertapenem. On [**11-30**] he
underwent a lap cholecystectomy after which he developed severe
abdominal pain. He went to OR again on [**12-1**] and was found to
have bile peritonitis. Lap chole incisions were used to irrigate
abdominal cavity and 2 JP drains were placed. Abx was changed to
pip-tazo. WBC increased to 13.8 with no left shift. Was
transferred to [**Hospital1 **] for [**Hospital1 **].
On arrival to the ICU, the patient was in no acute distress,
with stable vitals, conversational, but complaining of RUQ
abdominal pain.
ROS: The patient denies any fevers, chills, weight change,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity oedema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.
Past Medical History:
HTN, benign
Hyperlipidemia
Bile peritonitis s/p laprascopic cholecystectomy (prior to
transfer)
Social History:
Drinks 2 beers/day. No drug or tobacco use.
Family History:
All family members had gallbladder/gallstone issues with
cholecystectomies. Brother died of lung ca.
Physical Exam:
Vitals: Tm 100.2 Tc 98.5 113/77 P70 R18 95%RA
GEN: Middle-aged man in no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
CV: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: 2 JP drains in place, soft, nontender
EXT: No C/C/E
NEURO: alert, oriented to person, place, and time. Moves all 4
extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission labs:
[**2121-12-2**] 02:34AM BLOOD WBC-10.0 RBC-4.05* Hgb-13.6* Hct-38.1*
MCV-94 MCH-33.6* MCHC-35.7* RDW-12.1 Plt Ct-196
[**2121-12-2**] 02:34AM BLOOD PT-13.5* PTT-28.3 INR(PT)-1.2*
[**2121-12-2**] 02:34AM BLOOD Glucose-104 UreaN-12 Creat-1.2 Na-143
K-3.8 Cl-107 HCO3-27 AnGap-13
[**2121-12-2**] 02:34AM BLOOD ALT-146* AST-85* LD(LDH)-226 AlkPhos-64
Amylase-86 TotBili-1.1
[**2121-12-2**] 02:34AM BLOOD Lipase-90*
[**2121-12-2**] 02:34AM BLOOD Calcium-8.5 Phos-2.4* Mg-2.3
.
.
Discharge:
[**2121-12-4**] 06:50AM BLOOD WBC-7.7 RBC-3.73* Hgb-12.3* Hct-34.8*
MCV-93 MCH-33.0* MCHC-35.4* RDW-11.9 Plt Ct-255
[**2121-12-4**] 06:50AM BLOOD Glucose-95 UreaN-15 Creat-0.9 Na-139
K-3.6 Cl-106 HCO3-24 AnGap-13
[**2121-12-4**] 06:50AM BLOOD ALT-73* AST-32 LD(LDH)-166 AlkPhos-56
TotBili-0.8
[**2121-12-4**] 06:50AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.5* Mg-2.4
.
Pending (Please follow up)
[**2121-12-2**] 5:46 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
.
.
[**Month/Day/Year **] Report:
Impression: The major papilla appeared normal.
The common bile duct, common hepatic duct, right and left
hepatic ducts,and biliary radicles were filled with contrast
and well visualized. There was no evidence of stricture,
dilation or filling defects.
Cystic stump moderate bile leak identified.
Successful biliary endoscopic sphincterotomy performed in the 12
o'clock position using a sphincterotome over an existing
guidewire.
Successful placement of a 10Fr x 7cm plastic stent in the common
bile duct.
Recommendations:
Follow up for stent removal in 4 weeks.
.
Radiology Read of [**Month/Day/Year **]:
[**Month/Day/Year **]: Eighteen spot fluoroscopic images were obtained by
gastroenterology
without a radiologist present. Initial spot radiographs
demonstrate
indwelling surgical drains and surgical clips. Subsequent
cholangiogram
displayed no gross filling defects in the CBD and filling of the
cystic duct which displayed active extravasation. Proximal left
and right biliary ducts are normal with aberrant insertion of
the right posterior duct into the proximal left hepatic duct.
Final image displays placement of indwelling biliary plastic
stent.
IMPRESSION: Cystic duct stump leak status post stenting. Slight
variant
anatomy as described above.
Brief Hospital Course:
Mr. [**Known lastname 33976**] is a 58-year-old man with history of HTN, HL s/p
laparoscopic cholecystectomy on [**2121-12-1**] at OSH with major bile
leak, s/p 2 JP drain placements was transferred to [**Hospital1 18**] for
[**Hospital1 **].
.
# Bile peritonitis: post-cholecystectomy complication. Already
received abdominal cavity irrigation. Broad-spectrum abx started
on admission. [**Hospital1 **] was done [**12-2**] showing moderate bile leak
identified in the cystic stump. A successful biliary endoscopic
sphincterotomy was performed as well as placement of a 10Fr x
7cm plastic stent in the common bile duct. LFT's trended down.
Zosyn continued until [**12-5**]; no evidence of infection, pt
remained afebrile.
.
Original plan was for pt to be transferred back to [**Hospital1 498**]
[**Location (un) 2725**], however no beds were available in days following [**Location (un) **].
Discussed with Dr. [**Last Name (STitle) 80423**] (referring surgeon), and plan made to
consult [**Hospital1 18**] surgery. Surgery recommended discontinue
antibiotics, and leave drains in place. Pt stable for
discharge, and to follow up with Dr. [**Last Name (STitle) 80423**] as an outpatient
(scheduled [**12-9**]). Pt agreeable to plan.
.
Pt felt progressively better througout hospitalization, with
decreasing abdominal pain. No pain while in bed, and [**6-14**] pain
while up ambulating; improved with oxycodone 10 mg. JP drains
(2) draining only 10cc each over 8 hrs prior to discharge;
non-bilious.
.
# HTN: Blood pressure remained stable in 110's SBP off of BP
meds. BP meds held on discharge; patient to follow up with PCP.
.
# Hyperlipidemia: Simvastatin on hold at this time. Pt to follow
up with PCP.
.
Pt will be provided VNA services for management of
drains/dressing changes.
Medications on Admission:
Home meds:
simvastatin 40 mg qday
lisinopril/HCTZ 10/12.5 mg qday
.
Medications on transfer to [**Hospital1 18**]:
pip-taz
lisinopril/HCTZ (held b/c NPO)
metoprolol IV prn
pantoprazole
hydromorphone
morphine
metoclopramide
ketorolac
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
# Bile peritonitis
Discharge Condition:
stable
Discharge Instructions:
Take your medications as prescribed and follow up with Dr.
[**Last Name (STitle) 80423**], your PCP, [**Name10 (NameIs) **] the [**Name10 (NameIs) **] team for stent removal.
.
Return to emergency department if you develop fever, chills,
nausea, vomiting, increasing abdominal pain, jaundice, redness
around abdominal incisions, if drainage into drains increases
significantly or becomes green (bilious), or any other concern.
Followup Instructions:
Dr. [**Last Name (STitle) 80423**], Surgery: [**12-9**] at 10 am.
.
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2121-12-30**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2121-12-30**] 8:30
.
Please call to schedule a follow up appointment with your PCP
within the next several weeks.
|
[
"2724"
] |
Admission Date: [**2194-5-17**] Discharge Date: [**2194-6-2**]
Date of Birth: [**2152-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Leukocytosis with bandemia.
Major Surgical or Invasive Procedure:
1. Endoscopic esophagogastroduodenoscopy
History of Present Illness:
42 year old woman with EtOH hepatitis on multiple occasions, ?
cirrhosis, depression with multiple suicidal attempts, obesity
s/p Reux-en-Y gastric bypass surgery, [**Last Name (un) **] [**2192**] s/p multiple
abdominal surgeries who was admitted to ET service during ([**5-6**]
- [**5-16**]) for another bout of EtOH hepatitis in setting of
Urosepsis, started on steroids w/ resolution of encephalopathy,
improvement in WBCs/Tbili and discharged to rehab on [**5-16**] w/
elevated WBC and 3 bands thought to be due to steroids (based on
neg. inf. w/up and clinical improvement) who now presents with
right sided abdominal pain (unchanged), encephalopathy and
bandemia from rehab. Of note, on day of discharge, Lactulose had
been held due to frequent BMs and was not restarted.
.
In the interim, no precipitating events were noted. She became
progressively more confused (off lactulose), labs were drawn and
showed a WBC of 15.7K w/ 35% bands. She was sent to the ED for
re-evaluation.
.
In the ED, initial VS: 99.7 110 110/65 18 99%. She was found to
have a WBC of 17, bandemia of 10 (down from 34 from OSH). She
underwent a RUQ U/S which was negative for ascites, portal
thrombosis, or biliary pathology (s/p cholecystectomy). U/A was
initially dirty, but given CTX, then repeat U/A negative. CXR
showed lower lobe atelectasis, so azithromycin was added. She
was given 1g of CFTX, 500mg Azithro, and ? fluconazole 150mg (on
dashboard but not recorded in chart) and lactulose for presumed
hepatic encephalopathy. Liver was notified. Last set of vitals
98, 120/65, 18, 98%RA.
.
On the floor in initial evaluation, her ROS was negative w/
exception of "a severe headache that started yesterday, frontal
in nature, [**6-22**], and she states she's never experienced a
headache like this before. She denies neck stiffness,
photophobia, phonophobia, vomitting, flu/cold symptoms." On the
floor, she underwent an attempt at LP w/o success. Her MS
improved markedly w/ lactulose.
.
On my interview, she was alert, oriented to date, time and place
and was following commands. She recalls not being able to
participate with rehab due to confusion. She c/o of persistent
RUQ pain that was unchanged from prior as well as LLE pain
improved from prior. ROS was otherwise negative.
Past Medical History:
* Anemia of chronic disease
* Depression - two suicide attempts in past (one an overdose),
followed by counselor (unsure location)
* Anxiety
* Recent memory loss/black out spells
* Roux-en-Y gastric bypass
* Small bowel obstruction, lysis of adhesions
* Urinary incontinence
* Open cholecystectomy
* Tubovarian abscess [**2193-6-3**]
* Left hip plate s/p fall as child
* Multiple admissions for EtOH hepatitis.
Social History:
Separated from her husband, lives alone. Does not work. Brother
and boyfriend help her out. Patient denies tobacco and illicits.
Heavy alcohol use, last drink "two days ago" per patient.
Adopting a dog.
Family History:
Mother and father with diabetes mellitus.
Physical Exam:
Upon admission:
VS: 100.1 (100.9Tm) 110/60 112 21 98%RA
GENERAL: Sitting in bed, watching television, pleasant.
Obese, jaundiced (increased).
HEENT: NC/AT, sclerae icteric, MMM, OP clear. No sinus
tenderness.
NECK: Supple, no meningisumus, no JVD.
HEART: RR, no MRG, nl S1-S2.
LUNGS: Poor effort, bilateral crackles.
ABDOMEN: Obese, soft, TTP at RUQ, no rebound/guarding. Guiac
positive stool. SubQ mass of 2.5cm to 3cm in L abdominal wall.
EXTREMITIES: 4+ edema to hips.
SKIN: jaundiced, no rashes or lesions.
NEURO: Awake, A&Ox3, DOWb intact but not MOYb. Naming,
repetition, [**Location (un) 1131**] intact. no apraxia or neglect.
CNs EOMi, no nystagmus, face symmetric, sensation intact to LT
b/l, palate is symmetric as is tongue.
Full strength in UEs b/l. Sensation intact to LT and
proprioception.
Normal tone in LEs and UEs.
RLE w/ [**3-18**] IP/H/TA, full quad., limited by effort.
LLE w/ AG in IP, Quad/Ham,TA, when LLE liften above RLE and let
go to fall, it is abducted and extended by patient temporarily
before falling to bed.
Toes down b/l.
At discharge:
Vital signs: 98.8 98.4 118/76 101 18 97% RA. 117kg
I/O: 240/BR 1300+100/400
General: Overweight, jaundiced woman in no distress.
HEENT: +Scleral icterus.
Neck: Supple, no JVD.
Heart: RRR, normal s1s2, no murmurs.
Lungs: CTAB no w/r/c.
Abdomen: Obese, soft, mild TTP at RUQ, no rebound/guarding.
+hepatosplenomegaly. Multiple abdominal wall nodules.
Extremities: 1+ edema to hips.
Neurological: Oriented x3, moving all extremities.
Pertinent Results:
Labs upon admission:
[**2194-5-17**] 10:50PM URINE COLOR-DkAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2194-5-17**] 10:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-4* PH-5.5 LEUK-NEG
[**2194-5-17**] 10:50PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1
[**2194-5-17**] 10:50PM URINE GRANULAR-1* HYALINE-10* CELL-14*
[**2194-5-17**] 10:50PM URINE MUCOUS-OCC
[**2194-5-17**] 10:40PM LACTATE-3.2*
[**2194-5-17**] 10:35PM AMMONIA-81*
[**2194-5-17**] 09:50PM URINE HOURS-RANDOM
[**2194-5-17**] 09:50PM URINE UCG-NEGATIVE
[**2194-5-17**] 09:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2194-5-17**] 09:50PM URINE COLOR-DkAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019
[**2194-5-17**] 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-8* PH-5.5 LEUK-NEG
[**2194-5-17**] 09:50PM URINE RBC-0 WBC-12* BACTERIA-MANY YEAST-NONE
EPI-30
[**2194-5-17**] 09:50PM URINE HYALINE-5*
[**2194-5-17**] 09:50PM URINE MUCOUS-MANY
[**2194-5-17**] 08:45PM GLUCOSE-78 UREA N-10 CREAT-0.5 SODIUM-138
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-16
[**2194-5-17**] 08:45PM ALT(SGPT)-58* AST(SGOT)-147* ALK PHOS-109*
TOT BILI-17.3*
[**2194-5-17**] 08:45PM LIPASE-25
[**2194-5-17**] 08:45PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2194-5-17**] 08:45PM NEUTS-66 BANDS-10* LYMPHS-7* MONOS-14* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-2*
[**2194-5-17**] 08:45PM PLT COUNT-159
[**2194-5-17**] 08:45PM PT-19.0* PTT-29.7 INR(PT)-1.7*
[**2194-5-16**] 05:58AM GLUCOSE-62* UREA N-9 CREAT-0.5 SODIUM-138
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-31 ANION GAP-12
[**2194-5-16**] 05:58AM ALT(SGPT)-50* AST(SGOT)-137* ALK PHOS-111*
TOT BILI-15.1*
[**2194-5-16**] 05:58AM CALCIUM-8.0* PHOSPHATE-2.1* MAGNESIUM-1.5*
[**2194-5-16**] 05:58AM WBC-15.8* RBC-2.49* HGB-8.3* HCT-25.5*
MCV-103* MCH-33.4* MCHC-32.6 RDW-17.3*
[**2194-5-16**] 05:58AM NEUTS-80* BANDS-3 LYMPHS-10* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2194-5-16**] 05:58AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL TARGET-OCCASIONAL TEARDROP-OCCASIONAL
[**2194-5-16**] 05:58AM PLT SMR-NORMAL PLT COUNT-163
[**2194-5-16**] 05:58AM PT-18.6* PTT-30.2 INR(PT)-1.7*
Labs at discharge:
CBC: 18.7/7.8/23.9/207 MCV 96
Chem 7: 140/4.2/104/27/14/0.7<86
Chem 10: Ca: 9.6 Mg: 1.7 P: 3.4
ALT: 50 AST: 128 AP: 79 Tbili: 10.4
PT: 22.7 INR: 2.1
Micro:
[**2194-5-25**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2194-5-22**] URINE URINE CULTURE-yeast
[**2194-5-21**] MRSA SCREEN MRSA SCREEN-FINAL
[**2194-5-20**] BLOOD CULTURE Blood Culture, Routine-negative
[**2194-5-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2194-5-19**] BLOOD CULTURE Blood Culture, Routine-negative
[**2194-5-18**] BLOOD CULTURE Blood Culture, Routine-negative
[**2194-5-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2194-5-18**] BLOOD CULTURE Blood Culture, Routine-negative
[**2194-5-17**] URINE URINE CULTURE-negative
Imaging:
[**2194-5-21**] renal u/s: The kidneys are normal in appearance and there
is no evidence of hydronephrosis. The right kidney measures 13
cm and the left kidney measures 13.8 cm. The bladder is
collapsed around a Foley catheter. IMPRESSION: Normal renal
ultrasound study.
[**2194-5-20**] CXR: Aside from mild left basal atelectasis, left lung is
clear. Right lung volume has improved. Mild interstitial
abnormality at the right lung base reflected in bronchial
cuffing is minimal, and probably not sufficient to explain
clinical findings. Heart size is top normal. Pleural effusion is
minimal if any. No pneumothorax.
[**2194-5-18**] CXR: In comparison with the study of [**5-17**], there are lower
lung volumes. Atelectatic changes are again seen at both bases.
In the appropriate clinical setting, the possibility of
supervening pneumonia would have to be considered.
[**2194-5-18**] CT chest/abd/pelvis: intact Roux en Y, subcutaneous soft
tissue mass in abdominal wall 1.6x1.9cm
[**2194-5-17**] RUQ U/S: Echogenic liver again seen, most consistent with
fatty infiltration; advanced liver diseaes including hepatic
fibrosis/cirrhosis can not be excluded on this study. Patent
main portal vein with hepatopetal flow. Status post
cholecystectomy. No free fluid seen.
Brief Hospital Course:
42 year old female with EtOH hepatitis on multiple occasions,
likely cirrhosis, depression with multiple suicidal attempts,
obesity s/p Reux-en-Y gastric bypass surgery, [**Last Name (un) **] [**2192**] s/p
multiple abdominal surgeries who was initially admitted to ET on
[**5-6**] with EtOH hepatitis. Hospital course has been complicated
by gastric ulcer bleed, hypotension with MICU transfer, and
subsequent ATN. She was broadly covered with vanco/meropenem and
bolused IVF. She was previously on steroids but spiked fevers
with bandemia during her last hospitalization, so she was given
a trial of pentoxyfylline. However TB and INR continued to
uptrend for MDF of 80 so prednisone restarted with marked
improvement.
# Alcoholic hepatitis: MDF on admission was 50, and uptrended as
high as 80. Multiple complications including UTI, sepsis,
gastric ulcer bleed and ATN making prognosis worse. TB and INR
uptrending on trial of pentoxyfylline, so prednisone was
restarted at 30mg with taper by 10mg per week. She was
discharged on 20mg of prednisone. She is on a PPI [**Hospital1 **], calcium,
and vitamin D. Her sugars were within normal limits. She was
given supplemental enteral nutrition for goal kcal>[**2182**]/day.
She was set up with SW and outpatient EtOH counseling at [**Hospital1 **]
as an outpatient.
# [**Last Name (un) **]: Patient developed ATN after gastric ulcer bleed with
hypotensive episode. This improved with time. Diuretics were
restarted after the creatinine improved due to a large amount of
lower extremity edema. The creatinine increased on diuretics
likely representing [**Last Name (un) **]. FeUrea was 19%. She responded well to
midodrine, octreotide, and albumin challenge with creatinine
returning to baseline of 0.7 prior to discharge.
# Cirrhosis: Patient with alc hep. No thrombus on imaging, and
no evidence of varices on EGD. She likely has cirrhosis and has
been compensated between episodes of alcoholic hepatitis. She
was given ACE wraps to help with her lower extremity edema. She
was started on rifaximin with lactulose as needed. She will
follow up with liver as an outpatient and will need outpatient
Hep A/B vaccines.
# Acute on chronic blood loss anemia: She developed melena with
a drop in her hematocrit to 17. EGD performed in ICU showed
ulcer at the anastomosis site. The ulcer was clipped.
Otherwise normal EGD to third part of the duodenum. Resumed
clear liquid diet and discontinued PPI gtt/octreotide. Placed
on PPI [**Hospital1 **]. Subsequently, her hematocrit was stable at 24-26,
without signs of hematochezia or melena.
# Leukocytosis: No evidence of bandemia or infection without
fevers. Likely secondary to EtOH hepatitis. WBC stable at 17-21,
even with the addition of steroids.
# Right Upper Quadrant pain: Likely due to inflammation and
swelling within the liver capsule. Treated with oxycodone
5-10mg prn pain.
# Macrocytic Anemia: HCT at baseline. Likely secondary to ETOH
abuse with bone marrow toxicity. The patient is heme positive.
Suspect tachycardia from anemia.
# Hepatic Encephalopathy: Clear by HD#2. Continued lactulose
and rifaxamin.
# Thrombocytopenia: Likely splenic sequestration.
# Depression/Anxiety: Stable, no SI. All of her psychiatric
medications were held as they were on her last discharge. Her
outpatient physicians can consider starting Celexa when her
liver function improves.
Medications on Admission:
- gabapentin 300 mg Capsule q 8hrs
- multivitamin Tablet daily
- folic acid 1 mg Tablet daily
- thiamine HCl 100 mg Tablet daily
- miconazole nitrate 2 % Powder QID
- furosemide 40 mg Tablet DAILY
- spironolactone 50 mg Tablet daily
- oxycodone 5 mg Tablet q 6hrs prn
- cholecalciferol (vitamin D3) 1,000 unit Tablet daily
- docusate sodium 100 mg Tablet [**Hospital1 **]
- ferrous sulfate 325 mg (65 mg iron) Tablet daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
5. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day for 12
days: Please take 2 tablets daily for the first five days
([**Date range (1) 24549**]), and then take 1 tablet for the next 7 days
(6/25-6/31).
Disp:*17 Tablet(s)* Refills:*0*
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis: Alcoholic hepatitis, Bleeding gastric ulcer
s/p clipping, Acute tubular necrosis, Acute kidney injury
Secondary diagnosis: Alcohol abuse, Alcohol induced liver
disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Weight at discharge: 116.2kg
Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted for an elevated white blood cell count which
was secondary to your alcohol induced liver disease known as
alcoholic hepatitis. You were started on steroids with much
improvement in your liver function. You will need to continue
taking these steroids for another 12 days.
During your stay, you had large bloody bowel movements. An
endoscopic evaluation of your stomach revealed a bleeding ulcer.
The blood vessel within this ulcer was clipped and the bleeding
stopped. You were started on a medication called a PPI to help
heal this ulcer and prevent new ulcers.
As a result of this blood loss, your kidneys did not receive
enough blood flow and became dehydrated. This improved over the
course of your stay.
You have a large amount of lower extremity swelling. Diuretics
were tried, but this also dehydrated your kidneys. These water
pills were stopped and your kidney function improved to
baseline. You should continue to use ACE wraps on your legs,
keep your legs elevated, and walk around as much as possible.
The following changes have been made to your medication regimen:
START prednisone (steroid) 20mg for five days, then 10mg for one
week
START rifaximin twice daily for your liver
START pantoprazole twice daily to help heal the ulcer and
prevent rebleeding
START ursodiol twice daily for itching
STOP lasix
STOP spironolactone
Followup Instructions:
Please attend the following appointments:
Department: BIDHC [**Location (un) **]
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
When: FRIDAY [**2194-6-6**] at 5:00 PM
Address: 545A [**Street Address(1) **], [**Location (un) 538**], [**Numeric Identifier 7023**]
Phone: [**Telephone/Fax (1) 608**]
This appointment is to establish care with [**Doctor First Name **] who has cared
for you in the past. For insurance purposes, please list Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as your pcp with your insurance company.
Department: LIVER CENTER
When: MONDAY [**2194-6-9**] at 12:50 PM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: LIVER CENTER
When: MONDAY [**2194-6-30**] at 11:30 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"0389",
"5845",
"5180",
"2851",
"5990",
"99592",
"2875"
] |
Admission Date: [**2125-6-25**] Discharge Date: [**2125-6-27**]
Date of Birth: [**2046-6-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
RCA perforation
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
79 yo male with PMH of HTN and hyperlipidemia presents for
elective cardiac catheterization. Patient originally reported
chest tightness associated with shortness of breath after
lifting 40lb bags of stones which was relieved with rest. He
denied any symptoms of lightheadedness, near syncope, or
syncope. He experienced no symptoms while at rest. The patient
had a nuclear stress test on [**2125-6-13**] which he was able to
exercise for 5 minutes 1 second on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol to a peak HR
of 106 BPM, achieving 7 METS, during which he reported mild
chest tightness at peak exercise. ECG revealed [**Street Address(2) 4793**]
depression in leads II, III, AVF and V4-V6 which resolved at 1-2
minutes of recovery. TTE revealed mild inferior wall
ischemia with LVEF was 70%. He was scheduled for an elective
cardiac catheterization.
.
During cardiac catheterization, patient was found to have a
proximal RCA lucency which IVUS showed to be calcium, and a
tight 95% mid RCA lesion. Interventional attempted rotoblator
on mid-RCA lesion due to increased calcium. The wire broke
distal to the lesion was fractured and the arterial wall of RCA
distal to the lesion was perforated. Retreival of the wire was
attempted with snare tip, but was unsuccessful. CT [**Doctor First Name **] was
consulted, did not recommend surgical intervention at this time.
Patient received 2 stents to his RCA, one across the 95%
lesion, and one holding the remaining proximal portion of the
wire against the RCA wall. Patient has been asymptomatic and
stable throughout this procedure. Two TTE's were performed post
cath which showed no evidence of effusion/tamponade. Patient
was transferred to the CCU for further management.
.
On arrival to the CCU patient has no complaints other than his
right femoral site feels sore. Otherwise, has no CP, SOB,
lightheadedness, abdominal pain.
.
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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
HTN
Hyperlipidemia
GERD
BPH
Osteoarthritis
.
PAST SURGICAL HISTORY:
s/p Left TKR [**2116**]
s/p Right TKR [**2122**]
s/p Hernia repair
s/p bilateral cataract surgery
s/p Tonsillectomy
Social History:
Lives with: wife, [**Name (NI) 4489**].
Occupation: Retired.
Tobacco: denies
ETOH: Rare ETOH
Illicit drug: denies
.
Family History:
NC
Physical Exam:
96.7, 120/59, 61, 22, 99%RA
Pulsus: 4 mm Hg
GENERAL: WDWN male in NAD. AAOx3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VI systolic ejection murmur. 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. Right femoral sheath
still in place. No bleeding/hematoma. Nontender.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Cardiac Cath Study Date of [**2125-6-25**]
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
two vessel coronary artery disease. The LMCA had no
angiographically
apparent flow limiting disease. The LAD had minimal disease.
The LCX
had a 60-70% stenosis at the mid segment. The RCA had a 99%
calcified
eccentric lesion, an 80% mid segment stenosis, and an 80% distal
segment
stenosis.
2. Aortography showed no aortic insufficiency or aortic root
dilation.
3. Unsuccessful attempt to IVUS the RCA.
3. Rotational atherectomy using a 1.25mm burr of the proximal
and mid
RCA complicated by a small, contained perforation and Rotawire
fracture
resulting in retained wire. (see PTCA comments for details)
4. Successful PTCA and stenting of the ostial, proximal, and mid
RCA
using 4 overlapping bare metal vision stents (3.0 x 28mm, 3.0 x
12mm,
3.0 x 12mm, and 2.75 x 15mm) proximal to distal. Final
angiography
revealed no residual stenosis in the stented portion of the RCA,
no
angiographically apparent dissection, a small, contained
perforation in
the mid RCA, and TIMI 3 flow. (see PTCA comments for details)
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Unsuccessful attempt to IVUS RCA.
3. Rotional atherectomy of the proximal and mid RCA complicated
by
Rotawire fracture, a small, contained perforation, and retained
Rotawire.
4. Successful PTCA and stenting of the ostial, proximal, and mid
RCA.
5. RHC with normal left and right sided pressures.
6. Limited transthoracic echocardiography with nl LV and RV
function, no
peridardial effusion, and no evidence of tamponade.
Portable TTE (Focused views) Done [**2125-6-25**] at 10:00:00 AM
Left ventricular wall thicknesses and cavity size are normal.
There is no pericardial effusion.
Portable TTE (Focused views) Done [**2125-6-25**] at 12:45:00 PM
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size is normal. with focal basal free wall hypokinesis.
There is no pericardial effusion.
Portable TTE (Focused views) Done [**2125-6-25**] at 7:00:57 PM
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). The aortic valve
leaflets are mildly thickened (?#). The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse.
There is no pericardial effusion.
Portable TTE (Focused views) Done [**2125-6-27**] at 10:11:01 AM
PRELIM READ
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The descending
thoracic aorta is mildly dilated. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
an anterior space which most likely represents a prominent fat
pad.
Brief Hospital Course:
79 yo male with PMH of HTN and hyperlipidemia presents with
exertional angina and an abnormal stress test, referred for
cardiac catheterization. Admitted to CCU following cardiac cath
complicated by wire fracture and arterial perforation
.
# CORONARIES: patient has a history of HTN and hyperlipidemia.
Experienced chest pain and dyspnea on exertion at home. Had an
outpatient nuclear stress test during which he had mild chest
tightness at peak exercise. ECG revealed [**Street Address(2) 4793**] depression in
leads II, III, AVF and V4-V6 which resolved at 1-2 minutes of
recovery. TTE revealed mild inferior wall ischemia with LVEF of
70%. Patient was referred for elective cardiac catheterization,
which showed a calcific lesion in proximal RCA and 95% calcific
lesion in mid RCA. Rotoblation was attempted, however
complicated with wire fracture and RCA perforation. Patient
still has a segment of retained wire in the RCA. A bare metal
stent was placed to hold the remaining wire segment against the
RCA wall. Because of concerns for cardiac tamponade from RCA
perforation, three post-cath TTEs were performed which showed no
effusions. Patient was carefully monitored in the CCU for two
days, with no events. He was discharged home with full strength
aspirin, clopidogrel, metoprolol succinate, valsartan, and
rosuvastatin. He will follow up closely with his outpatient
cardiologist.
.
# PUMP: OSH nuclear stress test reported to have mild inferior
wall ischemia with LVEF of 70%. Patient had multiple focal TTEs
performed on this admission to evaluate for pericardial
effusions, all of which were negative.
.
# RHYTHM: patient is in normal sinus rhythm
.
# HTN - metoprolol succinate was increased from 25 mg daily to
50 mg daily. He was continued on home dose of valsartan
.
# Hyperlipidemia - patient has a history of LFT abnormalities
with simvastatin and pravastatin. Was on ezetimibe as an
outpatient. Discontinued ezetimibe on this admission and
started on rosuvastatin as it is water soluble and less likely
to cause LFT abnormalities. LFTs checked prior to initiation of
rosuvastatin is normal. Patient will require repeat check of
LFTs with his cardiologist.
.
# GERD - patient was continued on ranitidine
.
# BPH - patient was continued on tamsulosin
.
#. s/p bilateral cateract surgery - patient was continued on
timolol 0.5 % drops, one drop to left eye daily
Medications on Admission:
ergocalciferol 50,000 units qweek
ezetimibe 10 mg daily
metoprolol succinate 25 mg daily
nitroglycerin 0.4 mg prn chest pain
tamsulosin 0.4 mg daily
timolol 0.5 % drops, one drop to left eye daily
valsartan 160 mg daily
ascorbic acid 1000 mg daily
aspirin 81 mg daily
cyanocobalamin - dosage uncertain
omega 3 fatty acids 1,200 mg-144 mg capsule daily
vitamin E 400 units daily
Discharge Medications:
1. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total of 3 [**Street Address(2) 4319**] as needed for
chest pain.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily): Left eye.
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day.
8. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
10. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
11. Vitamin B-12 Oral
12. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week: as per your primary care doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a cardiac catheterization and 4 bare metal stents were
placed in your right coronary artery. A wire from a rotablator
broke off and was lodged in the side of the artery. The
cardiologists were unable to remove the wire so placed 4 bare
metal stents in the artery to trap the wire in place. We checked
echocardiograms to make sure that there was no damage to the
heart wall. These echocardiograms were all normal.
Medication changes:
1. Increase your aspirin to 325 mg daily
2. Start taking clopidogrel (Plavix) every day for at least one
month. Do not stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr.
[**Last Name (STitle) **] tells you to.
3. Increase Metoprolol to 50 mg daily
4. Discontinue Zetia
5. Start Crestor at 20 mg daily, talk to Dr. [**Last Name (STitle) **] if you
develop muscle aches on this medicine.
Followup Instructions:
Primary Care:
YEGHIAZARIANS,VARTAN Phone: [**Telephone/Fax (1) 12551**] Date/time: please keep
any scheduled appts.
.
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Street Address(2) 85402**]
[**Location (un) 7661**], [**Numeric Identifier 85403**]
Phone: ([**Telephone/Fax (1) 65679**] Fax [**Telephone/Fax (1) 73354**]
Date/time: Tuesday [**7-3**] at 11:15am.
|
[
"2724",
"4019",
"53081",
"41401"
] |
Admission Date: [**2182-7-22**] Discharge Date: [**2182-7-26**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
Gastric endoscopy
colonoscopy
History of Present Illness:
This is an 85 year old female presenting from OSH with bright
red blood per rectum with troponin I elevation to 8 with TWI in
inferior leads in the absence of anginal symptoms. Her past
medical history is remarkable for history of colon cancer s/p
right hemicolectomy in [**2170**], with repeat colonoscopy in [**2180**]
showing no recurrences but diverticulosis and benign polyps.
Her symptoms started two days prior to admission, when she
noticed loose stools in the absence of abdominal symptoms with
bright red blood and dark colored stool. She denied, nausea,
vomiting or hematemesis. No abdominal cramping, no prior
history of GI bleeds. She has been taking aleve twice a day for
the past three months for back pain secondary to recent fall,
but no other NSAIDs other than baby aspirin. In OSH, she was
started on a protonix drip and no further episodes of lower GI
bleed were noted. HCT on admission was 27; she was transfused 3
units pRBCs with improvement to 35. Hemodynamically stable.
Her cardiac enzymes at first set were noted to be elevated to 8
(troponin I) with T-wave inversions in inferior leads; there
were no anginal symptoms at this time. Given her troponin
elevations in the setting of GI bleed, she was transferred to
[**Hospital1 18**] for treatment of NSTEMI and possible catheterization.
.
Upon transfer to the CCU, she continued to be hemodynamically
stable. HCT was 35. There were no active signs of GI bleeding,
with no dizziness, lightheadedness. EKG showed persistent TWI
in inferior leads and sinus rhythm with frequent APCs. She has
a history of both tachy and brady arrythmias in the past. She
denied chest pain, pressure, shortness of breath, orthopnea,
PND, lower extremity edema, abdominal pain, nausea/vomiting,
diarrhea. Her last PO intake was on [**7-22**] and her last bowel
movement was loose stools on [**7-21**]. Review of systems otherwise
negative.
Past Medical History:
-History of acute inferolateral myocardial infarction
-lower GI bleed (not on coumadin)
-paroxysmal atrial fibrillation
-hypertension
-hyperlipidemia
-colon carcinoma s/p right hemicolectomy in [**2170**]
-colonoscopy in [**2180**] showing benign polyps and diverticulosis
Social History:
NC
Family History:
NC
Physical Exam:
GEN: NAD
CV: RRR, no m/r/g
RESP: CTAB, no w/r/r
Abd: soft, nt, nd, +bs
Ext: no edema
Pertinent Results:
Admission labs:
[**2182-7-22**] 02:31PM BLOOD WBC-15.8* RBC-3.95* Hgb-12.0 Hct-35.4*
MCV-90 MCH-30.4 MCHC-34.0 RDW-16.6* Plt Ct-248
[**2182-7-22**] 02:31PM BLOOD Neuts-83.4* Lymphs-11.6* Monos-4.7
Eos-0.1 Baso-0.2
[**2182-7-22**] 02:31PM BLOOD PT-11.8 PTT-21.0* INR(PT)-1.0
[**2182-7-22**] 02:31PM BLOOD Glucose-102* UreaN-22* Creat-0.8 Na-137
K-3.7 Cl-100 HCO3-25 AnGap-16
[**2182-7-22**] 02:31PM BLOOD ALT-22 AST-82* LD(LDH)-305* CK(CPK)-187
AlkPhos-48 TotBili-1.0
[**2182-7-22**] 02:31PM BLOOD CK-MB-38* MB Indx-20.3* cTropnT-0.95*
[**2182-7-22**] 02:31PM BLOOD Calcium-7.9* Phos-2.5* Mg-1.6
.
Cardiac Enzymes:
[**2182-7-22**] 02:31PM BLOOD CK-MB-38* MB Indx-20.3* cTropnT-0.95*
[**2182-7-22**] 02:31PM BLOOD CK(CPK)-187
[**2182-7-23**] 04:07AM BLOOD CK-MB-21* MB Indx-17.4* cTropnT-0.97*
[**2182-7-23**] 04:07AM BLOOD CK(CPK)-121
[**2182-7-23**] 10:01AM BLOOD CK-MB-15* MB Indx-17.0* cTropnT-0.88*
[**2182-7-23**] 10:01AM BLOOD CK(CPK)-88
[**2182-7-24**] 03:29AM BLOOD CK-MB-6 cTropnT-0.62*
[**2182-7-24**] 03:29AM BLOOD CK(CPK)-39
.
Discharge labs:
[**2182-7-26**] 05:50AM BLOOD WBC-11.7* RBC-3.52* Hgb-11.3* Hct-31.8*
MCV-90 MCH-32.0 MCHC-35.4* RDW-16.2* Plt Ct-248
[**2182-7-26**] 05:50AM BLOOD Glucose-105* UreaN-33* Creat-0.8 Na-133
K-3.9 Cl-99 HCO3-26 AnGap-12
[**2182-7-25**] 05:58AM BLOOD Triglyc-103 HDL-39 CHOL/HD-3.5 LDLcalc-76
.
[**2182-7-24**] H.Pylori IgG negative
.
[**2182-7-24**] Echo:
The left atrium is mildly dilated. 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 inferior and
inferolateral walls. The remaining segments contract normally
(LVEF = 40 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD (PDA distribution). Mild mitral regurgitation.
.
[**2182-7-22**] CXR:
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Heart is mildly to moderately enlarged. Thoracic aorta is
generally large,
tortuous and heavily calcified. Pulmonary vascularity is normal
and pleural effusion is minimal if any. Therefore the thickened
septal lines seen in both lungs are likely to be chronic rather
than due to acute pulmonary edema. No radiographic evidence of
pneumonia.
.
[**2182-7-23**] Colonoscopy
Diverticulosis of the descending colon and sigmoid colon
Ulcer at the site of anastomosis
Polyps in the rectum
Otherwise normal colonoscopy to site of anastomosis and
neoterminal ileum
Recommendations: No site of bleeding was noted although it could
be a diverticular bleed as well.
Patient is going to need a repeat colonoscopy as an outpatient
to remove the rectal polyps given history of colon cancer.
Brief Hospital Course:
This is a 85 year old female with history of paroxysmal atrial
fibrillation, hypertension, history of colon carcinoma s/p right
hemicolectomy in [**2170**] with repeat colonoscopy in [**2180**] showing no
recurrence now presenting from OSH with lower GI bleed and
NSTEMI
.
# NSTEMI: Since patient has history of GI bleed the decision was
made not to perform a cardiac catherization instead. The patient
was started on medical managment that included lisinopril,
metoprolol, aspirin, and atorvastatin.
.
# GI Bleed - Patient had colonoscopy. Most likely a diverticular
bleed. Patient needs to have colonoscopy as outpatient to remove
rectal polyps.
.
# Paroxysmal atrial fibrillation - Currently in sinus with heart
rates in the 70s, with frequent PACs. Not anticoagulated in
setting of GI bleed. Patient will continue on aspirin.
.
-low dose metoprolol as above for ACS
-Holding anticoagulation in setting of GI bleed; CHADS2 score is
2 (hypertension and age)
.
# Leukocytosis - Likely [**3-12**] ACS. No source of infection
identified.
.
# Hypertension - continue metoprolol, lisinopril, and
hydrochlorothiazide
.
# Hyperlipidemia - Switched to atorvastatin.
.
# Colon Carcinoma - Patient needs to have repeat colonoscopy as
outpatient to remove rectal polyps
Medications on Admission:
HCTZ 25 mg daily
nifedipine 60 mg daily
digitek .125 mg daily
simva 20 daily
asp 81 mg daily
tylenol
MVA
Discharge Medications:
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day): do not give within 1 hour of any ohter medicines.
10. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO once a
day: give in am.
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
Life Care Center - [**Location (un) 3320**]
Discharge Diagnosis:
Gastrointestinal bleed
Paroxysmal Atrial Fibrillation
Non ST Elevation Myocardial Infarction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a bleed in your intestine that has resolved. We started
you on some medicines to help prevent the bleeding from coming
back. You will probably have another colonoscopy in the next few
months. You also had a heart attack from the low blood counts.
We have adjusted your medicines to help your heart recover. You
will need to see a cardiologist at the end of this month.
Medication changes:
1. Stop digoxin and nifedipine
2. Change simvastatin to Atorvastatin
3. Start Lidoderm patch, tylenol, and Tramadol
4. Start colace and senna to prevent constipation
5. Start Ferrous sulfate, folic acid and vitamin C to help your
body make red blood cells
6. Start pantoprazole twice daily to prevent bleeding
7. Start Metoprolol to help control your heart rate.
Followup Instructions:
Department: Cardiology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**]
When: Wednesday [**2182-8-7**] at 11:30AM
Address: [**Doctor Last Name 37166**],LOWER LEVEL, [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 5315**]
Fax: [**Telephone/Fax (1) 66988**]
Department: Gastroenterology
Name: Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2520**]
When:
Address: [**Apartment Address(1) 85659**], [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 85660**]
Fax: [**Telephone/Fax (1) 85661**]
Completed by:[**2182-7-26**]
|
[
"41071",
"2851",
"42731",
"41401",
"4019",
"2724"
] |
Admission Date: [**2167-4-4**] Discharge Date: [**2167-4-10**]
Date of Birth: [**2167-4-3**] Sex: F
HISTORY: [**First Name4 (NamePattern1) **] [**Known lastname **] was born at full term at [**Hospital3 38099**] and was transferred to [**Hospital1 188**] for continuing care of pneumothorax and possibility of
infection. She was transferred by the [**Hospital3 1810**]
Hospital.
The infant was born to a 20 year old Gravida 2, Para 1, now 2
woman.
PRENATAL LABORATORY DATA: Blood type O negative, antibody
negative, rubella immune, RPR nonreactive, hepatitis surface
This pregnancy was induced by Pitocin. Rupture of membranes
occurred 27 hours prior to delivery. There was a maternal
fever to 101.5 F., interpartum. The mother did receive
antibiotics greater than four hours prior to delivery.
The infant emerged with poor tone, no respiratory effort.
She received positive pressure ventilation for two to three
minutes. The infant cried at three minutes and had increased
respiratory effort and improved tone.
The infants Apgars were 3 at one minute and 7 at five minutes
and 9 at ten minutes. At 15 minutes of age, the infant began
grunting and was given blow-by oxygen with improved
saturation to 100%. She was then given facial CPAP.
Her cord arterial blood gas was pH 7.31 and pCO2 of 53. The
infant received a normal saline bolus and was started on
Ampicillin and Gentamicin after labs were drawn and was
transferred to [**Hospital1 69**].
The infant's birth weight was 3705 grams.
PHYSICAL EXAMINATION: On admission, revealed a pink and
active infant. Anterior fontanel open and flat. Intact
palate. Positive subcostal retractions. Normal S1 and S2
heart sounds. No murmur. Pink and well perfused. Breath
sounds equal. Abdomen soft, nontender, nondistended.
Extremities were well perfused. Age appropriate tone and
reflexes.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY STATUS: The infant required oxygen by [**Doctor Last Name **]
for the first 24 hours of age. Her chest x-ray initially was
consistent with a pneumothorax, but this resolved
radiographically by the second day of life. The infant weaned to
room air on day of life number two and remained there. Her
respirations were comfortable and lung sounds were clear and
equal.
2. CARDIOVASCULAR STATUS: The infant remained normotensive
throughout her NICU stay. She has a normal S1 and S2 heart
sound. She is pink and well perfused. There are no
cardiovascular issues.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Enteral feeds were
begun on day of life number two and advanced without
difficulty to full volume feedings. At the time of transfer,
the infant is eating formula, Enfamil 20 calories per ounce
with iron, on an ad lib schedule. Her weight at the time of
transfer is 3605 grams.
4. GASTROINTESTINAL STATUS: Her peak bilirubin on day of
life number three was a total of 10.6, direct 0.5. She has
never required phototherapy.
5. HEMATOLOGY STATUS: At the time of admission, her
hematocrit was 47.5. She has never received any blood
product transfusions during her NICU stay.
6. INFECTIOUS DISEASE STATUS: The infant was started on
Ampicillin and Gentamicin at the time of admission for sepsis
risk factors. She completed seven days of the antibiotics
for presumed pneumonia, taking into consideration an immature to
total neutrophil ratio of 50% . Her blood cultures and
cerebrospinal fluid cultures remained negative at the time of
transfer.
7. NEUROLOGY: There are no neurological issues.
8. AUDIOLOGY: The infant has not yet had an audiology
screen but one is recommended prior to discharge after the
discontinuation of gentamicin.
9. PSYCHOSOCIAL: The family has been followed by [**Hospital1 1444**] social worker, [**Name (NI) **]
[**Name (NI) 40476**], beeper number [**Serial Number 36451**]. A 51A was filed at [**Hospital3 **]
for concerns of the father's behavior towards the mother and
behavior towards the staff. In addition, the mother does not
have custody of her previous infant, who is
in the custody of her mother.
There is a history of domestic violence concerns regarding
this family and safety issues for the mother. In addition,
there is concern that the couple does not appear to have a
fixed residence at present. The DSS social worker
investigating with this family is [**Female First Name (un) 22089**] Decas, telephone
number [**Telephone/Fax (1) 49010**]. A care and protection order was filed
at the Juvenile Court Department in [**Location 49011**] on
[**2167-4-9**]. The parents are aware of this and are aware that
they are unable to visit at this time.
DISPOSITION: Discharge disposition will be determined by
the Department of Social Services.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is transferred to the Newborn
Nursery.
PRIMARY PEDIATRICIAN: Is as yet unidentified.
RECOMMENDATIONS AT THE TIME OF TRANSFER:
1. The infant is eating Enfamil 20 calories per ounce with
iron on an ad lib schedule.
2. The infant is discharged on no medications.
3. State newborn screen was sent on day of life number
three.
4. The hepatitis B vaccine has not been given at the time of
transfer.
DISCHARGE DIAGNOSES:
1. Status post pneumonia.
2. Status post pneumothorax.
3. Sepsis, ruled out.
4. Complex social situation.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2167-4-10**] 18:01
T: [**2167-4-10**] 19:58
JOB#: [**Job Number 49012**]
|
[
"486",
"V290"
] |
Admission Date: [**2143-11-18**] Discharge Date: [**2143-12-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Septic Shock
Major Surgical or Invasive Procedure:
PEG placement
Swallow study
History of Present Illness:
[**Age over 90 **]F with hx of dementia, CRI presents to the ED with fever,
diarrhea and altered mental status. Per nursing home, pt had a
CXR on [**11-15**] (for congestion?) which showed an infiltrate. At
that time, she was started on levaquin for the PNA and flagyl
for ppx against C. diff. One day later, pt started having
fevers to 101 and large amounts of diarrhea associated with
change in mental status. Her blood pressure was in the 100s (nl
130s) with HR in the 120s. Labs were checked and she was found
to have a WBC of 38. Dr. [**Last Name (STitle) 1266**] was alerted and she was
transferred to [**Hospital1 18**].
.
On arrival to the [**Name (NI) **], pt's BP was in the 60s/30s with HR in the
110s, temp 101 (R). She received 4L NS and her bld pressure
gradually increased to 90s/40s. After blood and urine cx were
drawn, she was given vanc and zosyn.
.
Per nursing home, pt's baseline mental status waxes and wanes
[**1-31**] her dementia but she is verbal. She is dependent in all her
ADLs.
Past Medical History:
* dementia
* recurrent UTIs
* CRI, baseline Cr 0.9 in [**2138**]
* osteoarthritis
* lower ext edema, chronic pain in lower ext
* glaucoma
* macular degeneration
* s/p right knee surgery in [**7-30**]
* ?ischemic bowel
Social History:
lives at Nursing Home x 2 months
Family History:
not obtained. pt demented.
Physical Exam:
Exam: temp 96.5 BP 90/50, HR 98, R 22, O2 97% on RA
Gen: NAD
HEENT: MM dry, EOMI
Neck: no JVD
CV: RRR, 1/6 systolic murmur best heard at RUSB; PMI prominent
and nondisplaced
Chest: crackles at bilateral bases; no wheezes
Abd: old, well healed scar in suprapubic area; no bowel sounds;
soft, +rebound in lower quadrants; tender to deep palpation in
RLQ
Neuro: AO x 1 (person); follows some commands; not answering
questions; moves all ext;
Pertinent Results:
[**2143-12-4**] 07:45AM BLOOD WBC-10.8 RBC-3.36* Hgb-10.5* Hct-31.0*
MCV-92 MCH-31.1 MCHC-33.7 RDW-16.6* Plt Ct-447*
[**2143-11-24**] 06:15AM BLOOD Neuts-77.5* Lymphs-15.8* Monos-4.1
Eos-2.3 Baso-0.2
[**2143-11-23**] 06:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL
Polychr-OCCASIONAL Schisto-OCCASIONAL
[**2143-11-18**] 08:31PM BLOOD Fibrino-400
[**2143-11-19**] 04:50AM BLOOD Ret Aut-1.1*
[**2143-12-4**] 07:45AM BLOOD Glucose-127* UreaN-28* Creat-0.8 Na-135
K-4.6 Cl-97 HCO3-31 AnGap-12
[**2143-11-24**] 06:15AM BLOOD ALT-9 AST-15 LD(LDH)-247 AlkPhos-85
TotBili-0.3
[**2143-12-4**] 07:45AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.8
[**2143-11-26**] 07:55AM BLOOD VitB12-1359* Folate-15.3
[**2143-11-18**] 07:47AM BLOOD calTIBC-113* Ferritn-255* TRF-87*
[**2143-11-26**] 07:55AM BLOOD TSH-4.3*
[**2143-11-26**] 07:55AM BLOOD Free T4-1.5
PEG: IMPRESSION: Uncomplicated percutaneous placement of a
gastro jejunal feeding tube.
LIVER US: IMPRESSION:
1. One of the left lobe of liver lesions represents a cyst.
Another left lobe of liver lesion is not fully characterized but
may represent a cyst. Right liver lesions are not visualized on
this exam.
The examination could be re-attempted, when the patient is able
to tolerate it. Alternatively, contrast-enhanced CT or MRI could
be considered.
2. Ascites fluid is not visualized on this four-quadrant survey.
A very small amount is seen on CT.
3. Right pleural effusion.
CT HEAD: IMPRESSION: No intracranial hemorrhage. Calcified
extraaxial mass adjacent to the left frontal lobe likely
represents a calcified meningioma.
CT ABD: IMPRESSION:
1. Moderate-sized bilateral pleural effusions with probable
compression atelectasis, however, underlying pneumonia cannot be
ruled out and evaluation is limited due to lack of intravenous
contrast.
2. Mild amount of ascites and pelvic free fluid with diffuse
edema of the pelvic mesentery. No direct evidence of colitis or
diverticulitis noted.
3. Ill-defined hypoattenuating lesions within the liver, too
small to characterize by CT and evaluation limited by lack of
intravenous contrast. If clinically indicated, further workup
with ultrasound or contrast-enhanced CT/MRI may be ordered.
4. Levoscoliosis and degenerative changes of the spine.
Brief Hospital Course:
Pt was admitted to the [**Hospital Unit Name 153**] in septic shock with SBPs
70-80s/40-50s, MAPs 50-60s, s/p 6L IVF. Her O2 sats were stable
in the low 90s on RA. She was mentating, though mumbling
(demented at baseline). septic shock: the etiology of pt's shock
was presumed to be c. diff given her history of recent
antibiotic use (amoxicillin, levaquin) and profuse diarrhea.
Blood, urine, and sputum cultures were obtained on admission,
and pt was continued on broad spectrum antibiotics including
zosyn and vancomycin empirically given the severity of her
shock. she was also continued on IV flagyl as she was not
taking PO. per discussion with ID, PO vanco was not started as
she had not yet failed flagyl. KUB and CT abdomen were obtained
which were negative for toxic megacolon or diverticulitis.
Nursing home stool culture on [**11-19**] were positive for c. diff,
and vanco and zosyn were discontinued. her blood and urine
cultures were unremarkable. retrocardiac opacity on admission
CXR was not felt to represent infiltrate.
.
Pt was breifly treated with levophed for <12 hrs for MAPs 50s on
[**11-18**] after failing to have improvement in SBP after ~10L IVF.
she was weaned off on [**11-18**]. she subsequently required
intermittent IVF boluses (2L) for decreased UOP and MAPs 50s x 1
when she went for CT abdomen. On [**11-19**], pt was noted to have
increased O2 requirement to 2L, and had rales on exam. As she
was net +10L, she was given IV lasix 10mg to facilitate
diuresis on [**11-19**] and [**11-20**]. Her blood pressure tolerated this
well. Urine sediment revealed muddy brown casts on [**11-19**], and
plan was to avoid further IVF for low UOP as pt was
euvolemic/volume overloaded. If her mental status improves,
plan was to switch from IV flagyl to PO flagyl.
ARF/CRI: cre baseline ~0.9 ([**2138**]), peaked 2.2 on admission, then
trended down with aggresive IVF resucitation. however, urine
with +muddy brown casts on [**11-19**], c/w ATN likely [**1-31**]
hypotension. plan was to follow, and tolerate UOP 10-20cc/hr.
pt started on lasix 10mg IV prn (home dose 20mg po qd) on [**11-19**]
to try to remove fluid in anticipation of declining UOP from her
ATN (goal even to negative).
- lasix 10mg IV prn [**11-20**], goal even to negative.
- follow UOP, creatinine daily.
- low UOP [**1-31**] ATN, though unclear why creatinine is coming down
so quickly, will follow UOP, flush foley, and consider bladder
scan if UOP drops again.
# altered mental status: pt demented at baseline per report, but
her MS waxes and wanes at baseline per daughter, pt will have
long periods of being nonverbal followed by periods of being
much more interactive. current MS likely [**1-31**] infection
overlying baseline dementia. she responds to questions, but
generally mumbles. generally follows commands this AM. no
focal deficit on limited neuro exam.
- follow mental status
- iv/im 1-2mg haldol prn agitation.
- cont home zyprexa prn agitation
- cont namenda, remeron for dementia
# anemia: pt was noted to have hct drop from 30->25 after 5
liters IVF (normal saline); pt had a hct=32.5 in [**12-31**]. on [**11-19**]
pt receied 1U PRBC for hct=25 in the setting of septic shock.
iron studies were obtained which suggest ACD possibly [**1-31**] CRI
and OA. plan was to follow hct, and guaic all stools.
.
.
# Hyperglycemia: pt was treated with an insulin sliding scale.
.
# chronic lower extremity edema: 2+ edema B LE, chronic, could
be exacerbated by fluid resuscitation and ?dCHF on TTE (E/A
0.6). on [**11-19**] pt restarted on lasix 10mg iv prn (home dose
20mg po qdaily) as her SBPs were stable.
# glaucoma - continue home eye drops.
.
Pt ultimately transferred to floor. Pt with aspiration events,
with 2 failed swallowing study. Feeding initiated by NGT,
ultimately had PEG placed. Pt returned to baseline and
transferred back to [**Hospital1 1501**].
Medications on Admission:
* flagyl 500mg tid x 10days (first dose 11/17, for Cdiff ppx)
* levaquin 500mg qd x 7 days (first dose 11/17, for PNA)
* amoxicillin 500mg tid x 10 days (last dose on [**2143-11-7**], for
UTI)
* lasix 20mg qd
* MVI qd
* Calcarb 600/Vit D 200: [**Hospital1 **]
* Colace 100mg [**Hospital1 **]
* Namenda 10mg [**Hospital1 **]
* remeron 15mg q5pm
* ativan 0.5mg qhs prn agitation
* Zyprexa 1.25mg qd (d/c'd [**11-15**])
* travatan 0.004% eye drop; one drop to left eye at bedtime
* Brimonidine 0.2% eye drops, one drop to left eye [**Hospital1 **]
* Timolol 0.5% eye drops; one drop to both eyes daily
Discharge Medications:
1. Timolol Maleate 0.5 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
2. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
3. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS
(at bedtime).
4. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) puff
Inhalation Q6H (every 6 hours).
6. Levofloxacin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
7. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day) for 21 days.
8. Furosemide 40 mg/5 mL Solution [**Hospital1 **]: One (1) dose PO DAILY
(Daily).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
11. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
C. Diff Colitis
Aspiration Pneumonia
Malnutrition
Dementia
Diastolic CHF
Discharge Condition:
Good
Discharge Instructions:
[**12-11**] will need the sutures for the PEG cut. Cut them with a
normal suture removal kit, and pull the sutures out, the
internal string will come out the stool.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] as needed
|
[
"0389",
"78552",
"5070",
"4280",
"5849",
"99592"
] |
Admission Date: [**2197-6-18**] Discharge Date: [**2197-6-22**]
Date of Birth: [**2120-2-10**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
cold, painful right foot
Major Surgical or Invasive Procedure:
[**2197-6-18**]:
1. Ultrasound-guided puncture of left common femoral
artery.
2. Contralateral third order catheterization of the right
superficial femoral artery.
3. Balloon angioplasty of right femoral to below-knee
popliteal bypass graft.
4. Stenting of common femoral to below-knee popliteal
bypass graft.
5. AngioJet thrombectomy of obstructed common femoral
artery to below-knee popliteal bypass graft.
6. Balloon angioplasty of midportion of right posterior
tibial artery.
7. Perclose closure of left common femoral arteriotomy.
History of Present Illness:
77M with terminal, stage IV metastatic adenocarcinoma of the
lung who has been admitted on multiple occasions over the past
few months for medical problems, who presented to the [**Name (NI) **] on [**6-18**]
with a 1 day history of a cold, painful right foot and a history
of positive PF4ab after thrombocytopenia earlier this month. Pt
was just discharged from [**Hospital1 18**] for back pain on [**6-16**] and
discharged after rectal bleeding in early [**Month (only) 205**]. Per heme/onc his
Plavix was never stopped, although the pt is a poor historian
and is unable to verify the medications he is taking at home.
His Lung CA is terminal and he is end stage at this point. He
has known metastatic disease of the spine causing severe pain,
he denies known brain mets. He lives alone and is a poor
historian. He is unable to verbalize the medications he takes
daily but does report that his pain regimen of long and short
acting Morphine are working. He has had intermitent VNA
services in the past. His last visit was on [**5-24**] by
Multicultural VNA. He has a long history of refusing care in
the hospital and at home and frequently demands to be discharged
from the hospital prior to medical advice.
Past Medical History:
1. Stage IV non-small cell lung cancer, on palliative treatment;
[**Doctor Last Name **] to Spine
2.HTN
3. Peripheral [**Doctor Last Name 1106**] disease s/p R CIA stent and L EIA
angioplasty [**8-30**] and s/p R SFA balloon angioplasty and stent x2
- [**9-30**] and right lower extremity claudication status post
right
common femoral to above knee popliteal graft with PTFE on [**4-10**], [**2193**].
4. S/p bilateral shoulder displacement.
5. CAD s/p MI '[**85**]
6. Hypercholesterolemia,
7. GI bleed '[**87**]
8. Gout
9. Osteoarthritis
10. Herniated L4-5 disc
11. L5-S1 stenosis
PSH:
R CIA stent
L EIA angioplasty [**8-30**]
R SFA balloon angioplasty and stent x2
R common femoral to above knee popliteal graft with PTFE
Social History:
Smoking x 63 years. He smoked less than a pack per day for most
of his life and recently smokes only approximately five
cigarettes a day. He currently lives alone in [**Location (un) 538**]. He
consumes alcohol on occasion. He previously consumed significant
amounts of rum. He has been in the United States for over 20
years. He was born and raised in [**Country 5976**]. He only speaks Spanish.
He is a retired musician and automobile mechanic.
Lives alone - has a girlfriend "[**Doctor First Name **]" who visits daily. He
also has a friend/ neighbor who claims to be a nurse, who visits
several times per week.
Poor historian - unable to give clear history of illness, unable
to give names/doses of medications.
Family History:
Sister (D) throat cancer . Denies other CA, CAD, [**Doctor First Name 1106**]
disease
Physical Exam:
discharge exam:
VSS, Afeb
Gen: Cachetic appearing elderly male, who appears chronically
ill. In NAD. Alert and Oriented, x 3. Communicates through
spanish interpreter but gets easily aggitated when questioned
about medical history/medications/home situation
CVS: RRR
Pulm: CTA bilat
Abd: S/NT/ND thin abdomen.
EXT: Right LE warm, well perfused, without edema. Groin Incision
is clean/dry/intact. Sensory-motor function intact. Left LE
warm, well perfused, without edema or wounds.
Pulses: Right femoral palpable, dp and pt dopplerable
Left femoral palpable, dp and pt dopplerable
Pertinent Results:
[**2197-6-18**] 11:00AM BLOOD WBC-12.8* RBC-3.41* Hgb-9.1* Hct-28.0*
MCV-82 MCH-26.8* MCHC-32.6 RDW-21.0* Plt Ct-530*
[**2197-6-18**] 04:24PM BLOOD WBC-10.3 RBC-3.29* Hgb-8.8* Hct-27.6*
MCV-84 MCH-26.8* MCHC-32.0 RDW-21.0* Plt Ct-530*
[**2197-6-18**] 11:00AM BLOOD Neuts-85.1* Lymphs-10.1* Monos-4.4
Eos-0.2 Baso-0.2
[**2197-6-19**] 04:30PM BLOOD WBC-16.1*# RBC-2.91* Hgb-7.8* Hct-23.8*
MCV-82 MCH-26.7* MCHC-32.7 RDW-21.2* Plt Ct-406
[**2197-6-20**] 06:50AM BLOOD WBC-17.1* RBC-2.52* Hgb-6.9* Hct-20.9*
MCV-83 MCH-27.2 MCHC-32.9 RDW-21.3* Plt Ct-441*
[**2197-6-20**] 03:12PM BLOOD WBC-21.4* RBC-3.11* Hgb-8.3* Hct-25.9*
MCV-83 MCH-26.7* MCHC-32.0 RDW-20.6* Plt Ct-453*
[**2197-6-21**] 07:40AM BLOOD WBC-19.6* RBC-3.10* Hgb-8.3* Hct-25.6*
MCV-83 MCH-26.7* MCHC-32.3 RDW-19.8* Plt Ct-422
[**2197-6-22**] 07:35AM BLOOD WBC-20.1* RBC-3.29* Hgb-9.0* Hct-27.6*
MCV-84 MCH-27.5 MCHC-32.7 RDW-20.1* Plt Ct-464*
[**2197-6-22**] 07:35AM BLOOD Neuts-93.2* Lymphs-2.6* Monos-3.7 Eos-0.3
Baso-0.1
[**2197-6-22**] 07:35AM BLOOD Hypochr-1+ Anisocy-3+ Poiklo-2+
Macrocy-3+ Microcy-2+ Polychr-NORMAL Ovalocy-1+ Burr-2+
Pencil-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 16591**]1+
[**2197-6-18**] 11:00AM BLOOD PT-15.8* PTT-23.5 INR(PT)-1.4*
[**2197-6-18**] 04:24PM BLOOD PT-34.9* PTT-93.6* INR(PT)-3.6*
[**2197-6-18**] 08:30PM BLOOD PT-40.1* INR(PT)-4.2*
[**2197-6-19**] 04:30PM BLOOD PT-43.4* PTT-103.4* INR(PT)-4.6*
[**2197-6-20**] 06:50AM BLOOD PT-37.7* PTT-90.3* INR(PT)-3.9*
[**2197-6-21**] 07:40AM BLOOD PT-42.7* PTT-93.7* INR(PT)-4.5*
[**2197-6-21**] 06:00PM BLOOD PT-32.5* PTT-62.1* INR(PT)-3.3*
[**2197-6-22**] 12:00AM BLOOD PT-26.0* PTT-51.3* INR(PT)-2.5*
[**2197-6-22**] 07:35AM BLOOD PT-19.2* PTT-32.3 INR(PT)-1.8*
[**2197-6-18**] 11:00AM BLOOD Glucose-105* UreaN-19 Creat-1.1 Na-138
K-3.7 Cl-102 HCO3-25 AnGap-15
[**2197-6-18**] 04:24PM BLOOD Glucose-104* UreaN-17 Creat-1.0 Na-138
K-4.0 Cl-106 HCO3-21* AnGap-15
[**2197-6-19**] 04:30PM BLOOD Glucose-198* UreaN-13 Creat-0.9 Na-131*
K-3.9 Cl-101 HCO3-19* AnGap-15
[**2197-6-20**] 06:50AM BLOOD Glucose-159* UreaN-15 Creat-1.0 Na-136
K-4.1 Cl-104 HCO3-23 AnGap-13
[**2197-6-22**] 07:35AM BLOOD Glucose-133* UreaN-26* Na-137 K-4.5
Cl-104 HCO3-21* AnGap-17
[**2197-6-18**] 04:24PM BLOOD Calcium-8.0* Phos-3.3 Mg-1.9
[**2197-6-19**] 04:30PM BLOOD Calcium-7.4* Phos-1.8* Mg-1.8
[**2197-6-20**] 06:50AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.0
[**2197-6-18**] 11:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2197-6-18**] 11:00AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2197-6-18**] 11:00AM URINE RBC-[**1-27**]* WBC-0-2 Bacteri-0 Yeast-NONE
Epi-0
[**2197-6-22**] 12:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2197-6-18**]
11:44 AM
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with c/o left leg numbness, may need heparin
to re-vascularize
his leg, eval for brain mets
REASON FOR THIS EXAMINATION:
brain mets?
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
CT HEAD WITHOUT CONTRAST
COMPARISON: MR brain, [**2197-2-3**].
HISTORY: Lung mass and left leg numbness. Evaluate for
metastases.
TECHNIQUE: MDCT axially acquired images through the brain were
obtained. No
IV contrast was administered.
FINDINGS: There is no evidence of acute hemorrhage, large areas
of edema, or
mass effect. There is normal [**Doctor Last Name 352**]-white matter differentiation.
The
ventricles and sulci are mildly prominent, consistent with
age-related
atrophy. Mildly prominent bifrontal extra-axial spaces are also
stable,
likely also due to atrophy. A stable small hypodensity within
the right
lentiform nucleus is consistent with a chronic lacunar infarct.
There is no
evidence of acute major [**Doctor Last Name 1106**] territorial infarct. Mild
calcifications of
the anterior and the posterior circulation are noted. The
visualized
paranasal sinuses are clear.
IMPRESSION: No evidence of an acute intracranial process. Please
note that
MRI would be more sensitive for metastatic disease and acute
infarction.
Radiology Report CHEST (PA & LAT) Study Date of [**2197-6-18**] 12:03
PM
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with c/o of cold L leg, to surgery today eval
for acute CT
process
REASON FOR THIS EXAMINATION:
acute CT process?
Final Report
HISTORY: 77-year-old male with history of metastatic lung
cancer, now with
cold left leg for presurgical evaluation.
COMPARISON: CTA chest dated [**2197-6-14**] and chest x-ray dated
[**2197-6-14**].
FINDINGS: PA and lateral views of the chest were obtained. The
cardiomediastinal silhouette is stable in appearance with
calcifications.
Atherosclerotic calcifications again noted within the aortic
arch. There is
stable scarring within the upper lobes, left greater than right
with upward
retraction of the hila. Lung volumes are increased with
flattening of the
diaphragms consistent with a history of emphysema. No new
parenchymal
abnormalities are identified in the lungs. There are no pleural
effusions or
pneumothorax. Numerous sclerotic lesions are noted throughout
the spine and
ribs consistent with the patient's diffuse metastatic osseous
deposits. No
acute osseous abnormality is identified.
IMPRESSION:
1. No significant interval change with stable pulmonary scarring
and
retraction of the hila as described above.
2. Widespread osseous metastatic deposits.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Known lastname 1106**] service with an
occluded graft and known heparin induced thrombocytopenia. He
was started on an argatroban drip for therapeutic
anticoagulation and a dilaudid PCA for pain control. He was
taken to the endosuite on [**6-18**] where he underwent Balloon
angioplasty of the posterior tibial artery, Stent placement at
right common femoral artery to below-knee popliteal bypass graft
x4, AngioJet thrombectomy of right common femoral artery to
below-knee popliteal bypass graft. He tolerated the procedure
well, remaining hemodynamicaly stable.
He was transfered back to the VICU and continued on argatroban.
He was started on pletal 100mg [**Hospital1 **] as well. On POD 1 he was
hemodynamically stable, but refused to have labs drawn or take
any oral medications. His friend [**Name (NI) **] visited and his
oncology social worker, [**Name (NI) **] [**Name (NI) **] stopped to see him. After
discussion, he agreed to take meds and have labs , however, when
phelbotomy came he became aggitated and began flailing his arms
during his veinapuncture. He refused to have labs after that.
We explained that this was not safe given that he was on
argatroban. He acknowledged this, but continued to refuse labs
for that day. After reviewing his records at length, and
discussing the case with palliative care, and social work, it
became apparent that this is an ongoing problem on his
hospitalizations. ON POD 2 he was more cooperative, taking
medications and allowing phlebotomy to draw labs. He was started
on coumadin, and the argatroban gtt was continued. His dilaudid
pca was stopped and he was transitioned to his home regimen of
ms contin 100mg q8h with ir morphine 30-60mg q2h prn. His pain
was well controlled on this regimen. Later that day he went for
a plaiative radiation of L1-L3 which he tolerated well. We also
contact[**Name (NI) **] Dr. [**Last Name (STitle) **] at this time, who reinforced that the pt has
refused home hospice and vna care on multiple occasions and
frequently refuses inpatient treatments. He felt Mr. [**Known lastname **]
was terminal, with only a few months to live and agreed that our
goal would be to make him as comfortable and safe as possible.
A PT consult was obtained, and on [**6-21**] and the pt did ambulate
independently. A spanish speaking hospice nurse came to see
him, and discussed the availability of home services, and he
adamently refused any home care. His girlfriend [**Name (NI) **] agreed
to stay with him at his house, and a friend agreed to stop by
daily to assist as well. In the late pm on POD 3, the pt
received a dose of coumadin, and the argatroban gtt was stopped.
An INR was then checked 2 hours later, and was therapeutic at
3.3. On [**6-22**] the INR was 2.5 in the early am, and had fallen to
1.8 at the 7am draw. The pt was feeling well, pain free, with a
well healing groin puncture site. He was quite eager to be
discharged. Unfortunately his white count had trended up over
several days, and was 20 on the morning on POD 4. The pt had
been afebrile throughout his stay, and there was no obvoius
source of infection. A cxr ruled out pneumonia, and blood
cultures were sent to rule out bacteremia. Discussion with Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] resulted in the decision to allow Mr.
[**Known lastname **] to be discharged home in the care of his friends. [**Name (NI) **] is
to see his PCP [**Last Name (NamePattern4) **] 2 days for a follow up and pt/inr check, and
to see Dr. [**Last Name (STitle) **] in 5 days for a follow up, to include a repeate
cbc and f/u on his blood cultures. Mr. [**Known lastname **] and his
girlfriend [**Name (NI) **] are aware of the elevated wbc and know to
return immediately should he have a fever, prodcutive cough,
drainage from his wound or other concerning symptoms.
Medications on Admission:
pt is unclear but per prior d/c summary
Senna 8.6 mg PO BID, Docusate Sodium 100 mg [**Hospital1 **], Atorvastatin
40
mg PO DAILY, Clopidogrel 75 mg PO DAILY, Aspirin 81 mg
PO DAILY (Daily), Mirtazapine 15 mg PO HS, Folic Acid 1 mg PO
DAILY, Tamsulosin 0.4 mg 24 hr PO HS, Metoprolol Succinate 50 mg
24 hr Daily, Nifedipine 30 mg PO Daily, Isosorbide Mononitrate
30
mg Tablet Sustained Release 24 hr, Polyethylene Glycol 3350 17
gram PO Daily,Morphine 100 mg PO Q8H, Morphine 15 mg [**12-28**]
Tablets
PO Q2H, Lactulose 10 gram/15 mL PO TID, Dexamethasone 8 mg [**Hospital1 **],
Ezetimibe 10 mg daily, Acetaminophen 500 mg q8h, Lidocaine 5 %
Adhesive Patch, Albuterol Sulfate 90 mcg/Actuation HFA Aerosol
Inhaler, Omeprazole 20 mg daily, Ondansetron HCl 4 mg q8,
Dextromethorphan-Guaifenesin PRN, Lorazepam 0.5 mg q8h,
Megestrol
400 mg/10 mL Ten (10) ml PO once a day.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
10. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for pain.
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
13. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Ten (10)
ml PO Q 24H (Every 24 Hours).
14. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
17. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
18. Morphine 30 mg Tablet Sig: One (1) Tablet PO q2-3h prn as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
19. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime:
take at the same time daily.
Disp:*100 Tablet(s)* Refills:*2*
20. Outpatient [**Name (NI) **] Work
PT/INR to be checked twice per week by Dr. [**Last Name (STitle) **]
[**Apartment Address(1) 14920**], [**Location (un) **],[**Numeric Identifier 7023**]
Phone: [**Telephone/Fax (1) 14918**]
Dx: Heparin Induced Thrombocytopenia with arterial thrombus
INR goal: 2.0-3.0
Discharge Disposition:
Home
Discharge Diagnosis:
Right lower extremity ischemia with
rest pain and diminished motor and sensory function due to
known obstruction of previous bypass graft.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a cold, painful right foot and found to
have occlusion of your right lower extremity bypass graft. You
have been found to have an allergy to a medication called
"HEPARIN"; this can increase your risk of having blood clots in
your blood vessels, like the one you were diagnosed with. We
have treated your problem with surgical intervention. You have
been started on medication to help thin your blood, this
medication is called coumadin. It is very important that you
take this medication daily, and follow up with your primary care
doctor for frequent blood testing to monitor the medication
levels.
Medications:
?????? Take Aspirin 81mg once daily
?????? We have started you on two new medications Pletal 100mg twice
daily and coumadin 3mg once daily
?????? Continue all other medications you were taking before surgery
except for Plavix and Omeprazole, you should stop these
?????? You make take prescribed pain medications for any post
procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**12-28**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving
?????? Keep your f/u appt for [**Month/Day (3) **] work and to follow up with the
surgeon
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Month/Day (3) 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Your new medication "COUMADIN or WARFRIN" requires frequent
blood tests. You must have your labs drawn once to twice per
week initially and your primary care physician will call you
with instructions to adjust your coumadin dose if needed.
Followup Instructions:
Office Visit with Dr. [**Last Name (STitle) **], your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 95347**]y [**6-24**]. You can walk in to his office between 5am and 12
noon . It is very important that you see him and have your blood
checked.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: [**Apartment Address(1) 14920**], [**Location (un) **],[**Numeric Identifier 7023**]
Phone: [**Telephone/Fax (1) 14918**]
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2197-6-27**]
9:30 Location: [**Hospital Ward Name 23**] 9
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2197-7-5**] 10:30
Location: [**Hospital Ward Name **] ([**Doctor First Name **]) [**Hospital Unit Name **]
Completed by:[**2197-6-22**]
|
[
"41401",
"412",
"3051"
] |
Unit No: [**Numeric Identifier 16726**]
Admission Date: [**2185-6-27**]
Discharge Date: [**2185-6-29**]
Date of Birth: [**2120-9-24**]
Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 54-year-old black male had
a type B aortic dissection in [**2184-8-22**] from the left
subclavian at the level of the pulmonary vein. He was treated
medically for hypertension, and he has a penetrating ulcer in
his descending aorta of 3.2 cm which increased from 2.3 cm.
The diameter of his aorta is 6.7 cm. He was admitted for
thoracoabdominal repair. He had a cardiac cath on [**2185-5-30**]
which revealed an ejection fraction of 56% and clean coronary
arteries. An echocardiogram on [**2184-9-17**] revealed no MR
and no AS.
PAST MEDICAL HISTORY: Significant for a history of non-
insulin-dependent diabetes, hypertension, obesity, and
chronic renal insufficiency.
MEDICATIONS ON ADMISSION: Avandia 2 mg p.o. daily, labetalol
800 mg p.o. t.i.d., Lipitor 10 mg p.o. daily, lisinopril 20
mg p.o. b.i.d., nifedipine 90 mg p.o. daily, Protonix 40 mg
p.o. daily, isosorbide 30 mg p.o. daily,
hydrochlorothiazide/triamterene 37.5/25 one daily, and iron.
ALLERGIES: He has no known allergies.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: Occupation: He is retired from Fed Ex. He
does not smoke cigarettes. He does not drink alcohol. He
lives with his wife. [**Name (NI) **] does not use drugs.
REVIEW OF SYSTEMS: Significant for BPH.
PHYSICAL EXAMINATION: He is a well-developed and well-
nourished black male in no apparent distress. Vital signs are
stable. Afebrile. HEENT exam reveals normocephalic and
atraumatic. Extraocular movements are intact. The oropharynx
is benign. The neck is supple. Full range of motion. No
lymphadenopathy or thyromegaly. Carotids are 2+ and equal
bilaterally without bruits. The lungs are clear to
auscultation and percussion. Cardiovascular exam reveals a
regular rate and rhythm. Normal S1 and S2 with no rubs,
murmurs, or gallops. The abdomen is soft, nontender, with
positive bowel sounds. No masses or hepatosplenomegaly. The
extremities are without clubbing, cyanosis, or edema.
Neurologic exam is nonfocal. Pulses are 1+ and equal
bilaterally throughout.
HOSPITAL COURSE: He was admitted to the OR. He was intubated
and then an intrathecal catheter was attempted, and the
patient had spinal stenosis, and the anesthesiologists were
unable to advance into the CSF space. The procedure was
aborted, and the patient was transferred to the CSRU in
stable condition. Of note, they were also unable to place a
Foley catheter, and he needed a coude catheter which was
placed. He was extubated in the CSRU the same day, and the
following day was transferred to [**Hospital Ward Name 121**] Two.
DISCHARGE STATUS: He had his bladder catheter discontinued
and was able to void and was discharged to home on [**6-29**] in
stable condition. His hematocrit was 28.9, white count was
8600, platelets were 168,000. PTT was 31.5. INR was 1.2.
Sodium of 140, chloride of 106, CO2 of 24, BUN of 31,
creatinine of 2, potassium of 4.1.
MEDICATIONS ON DISCHARGE: Same as preoperatively.
DI[**Last Name (STitle) 408**]E FOLLOWUP: He will follow up with Dr. [**Last Name (Prefixes) **]
on [**7-7**] to reschedule his surgery.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2185-6-29**] 13:34:21
T: [**2185-6-29**] 14:31:22
Job#: [**Job Number 16727**]
|
[
"25000",
"4019"
] |
Admission Date: [**2130-2-3**] Discharge Date: [**2130-3-17**]
Date of Birth: [**2072-7-10**] Sex: F
Service: MEDICINE
Allergies:
Unasyn
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
Paracentesis X 3
Intubation
History of Present Illness:
57-year-old woman w/ h/o HTN, hyperlipidemia, alcoholic
cirrhosis transfered from OSH for worsening renal and liver
function. She stopped drinking four months ago and is scheduled
to have a BDIMC outpt liver transplant evaluation on [**2130-3-16**].
She was admitted from a [**Hospital1 1501**] to AJH on [**2130-1-24**] w/ worsening
ascites, abnormal LFTs including increased ammonia level (61 on
[**1-21**] to 129) and ARF. She was admitted w/ a WBC of 22, Cr of 3.1
(baseline 1.2). Given concern for SBP, she was tapped and 3.5L
fluid were removed but no cultures were sent. She was started on
Unasyn IV but developed desquamation of her soles on [**2-1**] so it
was stopped and steroid cream was used to treat the rash. Renal
consult diagnosed her w/ hepatorenal and started her on
midodrine 10mg po tid and octreotide 100mcg SQ tid. The patient
was retapped [**2-2**] and cultures are pending, gram stain negative,
WBC 280 with 29% neut.. Per OSH transfer note one out of four
bottles BCx grew noncandidal yeast (however micro lab now says
no yeast in cultures) and she was started on caspofungin IV. GI
consult felt she was recovering from severe alcoholic hepatitis
but recommended no specific therapy other than abstinence from
EtOH, diet, and vitamins.
.
During her hospitalization her INR was noted to be rising,
reaching 2.6 on [**2-2**]. Her WBC [**2-3**] was 26.4 (88.5% and 15
bands), an increase from 16 over the past few days. Her renal
function improved gradually w/ creatinine 1.6 today from 3.1.
.
On speaking with her husband, he states there is no way she
could have received alcohol within the last week and that she
has been sober for about 2 months. Besides her family, a couple
of family friends have visited her in the hospital and [**Hospital1 1501**]. She
is currently unable to answer questions. On the floor she was
very agitated, she received 6mg Haldol and was placed in
restraints. An NG tube was placed and labs sent. Based upon
her labs MICU was called to evaluate.
Past Medical History:
1. acute alcoholic cirhhosis, treated at AJH in [**12-23**]
2. hypercholesterolemia
3. HTN
4. chronic hyponatremia
5. depression
6. h/o TAH remotely
7. hemorrhoids seen on sigmoidoscopy
Social History:
Living at [**Hospital1 1501**]. Quit smoking and drinking ~2 months ago.
Previously was drinking [**2-19**] heavy liquor alcoholic beverages per
day. Used to work for children with special needs but now does
not work. Married. Father deceased, mother has dementia. 2
children, one in [**Location (un) 5028**] and one in [**Location (un) 8072**], NH, both well.
Family History:
n/c
Physical Exam:
VS: 98.9, 106/45, 112, 28, 98% on 2L NC
Gen: agitated, trying to get out of bed, responded yes to name
HEENT: MM dry, OP dried blood on palate and lips, anicteric, NG
tube in place
Neck: supple, no meningeal signs by agitated movement
Lungs: Diffuse rhonchi throughout, left greater than right.
CV: tachy, nl S1S2, no friction rub
Abd: hypoactive bowel sounds, soft, nontender, distended, +
ascites
Ext: 3+ pitting edema in LE bilaterally, no c/c, patchy
erythema/desquamation on feet bilaterally
Neuro: agitated, not responding appropriately to commands,
tremulous
.
EKG: sinus tach at 127, nl axis, nl intervals, low voltage,
right atrial abnormality, poor baseline due to agitation
Pertinent Results:
OSH Abd U/S: Ascites throughout abdomen, echogenic liver,
gallbladder sludge
OSH CXR: inspiration poor, minimal atelectasis.
OSH Head CT ([**2129-12-27**]) : mild atrophy, no acute abnormality
.
Brief Hospital Course:
A/P: 57F w/ alcoholic hepatitis, likely hepatorenal syndrome
transferred from OSH w/ worsening liver function, fevers,
agitation. Initially presented with sepsis based upon
tachycardia, elevated lactate, anion gap acidosis, elevated WBC,
and low grade temp. admitted with decreased mental status and
worsening renal function. Patient developed progressive
Respiratory failure, Liver failure, Coagulopathy, Sepsis and
Renal failure. Was admitted to the MICU. Was started on pressors
and was also intubated. Was given multiple units of FFP,
platelets and was put on many other life suportin measures.
However patient progressively deteriorated and ultimately she
was made CMO. She expires on [**2130-3-17**].
Medications on Admission:
Medications at nursing home:
Protonix 40mg po qd
aldactone 50 mg po bid
thiamine 100mg po qd
folate 1mg qd
MVI qd
Anusol [**Hospital1 **]
Protein powder 1 scoop tid
.
Meds on transfer:
albumin 12.5g daily IV
Lasix 40mg IV qd
Caspofungin 35mg IV qd
Levaquin 500mg IV qd (started [**2-3**])
Protonix 40mg po qd
Thiamine 100mg po qd
Folate 1mg po qd
Aldactone 50mg po qam
MVI qd
Mycolog cream ointment
Lactulose 30mL po q12h
Neomycin 500mg po tid
Ativan 0.5 po q6h prn
Triamcinolone ointment
Preparation H cream prn
Oxycodone 5mg po q4h prn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver Failure
Renal Failure
Coagulopathy
Respiratory Failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Completed by:[**2130-3-31**]
|
[
"0389",
"51881",
"5845",
"5070",
"78552",
"99592",
"2761"
] |
Admission Date: [**2115-2-18**] Discharge Date: [**2115-2-20**]
Date of Birth: [**2059-4-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
transfer from [**Hospital 5871**] hospital
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
55M with hx Hep C, cirrhosis (on [**Hospital1 **] transplant list), HIV
admitted to OSH with hemetemasis and Hct of 11 on [**2115-2-17**].
Received 15 units pRBCs, 16 units FFP, 1 unit platelets. Pt had
EGD that showed bleeding varices, 1 was banded. Upon subsequent
bleed, pt was re-scoped and sclerosis was attempted. Intubated
for airway protection. At OSH, pt was hyperkalemia, also had G
negative bacteremia, started on Zosyn and Levofloxacin. Pt was
hemodynamically unstable and transferred on Levophed and
Vasopressin.
.
Upon arrival to MICU, pt was assystolic. Code Blue called. Pt
received 2 of atropine and 2 mg epi. Received chest compression.
Pulse and rhythm regained. Pt also received 2 amps bicarb during
code blue. Continued on levophed and vasopressin. Bolused with
IVF. Lactate initally 24, K 6.3. A line and dialysis catheter
placed.
Past Medical History:
HIV CD4 200 VL low
Hep C
cirrhosis
EtOH abuse in past
Eval for transplant at [**Hospital1 **]
Social History:
Remote Iv drug use, no EtOH or drugs lateley. Lives with
partner, [**Name (NI) **] [**Name (NI) **].
Family History:
non-contributory
Physical Exam:
VS 98.5, BP 80/56 HR 101 R 18 95% on Vent 450 X 16 P5 FiO2 50%
Gen: intubated, sedated
HEENT: pupils reactive
Chest: CTAB
CV: RRR tachy, unable to appreciate murmur
Abd: soft, distended +BS
Ext: tr edema ankles
Pertinent Results:
[**2115-2-18**]
10:52p
pH6.82 pCO257 pO220 HCO311 BaseXS-30
Comments: Verified
Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art
Na:139 K:6.2 Cl:101 Hgb:9.3 CalcHCT:28 Glu:120 freeCa:1.05
Lactate:24.7
Comments: Verified'
[**2115-2-18**]
10:48p
Source: Line-femoral line
143 102 48 AGap=39
-------------< 129
5.8 8 3.7 D
Comments: Notified K.Rose @ 0035 [**2115-2-19**]
Anion Gap Verified
Ca: 9.5 Mg: 2.2 P: 11.7
ALT: 1357 AP: 227 Tbili: 12.4 Alb:
AST: 6055 LDH: 5700 Dbili: TProt:
[**Doctor First Name **]: 486 Lip: 186
Comments: Verified By Dilution
Source: Line-femoral line
91
9.7 \ 9.0 / 46
/26.2 \
N:61 Band:18 L:12 M:1 E:1 Bas:0 Metas: 6 Myelos: 1 Nrbc: 23
Comments: Adjusted For Nrbc
23nrbc'S/100wbc'S
Verified By Smear
BILOBED AND DYSPLASTIC POLYS SEEN
Hypochr: 2+ Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ Polychr: 1+
Schisto: 1+ Burr: 2+ Stipple: 1+ Tear-Dr: 1+
Comments: MANUALLY COUNTED
TOXIC GRANULATIONS
DOHLE BODIES
Plt-Est: Very Low
Source: Line-femoral line
PT: 25.6 PTT: 78.7 INR: 2.6
.
CXR: Enlarged cardiac silhouette and slight widened mediastinum
which could represent pericardial effusion and/or mediastinal
hematoma, however AP projection makes for difficult comparison
and enlargement could be attributed to projectional differences.
2. Bilateral hazy opacifications within the parenchyma which
could represent pulmonary edema. Again projectional differences
could account for these findings.
3. Bilateral small-to-moderate pleural effusions.
4. Distended stomach with NG tube tip overlying the proximal
stomach.
5. Endotracheal tube in likely appropriate position 4 cm from
the carina. Lateral radiographs which are unavailable would
ensure location.
.
ECHO:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is no pericardial effusion. Compared with the
prior study (images reviewed) of [**2115-1-7**], the heart rate is
faster.
Brief Hospital Course:
The patient was admitted to the ICU with asystole on transfer.
After the code described in the HPI, he was kept intubated but
required no sedation and was minimally responsive. He required
multiple transfusions of both PRBCs and FFP, and was given IVF
resuscitation as well. He was covered with broad spectrum
antibiotics and given Hydrocort for possible adrenal
insufficiency as well. He was started on 3 different pressors,
all of which were eventually maxed out at the highest dose in
order to maintain a MAP >60. Culture results from the outside
hospital were obtained, c/w high grade bacteremia.
.
Both surgery and liver services were consulted regarding his
esophageal bleed, and an octreotide drip was continued. He had
an abdominal US which showed cirrhosis, splenomegaly, and a
small amount of ascites. Given that he had an enlarged heart on
CXR a bedside echo was initially done to rule out effusion,
tamponade. Given his elevated creatinine and severe volume
overload in addition to hyperkalemia, renal service was
consulted, and CVVH was initiated. As the patient continued to
be unresponsive >24 hours after coding, it was thought that he
likely had a very poor neurological prognosis. An EEG was
obtained, and the neuro service was consulted. Goals of care
and prognosis were extensively discussed with the family by both
the primary medicine team and the liver attending. The family
decided to make the patient CMO. All pressors and medications
were discontinued, and the patient was started on a morphine
drip to titrate to comfort. The patient expired shortly after,
with his family present at bedside. An autopsy was offered, but
declined.
Medications on Admission:
Meds on transfer:
Nexium 40 mg IV BID
Octreotide gtt at 50 mcg
Zosyn 3.375g Iv q 6
Levaquin 500 mg IV qD
VP 0.4
Hydrocort 100 IV q 8
Propofol gtt
Discharge Disposition:
Expired
Discharge Diagnosis:
septic shock
bacteremia
end stage liver disease
cirrhosis
Discharge Condition:
expired
|
[
"78552",
"5849",
"2767",
"2762"
] |
Admission Date: [**2177-8-30**] Discharge Date: [**2177-9-1**]
Service: CARDIOTHORACIC
Allergies:
Indapamide / Atenolol
Attending:[**Known firstname 922**]
Chief Complaint:
84M s/p aorto-inomminate bypass with endocascular stents of the
aortic arch/CABGx1 who was at rehab and had a VT arrest.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This 84WM is well know to our service. He is s/p
aorto-inomminate bypass with endovascular stenting of the aortic
arch and descending aorta/CABG x 1 (SVG->PDA) on [**2177-6-24**]. He
had a prolonged post op course and was eventually [**Date Range 107589**] and
had a gastrostomy tube. He was initially transferred to rehab
on [**8-4**], but was readmitted with a pleural effusion. He had a
chest tube and was again discharged on [**8-22**]. He had a VT arrest
at rehab and was transferred to an outside hospital ER where he
had ACLS protocol with defibrillation. He had PO2 of 29 at the
outside ER. The O2 was brought up above 100 and he was
transferred to the CSRU in critical condition.
Past Medical History:
HTN
Depression
Syncope
Vocal hoarseness with L vocal cord paralysis
s/p sinus surgery
s/p CABGx1, aortic stenting
tracheostomy
respiratory failure
gastrostomy tube
Social History:
Lives alone
Cigs: 20 pk yr hx, quit 35 yrs. ago.
ETOH: none
Family History:
unremarkable
Physical Exam:
[**First Name5 (NamePattern1) 4746**] [**Last Name (NamePattern1) 107589**] on vent.
VS: T:95.8 BP: 123/66 P: 67 O2 sat 100% on TV 450 IMV 18 PEEP
10
HEENT: NC/AT, pupils fixed and dilated 4-5mm, non-reactive,
oropharynx benign
Lungs: Clear to A+P
CV: RRR without R/G/M, nl s1, s2
Abd: soft, nontender, g tube in place
Ext: no C/C/E
Neuro: non responsive to verbal or painful stimuli, myoclonic
movements
Pertinent Results:
[**2177-8-31**] 05:03AM BLOOD WBC-15.8* RBC-2.94* Hgb-8.7* Hct-25.9*
MCV-88 MCH-29.5 MCHC-33.4 RDW-15.4 Plt Ct-317
[**2177-8-31**] 05:03AM BLOOD Glucose-114* UreaN-36* Creat-1.2 Na-137
K-3.6 Cl-98 HCO3-29 AnGap-14
RADIOLOGY Final Report
CTA CHEST W&W/O C &RECONS [**2177-8-30**] 11:21 PM
CTA CHEST W&W/O C &RECONS
Reason: ? PE
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
84 year old man s/p CABGx1(SVG-PDA)/aoroto-inominate
bypass,endovascular stents of the aortic arch and descending
aorta, today - VT arrest in NH
REASON FOR THIS EXAMINATION:
? PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 84-year-old man status post CABG x1 with
aortoinnominate bypass endovascular stent of aortic arch and
descending aorta. Today with V-tach arrest. Evaluate for
pulmonary embolism.
COMPARISON: [**2177-8-14**] CTA chest.
TECHNIQUE: MDCT-acquired axial images of the chest were obtained
without and with IV contrast per non-gated chest pain protocol.
Multiplanar reformations were obtained.
CT CHEST WITHOUT AND WITH IV CONTRAST: There has been interval
decrease in size of the large right-sided pleural effusion,
which now is moderate in size. Diffuse bilateral ground-glass
opacities are seen throughout the lungs, likely representing
pulmonary edema. There has been interval development of opacity
within the left lower lobe, which could represent aspiration
pneumonia or atelectasis. The heart is enlarged. A saccular
aneurysm is again noted along the aortic arch. An aortic stent
is seen along the aortic arch. There is lack of IV contrast
within the aorta secondary to bolus timing. There are extensive
coronary and aortic calcifications. The patient is status post
median sternotomy.
CTA CHEST:
There is no evidence of filling defects within the pulmonary
arterial vasculature. No evidence of pulmonary embolism. As
mentioned above, the aorta is unopacified secondary to bolus
timing. A stent is seen extending along the aortic arch.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Diffuse bilateral opacities similar to prior study likely
represent pulmonary edema.
3. Interval improvement of right-sided pleural effusion, now
moderate in size.
4. Interval worsening of left lower lobe consolidation,
representing either pneumonia, aspiration or atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**]
Approved: SUN [**2177-8-31**] 3:36 PM
Brief Hospital Course:
The patient was admitted to the CSRU. Due to unstable
hemodynamics and ventricular dysrhythmias, he was maintained on
Dopamine and Lidocaine drips. He urgently underwent chest CTA to
rule out pulmonary embolus and a head CT to rule out stroke. The
head CT found no evidence of infarction or hemorrhage, and he
ruled out for PE by CT angiogram. The CTA was however notable
for interval worsening of a left lower lobe consolidation,
representing either pneumonia, aspiration or atelectasis. Given
his VF arrest and likely oxygen deprivation, he continued to
experienced generalized myoclonus. The neurology service was
consulted for further evaluation and EEG was performed. The EEG
showed generalized discharges and very little, if any normal
background was seen. Given his anoxic brain injury and grim
prognosis, the family decided to withdraw support. Patient
expired on [**9-1**] @[**2187**] with the family at bedside. Family
declined autopsy.
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
Anoxic brain injury after VT arrest, Seizures
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2177-9-17**]
|
[
"V4581",
"311",
"4019"
] |
Admission Date: [**2185-8-11**] Discharge Date: [**2185-8-21**]
Date of Birth: [**2185-8-11**] Sex: F
Service: NB
HISTORY: [**Known lastname 5877**] [**Known lastname 16599**] is a 28 [**1-15**] week 795 gram female
newborn who was admitted to the Neonatal Intensive Care Unit
for management of prematurity. The infant was born to a 47
year old gravida II, para 0, now I mother. Prenatal screens:
Blood type O positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group B
strep screening negative. The mother has a two year history
of hypertension worsening in the last week on atenolol,
hydralazine, and Aldomet. Concerns of fetal growth with
absent/reverse diastolic flow. Mother received a full course
of betamethasone on [**8-9**]. On the date of delivery there
were continued concerns for poor fetal growth.
Delivery was by cesarean section due to breech positioning.
There were no perinatal sepsis risk factors: Group beta strep
negative, no maternal fever, no prolonged rupture of
membranes, membranes were ruptured at time of delivery, there
was no fetal tachycardia. Infant was delivered under spinal
anesthesia. The infant emerged with good tone and activity
and spontaneous crying with drying. She was treated with bulb
suctioning, stimulation and positive facial, continuous
positive airway pressure for increased work of breathing.
She was shown briefly to the parents and then transported to
the Newborn Intensive Care Unit for further care. Apgar
scores were 7 at one minute and 8 at five minutes
respectively. Parents are both involved.
PHYSICAL EXAMINATION: Weight 795 grams (just at or below the
10th percentile), length 34 cm (10th to 25th percentile),
head circumference 24.5 cm (10th to 25th percentile. Briefly
examination consistent with gestational age with signs and
symptoms of respiratory distress with retractions and poor
aeration bilaterally. The remainder of examination normal
for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEM: Respiratory: Upon
admission to the Newborn Intensive Care Unit [**Known lastname 5877**] was
placed on 5 cm of continuous positive airway pressure.
Within the first 24 hours of life she developed an increased
oxygen requirement and was treated with intubation and one
dose of surfactant with improvement of respiratory symptoms.
She was extubated to CPAP again on day of life two. She has
continued to be on 5 cm of continuous positive airway
pressure requiring 21 to 25 percent FIO2.
Cardiovascular: [**Known lastname 5877**] presented with a murmur on day of
life three consistent with a PDA. Echocardiogram on day of
life three showed patent ductus arteriosus with left to right
flow and left atrial dilatation. She received a course of
indomethacin. She her received her last dose of indomethacin
at 2 A.M. on [**8-16**] with resolution of her patent ducts
arteriosus. Her blood pressure has been stable throughout
her hospitalization.
Fluid, electrolytes and nutrition: Upon admission to the
Newborn Intensive Care Unit a UAC and UVC were placed and
intravenous fluids of D10W were started at 100 cc per
kilogram per day. She remained NPO throughout her
indomethacin course and was started on entral feeds on day of
life six, started at 20 cc per kilogram per day. She only
got to 20 per kilo of entral feeds and was made NPO on day
of life nine due to concerns for sepsis with abdominal
distension.
She is currently on PN and intralipids total fluids at 140 cc
per kilogram per day. Dextrose sticks stable at 177.
Current weight today is 815 grams, up 40 grams from
yesterday. She has [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 37079**] tube in place that is draining
small amounts of green drainage. The last set of
electrolytes, on the 10th, sodium of 139, potassium of 5.0,
chloride of 105 and bicarbonate of 19. Electrolytes today,
[**8-21**], sodium of 132, potassium 5.0, chloride of 95
and a bicarbonate of 18.
Gastrointestinal: [**Known lastname 5877**] made it to 20 ml per kilogram of
entral feeds. Feeds were being advanced slowly due to
concerns of a distended abdomen. Serial KUBs showed diffuse
dilatation but no evidence of pneumatosis on her KUB.
Hematology: [**Known lastname 56929**] initial hematocrit on admission to the
Neonatal Intensive Care Unit was 55. She received 20 cc per
kilo of packed red blood cells on [**8-18**] with the onset
of the left arm infection. Her hematocrit just prior to that
transfusion was 36.6% - Hct on [**2185-8-21**] 40%.
Neurology: This baby had a cranial ultrasound on [**2185-8-16**] that
was negative for hemorrhage or other abnormality.
Neurologic examination consistent with her gestational age.
Infectious disease: Upon admission to the Newborn Intensive
Care Unit a CBC and blood cultures were drawn. Her initial
CBC had a white count of 5,000, hematocrit of 55, a platelet
count of 167 with 11 percent polys and 0 percent bands and an
ANC of 583. She was placed on ampicillin and gentamicin upon
admission to the Neonatal Intensive Care Unit. A follow up
CBC on day of life one showed a white count of 6.1, 53.8% was
her hematocrit at that time and platelets of 163 with 31
percent polys and 0 percent bands with an improved ANC of
1891. She was doing clinically well so antibiotics were
discontinued after 48 hours. A PICC line was inserted on day
of life six. Erythema to the left arm at the PICC line site
was noted on day of life eight in the evening. A CBC was
drawn at that time as well as a blood culture. The CBC had a
white count of 13.8, a hematocrit of 36.6, platelet count of
337 with 43 percent polys and 18 percent bands, 1 meta and 2
myelos.
Blood culture on [**8-19**] was positive for methicillin
resistant staph aureus. She was placed on vancomycin and
gentamicin with the initial presentation when cultures were
sent on the early evening of [**2185-8-19**]. PICC line was removed
at 20:00 [**2185-8-19**]. A repeat blood culture was drawn on
[**8-20**] which has also grown back gram positive cocci in
pairs and clusters. Infectious Disease service has been
consulted. On [**2185-8-20**], clindamycin was added to the
vancomycin and gentamicin for concerns of distended abdomen.
No blood culture has been drawn on [**8-21**] as of the time
of this dictation. She remains on vancomycin, gentamicin and
clindamycin. Despite antibiotic therapy, the left arm was
noted to develop worsened and more extensive erythema,
induration and multiple yellow pustules. The baby was
evaluated by [**Name (NI) **] and General Surgery consultants from
[**Hospital3 1810**]. She was transported to [**Hospital3 18242**] for surgical exploration because of concerns for
possible osteomyelitis or necrotizing fasciitis of the left
arm.
cbc on [**2185-8-21**] - wbc 40,000 diff 10P 62B 5L 19M 1AL 3 Meta
3nrbc plat 213,000.
Pre-vanco level 9.8 on [**8-21**] at 11:00 AM.
Psychosocial: Mom and Dad actively involved in the care of
this baby and have been updated on the current plan.
CONDITION AT TIME OF TRANSPORT: Infant has been intubated
with a 2.0 endotracheal tube and is transported with an
endotracheal tube. She was noted to have an anterior airway.
Vent settings 20/6 25 FIO2 25%.
TRANSFER DISPOSITION: To [**Hospital3 1810**] via ambulance.
TRANSFER DIAGNOSIS:
1. Prematurity at 28 2/7 weeks.
2. Respiratory distress syndrome.
3. MRSA sepsis with left arm infection (possible osteomyelitis
or fasciitis).
4. Patent ductus arteriosus, status post indomethacin.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2185-8-21**] 14:15:33
T: [**2185-8-21**] 16:00:22
Job#: [**Job Number 56930**]
|
[
"7742"
] |
Admission Date: [**2186-6-23**] Discharge Date: [**2186-7-1**]
Date of Birth: [**2110-10-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Hypoxia s/p elective ERCP
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
This is a 75 yo F with a past medical history significant for
COPD, CHF, CAD s/p CABG, CVA, who became increasingly hypoxic
and tachypneic following an elective ERCP today. The patient was
recently admitted to an OSH with cholangitis, treated and sent
to [**Hospital1 599**] [**Hospital1 1501**] in [**Location (un) 1439**] with this ERCP scheduled electively.
.
On the last admission in [**4-24**], the patient reportedly had
cholangitis induced sepsis. She underwent an ERCP at that time
and had a stent placed in the CBD. She was treated with
antibiotics and volume resuscitation and discharged to [**Hospital1 1501**] with
a scheduled follow up ERCP when the patient had stabilized.
.
From the ERCP periprocedure notes, the patient arrived today
satting 88% on 4L by NC. She was intubated for the procedure and
received a total of 400cc LR during the procedure and 500cc of
fluid in the PACU. She then gradually became more tachypneic to
20-25 and desatted to 88% on 4L, which increased to the low 90's
on 6L. She was given a nebulizer and a MICU eval was requested.
.
On initial evaluation, the patient was slightly tachypneic,
satting 89-91% on 6L by facemask. An ABG and CXR were requested
and given the patient's history of CHF and the fact that she
takes daily lasix and received almost 1L of fluid in several
hours, a dose of 40mg IV lasix was suggested as well.
.
A foley was placed and lasix administered, which the patient
responded to promptly, with improvement of her symptoms. CXR was
confirmatory for diffuse perihilar infiltrates characteristic of
pulmonary edema. Anesthesia placed an a-line and then obtained
an ABG which was 7.30/66/93 and after several hundred cc's of
diuresis, it improved to 7.34/63/98 (on 6L facemask). She was
then transferred to the [**Hospital Unit Name 153**] for further management.
Past Medical History:
COPD
CAD s/p CABG, s/p MI
CHF (reported EF=50%)
HTN
s/p CVA, on coumadin - residual L hemiparesis
recent history of cholangitis s/p ERCP in [**4-24**] with gallstones
identified; reportedly was septic at this time.
Hyperlipidemia
Hx of psychosis
GERD, PUD
Hypothyroidism
5cm AAA
s/p R hip replacement
Paget's ds
depression, anxiety
Constipation
Diverticulosis
dementia
Family History:
NC
Physical Exam:
vitals: T 96.2 HR 101 BP 157/67 R 18 Sat 88-96% on facemask with
nasal airway in place
General: elderly female, asleep, drowsy, NAD
HEENT: AT/NC, PERRL, OP clear. MMM
neck: JVP elevated to earlobes
chest: RRR
lungs: decreased lung volumes with dependent rales
abd: obese, soft NT/ND +BS
ext: no e/c/c
neuro: unable to do full neuro exam as patient is extremely
sleepy. DTR's in tact bilaterally.
skin: wwp.
Pertinent Results:
[**2186-6-23**] 09:30AM WBC-5.3 RBC-3.67* HGB-11.3* HCT-32.6* MCV-89
MCH-30.7 MCHC-34.6 RDW-18.2*
[**2186-6-23**] 09:30AM PLT COUNT-306
[**2186-6-23**] 09:30AM PT-13.2* PTT-27.3 INR(PT)-1.2*
[**2186-6-23**] 06:38PM GLUCOSE-126* UREA N-35* CREAT-1.5*
SODIUM-146* POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-34* ANION
GAP-13
[**2186-6-23**] 06:38PM ALT(SGPT)-12 AST(SGOT)-20 LD(LDH)-342*
CK(CPK)-88 ALK PHOS-88 TOT BILI-0.4
[**2186-6-23**] 06:38PM CK-MB-6 cTropnT-0.08*
[**2186-6-23**] 06:43PM LACTATE-0.8
[**2186-6-23**] 11:15PM CK-MB-6 cTropnT-0.08*
.
[**6-23**]: CXR: IMPRESSION: 1. Left lower lobe opacity, suspicious for
pneumonic consolidation. 2. Congestive heart failure.
.
ERCP report [**2186-6-23**]:
1. Stent in the major papilla which was removed.
2. Stones in the biliary tree
3. Cholagiogram showed the presence of 2 stones in the distal
CBD.
4. Balloon sweeps were done to remove the stones.
5. A sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire.
.
Brief Hospital Course:
75 yo F with acute hypoxia and tachypnea following elective
ERCP, due to volume overload, exacerbated by sleep apnea.
.
1. Respiratory Distress: Given her improved CXR and clinical
picture post-diuresis, it appeared that the primary cause of
respiratory distress was likely fluid overload, and most likely,
given that her sats were already decreased pre-procedure, that
she was already volume overloaded before even receiving the
additional liter of fluid pre-procedure. She was successfully
diuresed about 3L with noticeable improvement in pulmonary
status. Cardiac enzymes were negative x 3. Of note, the patient
has multiple apneic episodes with significant desaturations
while sleeping highly suggestive of OSA / central sleep apnea.
Blood gas analysis suggests improvement of respiratory acidosis
with bipap 10/5/5L, likely chronic compensatory metabolic
alkalosis. By the time she was transferred out to the floor, she
was on her baseline O2 requirement of 2L by NC, and tolerating
bipap at night well. On the floor the patient had one episode of
oxygen desaturation to the 70s which resolved with increasing
oxygen via nasal canula to 5L. A cxr was obtained at that time
which showed prominent pulmonary edema. The patient's diuretic
regimen was increased to 40mg po bid however her serum
creatinine continued to rise and her lasix was held. Her oxygen
saturation however has remained stable at her baseline requiring
2Liters nasal canula to maintain oxygen saturation at 92-94%.
We have restarted her lasix at a lower dose of 20mg daily. She
has continued on her prior COPD regimen of spiriva, low dose
prednisone and nebs prn.
2. s/p ERCP - patient is stable from an ERCP perspective with
successful removal of stone from CBD and subsequent
sphincterotomy. LFTs trended down and normalized by [**6-28**]. She
will only need outpatient GI follow up with Dr. [**Last Name (STitle) **] if she
develops new abdominal symptoms or has recurrent evidence of
obstruction.
3. Cardiac
Ischemia - known CAD s/p MI, CABG. No evidence of ischemia on
EKG, enzymes negative. Her BP meds were initially held after
she was transferred to the ICU however the isosorbide was added
back upon transfer to the floor. The patient remained chest
pain free during the entire hospitalization. Given her history
of CAD, a lipid panel was obtained showing evidence of
hypercholesterolemia with a cholesterol total of 259, LDL 158,
and triglycerides 250. She was started on lipitor 20mg po daily
and will need to have her LFTs monitored in the future. We have
added back her lopressor at a lower dose of 12.5mg po twice
daily which can be titrated as needed.
5. ARF - unclear baseline creatinine, prior cr of 1.5 suggesting
likely CKD at baseline. As discussed above, her creatinine rose
to a maximum of 2.6 and we felt this was likely attributed to
lower BP (systolics in the 110s) in combination with diuresis.
On the day of discharge her serum creatinine is 1.7. There were
no electrolyte abnormalities during this hospitalization. She
will need future monitoring of her renal function while at
rehab. We suggest checking a complete metabolic panel on [**7-2**].
6. s/p CVA - coumadin held for ERCP
-Resuming coumadin at prior dose of 5mg po daily. She will need
follow up with her PCP and neurologist regarding goals of care.
She is currently subtherapeutic and will need continued
coagulation panels. She is not a candidate for lovenox given
her renal function and it was felt that the risks outweighed the
benefits for starting her on IV heparin at this time. This was
discussed with the patient's daughter who serves as the
health-proxy.
.
7. Depression, anxiety, ?psychosis
- continue ritalin, lexapro
- continue to hold all sedating meds
.
7. FEN: Low sodium diet, heart healthy, puree diet. Continue to
monitor electrolytes.
.
8. PPx: heparin subcut, bowel reg, ppi was administered while
she was an inpatient.
Medications on Admission:
Tylenol prn
Bisacodyl
MOM
nitroglycerin prn
compazine
colace
K-dur
Isosorbide dinitrate
Advair
Albuterol
Spiriva
reglan
ativan prn
vicodin prn
Amlodipine
zyprexa
MVI
prednisone 2.5mg qdaily
coumadin 5mg qhs (on hold for procedure)
Ritalin 10mg [**Hospital1 **]
lasix 20mg [**Hospital1 **]
metoprolol 25mg [**Hospital1 **]
lexapro 20mg
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
4. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) 13089**] Care Center - [**Location (un) 1439**]
Discharge Diagnosis:
Respiratory failure
Acute renal failure
Altered mental status
Secondary diagnoisis:
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Dyslipidemia
Stroke
Discharge Condition:
stable
Discharge Instructions:
Patient should continue on 2L nasal canula titrated to keep
oxygen saturation between 90-92% given her CO2 retention. She
will require daily monitoring of her serum creatinine while her
lasix dose is titrated back to her baseline.
Followup Instructions:
She should follow up with her PCP [**Name9 (PRE) **],[**Name9 (PRE) 74395**]
[**Telephone/Fax (1) 74396**], in [**12-20**] weeks. She should also follow up with her
neurologist in 6 weeks time.
|
[
"5849",
"496",
"4280",
"5859",
"5990",
"32723",
"2724",
"V4581",
"V5861",
"2449",
"311",
"40390"
] |
Admission Date: [**2169-10-30**] Discharge Date: [**2169-11-4**]
Date of Birth: [**2100-2-18**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Morphine Sulfate / Tegretol
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Lower Lip melanoma
Major Surgical or Invasive Procedure:
1) Re-excision of lower lip melanoma
2) Rt mental nerve biopsy
3) Lt Estlander flap to lower lip
History of Present Illness:
69 y/o man with lower lip melanoma. Patient underwent excision
and repair of
right lower lip mass during previous admission of [**2169-10-9**]. He
was readmitted due to positive margins for re-excision and
reconstruction.
Past Medical History:
Essential Tremor
AAA, repaired
CRI s/p nephrectomy on hemodialysis
CAD s/p 4 vessel stenting
Lower lip melanoma
Social History:
The patient has a significant smoking history of two packs per
day times 55 years, with occasional alcohol use. He has an
occupational history as a retired
brick layer. Currently lives alone w/ daughter, who helps w/
his care.
Family History:
Father died at age 62 with coronary artery
disease. Mother died at 50 years old with breast cancer. He
has one brother with a heart attack history. Two brothers
with coronary artery bypass grafting history. Sister died at
67 from cancer.
Physical Exam:
T 98.0, BP 98/33, P 79, RR 16, SpO2 97% on RA.
A+O x3
PERRLA, no focal sensorimotor deficit.
JVP could not be appreciated.
Regular S1, S2. II/VI SEM @ RUSB.
LCA anteriorly.
+BS. soft abdomen, multiple abdominal scars, large R sided
hernia w/ extrusion bowel contents into R side of abdomen.
+L femoral bruit.
+R cephalic fistula bruit and thrill.
1+ dp pulses b/l.
Pertinent Results:
[**2169-10-30**] 08:47PM GLUCOSE-81 UREA N-47* CREAT-5.8* SODIUM-138
POTASSIUM-6.0* CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
[**2169-10-30**] 08:47PM CALCIUM-8.8 PHOSPHATE-4.9* MAGNESIUM-2.1
[**2169-10-30**] 08:47PM WBC-9.5# RBC-3.25* HGB-11.2* HCT-32.8*
MCV-101* MCH-34.4* MCHC-34.0 RDW-13.4
[**2169-10-30**] 08:47PM PLT COUNT-208
[**2169-10-30**] 08:47PM PT-13.2 PTT-28.0 INR(PT)-1.1
Brief Hospital Course:
After the operation he was admitted to the ICU for observation.
During the night following admission, the patient continued to
bleed out of the unclosed openings of his mouth. Eventually
required surgicell packing of oral cavity to stave off continued
bleeding. Unclear [**Name2 (NI) **] loss quantity but hematocrit remained
stable. Secondary to the ongoing bleeding and significant
drainage of dark red contents from NGT it was felt that the
patient should remain intubated until HD 2. Given inability to
intubate through the oropharynx, pt was extubated over
bronchoscope by ENT, w/o complication. Secondary to the ongoing
bleeding, Plavix and ASA were held Pt has been continued on
cefazolin 1g renally dosed w/ plan to continue for 7 day course
for propylaxis.
On HD2, pt developed low grade temperature to 100.4, and sputum
and urine were sent. Sputum grew out 4+ GNR and 4+ GPC in
clusters, chains, pairs. There was no indication for treatment
as pt was w/o s/sx of PNA and developed no further temperature.
He was maintained on IV Lopressor and transitioned to orals on
HD 3.
His fluid status was largely determined by HD. Only 1.3L taken
off on HD1 and pt remains w/ some residual UE edema. Daily CXRs
were followed and O2 requirements were closely monitored.
He underwent another session of HD and 3L were taken off. His
breathing improved (95-97% on RA) and he voided after his Foley
catheter was discontinued.
On day af his dicharge he was able to ambulate, void and breathe
w/o difficulty. His surgical sites were d/c/i.
Medications on Admission:
toprol xl 25 po qd
atorvastatin 40mg po qd
furosemide 40mg po qd
nephrocaps
sevalamar 400mg po tid
aspirin
plavix
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Acetaminophen 160 mg/5 mL Elixir Sig: Four (4) PO Q6H (every
6 hours) as needed for pain.
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed: Avoid Tylenol when taking
Percocet/Roxicet.
Disp:*500 ML(s)* Refills:*0*
4. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
7. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*10 Capsule, Sust. Release 24HR(s)* Refills:*0*
8. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for
7 days.
Disp:*28 Capsule(s)* Refills:*0*
10. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*50 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right lower lip melanoma
Discharge Condition:
Stable
Discharge Instructions:
Keep wounds clean and dry. Contact ENT if you experience fever
>101, shaking chills, difficulty in breathing or swallowing, lip
swelling or discharge (possible infection), wound dehiscence.
Mobilize at least three to four times daily.
Followup Instructions:
with Dr [**Last Name (STitle) 1837**] in one week. Please call [**Telephone/Fax (1) 7732**] to
schedule an appointment.
Completed by:[**2169-11-4**]
|
[
"4280",
"51881"
] |
Admission Date: [**2166-9-5**] Discharge Date: [**2166-9-18**]
Date of Birth: [**2126-3-16**] Sex: F
Service: MEDICINE
Allergies:
Apple / Strawberry / Almond Oil
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
pancreatitis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms [**Known lastname 24110**] is a 40 yo female with hx of alcohol abuse who has
been hospitalized at [**Hospital6 19155**] for acute
pancreatitis complicated by respiratory failure, persistent
acidosis, and pancytopenia.
.
She presented to [**Hospital3 **]Hosptial on [**9-3**] with 4 days
of abdominal pain, alochol use (by report drinking vodka), and
then hematemesis. Also admitted to hematochezia. Per EMS she
was hypotensive when they picked her up, however in the ED was
normotensive. On presentation she had a WBC of 13.6, Cr of 2.3,
amylase of 1206, lipase of 2098, and alcohol level of 98.
Additionally Hct 39.2, Plt 116, Ca was 6.9, albumin 2.8, INR
1.1, AST 227, and ALT 112.
.
She was admitted and given IVF. She was started on an ativan
gtt due to concern for alcohol withdrawal. Renal was consulted
regarding her renal failure and thought it was a combination of
prerenal and ATN. GI saw the patient due to her complaint of
hematemesis and felt she was not acutely bleeding and workup
should be deferred. On [**9-3**] she had a CXR which showed a
developing RLL infiltrate and questionable left lung infiltrate
which was felt to be concerning for developing ARDS. She was
intubated during her hospital course due to concern for her
tiring out. She was hypocalcemic and eventually started on a
calcium gtt. She was found to have a positive urine culture and
staretd on flagyl. She continued to spike and her antibiotics
were broadened to meropenem and levaquin. She had a persistent
metabolic acidosis and was started on IVF with bicarb.
.
On [**9-4**] her platlets dropped from 116 (on admission) to 26, and
her Hct dropped from 39.2 to 29 to 22.9 (in the setting of fluid
resuscitation). She was transfused 2 units of PRBC and 2 packs
of platlets on [**7-5**]. Additionally her WBC dropped from 3.9 on
admission to 2.7 with a predominance of neutrophils; (on [**9-3**]
she had 28% bands; on [**9-4**] she had 3% bands on her
differential).
.
Currently she is intubated and sedated.
.
Review of systems: Unable to obtain as patient is intubated.
.
Past Medical History:
Alcohol Abuse
CVA at age 24 (was found to have an atrial septal defect s/p
repair)
Insomnia
Depression
Seizure disorder
Sciatica s/p right gluteal repair
Chronic back pain
Hx of pancreatitis
Hx of alcoholic ketoacidosis
Transaminitis thought to be secondary to alcohol abuse
s/p appendectomy
s/p right oophorectomy
s/p left shoulder surgery
Social History:
She has a multiple year history of alochol abuse. Also smokes.
Family History:
Family History: Unable to obtain
Physical Exam:
Vitals: T: 99.8 BP: 96/49 P: 106 R: 15 O2: 75% on SIMV, volume
400, RR 20, 100% FiO2
General: Middle-aged female lying in bed sedated and intubated.
HEENT: Sclera anicteric, ETT in place
Neck: supple, JVP not elevated, no LAD
Lungs: Mostly clear with a few scattered rhochi anteriorly.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, hypoactive bowel sounds, striae present.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2166-9-5**] 02:08PM WBC-4.4 RBC-3.00* HGB-9.8* HCT-29.5* MCV-98
MCH-32.6* MCHC-33.1 RDW-21.3*
[**2166-9-5**] 02:08PM NEUTS-66 BANDS-6* LYMPHS-19 MONOS-6 EOS-2
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2166-9-5**] 02:08PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
SPHEROCYT-OCCASIONAL TARGET-OCCASIONAL
[**2166-9-5**] 02:08PM PLT SMR-LOW PLT COUNT-138*
[**2166-9-5**] 02:08PM PT-12.8 PTT-26.6 INR(PT)-1.1
[**2166-9-5**] 02:08PM FIBRINOGE-425*
[**2166-9-5**] 02:08PM GLUCOSE-107* UREA N-26* CREAT-3.1* SODIUM-143
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-18* ANION GAP-17
[**2166-9-5**] 02:08PM ALT(SGPT)-31 AST(SGOT)-66* LD(LDH)-481* ALK
PHOS-139* TOT BILI-0.7
[**2166-9-5**] 02:08PM LIPASE-80*
[**2166-9-5**] 02:08PM ALBUMIN-2.9* CALCIUM-8.3* PHOSPHATE-3.3
MAGNESIUM-2.0
[**2166-9-5**] 02:08PM TRIGLYCER-43
[**2166-9-5**] 02:08PM OSMOLAL-311*
IMAGING:
CT SCAN TORSO - [**2166-9-6**] - IMPRESSION:
1. Bilateral moderate-sized pleural effusions, with severe
compressive
adjacent atelectasis. An underlying consolidation cannot be
excluded.
2. Patchy pulmonary parenchymal opacities are compatible with
mild pulmonary edema.
3. Left seventh and eighth rib fractures appear to be recent.
Correlate with any recent history of trauma.
4. Small amount of intra-abdominal free fluid, and moderate
amount of pelvic free fluid. Severe anasarca is present.
5. Stranding around the pancreas may be related to stated
pancreatitis.
RUQ ULTRASOUND - [**2166-9-8**] - IMPRESSION:
1. No cholelithiasis or bile duct dilation. Slightly distended
gallbladder
without other signs of acute cholecystitis is likely secondary
to patient's fasting state pancreatitis.
2. Diffuse fatty deposition within the liver.
DISCHARGE LABS:
[**2166-9-17**] 06:55AM BLOOD WBC-5.9 RBC-2.51* Hgb-8.5* Hct-24.6*
MCV-98 MCH-33.7* MCHC-34.4 RDW-18.7* Plt Ct-515*
[**2166-9-17**] 06:55AM BLOOD Glucose-93 UreaN-8 Creat-1.2* Na-140
K-4.1 Cl-102 HCO3-27 AnGap-15
[**2166-9-17**] 06:55AM BLOOD ALT-22 AST-27 AlkPhos-256* TotBili-0.4
[**2166-9-14**] 04:03AM BLOOD Lipase-43 GGT-562*
[**2166-9-17**] 06:55AM BLOOD Calcium-9.1 Phos-4.6* Mg-1.8 Iron-39
[**2166-9-17**] 06:55AM BLOOD calTIBC-233* VitB12-GREATER TH
Folate-12.5 Ferritn-948* TRF-179*
[**2166-9-5**] 02:08PM BLOOD Triglyc-43
Brief Hospital Course:
Ms [**Known lastname 24110**] is a 40 yo female with hx of alcohol abuse who
presented to an OSH with pacreatitis and hematemesis which was
complicated by respiratory failure / ARDS, acute renal failure,
pancytopenia, and acidosis.
.
# Pancreatitis: The patient presented with abdominal pain and
pancreatitis in the setting of an alcohol binge so alcoholic
pancreatitis was felt to be the most likely eitology. Her RUQ
ultrasound was negative for gallstones. She was not on any
other medications that would likely cause her pancreatitis.
Calcium and triglycerides were normal. The CT of her abdomen
showed stranding around the pancreas but no other complications
from pancreatitis. She was treated with bowel rest, intravenous
fluids, antibiotics given the severity of her pancreatitis and
pain control. She gradually improved. Her lipase normalized
and her LFTs improved. The was able to tolerate a regular diet.
*She should have have follow up on her liver as her RUQ
ultrasound noted a fatty liver. LFT's will be repeated at the
time of her PCP follow up appointment.
.
# Respiratory failure/ARDS: The patient developed ARDS from her
pancreatitis and was intubated prior to admission to the ICU.
She was placed on ARDS net protocol for ventilatory settings.
Her respiratory status gradually improved and she was extubated
on [**9-12**] and her supplemental oxygen was weaned to room air.
.
# Acute kidney injury: Her [**Last Name (un) **] was felt to be from ATN from
hypotension and acute pancreatitis. Her renal function improved
to normal with fluids. She developed a prolonged metabolic
acidosis which was most likely secondary to her [**Last Name (un) **] which also
resolved with resolution of her kidney injury.
.
# Pancytopenia/Anemia: Patient had a pancytopenia on admission.
It was felt to be partially due to marrow suppression from
alcohol and partially from her acute illness. She was not felt
to have any further active bleeding after vomiting blood at OSH
likely from [**Doctor First Name 329**]-[**Doctor Last Name **] tear. However, her hemoglobin and
hematocrit slowly trended down from repeated phelbotomy and
malnutrition. She was offered and additional transfusion but
declined it. Her hematocrit stabilized at 23. She had no
evidence of iron, B12 or folate deficiency. She needs a repeat
CBC at outpatient follow up.
*She should see a gastroenterologist as an outpatient for
EGD/Colonoscopy given hemetemesis and guaic + stools in the
setting of critical illness. She was discharged on a PPI x 2
weeks.
.
# Delerium: The patient had altered mental status which was
likely a combination of delerium secondary to illness and
medication effect on a fragile baseline. Her head CT was
negative for an acute process and she did not have an elevated
ammonia level. She was treated with intravenous thiamine. She
was evaluated by psychitary who recommended controlling her
agitation with her home regimen of seroquel and lamictal. They
felt her home dose lamictal was most likely being used as a mood
stabilizer given it's dosing rather than an anti-epileptic
medication. Her delerium resolved by [**2166-9-17**]. She would benefit
from outpatient psychiatric care; she would like to arrange this
herself.
.
# Urinary Tract Infection: The patient was found to have a
urinary tract infection with Ecoli in her urine at the OSH. She
was treated with a 10 day course of antibiotics.
.
# Alcohol abuse/alcohol withdrawal: The patient was taken off
the ativan drip and instead versed was used for sedation. Was
off the ventilator she was given valium as needed for withdrawal
and eventually weaned off valium due to concern that it was
contributing to her altered mental status. The patient was
advised to stop drinking and social work followed the patient to
assist with substance abuse issues. The patient declined
referral to an outpatient treatment program.
.
# Depression: Her anti-depressants were held while she was
acutely ill. Psych was consulted for management of her
agitation and for a competency evaluation. Her mental status
steadily improved as above, and her delerium resolved. She was
discharged on her prior psychiatric regimen with the exception
of Ativan which was discontinued.
Medications on Admission:
Medications on transfer:
Ativan drip
Morphine drip
Calcium drip
TPN
Meropenem 2 gm IV q8h ([**9-4**]- )
Insulin drip
Protonix 80 mg IV bid
1/2 NS with 2 amps bicarb and 20 mEQ KCl at 70 cc/hr
Haldol 5 mg IV prn
Zofran 4 mg IV q8h prn
Compazine 10 mg IV q6h prn
Calcium gluconate multiple doses
Flagyl 500 mg IV ([**Date range (1) 31970**] x 3) - stopped
Zosyn 3.375 gm IV q8h ([**Date range (1) 6231**])
Levofloxacin
.
Home Medications:
Reglan 10 mg po q4h prn
Ativan 1 mg po q4h prn
Bupropion ER 100 mg po daily
Hydroxyzine 25 mg po qid
Lamictal 25 mg po daily
Promethazine 25 mg po
Quetiapine 25 mg po
Discharge Medications:
1. Outpatient Lab Work
[**2166-9-25**]
CBC, Chem 10, AST, ALT, Alk Phos, TBili, Lipase.
. RESULTS TO: Name: [**Doctor Last Name **],[**Name8 (MD) 86921**] MD
[**Name6 (MD) 86921**] [**Name8 (MD) **], MD. PC, [**Street Address(2) **], UNIT [**Unit Number **], [**Location **],[**Numeric Identifier 21918**], Phone: [**Telephone/Fax (1) 86922**], Fax: [**Telephone/Fax (1) 86923**]
2. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
3. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*14 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*14 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*28 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*1 bottle* Refills:*0*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]/[**Hospital1 8**] VNA
Discharge Diagnosis:
Acute pancreatitis
ARDS; hypoxic respiratory failure
Acute renal failure
Pancytopenia
Encephalopathy
GI bleed; acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with pancreatitis due to alcohol abuse. You
developed multi system organ failure and were on life support in
the ICU. You should avoid all alcohol in the future as it is
very harmful to your health. We offered to help you find an
alcohol treatment program but you refused. Your PCP will help
you arrange follow up with psychiatry.
You also suffered from some GI bleeding while you were
critically ill. You should be evaluated by a GI doctor [**First Name (Titles) **] [**Last Name (Titles) **]e for an endoscopy and colonscopy to find the source of
your bleeding.
Please take all medications as prescribed. We have given you
enough medications to last until you see your PCP.
Followup Instructions:
Name: [**Doctor Last Name **],[**Doctor Last Name 86921**]
Location: [**Name6 (MD) 86921**] [**Name8 (MD) **], MD. PC
Address: [**Street Address(2) **], UNIT [**Unit Number **], [**Location **],[**Numeric Identifier 21771**]
Phone: [**Telephone/Fax (1) 86922**]
Appointment: Monday [**2166-9-30**] 11:15am
**Please make sure you go to this appointment and if you cant
make it please call the office and reschedule.
|
[
"5845",
"2762",
"5990",
"2851",
"311",
"3051"
] |
Admission Date: [**2126-2-7**] Discharge Date: [**2126-2-12**]
Date of Birth: [**2066-5-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
transferred from OSH for STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization x 2
Placement of drug-eluting stent in LCx
Placement of drug-eluting stent in RCA
History of Present Illness:
HPI: 59 yo m w PMH CAD s/p MI in '[**13**] presents to [**Hospital1 18**] [**Location (un) 620**]
ED after 1 hour of substernal chest pain. Pain began in the
setting of practical exam for surgical technician training. The
pain was [**10-15**], radiated to the left arm and jaw, and was
associated with diaphoresis. There was no nausea or vomiting.
EKG showed STE in III>II and aVF, STD in I and aVL. Pt was given
ASA, SLNG x3, heparin, integrillin, and lopressor and
transferred to [**Hospital1 18**] [**Location (un) 86**] for PCI. Cath showed right-dominant
system with 90% blockage in mid LCx and 40% blockage in mid RCA.
There was chronic TO of LAD. Patient received 3.0x18 mm Cypher
DES in the LCx. Plan was to return to the cath lab for stenting
of RCA lesion. At end of procedure, pt showed cyanosis on R
thigh and foot, with brisk PT pulse by report, assoc with no
pain. After venous sheath removed, improvement in color. When pt
arrived in CCU, cyanosis was not apparent.
Hospital: On admission to CCU, pt continued on
ASA/Plavix/Integrillin/Statin. BB was held until r/o for occult
bleeding. ACE-I was held given recent contrast load and mild
hypovolemia. He had continued diaphoresis, mild chest pain, but
repeat EKG no changes suggestive of ichemia.
Past Medical History:
CAD s/p MI [**33**] yrs ago
Multiple Sclerosis dx'd 18 yrs ago
HTN
Hyperlipidemia
Depression
ADD
Social History:
Married with 2 sons. Lives in [**Location 620**]. He worked for most of
life as structural engineering technician, and is curently
studying to be a surgical technician. He has a 30 pack-year
smoking hx, though has not smoked for 25 yrs. No drug use.
Drinks 10 drinks per week.
Family History:
Adopted. Has 2 sons who are healthy.
Physical Exam:
VS: afebrile 106/73 49 20 96% RA
Gen: anxious appearing, diaphoretic
HEENT: NC/AT, PERRLA
Neck: no JVD
CV: S1, S2. bradycardic. regular rhythm. No S3 or S4. no mrg
Lungs: CTA bilaterally, anterior.
Abd: soft, nt, nd. + BS.
Ext: WWP bilaterally. 2+ DP and PT on RLE. 2+ DP and 1+ PT on
LLE. Normal color. No pain with palpation.
Neuro: A/O x 3.
Pertinent Results:
[**2126-2-7**] 10:40PM GLUCOSE-123* UREA N-23* CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-25 ANION GAP-10
[**2126-2-7**] 10:40PM ALT(SGPT)-42* AST(SGOT)-179* CK(CPK)-793* ALK
PHOS-65 AMYLASE-61 TOT BILI-0.6 DIR BILI-0.1 INDIR BIL-0.5
[**2126-2-7**] 10:40PM cTropnT-2.47*
[**2126-2-7**] 10:40PM ALBUMIN-4.9*
[**2126-2-7**] 10:40PM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2126-2-7**] 10:40PM WBC-8.3 RBC-4.69 HGB-14.9 HCT-41.8 MCV-89
MCH-31.9 MCHC-35.7* RDW-13.2
[**2126-2-7**] 10:40PM NEUTS-84.6* BANDS-0 LYMPHS-11.7* MONOS-2.9
EOS-0.4 BASOS-0.3
[**2126-2-7**] 10:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2126-2-7**] 10:40PM PLT SMR-NORMAL PLT COUNT-204
[**2126-2-7**] 10:40PM PT-13.5* INR(PT)-1.2*
Brief Hospital Course:
Hospital Course by problem:
1. Ischemia:
Pt p/w inferior STEMI with 90% blockage in LCx and 70% in RCA.
Pt had Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] in LCx on [**2-7**], with benign post-cath
course. CK peaked at 4733, MBI 8.8, trop 14.98 on [**2-7**]. Pt
continued on ASA, high-dose statin, and plavix. Integrillin was
continued for 18 hours after catheterization. Metoprolol and
ACE inhibitor were restarted on HD#1. RLE cyanosis observed
after catheterization was reduced after removal of venous sheath
and did not recur during inpatient course; right sided LENIs
revealed no evidence of DVT and CT scan of the abdomen and
pelvis did not show evidence of retroperitoneal bleed. Pt had
transient chest pain for 1 day following the procedure, but pain
was not associated with ischemic EKG changes. Chest pain was
not apparent by day #2 post-catheterization.
The patient underwent placement of a 3.0 x 18mm Cypher DES on
[**2-11**], this time targeting the second occlusion in the distal RCA.
The post-catheterization course was benign, with no evidence of
cyanotic extremities. The patient transiently complained of
chest pain following the procedure; the CP was not associated
with EKG changes suggestive of ischemia. The pain subsided by 6
hours post-cath. He continued on ASA/high-dose
statin/metoprolol/ACE-I/plavix. The patient was told to
continue the plavix for 3 months post-cath.
.
2. Pump:
Echcardiogram on [**2126-2-8**] was significant for impaired systolic
function, with EF 30-35%. There were multiple wall motion
abnormalities, including: inferolateral, mid-distal
anterioseptal, and distal anterior akinesis; and inferior
hypokinesis. These abnormalities were considered to be possibly
related to hibernating or stunned myocardium; follow-up
echocardiogram 3-4 weeks post-discharge will be helpful to
determine the level of recovery of hibernating/stunned
myocardium and the need for AICD placement. A follow-up
cardiology appointment was scheduled for several weeks after
discharge. The patient was continued on lisinopril and
metoprolol to improve long-term outcomes related to systolic
dysfunction.
.
3. Rhythm:
During the inpatient course, Mr. [**Known lastname 108450**] had persistent
asymptomatic bradycardia, which was ntreated. He had numerous 5
beat runs of AIVR, consistent with recovery form STEMI.
.
4. Cyanosis s/p cath
As mentioned above, the RLE cyanosis post-cath#1 was considered
to be due to venous insufficiency. It did not recur throuhgout
the hospital course or after the second catheterization. CT
abdomen and pelvis r/o RP bleed, and LENI r/o DVT. The patient
had brisk DP pulses during the cyanotic episode and throughout
the hospital course.
.
5. MS: Currently in remission. Not an active issue.
.
6. Depression/anxiety: On prozac and ritalin. Ritalin was held
during hospital course given risk of beta adrenergic
stimulation. The patient was advised not to take Ritalin until
consulting his outpatient cardiologist, given this risk.
Medications on Admission:
Metoprolol 25mg QD
ASA 81mg QD
Simvastatin 40mg QD
Lisinopril 10mg QD
Methylphenidate 40mg QD
Fluoxetine 60mg QD
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
ST segment elevation myocardial infarction
Discharge Condition:
Good
Discharge Instructions:
1) Continue your medications as directed
- You were started on a medication called Plavix. You must take
this medication every day.
- Your aspirin dose was increased to 325 QD.
- Your lisinopril was decreased to 5 mg daily.
- We changed your cholesterol medicine to Lipitor.
- Your Ritalin was stopped. Please talk to your cardiologist
before restarting.
2) Follow up with your PCP and cardiologist as mentioned below.
3) For the first few days after discharge, do not walk or sit
for prolonged periods of time. Do not lift objects greater than
15 pounds for at least one week after discharge. Return to the
hospital if you have return of chest pain, shortness of breath,
difficulty with exertion, swelling in your legs, palpitations,
or fever >101.5 F.
Followup Instructions:
1. You have an appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 7363**] on
Wednesday, [**2-20**] at 11:00 a.m. please call his office
with any questions or rescheduling needs.
.
2. You have an appointment with your cardiologist, Dr.
[**Last Name (STitle) **], tomorrow at 11:00am. However, it is important that
you follow up with an echocardiogram at 3-4 weeks after
discharge, so you should schedule a repeat visit for that time.
Completed by:[**2126-2-12**]
|
[
"41401",
"4019",
"2724",
"412"
] |
Admission Date: [**2105-12-3**] Discharge Date: [**2105-12-15**]
Service: Vascular Surgery
CHIEF COMPLAINT: Infected, ischemic left second toe.
HISTORY OF PRESENT ILLNESS: This is an 89-year-old
nondiabetic white male with coronary artery disease, status
post myocardial infarction and PTCA/stent in [**2105-2-10**],
atrial fibrillation, hypertension, hypothyroidism, with
history of renal cancer, colon cancer, and resection of
abdominal aortic aneurysm. He complained of recurrent left
second toe infection.
The patient had been evaluated by Dr. [**Last Name (STitle) 1391**] in [**2105-8-10**]
for an episode of left second toe infection and cellulitis.
The patient requested conservative treatment at that time
rather than a work-up for revascularization of his left leg
because of his cardiac events in [**2105-2-10**] which were
complicated by pneumonia as well.
The patient's left second toe became swollen, discolored, and
tender approximately one week prior to admission.
PAST MEDICAL HISTORY:
1. Coronary artery disease: Myocardial infarction,
PTCA/stent in [**2105-2-10**].
2. Atrial fibrillation, anticoagulation with Coumadin.
3. Hypertension.
4. Hypercholesterolemia.
5. Hypothyroidism.
6. Chronic renal insufficiency.
7. Gout.
8. Colon cancer.
9. Renal cancer.
10. Vertebral compression fractures.
11. Glaucoma.
12. Pneumonia in [**2105-2-10**].
PAST SURGICAL HISTORY:
1. Abdominal aortic aneurysm repair with an aortobifemoral
bypass graft in [**2093**].
2. Right nephrectomy in [**2099**].
3. Colon resection for cancer.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] uses a
cane to ambulate. He quit smoking cigarettes 30 years ago
after two packs per day for approximately ten years. He does
not drink alcohol.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Coumadin 5 mg p.o. q.d.
2. Metoprolol 12.5 mg p.o. b.i.d.
3. Lasix 40 mg p.o. q. 48 hours.
4. Synthroid 0.125 mg p.o. q.d.
5. Lipitor 10 mg p.o. q.d.
6. Allopurinol 100 mg p.o. q.d.
7. Aspirin 81 mg p.o. q.d.
8. Calcium supplement.
9. Sublingual nitroglycerin p.r.n.
10. Cosopt 1 drop OU b.i.d.
11. Alphagan 1 drop OU b.i.d.
12. Xalatan 1 drop OU q.h.s.
PHYSICAL EXAMINATION: Vital signs were temperature 96.1,
pulse 80, respiratory rate 18, blood pressure 125/60, O2
saturation equals 95% on room air. General: Alert,
cooperative white male in no acute distress. HEENT: Pupils
equal, round and reactive to light, extraocular movements
intact. Neck: Range of motion within normal limits. No
lymphadenopathy or thyromegaly. Carotids palpable. No
bruits. Chest: Heart rate was irregularly irregular. Lungs
clear bilaterally. Abdomen: Soft, nontender. Extremities:
right lower extremity was warm without lesions. The left
second toe was swollen with surrounding erythema. The toe
itself was a bluish mottled color. There was a superficial
ulceration with dry eschar. Pedal pulses had Doppler signals
bilaterally. Neurological: Examination nonfocal.
LABORATORY DATA: PT 19.0, PTT 33.4, INR 2.5, sodium 139,
potassium 5.2, chloride 110, CO2 28, BUN 30, urinalysis
negative. Chest x-ray showed no acute pulmonary disease.
EKG showed atrial fibrillation.
HOSPITAL COURSE: The patient was admitted to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], of podiatry. Cultures of the second toe were taken.
The patient was started on Kefzol. Wound cultures grew
sensitive Staphylococcus aureus.
Cardiology was consulted for preoperative clearance. They
felt that the patient was a high risk because of his known
LAD lesion from the cardiac catheterization done in [**2105-2-10**]. They felt he was a poor candidate for any kind of
cardiac intervention but recommended a pharmacological stress
test and review of his previous cardiac catheterization.
The patient had a Persantine thallium study on [**2105-12-7**].
There was an inferior defect which was partially reversible.
There was no anterior wall defect which suggested that the
LAD stenosis was not hemodynamically significant. Therefore
no other interventions were necessary and the patient was
cleared for vascular surgery.
On [**2105-12-10**] the patient underwent an uneventful left femoral
to below the knee popliteal bypass graft with nonreversed
saphenous vein. At the end of the surgery the patient had a
warm left foot with dopplerable pedal pulses.
Postoperatively the patient received two units of packed red
blood cells.
The patient's anticoagulation with Coumadin for his atrial
fibrillation was restarted. Physical therapy evaluated the
patient for full weight-bearing ambulation. The patient was
doing very well. At the time of discharge the patient's left
leg incision was clean, dry and intact. His left second toe
had improved considerably and would not require any
intervention during this hospitalization. His pedal pulses
were dopplerable bilaterally.
The patient was instructed to follow up with Dr. [**Last Name (STitle) 1391**] in
the office for staple removal in two weeks.
DISCHARGE MEDICATIONS:
1. Coumadin 5 mg p.o. q.d.
2. Lopressor 12.5 mg p.o. b.i.d.
3. Lasix 40 mg p.o. q. 48 hours.
4. Levothyroxine 125 mcg p.o. q.d.
5. Allopurinol 100 mg p.o. q.d.
6. Atorvastatin 10 mg p.o. q.d.
7. Aspirin 81 mg p.o. q.d.
8. Multivitamins 1 p.o. q.d.
9. Colace 100 mg p.o. b.i.d.
10. Tylenol 1-2 tablets p.o. q. 4-6 hours p.r.n.
11. Tylenol #3, 1-2 tablets p.o. q. 4 hours p.r.n.
12. Cosopt 1 drop OU b.i.d.
13. Alphagan 1 drop OU b.i.d.
14. Xalatan 1 drop OU q.h.s.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: Discharged home with [**Hospital6 407**]
services.
DISCHARGE DIAGNOSES:
1. Ischemic infected left second toe.
2. Left common femoral to below the knee popliteal
nonreversed saphenous vein graft on [**2105-12-10**].
SECONDARY DIAGNOSES:
1. Blood loss anemia, transfused.
2. Atrial fibrillation, requiring anticoagulation with
Coumadin.
3. Coronary artery disease, status post myocardial infarction
and stent [**2105-2-10**].
4. Hypothyroidism.
5. Renal cancer status post nephrectomy.
6. Colon cancer status post colectomy.
7. Abdominal aortic aneurysm repair.
8. Gout.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2106-5-13**] 22:36
T: [**2106-5-14**] 07:17
JOB#: [**Job Number 32159**]
|
[
"42731",
"40391",
"41401",
"2449",
"412"
] |
Admission Date: [**2139-4-5**] Discharge Date: [**2139-4-14**]
Date of Birth: [**2066-4-30**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Asymptomatic abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: A 72-year-old nondiabetic white
male status post cerebrovascular accident with left
hemiparesis, occluded right internal carotid artery, status
post left carotid endarterectomy, with hypertension,
hypercholesterolemia, chronic renal insufficiency,
pyelonephritis, was found to have a pulsatile abdominal mass
on routine physical exam in early [**Month (only) 958**] of this year.
Ultrasound showed a 6 x 6.6 cm abdominal aortic aneurysm and
a left renal mass. CT scan showed that patient was not a
candidate for endovascular repair because of short infrarenal
neck. Occlusion of the left external iliac artery was also
seen.
Patient was admitted on [**3-19**] to [**2139-3-21**] for
intravenous hydration prior to arteriogram with Mucomyst
protocol. Arteriogram showed a large infrarenal aneurysm
extending to the bifurcation, but not into the iliac
arteries. Tight stenosis at the origin of the right profunda
was seen. Left external iliac artery occlusion was seen.
The patient denies abdominal or back pain. No new onset of
claudication.
PAST MEDICAL HISTORY:
1. Status post cerebrovascular accident with residual left
arm paralysis.
2. Cerebrovascular disease, right internal artery occlusion;
status post left carotid endarterectomy.
3. Hypertension.
4. Hypercholesterolemia.
5. Chronic renal insufficiency: Baseline creatinine equals
1.8.
6. Pyelonephritis in [**2139-1-10**].
7. Left upper lobe kidney mass seen on CT scan in [**2139-1-10**].
8. EPH.
9. Gout PH.
PAST SURGICAL HISTORY:
1. Repair of left elbow fracture secondary to fall while
repairing a roof greater than 40 years ago.
2. Left carotid endarterectomy with Dacron patch on [**2139-2-26**]
by Dr. [**Last Name (STitle) **].
3. Cystoscopy on [**2139-3-31**] by Dr. [**Last Name (STitle) 4229**] at [**Hospital1 346**].
FAMILY HISTORY: Mother had diabetes. Mother had a stroke.
Family member had throat cancer.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] uses a
cane to ambulate at home. The patient quit smoking
cigarettes three years ago after one pack per day for 50
years. The patient has two alcoholic drinks per day.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Toprol XL 50 mg po q day.
2. Lotrel [**4-28**] po q day.
3. Lipitor 10 mg po q hs.
4. Colchicine 0.6 mg po bid.
5. Aspirin 325 mg po q day.
6. Vitamins.
7. Benadryl tablet q am for runny nose.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.2, pulse
64, respiratory rate 18, blood pressure 154/82, O2 saturation
equals 96% on room air. Weight is 89.8 kg, height is 5 feet
10 inches. General: Alert, cooperative white male in no
acute distress. Skin is warm and dry. No rashes. HEENT:
Sclerae are anicteric. Pupils are equal and reactive, full
dentures, no lesions, tongue in midline. Neck: Range of
motion is within normal limits. No lymphadenopathy or
thyromegaly. Carotids palpable. No bruits. Lungs clear.
Heart regular, rate, and rhythm without murmur. Abdomen is
soft. Bowel sounds present. Nontender. Pulsatile mass not
appreciated. Rectal examination deferred. Extremities:
Feet are equally warm, no ischemic changes, no lesions.
Pulse examination: Carotids are 2+ bilaterally. Radial
pulse is 2+ bilaterally. Abdominal aorta is nonpalpable.
Right femoral pulse 1+. Left femoral pulse, popliteal
pulses, and pedal pulses all nonpalpable, no bruits.
Neurologic examination: Left upper extremity paralysis
palpable. Alert and oriented times three.
ADMISSION LABORATORIES: White blood cells 8.4, hemoglobin
13.0, hematocrit 37.5, platelets 284,000. Sodium 138,
potassium 4.3, chloride 102, CO2 24, BUN 32, creatinine of
1.9, glucose of 114. PT 12.9, PTT 26.3, INR 1.0. Urinalysis
negative.
Chest x-ray on [**2139-2-20**] showed no acute pulmonary disease.
Electrocardiogram on [**2139-2-20**] showed a normal sinus rhythm at
a rate of 69. No acute ischemic changes.
Stress test on [**2138-5-27**] showed a fixed inferior wall defect
with an ejection fraction of 54%. Persantine thallium study
done on [**2139-2-13**] showed normal perfusion with stress and
ejection fraction of 53%.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2139-4-5**]. He was started on a bowel prep for surgery the
following day. The patient had been cleared by his
cardiologist, Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] for surgery during prior
admission.
On [**2139-4-6**], the patient underwent an abdominal aortic
aneurysm resection with an aorto-bifemoral bypass graft. At
the end of surgery, the patient had equally warm feet with
dopplerable pedal pulses. Estimated blood loss was 2,000 cc.
The patient was transfused several units of packed red blood
cells as well as crystalloid. Patient was extubated prior to
transfer to the PACU. However, patient showed respiratory
distress in the PACU and required reintubation. He was
extubated again on hospital day #2.
Subsequently, the patient's postoperative course was
relatively uneventful. Patient was diuresed with Lasix. His
diet was advanced as tolerated. He was able to ambulate with
assistance.
Patient's creatinine became elevated from its baseline of 1.9
up to 3.0 on [**2139-4-9**]. The patient's creatinine is closer to
baseline, approximately 2.4, at time of dictation. Patient
was seen again by Dr. [**Last Name (STitle) 4229**], Urology and arrangements made
for treatment of patient's left kidney mass by Dr. [**First Name (STitle) **].
Patient will see Dr. [**Last Name (STitle) 4229**] in the office on [**5-21**] at 10
am for further planning regarding treatment of his likely
left renal carcinoma by Dr. [**First Name (STitle) **] in Radiology.
At time of dictation, patient's abdominal and groin incisions
are clean, dry, and intact. His abdominal incision staples
will be removed and the incision will be Steri-Stripped. The
groin staples may be removed three weeks following surgery
approximately [**Last Name (LF) 766**], [**2139-4-27**]. Patient should follow up
with Dr. [**Last Name (STitle) **] in the office in two weeks.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg po bid.
2. Amlodipine 5 mg po q day.
3. Captopril 6.25 mg po tid.
4. Lipitor 10 mg po q hs.
5. Colchicine 0.6 mg po bid.
6. Aspirin 325 mg po q day.
7. Protonix 40 mg po q day.
8. Colace 100 mg po bid.
9. Dulcolax suppositories one/rectum q day prn.
10. Heparin 5,000 units subQ [**Hospital1 **].
11. Naphazoline 0.1% one drop OU q8h prn.
12. Tylenol 325-650 mg po q4h prn.
13. Percocet 1-2 tablets po q4-6h prn pain.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: Discharged to [**Hospital 3058**] rehabilitation
facility.
DISCHARGE DIAGNOSES:
1. Asymptomatic 6 x 6 cm abdominal aortic aneurysm.
2. Abdominal aortic aneurysm resection with aorto-femoral
bypass graft on [**2139-4-6**].
SECONDARY DIAGNOSES:
1. Blood loss anemia, status post transfusion.
2. Acute renal failure, resolving.
3. Hypertension, medications adjusted.
4. Hypercholesterolemia.
5. Gout.
6. Left renal mass, treatment scheduled with Drs.
[**Name5 (PTitle) 4229**]/[**Doctor Last Name **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2139-4-14**] 12:26
T: [**2139-4-14**] 12:29
JOB#: [**Job Number 49402**]
|
[
"2851",
"5849",
"4019",
"2724"
] |
Admission Date: [**2182-3-20**] Discharge Date: [**2182-3-24**]
Date of Birth: [**2130-8-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fentanyl
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
51F with ETOH cirrhosis with varices, chronic pancreatitis,
asthma, presented with hematemesis. Of note, she was recently
admitted [**Date range (1) 28561**] with abdominal pain and ETOH intoxication and
subsequent withdrawal. Subsequently she was admitted [**2182-3-15**] for
abdominal pain but patient signed out AMA on the same day after
IV narcotics were not given. She was at [**Hospital6 2752**]
on [**2182-3-19**] for domestic abuse by a friend but appears to have
left there AMA. She then started drinking vodka. She developed
symptoms of nausea, vomiting, and abdominal pain. She devoped
hematemesis which she describes as bright red blood mixed with
the vomit. She called for an ambulance and was taken to [**Hospital1 18**].
In ED vs 98.9, 105, 108/74, 18, 96%RA. Pt was intoxicated
with ETOH 333. She was admitted to [**Hospital Unit Name 153**] initially on octreotide
gtt given concern for hematemesis. However the hct was 32.7,
stable from 32.8 several days prior. Hct dropped to 28.8 the
following morning after hematemesis and roughly 3L IVF. She has
required no transfusions and hct has remained roughly stable
since. EGD [**2182-3-21**] showed 4 cords of grade I varices at the lower
third of the esophagus with portal hypertensive gastropathy and
2 small nonbleeding ulcers in duodenum.
Past Medical History:
- Alcoholic cirrhosis (dx: [**2178**])- complicated by varices,
ascites, encephalopathy
- Chronic pancreatitis (dx: [**2172**]) - on pancrease
- EtOH abuse - history of DT
- Low back pain (dx: [**2172**]) - degenerating L4-6 discs, seen in
pain clinic 8 years ago and received fentanyl patch and
oxycodone
- Asthma (since birth) - history of intubation in the past
- Uterine and cervical CA s/p hysterectomy ([**2166**])
Social History:
She is a former nurse who lives in apt in subsidized housing in
[**Location (un) 583**] alone. Divorced x2. She has one son, 30yo who lives in
[**State 15946**]. She is disabled from severe low back pain. She smokes
[**12-21**] ppd and recent heavy alcohol use, up to a gallon of vodka at
a time. Has tried AA. No illicit drug use
Family History:
Mother died at age 72 from a GIB, "blood clot in stomach" ;
Father died in mid-70s from cancer, possibly mesothelioma
(worked in shipping). Mother, father, paternal grandfather have
history of alcoholism.
Physical Exam:
VS: Temp: 98.4 BP: 108/70 HR: 72 RR: 18 O2sat: 96 3L
.
Gen: In awake, in bed, NAD
HEENT: PERRL, EOMI. No scleral icterus.
Neck: Supple, no LAD, no JVP elevation. EJ peripheral IV
Lungs: mild occasional wheezes
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3,
Skin: bruising noted on shoulders and neck
Psychiatric: Appropriate.
Pertinent Results:
[**2182-3-20**] 09:45PM URINE HOURS-RANDOM
[**2182-3-20**] 08:58PM GLUCOSE-90 UREA N-17 CREAT-0.6 SODIUM-142
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-20
[**2182-3-20**] 08:58PM GLUCOSE-90 UREA N-17 CREAT-0.6 SODIUM-142
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-20
[**2182-3-20**] 08:58PM ALT(SGPT)-66* AST(SGOT)-227* CK(CPK)-111 ALK
PHOS-121* TOT BILI-4.2*
[**2182-3-20**] 08:58PM LIPASE-77*
[**2182-3-20**] 08:58PM cTropnT-<0.01
[**2182-3-20**] 08:58PM CK-MB-3 cTropnT-<0.01
[**2182-3-20**] 08:58PM ASA-NEG ETHANOL-333* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2182-3-20**] 08:58PM WBC-7.0 RBC-3.47* HGB-11.4* HCT-32.7* MCV-94
MCH-33.0* MCHC-35.0 RDW-18.5*
[**2182-3-20**] 08:58PM NEUTS-59.1 LYMPHS-30.1 MONOS-5.1 EOS-5.3*
BASOS-0.3
[**2182-3-20**] 08:58PM PLT COUNT-39*#
[**2182-3-20**] 06:48PM URINE HOURS-RANDOM
[**2182-3-20**] 06:48PM URINE GR HOLD-HOLD
[**2182-3-20**] 06:48PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.027
[**2182-3-20**] 06:48PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-TR
[**2182-3-20**] 06:48PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2182-3-20**] 06:48PM URINE MUCOUS-MOD
.
EGD:
Protruding Lesions 4 cords of grade I varices were seen in the
lower third of the esophagus.
Stomach:
Mucosa: Erythema, congestion and mosaic appearance of the
mucosa were noted in the whole stomach. These findings are
compatible with portal hypertensive gastropathy.
Duodenum:
Mucosa: 2 small nonbleeding ulcers were seen.
Impression: Varices at the lower third of the esophagus
Erythema, congestion and mosaic appearance in the whole stomach
compatible with portal hypertensive gastropathy
Abnormal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: Avoid all NSAIDS and [**Doctor Last Name **]-2 inhibitors. Take
tylenol for pain (max dose of 2 grams per day).
D/C Octreotide.
Continue IV PPI [**Hospital1 **].
Carafate 1 gm po four times per day.
Continue cipro 400 mg IV BID for total of 3 days.
Clear liquid diet this PM.
Brief Hospital Course:
This is a 51 yo F with h/o ETOH cirrhosis with varices, chronic
pancreatitis, and asthma, who presented with hematemesis after
binge drinking. She was initially admitted to the ICU,
stabilized, and then called out to the general medicine floor.
The following is her course by problem.
.
# Upper GI bleed: Initially admitted to the ICU and started on
octreotide gtt. Admission hct was 32.7, stable from 32.8 several
days prior. Hct dropped to 28.8 the following morning after
hematemesis and roughly 3L IVF. The hct has remained roughly
stable since without transfusion. EGD [**2182-3-21**] showed 4 cords of
grade I varices at the lower third of the esophagus with portal
hypertensive gastropathy and 2 small nonbleeding ulcers in
duodenum. She was continued on [**Hospital1 **] PPI, carafate, and
prophylaxis with cipro for a 3 day course. Hct remained stable
at 30 at discharge.
.
# Alcoholic cirrhosis: The patient has met with SW during
previous admissions and attempts have been made to arrange for
detox and patient has had difficulty with compliance with
recurrent etoh use and missed appointments. T Bili and LFTs
elevated mildly above baseline on admission. She has remained
off lasix/aldactone over past month due to numerous binges/poor
po intake. Lactulose and nadolol were continued. Hepatology
followed the pt while in house, and the pt has follow up with
hepatology in [**4-27**].
.
# ETOH abuse/withdrawl: Pt has a history of DTs in the past.
She was treated here with valium per CIWA scale, thiamine, and
folate.
.
# Abdominal pain/Chronic pancreatitis: Pt had epigastric pain
with guarding on exam. Likely due to both vomiting, ulcers,
gastropathy, and chronic pancreatitis. Patient treated briefly
with IV narcotics, changed to po and then discharged off opiates
due to her well-documented history of opiate abuse. On multiple
occasions, she attempted to manipulate the medical staff to
maintain IV opiates for pain or to increase her pain med doses.
Her complaints of pain were out of proportion with her
functional status. She threatened to leave AMA when her
narcotics were changed from IV to oral. However, this was still
done and she backed down and stayed in hospital.
.
# Asthma: Noted mild wheezes on exam. Advair was started and pt
received Albuterol nebs PRN.
.
# Pancytopenia: Likely due to marrow suppression from ETOH abuse
as well as splenic sequestration. Platelets in 30s, hct stable
at 28. Last iron studies were borderline, and B12/folate were
WNL.
.
# Tobacco abuse: Written for nicotine patch
.
# Coagulopathy: secondary to cirrhosis.
.
Medications on Admission:
1. Albuterol 90 Two (2) Puff Q4H PRN
2. Sucralfate 1 gram PO QID
3. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS
4. Lactulose Thirty (30) ML PO TID
5. Docusate Sodium 100 mg PO BID
6. Senna 8.6 mg PO DAILY as needed.
7. Nadolol 20 mg PO once a day.
9. Thiamine HCl 100 mg PO once a day.
10. Omeprazole 20 mg PO twice a day.
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*1 bottle* Refills:*2*
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO QIDMWHS.
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): DO NOT USE IF YOU ARE SMOKING!!.
Disp:*30 Patch 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hematemesis
Anemia of acute GI bleed
Duodenal Ulcers
Grade 1 Esophageal Varices
Pancreatitis, ETOH
ETOH Abuse
Severe Thrombocytopenia
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Patient should return to the ED if hse is vomiting blood, has
large amounts of blood in her stool, has persistent high fevers.
YOU HAVE BEEN REPEATEDLY COUNSELLED AND STRONGLY INSTRUCTED TO
STOP DRINKING ALCOHOL COMPLETELY. ALCOHOL IS CAUSING MANY OF
YOUR MEDICAL ISSUES. WITHOUT STOPPING DRINKING ALCOHOL, THESE
MEDICAL ISSUES WILL WORSEN AND YOUR ABDOMINAL PAIN WILL WORSEN.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2182-3-26**] 11:00
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2182-5-6**] 9:30
|
[
"2851",
"2875",
"49390",
"3051"
] |
Admission Date: [**2156-8-7**] Discharge Date: [**2156-8-29**]
Date of Birth: [**2109-2-24**] Sex:
Service:
REASON FOR ADMISSION: Hypotension, hypoxia, sepsis,
complicated by multisystem organ failure, pneumonia,
acidosis.
The patient is a 47 year old female with a history of
multiple myeloma refractory to treatment who presents with
hypotension, respiratory failure, septicemia, pneumonia. She
was transferred from [**Hospital3 3583**] to [**Hospital6 649**] on [**2156-8-7**]. She developed a cough several
days prior to admission, according to her fiance on
[**2156-8-5**]. She was seen in the oncology clinic and
complained of progressive headache that had begun on [**2156-8-4**],
which she described as a band encompassing the perimeter of
her scalp. She had a history of hyperviscosity syndrome
secondary to her uncontrolled myeloma. She denied visual
changes, nausea or vomiting, or other symptoms at that time.
The patient had recently had plasmapheresis for
hyperviscosity/high IgG. That procedure was on [**2156-8-5**].
At the end of the procedure, she had shaking chills but no
fever and she was hemodynamically stable. On [**2156-8-6**] at
5:00 am, she had an unwitnessed fall and her fiance found her
nearly unresponsive and brought her to the [**Hospital1 46**] E.R.
She had temperature of 104 and was hypotensive. She received
I.V. fluids, four units of packed red blood cells, four units
of platelets, four units of FFP. Levophed and Neo-Synephrine
were started. She was intubated for acidosis. Antibiotics
were changed to Zosyn, sparfloxacin, vancomycin, and
Levaquin. She was dialyzed times two for acidemia.
Vasopressor was added. She was paralyzed and MedFlighted to
[**Hospital1 18**] for continued dialysis. Blood cultures were drawn and
grew out Gram-negative rods. Chest x-ray at [**Hospital1 46**] showed
right pneumonia. Later the blood cultures were to reveal
Pseudomonas.
PAST MEDICAL HISTORY: Notable for multiple myeloma diagnosed
in [**2156-2-14**], treated with thalidomide, prednisone, Decadron
and Cytoxan with refractory disease and continued myeloma.
The patient was found during this admission to have up to 22
percent of her peripheral blood smear to contain plasma
cells. The patient was also on Procrit and Lupron. She
received intermittent transfusions as an outpatient. She
also received plasmapheresis, the last time being on [**2156-8-5**],
the day prior to her collapse. Also she has history of
asthma.
ALLERGIES: No known drug allergies.
MEDICATIONS: Prior to massive septic shock included:
Metoprolol 150 mg b.i.d.
Nifedipine CR 30 q.day.
Allopurinol 100 mg q.day
Procrit 40,000 q.week.
Albuterol p.r.n.
Oxycodone p.r.n.
Her medications on transfer were:
Neo-Synephrine drip.
Levophed drip.
Ativan/fentanyl drips.
Vasopressin.
Sparfloxacin.
Zosyn.
PHYSICAL EXAMINATION: On the day of admission, her vital
signs at [**Hospital1 46**] revealed temperature 104, blood pressure
84/32 on Neo-Synephrine, breathing 25, 100 percent on AC 700,
14.5, FIO2 100 percent. On arrival at [**Hospital6 649**], her temperature was 98, her blood pressure
was 70/59, went up to 93/68, heart rate 110 on Levophed, Neo-
Synephrine and Vasopressin. Her vent settings were AC
500/26/5/1. Her gases on those settings were 7.19, 41, and
289 upon arrival. At [**Hospital3 3583**], she had 7 liters in
and 500 cc out. The patient was cyanotic, intubated,
anasarcic and non-responsive. Her pupils were equal,
minimally reactive at 3 mm to 2 mm. There was bleeding from
the oral and nasal mucosa. The patient had a right IJ
placed. She had bronchial breath sounds. She was
tachycardic, S1 and S2. No murmurs, rubs or gallops. She
had hypoactive bowel sounds. She is anasarcic. She had
diffuse mild erythroderma and she was unresponsive.
LABORATORY DATA: Laboratory values at [**Hospital3 3583**]
presentation: white count 3, hematocrit 27, platelets 134.
Chem-7: sodium 136, potassium 3.9, chloride 103, bicarb 20,
anion gap 13, BUN 24, creatinine 2.8.
At [**Hospital1 **] on [**2156-8-7**], the patient's bicarb
was 11 with an anion gap of 27. Platelets were 64, INR was
6, with picture being compatible with DIC. PTT was 72.5,
albumin 2.5, ALT 1719, AST 3421, compatible with shock liver.
LDH 4350. Her total bilirubin was 2.5, troponin 0.25, MB CK
467, MB 10, consistent with a non-ST elevation MI. Her
lactate was 12.3.
ASSESSMENT: 47 year old woman with multiple myeloma,
presented with pneumonia, Pseudomonas septic shock, with
multisystem failure, profound acidemia, anuria, shock liver,
myocardial infarction, DIC, and hypocalcemia. Her calcium
was 5.9.
HOSPITAL COURSE: HYPOTENSION SECONDARY TO GRAM-NEGATIVE
SEPTIC SHOCK: The patient was continued on pressors and
given many liters of I.V. fluids with a goal of MAP of 60.
CVPs were followed. An arterial line was placed and followed
as well for titration of pressors. She was initially started
on cefepime and vancomycin. When the Pseudomonas was
identified, she was treated with Zosyn and ciprofloxacin.
She completed a full course. Her pressors were eventually
weaned off and she completed a course of antibiotics for her
sepsis.
OTHER INFECTIOUS DISEASE ISSUES: The patient developed
fungemia secondary to central line, broad-spectrum
antibiotics and TPN. All her lines were removed and
peripheral IVs were placed. Cultures were drawn. The
patient was started on ampicillin. Ophthalmology consult was
done to rule out endophthalmitis. She had TEE with no
evidence of vegetations. After sterile blood cultures, she
had replacement of a central line. Fungus was identified as
[**Female First Name (un) 564**] albicans.
The patient developed herpes, crusted lesions in her
oropharynx and nasopharynx and on her nose. Derm was
consulted. DFA's were sent. Herpes virus grew out of them.
She was started on acyclovir. Encephalitis doses were used
due to the fact that the patient was unresponsive for the
length of her hospital course and it was impossible to know
whether she was suffering from encephalitis or not.
RESPIRATORY FAILURE: The patient was intubated. She
remained intubated throughout the course of her stay. She
remained on AC mode, unable to breathe herself. The
ventilator was used often to help blow off the metabolic
acidosis the patient had.
METABOLIC ACIDOSIS FROM LACTATE AND RENAL FAILURE: The
patient had CVVH and that was eventually titrated to regular
dialysis and patient was off of pressors. CVVH was done to
correct her acidemia. The patient also received liters of
bicarb drip in the acute episode to address her acidosis that
was not compatible with life.
HYPOTHERMIA: The patient had a temperature of the low 90s.
Bear hugger and warmed I..V. fluids were used to support her
and get her through her hypothermia.
ANEMIA: The patient had evidence of DIC at presentation,
also in conjunction with besides her septic shock her
myeloma, resulting in decreased production. The patient had
also oozing of blood from her mouth and from her lines and
from other sites during her stay secondary to DIC. She was
supported with FFP, platelet transfusions and red blood cell
transfusions. She had greater than 20 each of platelet and
red blood cell transfusions during the course of her stay in
the FI CU.
ELEVATED LFTS SECONDARY TO SHOCK LIVER
COAGULOPATHY SECONDARY TO DIC: The patient received, as
mentioned before, FFP, multiple units, throughout her stay
both for procedures as well as to prevent the oozing that she
had from multiple sites in her body, especially her
oropharynx.
HYPOCALCEMIA: The patient was on a calcium drip. This was
maintained especially during the CCVH where her hypocalcemia
became acutely worse. This also worsened her hypothermia.
MYELOMA: Dr. [**First Name (STitle) 1557**] followed the patient regarding her
myeloma, spoke to the family on multiple episodes saying that
there was no treatment that could be offered to the patient,
given the fact that she had already had multiple treatments
without response and that she presented with multi-system
organ failure with peripheral plasma cells and was deemed not
a candidate for further treatment of myeloma. Dr. [**First Name (STitle) 1557**]
played a further role in helping to talk to the patient's
family, her fiance, and close relatives at the end of the
patient's life.
FEN: The patient was NPO. She was on TPN, which led to
fungemia. The patient was a full code. The patient's fiance
served as healthcare proxy for the patient.
OTHER EVENTS: The patient had an intracranial bleed,
hyperintensity, small, on CAT scan done to evaluate the lack
of interaction that the patient had with the outside
throughout her hospital stay. She was not responsive to
voice or followed any commands. This bleed was stable
throughout her stay. Multiple CAT scans confirmed this and
she was supported with FFP and platelets to prevent further
bleeding. She had atrial fibrillation during her episode,
most likely in the context of volume overload and pressors.
She was hypotensive and had adenosine push once for what was
believed to be an early SVT, then was shocked and came out of
the atrial fibrillation. She remained in normal sinus rhythm
throughout the rest of her stay.
The patient received stress dose of steroids for her sepsis,
as she did not have an appropriate stress response.
Thrombocytopenia, as mentioned before, the patient had DIC
and was supported with platelets to prevent bleeding.
The patient during her stay was made cardiopulmonary
resuscitation not indicated, after a month in the hospital
with no improvement in her condition. On [**2156-8-28**], the
patient's condition began to worsen. After two units of
packed red blood cells, the patient began to become more
tachycardic, sinus tach at 150 - 160. She dropped her blood
pressure to the 80s, receiving boluses of fluid that brought
it back up to the mid-90s. The patient was sent for a
pulmonary CT to rule out pulmonary embolus that showed
diffuse patchy severe air-space disease consistent with ARDS,
pus, blood or capillary leak, with an PA:FIO2 ratio of less
than 200. Blood cultures were drawn on that day which
eventually grew out Pseudomonas aeruginosa in two out of four
bottles. The patient also had respiratory washings from that
day which also grew out Pseudomonas on her sputum.
Due to the patient's deterioration, a family meeting was held
by the author and the healthcare proxy, [**Name (NI) **] [**Name (NI) 6692**], who is
the patient's fiance. The patient's condition was explained
to the family and that the patient had gotten worse.
Reference was made to previous conversations with Dr. [**First Name (STitle) 1557**]
and Dr. [**Last Name (STitle) **], and decision was made to make the patient
comfort measures only. Drs. [**First Name (STitle) 1557**] and [**Name5 (PTitle) **] were notified
via e-mail and Dr. [**First Name (STitle) 1557**] was also called. The patient
passed away at 6:00 am with no spontaneous pulse or
respirations and was pronounced at that time.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981
Dictated By:[**Doctor Last Name 11627**]
MEDQUIST36
D: [**2157-5-19**] 18:37:44
T: [**2157-5-19**] 22:43:02
Job#: [**Job Number 48155**]
|
[
"51881",
"5845",
"41071"
] |
Admission Date: [**2125-4-30**] Discharge Date: [**2125-5-5**]
Date of Birth: [**2084-8-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Motrin / Naproxen / Vicodin / Tylenol/Codeine No.3
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
mitral regurgitation
Major Surgical or Invasive Procedure:
mitral valve replacement (25mm St. [**Male First Name (un) 923**]) [**2125-4-30**]
History of Present Illness:
This 40 year old Spanish speaking female presented with
complaints of dyspnea on exertion for a few months. She states
that she has noticed some ankle edema and 2 pillow orthopnea,
but no paroxysmal dyspnea. She was admitted to [**Hospital1 18**] with acute
heart failure and was diuresed with improvement. Echocardiogram
showed deformed mitral valve leaflets and 4+MR. She was
referred for surgical correction.
Past Medical History:
Hypertension
noninsulin dependent Diabetes Mellitus
Obstructive Sleep Apnea (uses CPAP)
Mitral Regurgitation
Anxiety
gastroesophageal reflux
BiPolar Disorder
h/o coma at [**Hospital1 2025**] for 6 months after MVA
s/p Hysterectomy
s/p right femoral rodding
s/p pelvic fracture
h/o fractured skull
s/p cyst excision right breast
Social History:
Patient lives with boyfriend. She smokes 10cig per day for 15
years. No ETOH/illicits.
Family History:
Brother passed away in his 30s from MI. Father passed away from
MI.
Physical Exam:
admission:
Pulse: Resp:26 O2 sat: 98% on 2L
B/P Right: 106/56
Height:5'3" Weight:167 LBS
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] Congested L conjunctiva, ? hemorrhage
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema +1
Varicosities:+1
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2125-5-3**] 05:20AM BLOOD WBC-14.2* RBC-2.94*# Hgb-8.8*# Hct-26.4*
MCV-90 MCH-30.1 MCHC-33.5 RDW-17.1* Plt Ct-186
[**2125-4-30**] 10:45AM BLOOD WBC-15.0*# RBC-2.16*# Hgb-6.6*#
Hct-20.3*# MCV-94 MCH-30.6 MCHC-32.5 RDW-13.9 Plt Ct-272
[**2125-5-3**] 05:20AM BLOOD PT-32.1* INR(PT)-3.2*
[**2125-4-30**] 10:45AM BLOOD PT-14.4* PTT-41.1* INR(PT)-1.2*
[**2125-5-2**] 04:17AM BLOOD Glucose-171* UreaN-16 Creat-0.9 Na-132*
K-4.5 Cl-101 HCO3-26 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 86151**] [**Hospital1 18**] [**Numeric Identifier 86152**] (Complete)
Done [**2125-4-30**] at 10:45:06 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2084-8-17**]
Age (years): 40 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Left ventricular function. Mitral valve disease.
Preoperative assessment. Shortness of breath.
ICD-9 Codes: 424.1, 394.0, 394.1, 424.2
Test Information
Date/Time: [**2125-4-30**] at 10:45 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW5-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 1.8 cm <= 3.0 cm
Aorta - Sinus Level: 2.5 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.2 cm <= 3.0 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Mitral Valve - Peak Velocity: 1.7 m/sec
Mitral Valve - Mean Gradient: 5 mm Hg
Mitral Valve - Pressure Half Time: 117 ms
Mitral Valve - MVA (P [**12-9**] T): 1.8 cm2
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%). [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR. Eccentric AR jet.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
thickening of mitral valve chordae. Mild valvular MS (MVA
1.5-2.0cm2). Moderate to severe (3+) MR. [**First Name (Titles) **] vena contracta is
>=0.7cm
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PREBYPASS
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). [Intrinsic
left ventricular systolic function is possibly more depressed
given the severity of valvular regurgitation.] Right ventricular
chamber size and free wall motion are normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque.The aortic valve leaflets (3)
are mildly thickened. Mild (1+) aortic regurgitation is seen.
The aortic regurgitation jet is eccentric. The mitral valve
leaflets are moderately thickened. There is mild valvular mitral
stenosis (area 1.5-2.0cm2). Moderate to severe (3+) mitral
regurgitation is seen. The mitral regurgitation vena contracta
is >=0.7cm.
POST BYPASS
Biventricular systolic function is preserved. There is a well
seated, well function, bileaflet mechanical prosthesis in the
mitral position. Valvular MR, which is normal in quantity and
location for this type of prosthesis, is visualized (washing
jets) The study is otherwise unchanged from the prebypass study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-4-30**] 11:01
?????? [**2117**] CareGroup IS. All rights reserved.
Brief Hospital Course:
She underwent mechanical mitral replacement on [**4-30**]. Please see
operative report for further details. She weaned from bypass on
Neo Synephrine and Propofol, weaned and extubated easily. All
lines and drains were discontinued in a timely fashion. Pressor
weaned off and she was transferred to the floor. As per Dr.[**Last Name (STitle) **],
atrial pacing wires were discontinued and the ventricular pacing
wires were cut, without difficulty.
Physical Therapy was consulted to evaluate her strength and
mobility. On POD 2 her hematocrit was found to be 20(repeated).
A CXR was unremarkable and she was stable. Two units of red
blood cells were given along with Lasix between units.
Anti-coagulation was initiated with coumadin and a heparin
bridge for goal INR 2.5-3.5. The remainder of her postoperative
course was essentially uncomplicated. On POD 5 she was cleared
for discharge to [**Hospital 2670**] rehab in [**Hospital1 487**] for further
increase in strength and mobility. INR on day of discharge was
2.7. Geodone and Klonopin were resumed for history of [**Hospital1 **]-polar
disorder. All follow up appointments were advised.
Medications on Admission:
Actos 30mg po daily
ASA 81mg po daily
Cyclobenzoprine 5mg po daily
Lisinopril 10mg po daily
Zolpidem 10mg po daily
Albuterol PRN
Flovent PRN
Erythromycin ointment
Clonazepam 2mg po PRN
Trazadone 100mg po daily
Geodone 80mg (not taking)
Singulair
Omeprazole 20mg po daily
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day).
10. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
14. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for sleep.
15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
Q6H (every 6 hours) as needed for itching.
16. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 10 Units of Glargine at breakfast.
17. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig:
One (1) Subcutaneous four times a day: dose per sliding scale
QID.
18. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
as needed for anxiety.
19. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
20. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
21. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
22. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
23. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Dose daily for goal INR 2.5-3.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Care& Rehab- Wood Mill
Discharge Diagnosis:
mitral regurgitation
s/p MVR (#25mm St.[**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 86153**])-[**4-30**]
anxiety
gastroesophageal reflux
obstructive sleep apnea
hypertension
noninsulin dependent diabetes mellitus
s/p femoral rodding
bipolar disorder
s/p hysterectomy
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with oral analgesics.
Incisions:
sternal - healing well, no erythema or drainage
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming until cleared by surgeon. Look at your
incisions daily for redness or drainage.
No lotions, cream, powder, or ointments to incisions.
Each morning you should weigh yourself and then in the evening
take your temperature, These should be written down on the chart
.
No driving for approximately one month, until follow up with
surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns ([**Telephone/Fax (1) 170**]).
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of sternal wound.
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) **] on [**6-6**] at 1pm ([**Telephone/Fax (1) 170**])
Please call to schedule appointments with:
Primary Care: Dr. [**First Name4 (NamePattern1) 20204**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 63309**]) in [**12-9**] weeks
Cardiologist: Dr. [**Last Name (STitle) **] in [**12-9**] weeks
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Labs: PT/INR for Coumadin ?????? #25mm ST.[**Male First Name (un) 923**] Mechanical Mitral
valve
Goal INR: 2.5-3.5
To be managed by rehab during stay, following discharge, Dr.
[**Last Name (STitle) **] will manage
First draw: upon discharge from rehab
Results to: Dr.[**Last Name (STitle) **] (Cardiologist)
phone: [**Telephone/Fax (1) 42006**]
Completed by:[**2125-5-5**]
|
[
"2851",
"4019",
"4280",
"2767",
"25000",
"32723",
"53081"
] |
Admission Date: [**2126-11-3**] Discharge Date: [**2126-11-7**]
Date of Birth: [**2044-8-30**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Change in mental status
Major Surgical or Invasive Procedure:
Left burr hole craniotomy
History of Present Illness:
Patient is a 82 year old RHM with Afib on Coumadin,
dementia, BPH, HTN, hypercholesterolemia and possible colon
cancer here after several unwitnessed falls today. Patient is
unable to give own history hence the history obtained per family
at bedside including daughter, [**Name (NI) **] [**Last Name (NamePattern1) **] who is the HCP.
She reports that the patient has had dementia for several years
and just moved into an [**Hospital3 **] facility with his wife
three months ago. He had an unwitnessed fall three weeks ago
and
was found to have black eye and sprained ankle but no head
imaging was obtained at that time.
Per family, he has been significantly declining in his mental
status including his speech and gait since then with increased
falls. He supposedly fell three times today. His wife heard
"thud" three times and found him on the floor each time although
unclear if he hit his head. His memory has been much worse
recently as well including inability to recall even his
[**Hospital1 **] names.
Of note, he has had gradual decline in his appetite and lost
significant amount of weight. He also reported abdominal
discomfort and bloating and was evaluated with abdominal CT
three
days ago that revealed multiple masses in his colon. He is
scheduled for further evaluation including PET next week per his
PCP (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 86987**]). Per daughter, his Coumadin
was discontinued three days ago for his abdominal CT.
Past Medical History:
1. Afib on Coumadin - Coumadin discontinued three days ago for
abdominal CT per family.
2. HTN
3. Hypercholesterolemia
4. BPH
5. Dementia
6. Colon cancer? - multiple lesions seen on abdominal CT a few
days, currently awaiting further evaluation.
7. s/p R hip replacement x2
8. s/p L TKR
Social History:
Lives in an [**Hospital3 **] facility with wife - moved
in only three months ago. Retired professor [**First Name (Titles) 767**] [**Last Name (Titles) **]. No
smoking or EtOH.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T:95.6 BP: 155/73 HR:71 R: 18 O2Sats 98% RA
Gen: WD/WN, NAD.
Neck: Supple.
Lungs: CTA
Cardiac: Irregularly irregular.
Abd: Soft, NT, BS+
Extrem: 2+ edema in both feet upto malleoli.
Neuro:
Mental status: Awake and alert, intermittently cooperative with
exam, normal affect.
Orientation: Oriented to person only. Unable to say hospital
and
does not know the month or year. However, knows that [**Last Name (un) 2753**] is
the president although initially said "[**Last Name (un) 86988**]."
Language: Speech fluent with intact repetition. Comprehension
appears poor - likely due to inattention. Unable to do DOW
forwards or even count down from 20. Lots of paraphasic errors
and +dyspraxia.
Cranial Nerves:
II: Pupils equally round but meiotic and minimally reactive.
Visual fields appear full but difficult to test formally due to
his inattention.
III, IV, VI: Extraocular movements intact.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements.
R
pronator drift and appears to have R deltoid and IP weakness.
Sensation: Intact to light touch, cold and pinprick bilaterally.
Reflexes: B T Br Pa Ac
Right 2 1 2 2 2
Left 2 1 2 2 2
?2 beat clonus in both ankles.
Toes appear downgoing but TFL contraction bilaterally.
Coordination: Slow but accurate FTN and FTF but very slow [**Doctor First Name **]
On discharge: HE is awake and alert. He is oritnetd to person.
PERRLA, EOMI, face symmetrical. MAE symmmetrically. Slight Right
pronator drift.
Pertinent Results:
[**2126-11-2**] 09:10PM PT-20.9* PTT-28.9 INR(PT)-1.9*
[**2126-11-2**] 09:10PM PLT COUNT-209
[**2126-11-2**] 09:10PM NEUTS-63.8 LYMPHS-26.3 MONOS-8.0 EOS-1.5
BASOS-0.5
[**2126-11-2**] 09:10PM WBC-6.4 RBC-3.95* HGB-9.3* HCT-29.0* MCV-73*
MCH-23.6* MCHC-32.2 RDW-17.5*
[**2126-11-2**] 09:10PM GLUCOSE-96 UREA N-13 CREAT-0.8 SODIUM-136
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-24 ANION GAP-13
CT head [**11-3**] from outside facility
Shows L chronic subdural hematoma with 10mm midline shift to the
right.
CT head [**11-3**] Post operative
1. Status post left frontal craniotomy and evacuation with
expected
post-surgical pneumocephalus and slight decrease in mixed
density extra-axial
fluid collection compared to the prior study. No evidence of new
hemorrhage.
2. Marked sulcal effacement in the left cerebral hemisphere and
slightly
decreased rightward shift of normally midline structures
compared to the prior
study.
Brief Hospital Course:
[**11-3**] Pt taken to the OR for L burr hole craniotomy after he was
transferred from OSH after a large left sided chronic SDH was
found on ct scan. Prior to his procedure he received multiple
units of FFP to correct an elevated INR in the setting of home
Coumadin therapy. His INR responded well to value less than 1.3.
Pt tolerated his procedure well with no complications. Post
operatively he was transferred to the ICU for further care
including q1 neurochecks and strict blood pressure control less
than 140 systolic.
On post op exam pt is improved. He is slightly more awake and
alert and will follow simple commands. He is moving all
extremities with full strength and his surgical site is clean
and dry with no active drainage. Post operative CT scan showed
good evacuation of subdural hematoma with frontal pneumocephalus
and some improvement in midline shift.
[**2037-11-3**] Pt transferred to the floor in stable condition and his
diet was advanced. He had no difficulty taking PO diet and was
able to void on his own. He was seen by physical therapy and
plan was for discharge to rehab. Family was concerned about new
diagnosis of colon CA and requested guidance and workup.
Heme/onc was consulted for guidance a recommended a palliative
care consult.
On [**11-6**], patient exam remains stable and social work consult was
placed for discussion of colon CA. He was being screened for
rehab. HE met with palliative care and hem/onc on [**11-7**] to
discuss his colon cancer diagnosis. He was transferred to rehab
on [**2126-11-7**].
Medications on Admission:
1. Aricept 10mg daily
2. Flomax 0.4mg daily
3. Lasix 20mg daily
4. Lipitor 10mg daily
5. Metoprolol 50/25mg
6. Lotensin 40mg daily
7. Potassium 20MeQ daily
8. Coumadin 5mg at night
Discharge Medications:
.
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
7. Benazepril 10 mg Tablet Sig: Four (4) Tablet PO daily ().
8. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO DAILY (Daily).
13. Insulin Regular Human 100 unit/mL Solution Sig: Two (2)
units Injection ASDIR (AS DIRECTED): see scale.
14. Phenytoin 50 mg Tablet, Chewable Sig: 2.5 Tablet, Chewables
PO QAM (once a day (in the morning)).
15. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO NOON (At Noon).
16. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO QPM (once a day (in the evening)).
17. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
18. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Five (5) mg
Intravenous Q4H (every 4 hours) as needed for tachycardia,
hypertension.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
left chronic subdural hematoma
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:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery.
MEDICATIONS
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your
rehab/nursing facility.
?????? You can take your Coumadin on [**11-17**].
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
Follow-Up Appointment Instructions
??????You can have your sutures removed at rehab on [**11-13**]. 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.
Completed by:[**2126-11-7**]
|
[
"42731",
"V5861",
"2720"
] |
Admission Date: [**2133-3-6**] Discharge Date: [**2133-3-12**]
Date of Birth: [**2084-3-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Transferred to ICU for monitoring of alcohol withdrawal
Major Surgical or Invasive Procedure:
Endotracheal intubation.
Subclavian central venous line insertion.
History of Present Illness:
48 y/o male with history of alcohol abuse presents after having
two episodes which he describes as seizures. Unable to get
report from his girlfriend, who was the only witness to theses
episodes. Unclear if he lost consciousness or had a postictal
period. He reports that he drank a case of beer and 3 half pint
bottles of vodka yesterday, his last drink was at around 10 PM
on the night of [**2133-3-5**].
In the [**Hospital1 18**] ED, he complained of nausea, vomiting, dizziness,
shaking, fever/chills, chest pain, and visual hallucinations
which he reports as seeing spots. He denies auditory
hallucinations. He received Thiamine, Folate, 4 mg Ativan, and
40 mEq potassium repletion for a potassium of 2.8.
Past Medical History:
? CAD with reported MI [**35**] years ago
Thrombocytopenia, thought secondary to alcohol use
Lower leg pain
ETOH abuse
h/o hypercholesterolemia per prior d/c summary
h/o prior IVDU though he denies this to me, girlfriend similarly
denies. + distant nasal cocaine use
Social History:
Patient currently lives with his girlfriend in [**Name (NI) 86**], MA
although he has previously engaged in sexual intercourse with
men as well. He and his girlfriend report they were recently HIV
negative.
ETOH: 1-1.5 pints of liquor each day. This has been going on
since age 14. He has attempted to quit in the past but has
relapsed each time. He lives with his girlfriend. His girlfriend
and her daughter are involved in his care.
Tobacco: Smokes 1-1.5 packs of cigarettes per day (50+ pack year
history).
IVDU: Denies
Family History:
Positive for lung cancer in his mother & father. His brother had
HIV from sexual contact.
Physical Exam:
T 98.3 BP 162/100 HR 96 RR 14 SAT 99% 2L
HEENT: Head Atraumatic. Pupils 3mm and reactive to light. Sclera
anicteric. Throat clear.
NECK: No LAD. Normal carotid pulses.
CHEST: Large lungs fields. Lungs with poor air movement. No
wheezes.
HEART: Regular rhythm. No murmurs, gallops, rubs.
ABD: NABS, Soft, NT, ND, no organomegaly.
EXT: Thin legs. No edema. Good peripheral pulses.
NEURO: Mental status- oriented to person and place, but not time
(year [**2102**]). Cranial nerves- significant jerky eye movements
with no localizing directionally. Tongue midline. Motor strength
intact in upper and lower extremities. Toes upgoing bilaterally.
Pertinent Results:
[**2133-3-6**] 07:40PM PLT SMR-LOW PLT COUNT-84*#
[**2133-3-6**] 07:40PM NEUTS-83.3* LYMPHS-10.3* MONOS-5.3 EOS-0.4
BASOS-0.7
[**2133-3-6**] 07:40PM WBC-8.8 RBC-4.03* HGB-12.8* HCT-36.9* MCV-92
MCH-31.7 MCHC-34.6 RDW-13.8
[**2133-3-6**] 07:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2133-3-6**] 07:40PM CALCIUM-9.3 PHOSPHATE-2.3*# MAGNESIUM-1.3*
[**2133-3-6**] 07:40PM estGFR-Using this
[**2133-3-6**] 07:40PM GLUCOSE-164* UREA N-8 CREAT-0.6 SODIUM-136
POTASSIUM-2.8* CHLORIDE-95* TOTAL CO2-27 ANION GAP-17
AT DISCHARGE
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2133-3-12**] 03:56AM 7.8 3.45* 11.0* 31.7* 92 32.0 34.8 13.8
179
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2133-3-6**] 07:40PM 83.3* 10.3* 5.3 0.4 0.7
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2133-3-12**] 03:56AM 179
HEMOLYTIC WORKUP Ret Aut
[**2133-3-7**] 03:26AM 1.1*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2133-3-12**] 03:56AM 92 7 0.5 138 3.6 100 29 13
CT HEAD W/O CONTRAST [**2133-3-10**] 11:58 AM
CT HEAD W/O CONTRAST
Reason: please rule out bleed
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with ETOH withdrawal with persistent altered
mental status.
REASON FOR THIS EXAMINATION:
please rule out bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 48-year-old man with alcoholic withdrawal with
persistent altered mental status. Rule out bleed.
COMPARISON: [**2132-11-27**].
TECHNIQUE: Non-contrast head CT.
CT HEAD WITHOUT CONTRAST: There is motion artifact, which
degrades the quality of the study. Soft tissues and partial
posterior skull are excluded, which represents a technical
positioning error.
FINDINGS: No intracranial mass lesion, hydrocephalus, shift of
normally midline structures, minor or major vascular territorial
infarct is apparent. The density values of the brain parenchyma
are within normal limits. The visualized osseous structures
demonstrate no evidence of fracture. Minimal maxillary mucosal
sinus thickening, bilaterally.
IMPRESSION: No acute intracranial pathology, including no sign
of intracranial hemorrhage. Technically suboptimal study, as
noted above.
Brief Hospital Course:
A/P: 48 y/o alcoholic male presenting with nausea, vomiting,
dizziness, shaking, fever/chills, and chest pain, likely due to
alcohol withdrawal.
.
# Alcohol Abuse/Withdrawal: the last drink was 10 PM on [**2133-3-5**].
He has a history of Delirium Tremens and Seizures as well as a
history of heavy benzodiazepine requirements in the past to the
point of intubation. The patient required>300 mg Valium the
first 48 hours, as well as 8-10 mg Ativan. He had to be placed
on soft restraints due to severe agitation. He developed
hallucinosis but no DTs or seizures. Initially, CIWAs>30, but
steadily decreased and 24 hours prior to discharge the patient
required no benzos, haldol or restraints. Thiamine was repleted
in ED and subsequently the patient received one liter banana bag
daily IV with thiamine, folate, multivitamin. LFTs and coags
remained stable.
.
# Nausea/Vomiting: Resolved within the first 24 hours. The
patient did not take POs until 24 hours prior to discharge,
first because of severe agitation and stupor, and 48 hours prior
to discharge because of sedation. He was kept well hydrated and
is discharged tolerating a regular diet.
.
# Respiratory Distress: On [**3-10**], the patient desatted to low
80s, possibly due to aspiration in the setting of severe
agitation. He was instubated to protect his airway. He remained
afebrile, CXR indeterminate not specific for pneumonia or
pneumonitis, and was successfully extubated 24 hours later. On
Levofloxacin for which he needs to continue 10 more days.
.
# Shaking: There was no evidence of seizures. Shaking stoppd as
withdrawal resolved. He had CK>1000 that rapidly trended down as
his shaking resolved.
.
# Reported Fever/Chills: Differential includes alcohol
withdrawal and infection. The patient remained afebrile with no
leukocytosis.
.
# Hypokalemia: Differential includes vomiting, diarrhea, poor
nutritional intake. Potassium was repleted prn.
.
# Hypomagnesemia: Differential includes poor nutrition intake.
Mg was repleted.
.
# Hypophosphatemia: Differential includes poor nutritional
intake. Phos was repleted.
.
# Anemia: Differential includes impaired RBC production from
B12, folate, iron deficiency or bone marrow suppression,
infiltration vs. RBC destruction vs. blood loss. Iron, folate
and B12 were checked and were normal. Active T and S was kept,
but the patient required no transfusions and his Hct remained
stable. His anemia is probably due to etoh induced bone marrow
suppression. Retic was 1.1
.
# Thrombocytopenia: He has a history of thrombocytopenia in the
past. Differential includes decreased platelet production from
marrow suppression or infiltration vs. platelet destruction vs.
consumption vs sequestration. Spleen tip not palpable.
.
Prophylaxis: SQ heparin. Pantoprazole. Nicotine patch for
smoking history.
.
Diet: Regular but patient unable to take POs except occasionally
due to agitation. 24 hours prior to discharge, he was able to
tolerate a regular diet and ensure supplements.
.
Code: Full.
.
Contact: [**Name (NI) 6480**] [**Name (NI) 110320**] [**Telephone/Fax (1) 110321**]
Medications on Admission:
None
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Ensure Shakes
Disp # 30 day supply
Sig: Take 1 shake with meals for 30 days.
5. Nicotine 22 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day.
Disp:*10 patch* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Withdrawal.
Respiratory failure
Discharge Condition:
Good. Eating and drinking, no signs of active withdrawal.
Discharge Instructions:
You were admitted for alcohol withdrawal. You required a brief
period of time on a ventilator for respiratory distress.
You should never drink any alcohol ever again.
We strongly recommend checking into an inpatient alcohol abuse
treatment program directly after leaving the hospital.
Please take your medications only as prescribed.
Followup Instructions:
Inpatient alcohol treatment program.
|
[
"51881",
"5070"
] |
Admission Date: [**2114-11-25**] Discharge Date: [**2114-11-27**]
Date of Birth: [**2047-3-21**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 11974**]
Chief Complaint:
refractory ventricular tachycardia
Major Surgical or Invasive Procedure:
[**2114-11-26**] - Left-sided video-assisted thorascopic surgery (VATS)
with sympathectomy
History of Present Illness:
67 year old female with idiopathic dilated cardiomyopathy (?
viral myocarditis 10 years ago) with LVEF of 20% sp BiV ICD,
moderate mitral regurgitation (improved on recent echo), who is
s/p L VATS for sympathectomy in setting of recurrent VT. The
patient is currently endorsing pain in her incision site and is
rather somnolent. She is in NSR currently.
.
The patient has had a long course of admissions since [**Month (only) 359**]
[**2113**] for recurrent VT and ICD firings. She was found to have
multiple inducible VTs arising from the septum, lateral wall and
apex. Septal origin of VT precluded ablation. She was started on
mexilitine. She continued to have frequent sustained VT.
Anterior septal ablation was attempted, but she did experience
recurrent VT and shocks x2. She was readmitted and had
successful stellate ganglion block and was started on qunidine.
About one week later, she did have recurrent palpitations. She
was readmitted for repeat stellate ganglion block. Dr. [**Last Name (STitle) **]
saw the patient on [**11-15**] and reprogrammed the ICD to have LV pace
before the RV by 50msec to improve low cardiac output since her
main issue is low CO and orthostasis. He started midrodrine 5mg
TID.
.
At time of admission, the patient felt well, her last episode of
firing and palpitations was 4 days ago. No symptoms since then.
Reports SOB with ambulation from bedroom to kitchen, this is
chronic x 12 years. No chest pain.
.
REVIEW OF SYSTEMS
On review of systems, she 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. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema.
Past Medical History:
1. CARDIAC RISK FACTORS: None.
2. CARDIAC HISTORY: Idiopathic dilated cardiomyopathy (?viral
myocarditis), EF 20-25%%.
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: ICD and BiV device
3. OTHER PAST MEDICAL HISTORY:
- Osteoarthritis
- h/o Gout
- Stellate Ganglion Block x2
Social History:
Tobacco history: Denies.
-ETOH: rare
-Illicit drugs: Denies.
The patient lives with her husband.
Family History:
Negative for premature atherosclerotic cardiovascular disease
and sudden death. There is no diabetes or hypertension in the
family history.
Son: viral induced DM1
Father- MI [**66**]
Mother- died at 93
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T= 97.5 BP=89/49, HR= 72 RR=18O2 sat=100%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Soft 1/6 systolic murmur left sternal
border. 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.
SKIN: stasis dermatitis on bilateral shins, 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+
DISCHARGE EXAM Notable for R hand-cold; L hand-warm, otherwise
unchanged. PERRL.
Pertinent Results:
ADMISSION LABS:
[**2114-11-25**] 09:47PM BLOOD WBC-6.8 RBC-3.40* Hgb-10.9* Hct-32.5*
MCV-96 MCH-32.0 MCHC-33.5 RDW-13.4 Plt Ct-204
[**2114-11-25**] 09:47PM BLOOD PT-11.0 PTT-35.7 INR(PT)-1.0
[**2114-11-25**] 09:47PM BLOOD Glucose-108* UreaN-34* Creat-1.5* Na-142
K-4.3 Cl-103 HCO3-27 AnGap-16
[**2114-11-26**] 07:15AM BLOOD ALT-23 AST-21 LD(LDH)-185 AlkPhos-72
TotBili-0.3
[**2114-11-25**] 09:47PM BLOOD Calcium-8.6 Phos-4.0 Mg-2.4
.
MICROBIOLOGIC DATA:
[**2114-11-26**] Urine culture - pending
.
IMAGING STUDIES:
[**2114-11-26**] CHEST (PORTABLE AP) - Small left apical pneumothorax.
Subcutaneous gas in left chest wall. New surgical clips
projecting over left upper mediastinum. Final radiology report
pending.
.
[**2114-11-27**] CHEST (PORTABLE AP) - pending
DISCHARGE LABS:
[**2114-11-27**] 04:39AM BLOOD WBC-8.6# RBC-3.46* Hgb-11.0* Hct-33.5*
MCV-97 MCH-31.8 MCHC-33.0 RDW-13.7 Plt Ct-182
[**2114-11-27**] 04:39AM BLOOD Glucose-95 UreaN-23* Creat-1.0 Na-141
K-4.1 Cl-107 HCO3-26 AnGap-12
[**2114-11-27**] 04:39AM BLOOD ALT-24 AST-33 LD(LDH)-193 AlkPhos-67
TotBili-0.4
[**2114-11-27**] 04:39AM BLOOD Albumin-3.2* Calcium-8.7 Phos-4.1 Mg-2.3
Brief Hospital Course:
IMPRESSION: This is a 67-year-old woman with an idiopathic
dilated cardiomyopathy with LVEF of 20% (? viral myocarditis,
non-ischemic) status-post biventricular ICD placement, moderate
mitral regurgitation, recurrent episodes of multifocal
ventricular tachycardia who is status-post partial ablation in
[**2114-10-25**] and stellate ganglion block (x 2) who presented for
sympathectomy procedure.
.
# RECURRENT, MULTIFOCAL VENTRICULAR TACHYCARDIA - The patient
has a history of recurrent, multifocal ventricular tachycardia
for which she has undergone partial ablation and stellate
ganglion block twice, previously. She went to the operating room
with Thoracic Surgery on [**2114-11-26**] and had a left-sided
video-assisted thoracoscopic surgery (VATS) procedure with
sympathectomy without issues. She was monitored on telemtry
without significant issues and her electrolytes were optimized.
Her incisions were clean, dry and intact without evidence of
drainage. Her CXR the evening of her procedure did demonstrate a
small, ipsilateral apical pneumothorax, however, her oxygen
saturations were optimal and she had no dsypnea symptoms, so
this was closely monitored conservatively. A repeat CXR in the
AM on [**11-27**] showed pneumothorax of unchanged size on preliminary
read, but the final read should be followed up.
.
# PRIOR TRANSAMINITIS - The patient had prior transminitis noted
while she was being treated with Amiodarone and Mexiletine;
these were thought to be the culprit agents driving her abnormal
liver tests. However, they were also elevated on last admission
when both of these medications were held. Congestive hepatopathy
was also considered, but she appeared euvolemic on exam with
reassuring JVP, no crackles, and no peripheral edema. LFTs were
reassuring this admission.
.
# IDIOPATHIC DILATED CARDIOMYOPATHY - Patient has a history of
idiopathic dilated cardiomyopathy with an LVEF of 20% (thought
to be attributed to viral myocarditis, non-ischemic in origin)
and she is status-post biventricular ICD placement, with
evidence of moderate mitral regurgitation of her 2D-Echo
imaging. She has had heart failure for roughly 12-yeras and is
currently being managed on a beta-blocker, Torsemide and with an
aldosterone-antagonist, which were all continued this admission.
She has not been on an ACEI/[**Last Name (un) **] given her chronic renal
insufficiency.
.
# CHRONIC RENAL INSUFFICIENCY - The patient has a baseline
creatinine of 1.4-2.0. On this admission, her creatinine was
stable in the 1.3-1.5 range. Her medications were renally dosed,
and nephrotoxins were avoided.
.
# OSTEOARTHRITIS - On exam, she has mild Heberdan's nodules
noted in her distal extremities. The patient notes her symptoms
are relieved with Tylenol only.
.
# GOUT - We continued her home dosing of Allopurinol 100 mg PO
daily without issues. She had no evidence of acute flare this
admission.
.
TRANSITION OF CARE ISSUES:
1. CODE STATUS DURING THIS ADMISSION: FULL CODE
2. CONTACT: husband, [**Name (NI) 401**] [**Name (NI) **], [**Telephone/Fax (3) 27849**]
3. PENDING STUDIES: please follow up final read of CXR done
[**11-27**].
Medications on Admission:
allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for anxiety.
torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO BID (2 times a day).
magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
Midodrine 5mg TID (started few days ago)
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for anxiety.
5. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
7. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain: Avoid taking this medication while
consuming alcohol; or if you anticipate driving.
Disp:*40 Tablet(s)* Refills:*0*
12. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Recurrent ventricular trachyarrhythmia
.
Secondary Diagnoses:
1. Idiopathic dilated cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Coronary Care Unit (CCU) at [**Hospital1 771**] on [**Hospital Ward Name 121**] 6 following your left-sided
video-assisted thorascopic surgery (VATS) with sympathectomy for
your recurrent ventricular arrhythmia. You tolerated the
procedure well and were discharged home in stable condition.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Oxycodone 5 mg (1-2 tablets) by mouth every 4 hours as
needed for pain. Avoid taking this medication if your anticipate
driving or if you are consuming alcohol.
START: Colace 100 mg by mouth twice daily and Senna 8.6 mg (1
tablet) by mouth twice daily, for constipation.
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**]
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 8724**]
Phone: [**Telephone/Fax (1) 8725**]
** The office is working on an appt for you in the next week and
will call you at home with an appt. If you dont hear from them
in the next two days, please call them directly to book.
.
Department: THORACIC SURGERY
When: THURSDAY [**2114-12-6**] at 3:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
|
[
"5859",
"4240"
] |
Admission Date: [**2189-10-17**] Discharge Date: [**2189-11-3**]
Date of Birth: [**2132-7-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20846**]
Chief Complaint:
57 year old male with polycythemia [**Doctor First Name **] for twelve years, who
after long period of medical management had splenectomy at
[**Hospital6 **] complicated by hypotension and drop in
hematocrit, also with renal failure with creatinine to 2.6, then
transferred to [**Hospital1 18**] and blood in right upper quadrant on CT
scan.
Major Surgical or Invasive Procedure:
exploratory laparotomy and hematoma evacuation
History of Present Illness:
57 year old male with polycythemia [**Doctor First Name **] for twelve years, who
after long period of medical management had splenectomy at
[**Hospital6 **] complicated by hypotension and drop in
hematocrit, also with renal failure with creatinine to 2.6, then
transferred to [**Hospital1 18**] and blood in right upper quadrant on CT
scan.
Past Medical History:
polycythemia [**Doctor First Name **], myelolplastic metaplasia, ankylosing
spondylitis, open splenectomy
Social History:
married, lives with wife and son, no tobacco, no alcohol
Family History:
mother with lung cancer, father with DM, no history of
hematologic disorders
Physical Exam:
97.6 degrees, HR 112, 104/78, 100% on NRB
Ill appearingm pleasant, appears slightly short of breath
NCAT slight scleral icterus, dry mucous membranes, PERRL, EOMI
tachy, s1 and s2, no m/r/g
CTAB with slightly decreased breath sounds at bases bilaterally,
no wheezes or crackles
distended with surgical staples in place, nontender to
palpation, some ascites
no clubbing, cyanosis, edema
CNII-XII intact, normal strength and sensation
Pertinent Results:
[**2189-11-1**] 10:25AM BLOOD Hct-28.7*
[**2189-11-1**] 10:25AM BLOOD Hct-28.0*
[**2189-11-1**] 12:30AM BLOOD Hct-25.2*
[**2189-10-31**] 07:14AM BLOOD Hct-28.3*
[**2189-10-31**] 01:15AM BLOOD Hct-27.6*
[**2189-10-30**] 05:30AM BLOOD WBC-32.3* RBC-3.27* Hgb-8.6* Hct-29.4*
MCV-90 MCH-26.4* MCHC-29.4* RDW-22.3* Plt Ct-591*
[**2189-10-28**] 05:40AM BLOOD WBC-35.2* RBC-3.08* Hgb-8.0* Hct-27.7*
MCV-90 MCH-26.0* MCHC-28.9* RDW-21.2* Plt Ct-538*
[**2189-11-2**] 05:35AM BLOOD PT-15.1* PTT-54.6* INR(PT)-1.4
[**2189-11-1**] 07:17PM BLOOD PT-15.4* PTT-69.2* INR(PT)-1.5
[**2189-11-1**] 10:25AM BLOOD PT-15.8* PTT-75.8* INR(PT)-1.6
[**2189-11-1**] 10:25AM BLOOD PT-15.5* PTT-71.0* INR(PT)-1.5
[**2189-10-31**] 04:30PM BLOOD PT-15.4* PTT-63.6* INR(PT)-1.5
[**2189-10-31**] 07:14AM BLOOD PT-16.2* PTT-88.9* INR(PT)-1.7
[**2189-10-31**] 01:15AM BLOOD PTT-97.9*
[**2189-10-30**] 04:00PM BLOOD PTT-79.1*
[**2189-10-30**] 05:30AM BLOOD Plt Smr-VERY HIGH Plt Ct-591*
[**2189-10-30**] 05:30AM BLOOD Plt Smr-VERY HIGH Plt Ct-591*
[**2189-10-28**] 10:15AM BLOOD PTT-76.9*
[**2189-10-28**] 12:00AM BLOOD PTT-51.5*
[**2189-10-18**] 09:43PM BLOOD Plt Smr-VERY HIGH Plt Ct-627* LPlt-3+
[**2189-10-18**] 05:26PM BLOOD Plt Smr-VERY HIGH Plt Ct-645*
[**2189-10-18**] 05:26PM BLOOD PT-15.2* PTT-28.9 INR(PT)-1.5
[**2189-10-18**] 05:32AM BLOOD Plt Ct-632* LPlt-3+
[**2189-10-20**] 09:41PM BLOOD Plt Smr-VERY HIGH Plt Ct-864* LPlt-3+
[**2189-10-21**] 09:45AM BLOOD Plt Ct-948* LPlt-3+
[**2189-10-21**] 09:46PM BLOOD Plt Smr-VERY HIGH Plt Ct-976* LPlt-3+
PltClmp-1+
[**2189-10-23**] 03:54AM BLOOD PT-15.7* PTT-36.9* INR(PT)-1.6
[**2189-10-23**] 02:26PM BLOOD PT-16.3* PTT-65.8* INR(PT)-1.7
Brief Hospital Course:
Patient admitted to [**Hospital1 69**] to
medical service and serial hematocrit checks performed,
initially at 20.8, patient transfused 1 unit of packed red blood
cells and surgery consulted. Patient was seen by surgery at
130am on [**10-18**] and patient was then brought to operating room
for exploratory laparotomy where clot was found and removed from
splenic artery/vein.
The patient was admitted to the SICU at this time and was
resuscitated appropriately with 3 units PRBC and 2 units FFP and
was followed by the hematology service. Hematocrit was being
checked serially every 6 hours. The ventilator was slowly
weaned at this time, epidural catheter that had been placed at
the outside hospital was discharged, and hydroxyurea and
supportive care for myeloid metaplasia was continued.
On [**10-20**] patient found to have portal vein thrombosis on liver
ultrasound and no PE on CTA. Patient started on heparin drip
and coagulation labs followed closely. Also found to have a
pneumonia on CXR and culture and started on Zosyn which was then
switched to vanco, imipenem, flagyl.
On [**10-22**] while patient in angio suite for portal vein
thrombectomy he became bradycardic and then pulseless with
hypotension, patient resuscitated, given atropine, epinephrine,
ACLS protocol followed, fluid bolus given, heart rate returned
to baseline after brief bout of SVT and patient returned to
SICU.
Solumed and benadryl also given in case of dye reaction. Cordis
and Swan catheters placed for further monitoring.
TPN started on [**10-24**] and stopped on [**10-29**]. Heparin drip
continued and goal of PTT 60-80 established and drip adjusted
accordingly throughout his stay here.
On [**10-27**] patient extubated and Swan line removed, NG tube removed
and patient discharged to floor from ICU. Coumadin started with
goal INR of 2.5 to 3.0, this was slow to rise to the therapeutic
levels. C diff negative. Also given lasix [**Hospital1 **] for purposes of
diuresis.
On [**10-31**] patient's PICC line removed due to bleeding at the
site. Pressure dressing applied and HCT checked and no
transfusion deemed necessary for HCT 25.2. Bleeding controlled
and patient throughout without any complaints of
lightheadedness, dizziness, palpiations, chest pain, or
shortness of breath. Imipenem was then stopped and patient was
now not on any antibiotics. On the day of discharge patient
stable and tolerating a regular diet.
Medications on Admission:
hydroxyurea, diclofenac, zantac
Discharge Medications:
1. Hydroxyurea 500 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) for 1 doses.
9. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
polycythemia [**Doctor First Name **], myelolplastic metaplasia, ankylosing
spondylitis, open splenectomy, portal vein thrombosis
Discharge Condition:
good
Discharge Instructions:
Patient to be discharged to rehab facility.
Go to an Emergency Room if you experience symptoms including,
but not necessarily limited to: new and continuing nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Proceed to the ER/EW/ED if your wound becomes red, swollen,
warm, or produces pus.
You may remove your dressings 2 days after your surgery if they
were not removed in the hospital.
Leave the steri strips on until they begin to peel, then you may
remove them. Staples and stitches will remain until your
follow-up
appointment.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Continue taking your home medications unless otherwise
contraindicated and follow up with PCP.
Followup Instructions:
Patient to follow up with Dr. [**Last Name (STitle) **] in two weeks, call to confirm
appointment. [**Telephone/Fax (1) 34711**]
|
[
"5849",
"486"
] |
Admission Date: [**2138-7-3**] Discharge Date: [**2138-7-6**]
Date of Birth: [**2108-12-12**] Sex: F
Service: MEDICINE
Allergies:
Tramadol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 29 yo female with asthma, hx of 2 icu admissions in
the past, no intubations who presents with asthma exacerbation
since 8pm last night. She is unable to give a full history but
believes that the triggers are environmental allergies.
.
Denies cp/n/v/d/abd pain/urinary/bowel symptoms
.
In ed rec'd steroids, cont nebs, magnesium heliox from 12 am to
4:30 am with minimal effect. PF was initially 200, increased to
250 with nebs. Patient was transferred to MICU for increased
work of breathing.
.
pcp: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Hospital1 756**]
Past Medical History:
asthma
gerd
anemia
migraines
ptsd
hypothyroid
fibromyalgia
uti's
legally blind--secondary to optic neuritis at age 10
chronic pelvic pain
chronic low back pain
Social History:
no smoking, etoh, drugs. lives alone with guiding eye dog, on
disability. Hx of sexual abuse.
Family History:
+asthma in father, cervical, [**Name2 (NI) 24817**] ca in grandparents
Physical Exam:
97.9 HR 146 sinus tach BP 121/42 O2 96-98% on 2L, pf 330
GEN: anxious, tachypneic
HEENT: PERLLA, EOMI, jvp flat, no erythema/exudate
Lungs: insp wheezes in all quadrants with moderate air flow,
right worse than left
Heart: s1 s2 tach, no m/r/g
Abd: obese, soft, +bs, rlq tenderness, no r/g
Ext: no c/c/e
Neuro: AOx3
Pertinent Results:
Admission Labs:
[**2138-7-3**] 04:47AM TYPE-ART O2 FLOW-2 PO2-110* PCO2-16* PH-7.49*
TOTAL CO2-13* BASE XS--7 INTUBATED-NOT INTUBA COMMENTS-NASAL
[**Last Name (un) 154**]
[**2138-7-3**] 01:04AM GLUCOSE-118* UREA N-11 CREAT-0.8 SODIUM-142
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-20* ANION GAP-18
[**2138-7-3**] 01:04AM CALCIUM-9.2 PHOSPHATE-2.6* MAGNESIUM-2.0
[**2138-7-3**] 01:04AM TSH-5.9*
[**2138-7-3**] 01:04AM FREE T4-0.97
[**2138-7-3**] 01:04AM ASA-NEG
[**2138-7-3**] 01:04AM WBC-7.8# RBC-4.33 HGB-11.7* HCT-33.2*
MCV-77*# MCH-27.0# MCHC-35.2* RDW-16.6*
[**2138-7-3**] 01:04AM D-DIMER-515*
.
CXR: IMPRESSION: No acute cardiopulmonary abnormality
.
LENIs: Using linear probe, [**Doctor Last Name 352**] scale and color Doppler
son[**Name (NI) 1417**] of the common femoral, superficial femoral, and
popliteal vessels were performed bilaterally. Study is limited
by large body habitus. Allowing for limitations, there is no
intraluminal thrombus. Vessels demonstrate normal flow,
compressibility, respiratory variability, and augmentation.
Brief Hospital Course:
Patient is a 29 yo legally blind female with h/o asthma and
anxiety presenting with respiratory distress.
.
1. Shortness of breath: the patient was treated for an asthma
flare with immediate improvement in her peak flow, symptoms and
oxygen requirement. There was a strong anxiety component to her
presentation. After obtaining [**Hospital1 112**] records, we learned that the
patient also has paradoxical vocal cord motion and
severe/difficult to control GERD which are also contributing to
her presentation. The patient had negative LENIs and a d-dimer
of 515. The patient was discharged to complete a 2 week steroid
taper and with the addition of Singuair to her outpatient
regimen of Advair, Albuterol, Flovent, Rhinocort, and Xolair. We
recommended she follow up with her Pulmonologist and ENT. She
was to complete a 10 day course of Amoxicillin for sinusitis.
.
2. Tachycardia: related to anxiety and albuterol. Quickly
improved with spacing out nebulizer treatments. Negative LENIs
and no clinical evidence or history of PE or cardiac pathology.
.
4. GERD: continued on protonix and famotidine. The patient has
an outpatient pH monitoring soon for further evaluation of this
chronic problem.
.
5. Iron deficiency anemia-continue patient on ferrous sulfate
.
6. Respiratory alkalosis- 1) partially compensated primary
respiratory alkalosis, or (2) acute superimposed on chronic
Primary Respiratory Alkalosis, or (3) mixed acute respiratory
alkalosis with a small metabolic acidosis. Pt appears to be a
chronic hyperventilator given anxiety.
.
7. fibromyalgia/ptsd- cont nsaids, celexa. Ativan given in house
with good effect.
.
8. Hospital:
-prophylaxis: sq heparin, ppi/h2 blocker
-code: full
-disposition: discharged home to complete 2 week steroid taper.
She will need PCP, [**Name10 (NameIs) 17329**] and ENT follow up.
Medications on Admission:
advair
albuterol
flovent
protonix
rhinocort
xolair
celebrex
meropex
synthroid 100 mcg'
zantac
celexa 80
Discharge Medications:
1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q4-6H (every 4 to 6 hours) as needed.
2. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO three times
a day for 7 days.
Disp:*0 Tablet(s)* Refills:*0*
3. Celexa 40 mg Tablet Sig: Two (2) Tablet PO once a day.
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Rhinocort Aqua 32 mcg/Actuation Spray, Non-Aerosol Sig: One
(1) inh Nasal twice a day.
6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] ().
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Prednisone 10 mg Tablet Sig: variable Tablet PO once a day:
-take 4 tabs (40 mg) daily from [**Date range (1) 24818**], then
-take 3 tabs (30 mg) daily from [**Date range (1) 24819**], then
-take 2 tabs (20 mg) daily from [**Date range (1) 24820**], then
-take 1 tab (10 mg) daily from [**Date range (1) 24821**], then stop. .
Disp:*36 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Asthma exacerbation
Anxiety
Secondary:
Sinusitis
Gastroesophageal reflux disease
Iron deficiency anemia
Migraines
Post-traumatic stress disorder
Legal blindness
Fibromyalgia
Hypothyroidism
Recurrent Urinary Tract Infection
Discharge Condition:
Stable, on room air, on steroid taper.
Discharge Instructions:
You were admitted with an asthma exacerbation. You were treated
with steroids and nebulizer treatments with improvement in your
symptoms. It is important that you take all of your medications
and make and keep all of your follow up appointments. Please
return to the ED if you develop worsening shortness of breath,
fever, chills, chest pain, worsening peak flow or any other
concerning symptom.
.
Please continue to take all of your medications as you were
prior to admission. This includes completing your course of
Amoxicillin 1000 mg by mouth three times daily for 6 additional
days. Your last day of antibiotics should be [**2138-7-12**]. The
additions to your home regimen include:
1. Singulair 10 mg daily
2. Prednisone, according to the following taper:
-A. Take 40 mg (4 tabs) daily from [**2138-7-7**] through [**2138-7-9**], then
-B. Take 30 mg (3 tabs) daily from [**2138-7-10**] through [**2138-7-13**], then
-C. Take 20 mg (2 tabs) daily from [**2138-7-14**] through [**2138-7-17**], then
-D. Take 10 mg (1 tab) daily from [**2138-7-18**] through [**2138-7-21**], then
stop.
Followup Instructions:
Provider: [**Name10 (NameIs) 24822**] you do not have an appointment with your
outpatient ENT, please call [**7-7**] for an appointment.
Please call for an appointment with your primary care doctor,
Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 24823**], for 1-2 weeks after hospital discharge
to discuss your recent hospitalization and for evaluation of
your progress.
|
[
"2449",
"53081"
] |
Admission Date: [**2140-9-5**] Discharge Date: [**2140-9-12**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Doctor First Name 16342**]
Chief Complaint:
hypotension/sepsis
Major Surgical or Invasive Procedure:
No major surgical or invasive procedures.
History of Present Illness:
[**Age over 90 **] yo M resident of [**Hospital 100**] Rehab, h/o dementia, DM, with recent
admission to [**Hospital1 18**] last month for fever, likely PNA. Patient's
condition improved with levofloxacin at that time. Patient
returns today with fever to 102, confusion, hypotension (70/p
--> 102/48) with IVF. Patient reportedly was not opening eyes.
Of note, patient has stage 3 decubitus ulcer on ankle. Was given
po vanco for foot infection and recently started on clindamycin
on [**8-31**] for foot. Also ? has had more frequent stools recently.
.
In ED, patient was fluid resuscitated and then started on
pressors through a peripheral iv. Transfused 1 unit blood for
hct 25. Given Vanco, Levo, Flagyl, dexamethasone.
.
In the MICU, vitals were temp: 97.3 BP: 86/31 on levophed 0.02 P
69 16 98% 4L NC, pan cultures were obtained [**9-5**], with urine cx
showing no growth, blood cx pending X2, and stool assay positive
for C.diff. Empiric coverage was continued with Vanco (renal
dosing), Levo 250 q48, and Flaygl 500mg [**Hospital1 **]. IVF were given to
maintain a MAP of >60, UOP>30cc/hour. Her Creatinine at
admission was noted to be 2.6, baseline of 1.3-1.6. It was
thought this was secondary to prerenal azotemia. Her creatinine
responded well to hydration. Her UOP has been from 30-100cc per
hour. To maintain BP, pt was on levophed, however, this was
discontinued [**9-6**] 4pm.
.
For the Stage III Decubitus ulcer, [**Month/Year (2) 1106**] surgery was
consulted on [**2140-9-6**]. She is a familiar pt to them, and her son
and daughter had expressed that she did not want any
intervention done on her leg (angio or amputation). The
daughter stated that she wanted comfort measures only. Vacular
subsequently signed off. Podiatry also saw the pt, and noted
that she will likely need BKA. As pt's family refusing
operation, vanco and the wet to dry dressings were continued.
.
As pt's family is requesting primarily measures for comfort,
(son is [**Name (NI) 382**], the pt was called out of the MICU. Family is
requesting IVF for BP only, no pressors. They would like
antibiotics given, as well as morphine for pain. They are
refusing central line, surgery, angioplasty vs. amputation for
his leg. They want him to be as comfortable as possible.
Past Medical History:
Dementia
Depression
DM
HTN
? CAD
Hypercholesterolemia
Social History:
Originally from [**Country 532**], immigrated 18 years ago. Worked in
construction. [**Hospital1 **]. No etOH, +tobacco in the past, but none in
many years, no recreational drugs.
Family History:
N/C
Physical Exam:
97.3 86/31 on levophed 0.02 P 69 16 98% 4L NC
Gen: somnolent, arousable and moaning with stimulation
HEENT: pupils pinpoint, dry mm, mouth breathing, JVP 10 cm
CV: irreg, S1, S2, 2/6 systolic murmur at RUSB
Lungs: mild crackles at bases, L > R
Abd: soft, mildly distended, ? moderately tender to palpation
Ext: warm, 2+ pitting edema bilaterally, L heel stage 3 ulcer,
toes with areas of necrosis
Neuro: minimally responsive, moving all extremities
Pertinent Results:
[**2140-9-5**] 11:40PM URINE COLOR-LtAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2140-9-5**] 11:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2140-9-5**] 11:40PM URINE RBC-[**4-16**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-<1
[**2140-9-5**] 08:05PM LACTATE-3.5*
[**2140-9-5**] 07:30PM GLUCOSE-74 UREA N-54* CREAT-2.6*# SODIUM-136
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-18* ANION GAP-18
[**2140-9-5**] 07:30PM WBC-17.6*# RBC-2.69*# HGB-8.5*# HCT-25.0*#
MCV-93 [**2140-9-5**] 07:30PM NEUTS-92* BANDS-0 LYMPHS-6* MONOS-2
EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2140-9-5**] 07:30PM PLT SMR-NORMAL PLT COUNT-339#EKG: wavy
baseline due to patient movement, AF @ 90, RBBB, TWI II.
[**2140-9-6**] 05:02AM BLOOD Cortsol-33.3*
[**2140-9-7**] 05:10AM BLOOD Vanco-22.0*
[**2140-9-6**] 07:40PM BLOOD Vanco-6.9*
[**2140-9-6**] 04:00AM BLOOD Vanco-9.2*
[**2140-9-9**] 10:03AM BLOOD Type-[**Last Name (un) **] pO2-34* pCO2-28* pH-7.29*
calHCO3-14* Base XS--12
[**2140-9-5**] 08:05PM BLOOD Lactate-3.5*
.
CXR: Left lung base opacity, likely representing atelectasis,
unchanged since [**2140-7-11**].
URINE CULTURE (Final [**2140-9-7**]): NO GROWTH.
EKG from ED: NSR@ 80, nl axis, ? 1st degree block
RENAL ULTRASOUND SCAN (PORTABLE) [**2140-9-7**]
CLINICAL DETAILS: Dementia, rule out obstructive hydronephrosis.
CONCLUSION: Limited exam but no evidence of hydronephrosis.
BEDSIDE SWALLOW EVAL: [**2140-9-8**]
There were no signs of aspiration on his bedside swallowing
evaluation today, i.e., no cough, no throat clear and no change
in voice quality after eating or drinking. Pt. denied food
sticking in his throat or liquids going down the wrong way. Due
to extreme oral cavity dryness, the [**Location (un) **] cracker was not
given,
but I think he would do fine with very soft, moist solids and
ground meat.
However, he has pain on swallowing and does not want to eat.
This
may be due to dryness or thrush.
Brief Hospital Course:
A/P: [**Age over 90 **] yo M with dementia, DM who presents with septic shock,
s/p 2 days in MICU, stabilized on IV antibiotics. Family
requesting no aggressive interventions. Pt on IVF, abx, being
transferred to floor for supportive care.
**** He is now a complete [**Age over 90 3225**]. No agressive measures. No
central line, no peripheral IV, NO picc, no fingersticks, no
heparin. Documented in chart, per family meeting with his son
[**Name (NI) 2491**], on Friday, [**2140-9-9**].
1. Clostridium difficle colitis: Pt has been tx with IV flagyl
since [**9-5**] then switched to po flagyl on [**2140-9-9**] after
demonstrating tolerating po by swallow evaluation.
- Rectal tube was removed by RN secondary to pt agitation from
tube. However, with continued diarrhea, as his bicarb is low.
We performed an ABG, however, since he was a difficult person to
obtain blood on, we obtained venous blood. We had a family
meeting, and clarified with [**Doctor First Name 109734**] health care proxy, that he
did not want any more needlesticks (no insulin, no heparin, no
ABG), so we honor his wishes.
- We held off on sodium bicarb.
- He placed on contact precautions.
- [**Name2 (NI) **] has remained afebrile.
- Pt passed his swallow study, did well. Started him on pureed,
thin liquid diet.
.
# Initial presentation of sepsis: Given presentation of fever,
tachycardia, persistent hypotension, patient met definition of
septic shock at admission. Source not entirely clear but could
be related to LE ulcer, or C. diff colitis. CXR with no PNA;
patient with no evidence of UTI. -ABX: [**Doctor Last Name **]/LEVO/FLAGYL ([**9-5**])
D/C VANCO on [**9-9**] (lost IV access, had family meeting, agreed to
d/c vanco)
- Continue broad spectrum Abx po (levo, flagyl) renally dosed.
- Patient has reported h/o MRSA in LE wound, tx with IV Vanco
[**Date range (1) 109735**]. D/c'd as pt is [**Name (NI) 3225**] and family requesting d/c all
IVs.
- Per ED, patient's family declined invasive interventions
including central line. Pt is off pressors, and s/p IVF for
pressure maintenance. No IVF now as [**Name (NI) 3225**] status per family
request.
.
2. Stage 3 decubitus ulcer
- Family refusing angio or amputation. [**Name (NI) **] signed off (as
per HPI). Podiatry saw pt, thought may need possible BKA,
however, family refusing, do not want aggressive
measures/intervention undertaken.
-wet--> dry dressings [**Hospital1 **]
- Vanco d/c'd on [**9-9**] as per above.
.
3. Anemia: Patient has h/o anemia (Fe-def/ACD) and required 2
unit transfusion during previous admission.
-guaiac negative per ED report
- NO transfusions ([**Month/Year (2) 3225**])
.
#agitation
- We had to restrain with 2 point restraints on upper
extremities b/c he was pulling at his lines.
- We started zydis orally [**9-8**] for agitation in preparation for
d/c to [**Hospital 100**] rehab. He tolerated this well.
- He self d/c'd his foley on [**9-10**]. Replaced his foley on [**9-9**].
UOP has been decreased, dark amber in color. Pt encouraged to
take po liquids. No IV, as pt [**Name (NI) 3225**] and family refusing
needlesticks, fingersticks, IV.
.
4.DM2:
- D/C SSI D/C fingersticks
.
5. ARF: Baseline creat 1.3- 1.6. ? On admission, Creatinine 2.6,
most likely prerenal azotemia, responded well to IVF, with
Creatinine trending down.
- last Cr, 1.4 [**9-9**] (trended down from 1.9) so pt is improving
with hydration and feeds.
- FEna on admission was <1% in favor of prerenal
- Continue feeds with pureed liquids.
.
6. ?AF vs ectopy: no known history of AF. no clear p waves on
EKG from ICU. ? ectopy related to pressors. rate well
controlled. ? candidate for anti-coagulation.
- Pt is rate-controlled, and we will not intervene with medical
intervention now.
.
7. HTN: We held his antihypertensive medication as his blood
pressure was low in MICU, he is now normotensive.
.
8. Hypercholesterolemia:
- His statin was discontinued secondary to elevated CK's.
.
9. PPX:
- SC heparin
- PPI.
.
10. Code: DNR/DNI, now [**Month/Year (2) 3225**], to [**Hospital 100**] rehab on Sunday, [**2140-9-11**]
with referral for Hospice care.
Medications on Admission:
Aspirin 81 mg qd
Ferrous Gluconate 300 mg qd
Brinzolamide 1 % Drops [**Hospital1 **]
Enalapril Maleate 5 mg Tablet qd
Simvastatin 20 mg Tablet qd
Senna 8.6 mg Tablet [**Hospital1 **]
Tylenol #3
Clindamycin 300 qid
Glipizide 10 qd
Metformin 500 [**Hospital1 **]
Vancomycin po
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. Morphine 10 mg/5 mL Solution Sig: One (1) PO Q2-4H (every 2
to 4 hours) as needed for pain.
Disp:*qs 1 bottle * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
1. sepsis
2. Clostridium difficile colitis
3. Stage III decubitus ulcer left heel
4. Diabetes mellitus
5. Dementia
6. Hypercholesterolemia
Discharge Condition:
Stable
Discharge Instructions:
Please take all of your medications as directed.
Please follow up with your physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Please see
instructions below.
Followup Instructions:
1. Please follow up with your Primary Care Physicians at [**Hospital 100**]
Rehab.
2. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] Where: [**Name12 (NameIs) **]
[**Name12 (NameIs) 3628**] Date/Time:[**2140-9-14**] 11:30
3. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where:
[**Last Name (NamePattern4) **] SURGERY Date/Time:[**2140-9-14**] 12:00
Completed by:[**2140-9-11**]
|
[
"0389",
"78552",
"5849",
"99592",
"2859",
"2720",
"4019",
"25000"
] |
Admission Date: [**2105-12-18**] Discharge Date: [**2105-12-22**]
Date of Birth: [**2040-10-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left lower lobe nodule.
Major Surgical or Invasive Procedure:
[**2105-12-17**] VATS left lower lobe wedge resection.
History of Present Illness:
Ms. [**Known lastname **] is a 65-year-old woman with an incidentally noted
left lower lobe nodule. She presents for diagnosis and
treatment. Because of her co-
morbidities it was decided that a limited resection would be the
extent of the treatment as opposed to anatomic resection.
Past Medical History:
COPD, allergic rhinitis,
severe OSA
Heavy ETOH use
restless leg syndrome,
GERD/hiatal hernia
CAD
CHF EF 55-60%
Diabetes Mellitus Type 2 on insulin
Hypertension
CRI baseline 1.5
PVD
Hyperlipidemia
arthritis of hip.
Social History:
Lives with family. Tobacco 40 pack-year quit [**4-/2103**]
ETOH drinks 5 Vodka's per day
Family History:
Mother CAD
Father CAD
Siblings 1 sister healthy
Offspring 2 children (1 deceased)
Other
Physical Exam:
VS: T 98.4 HR 56 BP: 116/54 Sats: 96% TM FS: 454-163
General: sitting up in chair no apparent distress
HEENT: normocephalic
Neck: trach in place: site no erythema
Card: RRR
Resp: decreased breath sounds bilateral no crackles
GI: obese, benign
Extr: warm no edema
Incision: Left lower lobe VATs site clean dry intact
Neuro: non-focal
Pertinent Results:
[**2105-12-21**] WBC-5.6 RBC-3.41* Hgb-9.9* Hct-30.9 Plt Ct-325
[**2105-12-19**] WBC-5.7 RBC-3.27* Hgb-9.7* Hct-29.2 Plt Ct-277
[**2105-12-21**] Glucose-320* UreaN-28* Creat-1.8* Na-133 K-4.6 Cl-95*
HCO3-25
[**2105-12-19**] Glucose-133* UreaN-54* Creat-2.7* Na-141 K-4.2 Cl-103
HCO3-26
[**2105-12-21**] Calcium-8.7 Phos-2.4* Mg-1.9
Cultures: Urine, blood x 2 and pleural no growth
Pleural tissue: no growth
CXR:
[**2105-12-22**] the degree of pulmonary vascular congestion has
substantially reduced, and there is improved aeration in the
left lung. The tube coiling over the upper neck has been
removed. Ileostomy tube remains in place.
[**2105-12-21**] Tracheostomy tube is at the midline with its tip 5 cm
above the carina. A coiled tube is projecting over the
oropharynx and it is unclear if it represents an internal or
external device. It should be correlated with patient's
supporting devices.
Cardiomediastinal silhouette is stable. There is interval
development of
vascular engorgement/mild pulmonary edema since prior study
obtained on
[**2105-12-20**] increased opacification at both bases consistent with
volume loss and infiltrate. There is a right greater than left
pleural effusion. The left-sided chest tube remains in place.
The tracheostomy tube is unchanged.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted on [**2105-12-18**] for VATS left lower lobe
wedge resection. She was transferred to the PACU requiring CPAP
[**10-15**] FIO2 60% and was later transfer to SICU for respiratory
distress The FIO2 was increased to 70% for oxygen saturation
87-89% improved to 90-93%.
Respiratory: POD2 she weaned to TM, 12L 02 sats 88-92% which is
her baseline. She was gent ley diuresed. Her Trach was changed
back to fenestrated, [**Location (un) **] #4 cuff less with oxygen
saturations 90-92% on 50% Trach mask (her baseline).
She was followed by serial Chest films which showed improving
pulmonary vascular congestions with improved left lung aeration.
Left [**Doctor Last Name 406**] drain was removed on POD 2.
Cardiac: her home cardiac medications were restarted with stable
HR and hemodynamics.
Renal: CRI baseline 1.5-2.0. Peak CRE 2.7->.2.2. Foley was
removed and she voided without difficulty
Endocrine: Insulin sliding scale was started until taking PO's
then her Home insulin dose was started.
Nutrition: Tolerated a regular diet once able to eat.
ETOH: she was maintained on Ativan prophylactic.
ID: Temp 101 pan cultured with no growth
Neuro: pain well controlled with Dilaudid discharged on
Percocet.
Disposition: home with VNA on POD4.
Medications on Admission:
Crestor 40mgdaily, lopressor 50 TID, tricor 145 mg daily,
Norvasc 10 mg daily, protonix 40mg [**Hospital1 **], paxil 20 mg daily,
ativan 2 mg prn, lasix 40 mg daily insulin humulin N 25 units
[**Hospital1 **], humalog 5 units [**Hospital1 **], ASA 325 mg daily, advair inhaler
250/50 1 puffs [**Hospital1 **] daily, fluicasone 110 2 puffs [**Hospital1 **]
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
8. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Ativan 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Humalog 100 unit/mL Solution Sig: Five (5) units
Subcutaneous twice a day.
14. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous twice a day.
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community Health and Hospice
Discharge Diagnosis:
Left lower lobe nodule.
Discharge Condition:
stable.
Discharge Instructions:
-You may shower, keep covered with bandaid.
-Do not drive while taking narcotics.
-resume home medications.
-Trach care as per your home routine.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] [**1-5**] at 1:00pm on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]. Phone:[**0-0-**]
Chest X-Ray 45 minutes before your appointment on the [**Location (un) 861**]
Radiology Department
Completed by:[**2105-12-22**]
|
[
"5849",
"5119",
"4280",
"32723",
"496",
"412",
"40390",
"5859",
"V4581"
] |
Admission Date: [**2188-8-1**] Discharge Date: [**2188-8-8**]
Date of Birth: [**2110-2-13**] Sex: M
Service: MEDICINE
Allergies:
Cardura
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Colonoscopy [**2188-8-2**], [**2188-8-8**]
Esophagogastroduodenoscopy (EGD) [**2188-8-8**]
History of Present Illness:
The patient is a 78 year-old male with DM, HTN, HLD, history of
diverticular bleed s/p clipping who presented with continued
maroon stools.
The patient was hospitalized at OSH from [**Date range (1) 87437**] for
diverticular bleed with a colonoscopy showing a site of active
diverticular bleeding estimated at 45cm. No other active sites
were identified to the level of the cecum. 5 clips were placed
at the site of diverticular bleeding and epinephrine was
injected. An EGD did not reveal blood from above. The patient
reportedly became hypoxic during the colonoscopy, thought to be
due to an aspiration event. He was transferred to [**Hospital1 18**] for
further care from [**Date range (1) 87438**]. At [**Hospital1 18**], he remained HD stable and
was transfused 2 units packed RBCs, with his HCT remaining
stable. He completed a course of levofloxacin and flagyl and
was transitioned to Zosyn for aspiration pneumonitis. His
respiratory status continued to improve and he was discharged on
[**7-30**].
.
This morning of his current admission, the patient awoke and had
two episodes of maroon stools. He had no light-headedness at
the time, but endorsed crampy abdominal pain. In the ED, he
became very dizzy and light-headed. He had some dyspnea on
exertion, but denied nausea, vomiting, fever, chills, continued
cough, constipation, straining, or tenesmus. He was admitted to
the MICU for further management of his presumed continued lower
GI bleed.
.
In the ED, VS T 98.2 HR 80 BP 153/62 RR 20 O2Sat 100% on RA. Pt
was complaining of light-headedness but no abdominal pain.
Denied cp. Three peripherals placed (20 G, 16 G, 18 G). Seen
by GI with plan to rescope on Monday. Originally admitted to
floor but had another episode of dark red stool and was
light-headed so transferred to MICU.
.
In the MICU, he reports no light-headedness, sob, cp, abd pain,
n/v, diarrhea.
.
Review of systems: per HPI
Past Medical History:
CAD
Type II DM
HTN
HLD
Obesity
Distal Adominal Aortic Dissection on CT scan ([**2187-5-23**])
Thoracic Aortic Aneurysm measuring 4.8cm on CT Scan ([**2187-5-23**])
RAS
Bladder Cancer
GERD
Barrett's esophagus (endoscopy [**2180**])
Diverticular disease
Chronic Anemia
Lumbar disc Disorder
Social History:
Lives with wife. Two Children. Retired from the paper mill
business. Tobacco: quit 20 years prior. Alcohol: endorses
occasional EtOH use. Illicits: none.
Family History:
Father - MI.
Mother - diabetes.
Physical Exam:
Vitals: T: 98.8 BP: 148/54 P: 85 R: 18 O2: 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucous membranes Dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: good air movement throughout, with mild crackles in left
lower lobe
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: bowel sounds present, soft, non-tender, non-distended,
no rebound tenderness or guarding
Ext: warm, well perfused, 2+ DP pulses, 1+ edema to mid shin
bilaterally, no clubbing, cyanosis
Neuro: CN II-XII grossly intact, moving all extremities
Pertinent Results:
ADMISSION LABS
WBC-9.3# RBC-3.24* Hgb-9.5* Hct-29.2* MCV-90 MCH-29.4 MCHC-32.6
RDW-15.8* Plt Ct-477*#
Neuts-77.9* Lymphs-17.8* Monos-2.9 Eos-1.1 Baso-0.4
PT-13.9* PTT-28.6 INR(PT)-1.2*
Glucose-88 UreaN-10 Creat-1.0 Na-141 K-4.0 Cl-109* HCO3-21*
AnGap-15
Calcium-8.0* Phos-3.9 Mg-1.7
STUDIES
COLONOSCOPY [**2188-8-2**]: A single sessile 4 mm polyp of benign
appearance was found in the 30 cm. Multiple diverticula with
mixed openings were seen in the sigmoid and descending colon;
scattered diverticula in the right colon and cecum.
Diverticulosis appeared to be of moderate severity. Three
Hemoclips were present in the sigmoid colon 30 cm. There also
appeared to be evidence of previous [**Country **] ink injection at
approximately 35 cm. No evidence of active bleeding or stigmata
of recent bleeding. Impression: Diverticulosis of the sigmoid
and descending colon; scattered diverticula in the right colon
and cecum Three Hemoclips were present in the sigmoid colon 30
cm. There also appeared to be evidence of previous [**Country **] ink
injection at approximately 35 cm. Polyp in the 30 cm. No
evidence of active bleeding or stigmata of recent bleeding.
TAGGED RBC SCAN [**2188-8-4**]: Following intravenous injection of
autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and
dynamic images of the abdomen were obtained for 77 minutes. A
left lateral view of the pelvis was also obtained. Blood flow
images show no evidence of active GI bleed. Dynamic blood pool
images show no evidence of active GI bleed.
COLONOSCOPY [**2188-8-8**]: Large internal hemorrhoids with stigmata of
recent bleeding were noted. Multiple non-bleeding diverticula
were seen in the whole colon. Diverticulosis appeared to be of
moderate severity. Surgical anastamosis in the distal right
colon was seen. The terminal ileum was intubated and appeared
normal. 3 clips were seen in the sigmoid colon with mild
ulceration but no stigmata of recent bleeding. Impression:
Surgical anastamosis in the distal right colon was seen. The
terminal ileum was intubated and appeared normal. Diverticulosis
of the whole colon. Internal hemorrhoids. 3 clips were seen in
the sigmoid colon with mild ulceration but no stigmata of recent
bleeding. Otherwise normal colonoscopy to cecum.
EGD [**2188-8-8**]: A hiatal hernia was seen, displacing the Z-line to
39 cm from the incisors, with hiatal narrowing at 41 cm from the
incisors. Mucosa: Normal mucosa was noted in the whole
esophagus. Stomach: Nodularity of the mucosa without evidence of
bleeding. Duodenum: A single irregular, sessile, 10-15 mm
non-bleeding polyp of benign appearance was found in the second
part of the duodenum. Cold forceps biopsies were performed for
histology at the second part of the duodenum. Impression:
Nodularity of the mucosa without evidence of bleeding. Polyp in
the second part of the duodenum (biopsy). Hiatal hernia. Normal
mucosa in the whole esophagus. Otherwise normal EGD to third
part of the duodenum.
DISCHARGE LABS
WBC-5.5 RBC-3.84* Hgb-11.2* Hct-34.0* MCV-89 MCH-29.2 MCHC-33.0
RDW-16.9* Plt Ct-242
Glucose-134* UreaN-8 Creat-1.0 Na-142 K-3.7 Cl-108 HCO3-27
AnGap-11 Mg-2.3
Brief Hospital Course:
The patient is a 78 year-old male with DMII, HTN, HLD, history
of diverticular bleed s/p clipping who presented with continued
maroon stools. The patient was hospitalized from [**Date range (1) 87439**]. Brief
hospital course is detailed below.
1. GI Bleed: at the time of discharge, the source of the
patient's maroon stools remained unknown. Upon presentation, the
patient was hemodynamically stable, but in the setting of
orthostasis, was transferred to the MICU. Hematocrit was
monitored, and nadired at 22.4. He received a total of 6 units
of packed RBCs and underwent colonoscopy, which was negative for
acute bleeding. EGD was not repeated, as his EGD at the OSH was
negative. The patient was transferred to the floor, where he
continued to have maroon stools. He required only one unit of
RBCs throughout the remainder of his hospital course. He was
maintained on IV pantoprazole and was followed with serial HCTs.
In the context of his continued bleeding, GI, IR, and surgery
were consulted. A tagged RBC was performed, which did not show
evidence of active bleed. A second colonoscopy and EGD were
performed because of concern for upper, rather than lower GI
bleed, but these studies again did not show evidence of acute
bleeding. He was noted to have extensive diverticulosis and a
duodenal polyp (biopsied). At the time of discharge, the patient
had not had maroon stools for ~48 hours. He was hemodynamically
stable and his had HCT stabilized. His aspirin was held and not
restarted. Omeprazole was increased from 20mg to 40mg daily. He
was discharged with follow up with GI for a capsule endoscopy,
and with instructions to return to the emergency department for
dark or bloody stools. He was also instructed to follow a low
residue diet. He was instructed to have a repeat hematocrit
checked with his primary care physician within one week of
discharge. He was advised to discuss restarting aspirin low
dose with his PCP after completion of evaluation for GI
bleeding.
The patient's following chronic medical problems remained stable
and were treated as follows.
1. Hypertension: in the setting of presumed GI bleed, the
patient's home regimen of lisinopril, metoprolol, and
chlorthalidone were held. As he stabilized, his lisinopril and
metoprolol were re-introduced. He was discharged on his home
regimen.
2. Diabetes: the patient's home glyburide and metformin were
held, and he was maintained on a HISS. On discharge, he was
restarted on his home regimen.
3. GERD/Barretts: in the setting of concern for GI bleed, the
patient was maintained on IV pantoprazole. Omeprazole was
increased to 40mg daily on discharge.
4. Asthma: the patient was maintained on his home regimen of
albuterol and fluticasone-salmeterol.
Medications on Admission:
. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily .
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation twice a day.
8. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
Two (2) Inhalation four times a day as needed for shortness of
breath or wheezing.
9. Chlorthalidone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
12. Omega-3 Fatty Acids 1,250 mg Capsule Sig: One (1) Capsule PO
once a day.
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) inhalation Inhalation twice a day.
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
8. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Outpatient Lab Work
Please have your CBC (blood counts) checked with your primary
care provider on Tuesday, [**2188-8-12**].
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
11. Chlorthalidone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Gastrointestinal bleed
Anemia
SECONDARY
Hypertension
Diabetes mellitus
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
blood in your stools. You were cared for by gastrointestinal
physicians, surgeons, and general medicine doctors. [**First Name (Titles) **] [**Last Name (Titles) 8783**]t two colonoscopies, one EGD, and a tagged red blood
cell scan that looked for active bleeding in your intestines.
These tests did not show evidence of active bleeding in your
esophagus, stomach, or colon. You will need to follow up with a
GI physician to undergo further workup.
We have made the following changes to your medications:
- INCREASED your omeprazole
- STOPPED your aspirin
Please be sure to keep your appointments, as listed below.
Followup Instructions:
The following appointments have been made for you. Please keep
these as scheduled.
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Street Address(2) 75551**] [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 87435**]
Phone: [**Telephone/Fax (1) 65542**]
Appointment: Tuesday [**2188-8-12**] 10:45am
You are planned to have a capsule endoscopy as an outpatient.
You will be contact[**Name (NI) **] regarding scheduling this appointment.
You will need a small bowel follow through prior to the capsule
endoscopy. Please call ([**Telephone/Fax (1) 10796**] to schedule this study.
Completed by:[**2188-8-12**]
|
[
"2851",
"25000",
"4019",
"2724",
"53081",
"41401"
] |
Admission Date: [**2105-10-27**] Discharge Date: [**2105-11-12**]
Date of Birth: [**2054-3-7**] Sex: M
Service: Neurosurgery
HISTORY OF THE PRESENT ILLNESS: The patient is a 52-year-old
gentleman with a history of hypertension, migraines, who had
a five day history of sudden onset of headache that persisted
but never resolved. He reports having neck stiffness and
dizziness with nausea but no vomiting. No double vision or
weakness and numbness and no history of head injury. He was
taking Motrin without relief.
He presented to an outside hospital where a head CT revealed
a subarachnoid hemorrhage in the right sylvian fissure with a
12 mm hyperdense area in the region of the ACOM junction just
anterior to the clivus.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes type 2.
3. Migraines.
4. Status post cataract surgery.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.6, blood pressure 214/101, heart rate 75, respiratory rate
14, saturations 98% on room air. General: The patient was
awake, alert, at times drowsy but oriented times three. He
had no drift. He was following commands. The pupils were
equal and reactive to light. The strength was [**5-18**] in all
muscle groups. Memory was [**3-16**] within five minutes. His
cranial nerves were intact. His sensation was intact to
light touch. Finger-to-nose was within normal limits. His
toes were downgoing. His reflexes were 2+ throughout.
HOSPITAL COURSE: The patient was admitted to the ICU and
underwent an arteriogram that showed a ruptured ACOM
aneurysm with subarachnoid hemorrhage. He had coil
embolization of the aneurysm without complication.
Postoperatively, the patient was monitored in the Recovery
Room. He became extremely agitated and combative requiring
intubation, sedation, and repeat head CT which showed no
initial change. The patient also developed chest pain and
was seen by the Cardiology Service who recommended changing
some of his medications. He did rule out for an MI and his
EKG changes did resolve.
He remained in the ICU, being watched for possible vasospasm
for two weeks time. Postprocedure and after this episode of
agitation, he was awake, easily arousable. EOMs were full.
He had no drift. His strength was [**5-18**] in all muscle groups.
He also had a vent drain placed that was discontinued on
[**2105-11-6**]. He was transferred to the floor on [**2105-11-10**] and
discharged to home on [**2105-11-12**] in stable condition.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 1132**] in two
weeks time.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Clonidine 0.1 mg two tablets t.i.d.
3. Accupril 60 mg p.o. q.d.
4. Hydralazine 75 mg p.o. t.i.d.
5. Metformin 500 mg p.o. b.i.d.
CONDITION ON DISCHARGE: Stable. The patient will follow-up
with Dr. [**Last Name (STitle) 1132**] in two weeks time and will follow-up with his
primary care doctor in two weeks for glucose and hypertension
monitoring.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2105-11-12**] 01:33
T: [**2105-11-12**] 19:16
JOB#: [**Telephone/Fax (2) 101223**]
|
[
"4019",
"25000"
] |
Admission Date: [**2174-3-18**] Discharge Date: [**2174-4-14**]
Date of Birth: [**2095-12-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
66% atypical white blood cells and low platelets on a routine
CBC.
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
History of Present Illness: The pt is a 78 yo M with a h/o CAD,
HTN, HL, DM who presents from his PCP's office after routine CBC
showed 66% atypical white blood cells and low platelets on a
routine CBC. He initially sought care from his PCP after he had
noticed that he had noticed increased bleeding from the site of
a removed childhood skin tumor which had been severely pruritic,
causing him to scratch it with a sharp back-scratcher
repeatedly. The PCP felt the patient had an infected cyst and
started abx. His PCP drew [**Name Initial (PRE) **] CBC which showed 66% atypical white
cells and thrombocytopenia with a normal white cell count and
hematocrit. He then ordered immunophenotyping which is pending,
and sent the patient to the ED. On review of systems, the
patient also notes more malaise and dyspnea on exertion over the
last month, as well as intermittently blood streaked stools and
melena.
In the ED, the patient was noted to have no evidence of bleeding
but labs concerning for DIC and tumor lysis. He was seen by the
heme-onc consult fellow. He was given 2 amps of bicarb with D5W
at 100 cc/hr. He was given 10u of cryoprecpitate and transfused
platelets. He also received 50 mg PO of all-trans retinoic acid.
Review of Systems:
(+) recent chills, headaches,
(-) Review of Systems: GEN: No night sweats, recent weight loss
or gain. HEENT: No headache, sinus tenderness, rhinorrhea or
congestion. CV: No chest pain or tightness, palpitations. PULM:
No cough, or wheezing. GI: No nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel
habits. GUI: No dysuria or change in bladder habits. MSK: No
arthritis, arthralgias, or myalgias. DERM: No rashes or skin
breakdown. NEURO: No numbness/tingling in extremities. PSYCH: No
feelings of depression or anxiety. All other review of systems
negative.
Past Medical History:
Past Oncologic History: Received radiation as child to back for
"tumors".
.
Other Past Medical History:
CAD - stable angina
Gout - no recent flares
HTN
PUD - last EGD [**2169**]
Type II DM - A1c 6.2% on metformin
Social History:
He lives with his partner, [**Name (NI) **], who he has been with for over
50yrs and married to for 6 yrs. He has one brother who his is
not in contact with and no children. He has had several prior
employments, including journalism, dance, stage management, and
travel reporter. He also worked as a silver [**Doctor Last Name **] when he was
exposed to sulfer products. He has travelled extensively. Last
HIV negative 1 year ago, Hepatitis negative in the distant past.
He has a distant history of smoking for 1 year. He has a history
of 'heavy' drinking with scotch, but now drinks only wine with
dinner per his report. Smokes occasional marijuana, and distant
history of experimenting with other drugs.
Family History:
Father died of MI at 51. Mother of throat cancer in early 80s
after long smoking and alcohol history. His brother is
apparently healthy.
Physical Exam:
On Admission:
VS: T: 100.6 F, BP 130/78, HR 96, RR 20, O2sat 100% on RA
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RRR. S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: excoriations in R axilla. scab centrally located on
central thoracic back with mild surrounding erythema but no
purulent drainage or warmth though somewhat tender
Neuro: CNs II-XII intact. 5/5 strength globally. sensation
intact to LT, gait WNL.
Pertinent Results:
Admission labs:
[**2174-3-17**] 04:55PM BLOOD WBC-5.3 RBC-3.96* Hgb-11.9* Hct-32.8*
MCV-83 MCH-30.2 MCHC-36.4* RDW-14.9 Plt Ct-22*#
[**2174-3-18**] 10:00AM BLOOD PT-16.1* PTT-22.0 INR(PT)-1.4*
[**2174-3-17**] 04:55PM BLOOD UreaN-22* Creat-1.2 Na-137 K-4.5 Cl-99
HCO3-28 AnGap-15
[**2174-3-17**] 04:55PM BLOOD Glucose-143*
[**2174-3-18**] 05:32PM BLOOD ALT-24 AST-33 LD(LDH)-483* AlkPhos-68
TotBili-1.0
Brief Hospital Course:
78 yo male with distant history of stable angina, new diagnosis
of acute promyelocytic leukemia, transferred to the ICU with
tachycardia after ATRA treatment on the hematology malignancy
floor, with DIC, pulmonary edema, and delirium.
.
# APML: He was diagnosed with APML with 56% blasts on
differential [**2174-3-18**]. He was treated with ATRA and subsequently
suffered from ATRA syndrome with an acute elevation in his WBC
to >50 K. He had significant pulmonary leak. He was treated with
ATRA throughout and received Idarubicin which had to be stopped
secondary to elevated bilirubin. His blasts and WBC subsequently
decreased, and on smear [**2174-4-4**] his myelocytes showed
differentiation with improving status of his leukemia. ATRA was
continued throughout his hospitalization. As a consequence of
treatment, his course was complicated by tumor lysis syndrome
with his uric acid peaking above 10, with a change an increase
in creatinine to 2.5 initially and subsequently higher as
described below. He was treated with allopurinol initially, and
required a 1x dose of Rasburicase which led to the resolution of
his TLS. He was maintained on his allopurinol for continued
treatment.
.
# Respiratory Failure: Likely multifactorial in the setting of
pulmonary leak from ATRA and likely alveolar hemorrhage. His
fluid balance reached a peak of 27L positive secondary to his
blood product requirement. He initially required a PEEP of 22
with FiO2 of 100%. Over the course of 10 days he was able to be
weaned down with the assistance of CVVH for fluid overload to
pressure support of [**5-19**]. His mental status was the largest
obstacle to extubation and he was taken for tracheotomy tube
placement by Thoracic Surgery on [**2174-4-8**]. He tolerated the
procedure well, and was able to be transitioned to trach collar
starting on [**2174-4-10**] for periods of time.
.
# DIC: Due to his APML, he developed DIC evidenced by active
bleeding from his ET tube, his OG tube, his stool and urine. He
had acute drops in fibrinogen, increase in LDH and increase in
bilirubin. He was supported through this with massive
transfustions requiring 18 units of PRBCs, 35 units of
platelets, 5 units of FFP, and 24 units of cryoprecipitate. He
was intubated due hypoxia and increased work of breathing on
[**2174-3-26**]. His CXR after intubation showed a fluffy infiltrate
suggestive of either ARDS or hemorrhage (likely both). Due to
his subdural hematomas, he was transfused to goals of Hct>30,
plts > 100, fibrinogen > 175, and INR <1.6. Once the DIC
resolved, his goals changed to Hct>25, plts > 20, fibrinogen >
100, and INR <1.6.
.
# Toxic Metabolic Encephalopathy: He started experiencing a
decline in mental status 2 days prior to intubation with severe
asterixis and confusion. He had a number of potential causes
such as medications, central focus with his SDH, and
hypertension to 180 making PRES a less likely, but possible
concern. Also, his uremia given his acute renal failure. He
required several doses of Haldol and intermittent restraints for
safety prior to intubation, when he was put on midazolam and
Fentanyl drips. 5 days after intubation his was sedation was
discontinued and he remained obtunded. He was treated with
dialysis for a uremia over 200. His mental status was the
barrier to extubation as his vent setting were minimal at the
point of weaning sedation. He was non responsive after 4 days
off of sedation. A family meeting was held with his husband
[**Name (NI) **], and the decision was made to take him to trach, with the
goal of trying to improve his mental status with dialysis.
# Acute renal failure: His creatinine sharply rose from 1.2 on
admission to a peak of 4.9. This was thought to be in the
setting of Tumor Lysis Syndrome (TLS) and abdominal compartment
syndrome. Also complicated by ATN in the setting of low blood
volume and possible microthrombi during DIC. He was treated
allopurinol and Rasburicase for TLS with good resolution as well
as with CVVH initially (1 day) for fluid removal. His urine
output responded. Shortly after he began autodiuresing He was
initiated on dialysis for AMS as described above and a BUN of
greater than 200. He was treated with dialysis with a fall in
BUN to 113, however, he had a fever to 100.6 and cultures came
back positive for GPC in chains from dialysis catheter [**2174-4-9**].
.
# Abdominal Compartment Syndrome: In the setting of acute volume
overload from large volume transfusions given DIC as above. He
was ~25L positive for LOS fluid balance. He developed elevated
bladder pressures and decreased urine output. Surgery was
consulted and felt that as long as he was making urine there was
no need for surgical intervention (as well as given his critical
illness, it was not indicated). He was started on CVVH as above
and had 3L removed. His kidneys responded and began making
100-200cc/hr of urine. His CVVH was stopped and he was allowed
to diurese on his own with support of lasix and metolazone as
needed.
.
# Atrial Fibrillation / Flutter: He developed tachycardia to the
140s with initial EKG most consistent with Afib, and later EKG
more consistent with Aflutter vs AVNRT. His HR did not respond
to Diltiazem drip or multiple subsequent IV boluses of Diltiazem
and Metoprolol. Cardiology suggested Verapamil, followed by
Amiodarone. He was loaded with Amiodarone drip and bolus of 150
mg x2. He was cardioverted on [**2174-3-22**] and continued on
Amiodarone. He got an extra 150mg of amiodarone on [**3-25**] with
minimal effect on tachycardia. He converted to NSR, and reverted
back to atrial fibrillation. In the setting of controlling his
blood pressure with IV medications he received multiple doses of
metoprolol and labetalol, and he converted to NSR. However, [**4-1**]
he converted back to rapid a-fib with RVR and required
uptitration of his B-blockade and a diltiazem drip which was
eventually converted back to PO.
.
# Bilateral Subdural Hematomas: Unclear time course.
Neurosurgery followed along and he had serial scans. His
hematomas had interval increased in the setting of the DIC;
however, not thought to be clinically significant. Neurosurgery
preferred medical management with antiepileptics and reversal of
his coagulopathy.
.
# Right basal ganglia infarct: On repeat scan of his head to
evaluate interval change of his subdural hematomas on [**2174-4-4**], a
new right sided basal ganglia infarct was noted. Neurosurgery
followed, and neurology was consulted. They felt that medical
management and blood pressure control were the best means of
treatment.
.
# Positive Blood Cultures: Blood cultures were positive in [**2-16**]
bottles from his PICC line on [**2174-3-22**]. The aerobic culture was
speciated as Staph aureus. No peripheral culture was obtained
on that date. He was started on Vancomycin / Meropenem on
[**2174-3-22**] after spiking a fever to 102.5. This was changed to
Vancomycin / Cefepime the next day. Given the concern for
translocation of gut bacteria with his compromised immune
system, he was switched to Vancomycin / Zosyn on [**2174-3-24**] for
better coverage of gut pathogens. Micafungin was added to cover
for fungal pathogens. He had multiple sets of negative
surveillance cultures, and his antibiotics were continued while
he remained neutropenic. He had a fever to 100.6 on [**2174-4-9**] and
cultures were drawn from his dialysis catheter which were
positive for GPCs in chains. His catheter was pulled and he was
continued on vancomycin.
.
# Pericardial Fat Pad: On echo on [**2174-3-24**] there was concern for
pericardial effusion because the echo showed a new anterior
pericardial effusion with complex echodensity. No evidence of
tamponade physiology was seen on the echo. His repeat echo
showed that the effusion was actually a fat pad.
.
# Alcoholism/Cirrhosis: He was known to drink a bottle of
alcohol per night. He initially required 10 mg IV diazepam
several times and started on a CIWA scale. On RUQ imaging for
persistent elevation of his bilirubin, cirrhosis was noted. More
than likely his cirrhosis was secondary to alcoholism and he had
poor clearance of his bilirubin (from reabsorption from pooled
blood).
.
# Elevated Glucose: He initially had glucose's in the 400??????s in
the setting of getting steroids. His insulin coverage was
briefly switched to an insulin drip, and he was subsequently
converted to subcutaneous insulin based on his requirements.
# Goals of care: Pt remained in coma. His overall clinical
status continued to decline over the course of hospitalization,
with evolution of multi-system organ failure including increased
pulmonary ventilatory requirements, persistant renal failure,
LFTs continued to increase and he developed recurrent bacteremia
(initially MSSA, then VRE). He was given 1 dose of daptomycin
for VRE coverage. Given his multiple organ failure, worsening
ventilatory requirements and persistent altered mental status, a
family meeting was held and decision made to focus efforts on
patient comfort beginning [**2174-4-12**] AM. The patient quietly
expired on [**2174-4-14**] with family at the bedside.
Medications on Admission:
- Metformin 500mg [**Hospital1 **]
- Metoprolol tartrate 50mg [**Hospital1 **]
- Cimetidine 100mg [**Hospital1 **]
- Amlodipine 10mg daily
- Lisinopril 2.5mg daily
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"51881",
"5845",
"2760",
"25000",
"41401",
"4019",
"2724",
"42731"
] |
Admission Date: [**2195-7-6**] Discharge Date: [**2195-7-9**]
Date of Birth: [**2112-2-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Shortness of breath, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 y/o F with hx of bronchiectasis and asthma (with multiple
recent admissions) presents today with worsening SOB, starting
this past Friday. She had felt short of breath, especially with
walking, but even at rest. Nothing she could do could make it
better. She was taking up to 5 nebulizer treatments in the
morning and still not feeling relief. She had a cough, not
productive, and similar in nature to her baseline cough. She has
been losing weight (unknown amount). She does not have a very
good appetite. Denies fevers, chills or sweats. No
lightheadedness, falls or fainting. No headache, abdominal pain,
nausea, vomiting, diarrhea. No leg swelling, rashes or leg pain.
She does have chronic hand and shoulder pain which is her most
bothersome symptom right now.
.
In the ED, inital vitals were T 98.0, P 92, BP 128/28, R 18 and
84% on room air. She had a CXR that showed bibaliar opacities
with differential being atelectasis vs. infection (per the
radiology read). She received ceftriaxone 1 gm x1, azithromycin
500 mg x1, solumderol 125 mg x1 and several combivent nebulizer
treatments. She remained tachypneic but only required nasal
canula for oxygen supplementation. She did spike a fever to
101.2 rectally in the ED. She was on 2L NC (her home oxygen
level) upon transfer from the ED.
.
On arrival to the floor, she is feeling well. She is still
tachypneic to the 30s, although does not feel that she is
breathing faster than normal. She is speaking quickly and in
full sentences. She appears comfortable. She is coughing
intermittently. She is complaining of hand and shoulder pain.
Per daughter-in-law's report, patient took 15 mg prednisone,
diltiazem, 1 tab Ca supplement, and her nebs x2 this morning.
.
ROS was notable for only that mentioned in the HPI, otherwise
negative.
Past Medical History:
Bronchiectasis
Asthma
Hx of H1N1 in [**11-10**]
Chondrocalcinosis: She has asymmetric polyarthritis involving
wrists, MCPs and PIPs. X-rays showed cartilage calcification on
wrists and knees, did not respond to nonsteroidals or
colchicine, has been in treatment with low doses of steroids
successfully
Flexor tendonitis
Osteoporosis
Allergies
Hypertension
Gout
History of strongyloides infection, treated with Ivermectin
Social History:
She lives with her nephew and his wife [**Doctor Last Name **] [**Telephone/Fax (1) 69215**]
[**Female First Name (un) 69216**] [**Telephone/Fax (1) 69217**]). (they have both been sick w/ influenza)
She came from [**Male First Name (un) 1056**] in [**2191**]. She does not smoke or drink
alcohol.
Family History:
No family history of lung cancer, COPD, or asthma.
Physical Exam:
Vitals - 98.8, 99, 135/56, 30, 95% on 2L
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,
dentures
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: (Expansion: Symmetric), (Breath Sounds:
Crackles : at bilateral bases, Wheezes : scant, most at R upper
lobe), good airmovement throughout all lung fields
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Musculoskeletal: Muscle wasting
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Pertinent Results:
On admission:
[**2195-7-6**] 11:55AM BLOOD WBC-18.0*# RBC-4.37 Hgb-12.5 Hct-37.3
MCV-86 MCH-28.7 MCHC-33.5 RDW-13.5 Plt Ct-418
[**2195-7-6**] 11:55AM BLOOD Neuts-82.4* Lymphs-13.5* Monos-2.9
Eos-0.8 Baso-0.4
[**2195-7-6**] 11:55AM BLOOD Glucose-183* UreaN-20 Creat-1.3* Na-137
K-4.1 Cl-96 HCO3-30 AnGap-15
[**2195-7-6**] 12:16PM BLOOD Lactate-2.7*
On discharge:
[**2195-7-9**] 06:43AM BLOOD WBC-12.3* RBC-3.64* Hgb-10.4* Hct-30.9*
MCV-85 MCH-28.5 MCHC-33.5 RDW-13.7 Plt Ct-348
[**2195-7-6**] 11:55AM BLOOD TSH-13*
[**2195-7-8**] 06:55AM BLOOD Free T4-0.76*
[**2195-7-7**] 3:54 pm SPUTUM Site: EXPECTORATED
Source: Expectorated.
GRAM STAIN (Final [**2195-7-7**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). HEAVY GROWTH
ECG on admission: Baseline artifact. Sinus tachycardia. Delayed
R wave progression. ST-T wave abnormalities. Since the previous
tracing of [**2195-3-18**] the rate is faster.
CXR on admission: Redemonstration of hyperexpansion and
interstitial changes compatible with chronic lung disease.
Equivocal new nodular opacities at the bases, though may be
better evaluated by PA and lateral chest radiographs if there is
concern for infectious etiology.
Brief Hospital Course:
83 y/o Spanish-speaking only F with hx of bronchiectasis,
asthma, mutliple admissions recently for SOB who presents again
with 5 days of worsening SOB and is admitted to MICU for
monitoring.
# Dyspnea: patient has known bronchiectasis and asthma, on home
O2, with multiple admissions recently for pneumonias (with
pan-sensitive pseudomonas and influenza). Patient was
tachypneic and febrile in ED concerning for infection, and since
CXR unrevealing, she was started on Ceftriaxone and
Ciprofloxacin in the ICU. Sputum culture was sent, however past
sputum cultures have grown Pseudamonas (pan-[**Last Name (un) 36**]) and E.Coli
(resistent to Cipro), which is why these antibiotics were
originally chosen. Pt was given Albuterol and Ipratropium
nebulizers, and supported with O2 to maintain O2 sat >92%. She
was also started on 60 mg Prednisone with plan for a long taper
(not to decrease below 5mg per rheumatology notes). After
leaving the ICU, patient was switched from Ceftriaxone and
Ciprofloxacin to Zosyn and Ciprofloxacin given by IV. Patient
steadily improved with each subsequent day and was discharged
home with a PICC line to receive Cefepime IV for twelve
additional days per discussion with her pulmonologist. Sputum
cultures are still pending, but have identified gram negative
rods and gram positive cocci (update: shows pseudomonas,
sensitive to cefepime). Patient was set up for follow-up
appointments with her PCP and pulmonologist and is to have a VNA
visit her to help with antibiotic administration and chest
physical therapy.
# Fevers/leukocytosis: pt has a chronic leukocytosis from her
steroids, but was slightly higher than baseline on admission.
As such, she was begun on antibiotics. Blood culture and sputum
culture were ordered. Pt's WBC count trended down throughout
hospital course but was still mildly elevated at discharge.
Patient remained afebrile during remaining hospital course.
# Tachycardia: Pt has baseline tachycardia, and also received
nebulizers in ED and in ICU. This finding may be due to use of
beta agonists and may also be related to chronic pain in hands,
shoulders from chondrocalcinosis. Pt received a fluid bolus in
ICU for other reasons, but tachycardia did not improve. She was
monitored on telemetry, and pain was controlled with scheduled
tramadol and PRN tylenol. ECG was checked on admission and
revealed sinus tachycardia.
# Chondrocalcinosis: patient has known chondrocalcinosis of her
MCPs, PIPs and wrist, which is stable symptom wise while on low
dose steroids. Pain control was accomplished with scheduled
tramadol and PRN tylenol.
# Hypertension: patient was mildly hypertensive to 130s-140s
during most of her admission. She is on diltiazem at home,
though it is unclear why patient is on this regimen. She was
continued on her Diltiazem, and BP was trended.
# Chronic kidney disease: Pt has baseline creatinine of 1.3,
though on transfer from ICU, creatinine was 1.0. She received
trial of fluids and creatinine was trended. Levels returned to
baseline by time of admission.
# Rotator cuff tendonopathy: pain was at baseline during
hospital stay, and was controlled with tramadol and PRN tylenol.
# Flexor Tendonitis: condition was stable during stay. This
does bother her, and she cannot use her hands well and is
permanently flexed. Patient is not an operative candidate per
outpatient notes. Pain control was accomplished with tramadol
and PRN tylenol.
# Hypercalcemia: pt with initial hypercalcemia on admission
labs, but this resolved with fluids. As part of hypercalcemia
work-up, pt was noted to have elevated TSH.
# Elevated TSH: pt was observed to have elevated TSH during
work-up for hypercalcemia, so free T4 was ordered. Level was
found to be low. Patient should have this followed up by her
PCP upon [**Name9 (PRE) 702**] appointment after discharge.
# Osteoporosis: patient has known osteoporosis. She was
continued on home Fosamax and Ca/Vit D treatment.
Medications on Admission:
Home Oxygen since [**Month (only) 958**]
Diltiazem 180 mg SR daily
Omeprazole 20 mg daily
Prednisone 15 mg (from last note on [**2195-5-15**])
Albuterol nebulzers QID PRN
Pulmicort 1 amp TID PRN
Omalizumab 150 mg q2weeks (Xolair mono-clonal Ab) - due [**7-15**]
Tramadol 50 mg TID PRN
Fosamax 70 mg qweek
Calcium 600 mg [**Hospital1 **]
Discharge Medications:
1. Cefepime 1 gram Recon Soln Sig: One (1) Intravenous every
twenty-four(24) hours for 12 days.
Disp:*12 * Refills:*0*
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheeze.
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day) as needed for calcium
supp.
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day:
Take five pills once a day for five days ([**Date range (1) 69222**]), THEN take
four pills once a day for five days ([**Date range (1) 27564**]), THEN take three
pills once a day for five days ([**Date range (1) 69223**]), THEN take two pills
once a day for five days ([**Date range (1) 69224**]), THEN resume normal dose of
15 mg (on another prescription).
Disp:*70 Tablet(s)* Refills:*0*
10. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day:
Take three pills per day once a day by mouth starting on [**7-30**]
and continue from then on.
Disp:*90 Tablet(s)* Refills:*2*
11. Pulmicort Flexhaler 90 mcg/Inhalation Aerosol Powdr Breath
Activated Sig: One (1) amp Inhalation three times a day.
Disp:*1 * Refills:*2*
12. Omalizumab 150 mg Recon Soln Sig: One (1) Subcutaneous
q2weeks.
13. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Probable pneumonia
Bronchiectasis
Asthma
Chondrocalcinosis
Flexor tendonitis
Osteoporosis
Allergies
Hypertension
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at the [**Hospital1 18**]. You came for
further evaluation of shortness of breath and cough. Further
tests showed that you had probable pneumonia. It's important
that you take your antibiotics as scheduled and continue to take
your medications as prescribed. It is also important that you
follow up with your primary care provider and pulmonologist, Dr.
[**Last Name (STitle) **], as well as your primary care doctor.
The following changes have been made to your medications:
Added cefepime
Changed prednisone dosing
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2195-7-15**] at 9:00 AM
With: ALLERGY NURSE [**Telephone/Fax (1) 9316**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RHEUMATOLOGY
When: FRIDAY [**2195-8-7**] at 11:00 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2195-8-10**] at 9:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 5533**],[**First Name3 (LF) **] M.
When: TUESDAY, [**7-14**], 2:45PM
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**] 1250
|
[
"40390",
"5859",
"42789"
] |
Admission Date: [**2143-8-13**] Discharge Date: [**2143-8-21**]
Date of Birth: [**2063-2-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Endocarditis
Major Surgical or Invasive Procedure:
Temporary pacing wire placement
History of Present Illness:
Patient is an 80yoM with a history of AVR, hx abd aortic
aneurysm repair, htn, hyperlipidemia, transferred from [**Hospital 7912**] for prosthetic AV valve endocarditis who
presented to [**Hospital6 **] [**8-3**] w/CC "weakness and fall"
without aura, lightheadedness, or signs of seizure. Found to
have L-sided weakness, +new hypodensity R frontal lobe, L
posterior parietal lobe (with supratherapeutic INR). Had
bradyarrythmias (seen by EP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23651**]), slow afib noted
with high-grade AV-Wenkebach. On [**8-10**], pt febrile, [**2-26**] bottle
grew GPC chains, initiated on vanco (with subsequent bottles
negative). ID consult high suspicion for AV endocarditis, TEE
[**8-13**] then showed mechanical valve prosthesis, mobile echodensity
7mm on ventr side of aortic valve, +echolucency along posterior
annulus, concern for abscess, trace AR. Pt transferred to [**Hospital1 18**]
for treatment and assessment for valve replacement.
Upon arrival to [**Hospital1 18**] CCU [**8-13**] 23:45, pt on 99% ra, sbp
121/63, hr 73, moving all extremities, heparin gtt infusing.
Per [**Month (only) 16**] from [**Hospital3 **], ampicillin 2000mg q4hrs, gentamycin
55mg q12hrs, vanco 1g q24hrs. The patient denies chest pain,
shortness of breath. He denies any loss of muscle strength,
changes in speech or vision. He reports a diminished appetite
for several months and an unintentional weight loss of ~15lbs
over the past year. He denies any other symptoms.
.
ECHO - LV ef 55%, av mobile density (as above) 7mm, echolucency
along posterior annulus.
Past Medical History:
Aortic valve replacement - mechanical [**Company **] [**Doctor Last Name **], [**Hospital1 2025**]
(~[**2124**])
Atrial fibrillation - on coumadin
Abdominal aortic aneurysm - s/p repair (unknown date)
Hyperlipidemia
Squamous cell cancer
Spinal Stenosis
Social History:
Married, has 3 children, former director software company, lives
in [**Location (un) **], no etoh or tobacco use.
Family History:
Father with CVA.
Physical Exam:
PE: T 99.0 , BP 121/63 , HR77 , RR22 , O2 96 % on RA
Gen: thin middle aged man in NAD. Oriented x3. Mood, affect
appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2 with systolic ejection click best at left SB.
No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis.
Unlabored respirations, no accessory muscle use. No crackles,
wheeze, rhonchi.
Abd: thin, +hyperactive bowel sounds, soft, NTND, No HSM or
tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: Diffuse echymosis on BLUE, multiple small bruises and
healing skin wounds on legs.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro: Alert and oriented x3. Cranial nerves [**2-5**] intack. [**4-29**]
strength through all limb flexors/extensors. Sensation intact.
3+ patellar reflexes, 5 beats clonus at right ankle, 9 beats on
left.
Pertinent Results:
Admission labs:
[**2143-8-14**] 01:30AM BLOOD WBC-9.6 RBC-3.32* Hgb-8.6* Hct-27.6*
MCV-83 MCH-26.0* MCHC-31.3 RDW-13.5 Plt Ct-382
[**2143-8-14**] 01:30AM BLOOD PT-14.9* PTT-51.1* INR(PT)-1.3*
[**2143-8-14**] 01:30AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-140
K-4.0 Cl-106 HCO3-25 AnGap-13
[**2143-8-14**] 01:30AM BLOOD ALT-24 AST-39 LD(LDH)-249 AlkPhos-89
TotBili-0.4
[**2143-8-14**] 01:30AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.7
.
Discharge labs:
[**2143-8-20**] 05:58AM BLOOD WBC-7.4 RBC-3.13* Hgb-8.4* Hct-26.2*
MCV-84 MCH-26.8* MCHC-32.0 RDW-14.4 Plt Ct-431
[**2143-8-20**] 05:58AM BLOOD Glucose-191* UreaN-8 Creat-1.1 Na-134
K-3.4 Cl-103 HCO3-21* AnGap-13
[**2143-8-20**] 05:58AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9
[**2143-8-15**] 09:30AM BLOOD calTIBC-156* Ferritn-372 TRF-120*
[**2143-8-18**] 06:32AM BLOOD PSA-0.2
[**2143-8-14**] 01:30AM BLOOD CRP-112.6*
[**2143-8-15**] 04:10AM BLOOD ESR-86*
[**2143-8-16**] 05:06AM BLOOD SPEP-NO SPECIFIC ABNORMALITIES SEEN
.
CHEST (PORTABLE AP) Study Date of [**2143-8-14**]
Cardiac size is normal. The aorta is elongated. The lungs are
clear. There
is no pneumothorax or sizable pleural effusion. Note is made
that the left
lateral CP angle was not included on the film. Right central
venous pacemaker leads terminate in the right ventricle.
.
CT HEAD W/O CONTRAST Study Date of [**2143-8-15**]
1. Hypoattenuating areas in the right frontal and left parietal
lobes are
concerning for acute or subacute infarcts given the patient's
history. Further characterization with MRI is recommended.
2. Probable old infarcts in the right frontotemporal lobe and
left occipital lobe.
3. Enlargement of the ventricles out of proportion to the sulci,
which may be related to central atrophy, the normal pressure
hydrocephalus should be
excluded clinically. Dr. [**First Name8 (NamePattern2) 1439**] [**Last Name (NamePattern1) 22924**] has been paged with these
findings.
.
CT ABDOMEN W/CONTRAST Study Date of [**2143-8-15**]
IMPRESSION:
1. No evidence of abscess in the abdomen or pelvis.
2. The colon appears normal without colonic wall thickening or
mass lesion.
3. Reticular opacities are noted in the lung bases, consistent
with chronic
interstitial lung disease.
4. Cholelithiasis.
5. Findings consistent with prior granulomatous disease in the
spleen.
6. Patient is status post aortobifemoral bypass graft. The graft
is patent.
.
CAROTID SERIES COMPLETE PORT Study Date of [**2143-8-16**]
PRELIM: R >70% diameter reduction, L >50-69% diameter reduction
.
TEE (Complete) Done [**2143-8-19**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is low normal (LVEF 50-55%). There are simple atheroma
in the descending thoracic aorta. A mechanical aortic valve
prosthesis is present with a small vegetation (0.4cm) on the
ventricular side of the valve. There is an area of echolucency
on the perimeter of the prosthesis near the inter-atrial septum
that could be a paravalvular [**Last Name (LF) 3564**], [**First Name3 (LF) **] annular abscess or a
combination of both. It is contiguous to but not involving the
anterior mitral leaflet. Moderate (2+), eccentric aortic
regurgitation is seen through the paravalvular abcess.The
severity of aortic regurgitation may be underestimated due to
shadowing. The mitral valve leaflets are mildly thickened but no
distinct vegetation is seen. Mild to moderate ([**12-26**]+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Aortic prosthetic valve endocarditis with probable
abscess and at least moderate aortic regurgitation.
Compared with the prior study (images reviewed) of [**2143-8-13**],
the echolucent area is larger, suggesting an enlarging abscess
or worsening valve dehiscence.
Brief Hospital Course:
A/P: 80 yo man s/p AVR [**2124**], history of abdominal aortic
aneurysm repair, a fib, hypertension, hyperlipidemia,
transferred from [**Hospital6 33**] on [**8-13**] for prosthetic
valve endocarditis in setting of R-frontal embolic stroke and
new second degree heart block.
.
1) Rhythm--atrial fibrillation, 2nd degree heart block: Pt has
a history of afib on Coumadin. He presents with worsening of
AV-nodal disease; EKG shows 2nd-degree AV block with increasing
intervals compared to [**8-12**] EKG at OSH. Pt was initially
anticoagulated on heparin gtt and transitioned to warfarin by
discharge. Given the marked AV block and risk of progression to
complete HB, temporary pacer was placed. His beta blocker was
stopped. After discussion of risks and benefits, patient has
declined to have a permanent pacer, a procedure that would have
been risky given his active infection.
.
2) Valves--Endocarditis: Patient presented with aortic valve
endocarditis on mechanical valve with abscess. Blood cultures
at OSH showed E. faecalis, sensitive to Vancomycin and Amp. ID
was consulted and recommended 4 week course of Amp/Gentamycin.
Surveillance cultures at [**Hospital1 18**] were all negative or no growth to
date. CT Surgery was consulted and discussed with the patient
and his family the risks/benefits of CT surgery. The patient
has declined surgery at this time. He does have an outpatient
cardiac surgery appointment scheduled should he change his mind.
TEE showed possible progression of abscess.
.
3) CAD/Ischemia: Pt had no evidence of acute ischemic changes.
Pt was continued on Aspirin 81 mg, Simvastatin 40 mg, Lisinopril
10 mg.
.
4) Neuro/embolic stroke: Pt had minimal residual neurological
deficits upon transfer to [**Hospital1 18**]. CT head showed "(a)
Hypoattenuating areas in the right frontal and left parietal
lobes (acute or subacute infarcts given the patient's history).
(b) Probable old infarcts in the right frontotemporal lobe and
left occipital lobe. (c) Enlargement of the ventricles out of
proportion to the sulci, which may be
related to central atrophy." Serial neuro exams showed no gross
changes.
.
5) Anemia: Pt was found to have guaiac positive stool; last
colonoscopy was 15 years ago. Pt also reported gross hematuria x
3 days 3 wks PTA and underwent cystoscopy at [**Hospital3 **]. Report is not currently available; we are awaiting
the fax. In addition, iron profile was consistent with ACD.
SPEP was checked and was negative. He did not require blood
transfusions. HCT remained stable between 24-27.
.
6) HTN: Pt was continued on Lisinopril 10 mg PO daily. His
atenolol was discontinued due to heart block.
.
7) GERD: Pt was continued on Protonix.
.
8) Code: DNR/DNI
.
9) Disposition: Patient expressed that his main goal is to go
home. After discussion with ID, cardiac surgery, palliative
care, and the primary team, pt has decided to go home with
antibiotics, NO pacemaker, and NO plans for cardiac surgery. He
will go home with hospice care. Patient will have INR levels
drawn by his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], and he will continue Lovenox
injections until his INR is therapeutic. Patient will have labs
drawn for vancomycin trough, gentamicin trough, ESR, CRP, and Cr
weekly, and these results will be faxed to the Infectious
Disease department.
Medications on Admission:
MEDs at-home:
1. lanoxin 0.125mg qd
2. tenormin 25mg qd
3. prinivil 10mg qd
4. zocor 40mg qd
5. protonix 40mg qd
6. coumadin 5mg qd
.
MEDs on transfer:
1. tylenol prn
2. pantoprazole 40mg qd
3. lisinopril 10mg qd
4. aspirin 81mg qd
5. vanco 1g q24hr (d#1? [**8-13**])
6. heparin gtt (d#1? [**8-13**])
Discharge Medications:
1. Gentamicin Sulfate (PF) 100 mg/10 mL Solution Sig: One
Hundred (100) mg Intravenous twice a day for 4 weeks: To be
continued until [**9-13**].
Disp:*50 solutions* Refills:*0*
2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush for 4
weeks.
Disp:*qs x 4 weeks ML(s)* Refills:*0*
3. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
4. Sodium Chloride 0.9 % 0.9 % Solution Sig: Three (3) mL
Injection once a day as needed for line care for 4 weeks.
Disp:*qs x 4 weeks * Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. Outpatient Lab Work
Please draw weekly Creatinine, gentamicin trough, vancomycin
trough, Erythrocyte Sedimentation Rate (ESR), and C-Reactive
Protein (CRP) every Monday while on IV antibiotics and please
call results in to [**Hospital **] clinic at ([**Telephone/Fax (1) 6313**] Attn: Dr. [**Last Name (STitle) 111**].
12. Outpatient Lab Work
Please check INR on [**2143-8-23**] and call in result to Dr.
[**Last Name (STitle) **],[**First Name3 (LF) 177**] D [**Telephone/Fax (1) 33129**].
Please also check gentamicin/vancomycin trough with same blood
draw and call results to [**Hospital **] clinic at ([**Telephone/Fax (1) 6313**] Attn: Dr.
[**Last Name (STitle) 111**].
13. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
14. Vancomycin 1,000 mg Recon Soln Sig: One (1) bag Intravenous
q 12 hours for 28 days: Please draw trough vanco level each
monday.
Disp:*56 bags* Refills:*0*
15. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO up to
q 1 hour sublingual as needed for pain.
Disp:*60 cc* Refills:*0*
16. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for agitation.
Disp:*20 Tablet(s)* Refills:*0*
17. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours as needed for increased
secretions.
Disp:*5 patches* Refills:*0*
18. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 4-6 hours as needed for increased secretions.
Disp:*20 * Refills:*0*
19. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): Use daily but stop after your Warfarin level is
more than 2.0.
Disp:*6 syringes* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary:
Endocarditis
.
Secondary:
Second degree heart block
Embolic stroke
Anemia
Hypertension
Discharge Condition:
Good condition. HR 69-74 , SBP 133-165/50-60's , temp 97.9. O2
sat 96% on RA.
Discharge Instructions:
You were admitted to the hospital for a bacterial infection on
your heart valve. The Infectious Disease doctors have [**Name5 (PTitle) 12314**] [**Name5 (PTitle) **]
in the hospital and have recommended a 4-week course of
antibiotics (gentamicin and vancomycin). In addition, a
temporary pacemaker was placed to make sure your heart beats
correctly. You have decided against having a permanent
pacemaker placed. The Cardiac Surgery team has also discussed
the benefits and risk of cardiac surgery. You expressed
understanding that surgery is likely the only option in
completely curing the bacterial infection; however, at this
time, you did not want to pursue surgery. An appointment with
Cardiac Surgery is scheduled for [**2143-9-3**] if you decide to pursue
surgery. Please call [**Telephone/Fax (1) 170**] if you want to cancel the
appt. The Pallative Care team has also visited you and you have
clearly stated that your main goal is to return home. We have
arranged to have hospice nurse help care for you at home. You
will have visiting nurses to help administer your IV
antibiotics.
.
Your medications have been changed. You will STOP the following
medications: lanoxin and tenormin. You will continue zocor
(simvastatin) and coumadin. NEW medications include the
antibiotics vancomycin and gentamicin that will go through your
PICC line. Please see the attached list. You will need to have
Lovenox injections once daily to prevent blood clots until your
coumadin level is therapeutic (between [**1-27**])Dr.[**Name (NI) 78948**] office
will tell you when to stop the Lovenox injections.
.
If you develop fevers, chest pain, shortness of breath,
bleeding, black stools, blood in your stools, lightheadedness or
any other concerning symptoms, please call your primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 33129**] or 911.
Followup Instructions:
Cardiac Surgery:
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2143-9-3**] 2:30
Primary care:
[**Last Name (LF) **],[**Name6 (MD) 177**] D, MD Phone: [**Telephone/Fax (1) 33129**] Date/Time: Office will
call you at home to set up an appt
Cardiology:
[**Last Name (LF) **],[**Name8 (MD) 819**], MD Phone: ([**Telephone/Fax (1) 64863**] [**Hospital **] Medical
Associates
[**Street Address(2) **],[**Location (un) 936**], [**Numeric Identifier 78949**]
Date/time: [**8-27**] at 10 am.
Completed by:[**2143-8-21**]
|
[
"4019",
"53081",
"2724",
"42731",
"41401",
"3051",
"2859"
] |
Admission Date: [**2158-3-25**] Discharge Date: [**2158-3-29**]
Date of Birth: [**2106-10-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22401**]
Chief Complaint:
sepsis/ARF
Major Surgical or Invasive Procedure:
Portacath removal
PICC line placement
History of Present Illness:
This is a 50 year old man with Crohn's disease with short gut
syndrome on TPN since [**2143**] with >6 episodes of line infection
([**10-1**] staph epi, acinobacter, entroccoccus c/b septic pulmonary
emboli) who was admitted on [**2158-3-25**] to [**Hospital1 18**] with hypotension
(BP in 70s/40s), T 102.2. He reports that he developed diffuse
myalgias, nasal congestion, non-productive cough 4 days prior to
admission. He also developed "aching" left lower back pain. On
the day of admission, he accessed his left portocath, and ~ 1
hour later, developed shaking chills.
.
In ED, he received 4L NS and vancomycin/ceftazidime. He was
started on a levophed drip and a right subclavian central line
was placed. Pt was admitted to the MICU, where he was volume
resuscitated, covered with vancomycin/levofloxacin/ceftazidime.
The levophed gtt was titrated off the morning of [**3-25**].
.
He denies nausea, vomiting, dysuria, hematuria, increased
urinary frequency/urgency, abdominal pain, change in ostomy
output, bleeding from ostomy, pain at portacath site. No
numbness, tingling, or shooting pain down legs. No urinary
incontinence.
Past Medical History:
1.Crohn's disease.
2.Short Gut Syndrome on TPN
3.Recurrent central line infection with MSSA, E.Coli,
Acinobacter
4.Septic pulmonary emboli
5.Bronchiectasis
6.Recent RUL infiltrates of unclear etiology (followed by
Dr.[**Last Name (STitle) **])
.
PSH:
1.)Proctocolectomy
2.)Parathyroidectomy
3.)Cholecystectomy
Social History:
Works in finance department at [**Hospital6 **]. Wife is a
nurse manager. He's got 2 kids, 18 and 15. He smoked 1ppd for
15-20 yrs, quit 20 yrs ago. No EtOH or IVDU.
Family History:
No fhx of CAD, CVA, or CA.
Physical Exam:
Tc 99.3, Tm 102 (4 p.m. [**3-25**]), pc 65, pr 60s-90s, bpc 101/63.
n[r 90s-110s/60s, resp 24, 100% RA
Gen: Middle-aged male A&OX3, NAD
HEENT: anicteric, nl conjunctiva, OMMM, OP clear, neck supple,
no LAD, no JVD
Cardiac: RRR, no M/R/G appreciated
Pulm: (+) minimal crackles at left base, clear with coughing.
Abd: Ostomy bag in place with air/liquid stool. Minimal
tenderness to deep palpation over the epigastrium. No R/G, NABS.
Ext: No C/C/E in LE, warm with 2+ DP bilaterally. (+) mild LUE
edema
Lines: Right SCL with surrounding dried blood, no
tenderness/erythema. L portacath non-tender without warmth or
erythema.
Neuro: 5/5 strength throughout, 1+ DTR LE bilaterally,
symmetric. CN II-XII grossly intact and symmetric bilaterally.
Toes downgoing bilaterally.
Back: No tenderness to percussion over spine or paraspinal
muscles. No CVA tenderness.
Pertinent Results:
WBC-11.1*# RBC-4.62 Hgb-14.0 Hct-40.4 MCV-87 MCH-30.3 MCHC-34.6
RDW-14.4 Plt Ct-94* Neuts-73* Bands-24* Lymphs-1* Monos-1* Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0 Hypochr-NORMAL Anisocy-NORMAL
Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-1+ Stipple-OCCASIONAL
.
PT-13.6* PTT-25.8 INR(PT)-1.2*
.
Glucose-99 UreaN-28* Creat-1.8* Na-136 K-3.7 Cl-102 HCO3-25
AnGap-13 Calcium-8.1* Phos-2.4*# Mg-1.2*
.
ALT-51* AST-48* LD(LDH)-167 CK(CPK)-61 AlkPhos-53 Amylase-54
TotBili-2.0* Lipase-22 Albumin-2.8*
.
CK-MB-NotDone cTropnT-<0.01
.
ESR-12 CRP-113.1*
.
ART O2 Flow-2 pO2-105 pCO2-40 pH-7.34* calHCO3-23 Base XS--3
Lactate-2.0 K-3.9
.
HEPARIN DEPENDENT ANTIBODIES- NEG
.
URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.023 Blood-NEG
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG
Urobiln-NEG pH-6.0 Leuks-NEG Hours-RANDOM Creat-79 Na-80
.
.
[**2158-3-27**] CATHETER TIP-IV WOUND CULTURE-FINAL {KLEBSIELLA
PNEUMONIAE}
.
[**2158-3-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STENOTROPHOMONAS
(XANTHOMONAS) MALTOPHILIA}; ANAEROBIC BOTTLE-FINAL
.
[**2158-3-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL {KLEBSIELLA PNEUMONIAE} EMERGENCY [**Hospital1 **]
.
[**2158-3-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {KLEBSIELLA
PNEUMONIAE}; ANAEROBIC BOTTLE-FINAL {KLEBSIELLA PNEUMONIAE}
.
Radiology
[**3-26**] Abd CT (prelim): Small bilateral pleural effusion with
atelectasis, RML scarring. No evidence of abscess in liver. Soft
tissue stranding at the antrum of stomach and duodenum (could be
c/w duodenitis).
.
[**3-25**] RUQ U/S: Minimal intrahepatic ductal prominence. No
evidence of cholecystitis
.
[**3-25**] CTA: No PE. Stable bronchiectasis in RML/Lingula
.
[**3-25**] LUE U/S (-) DVT
Brief Hospital Course:
MICU course: Blood cx grew 3/6 bottles of GNR(speciation
pending). Given rigors following portacath access, surgery was
consulted with a plan to remove left portocath. Given elevated
TBili, RUQ U/S was obtained, which was negative for
cholecystitis, although it did show minimal intrahepatic ductal
prominence. Abd CT [**3-26**] showed soft tissue stranding around
antrum of stomach and duodenum. Currently, he reports that he
continues to have "aching" left lower back pain, improved since
admission.
.
Briefly, 51 year old man with Crohns, shortgut syndrome on TPN
who present with Klebsiella sepsis.
.
#.) GNR sepsis: Pt was hemodynamically stable on the floor.
Given time association of clinical deterioration and accessing
left portocath, there was concern that portocath could either be
the source or be a site of secondary seeding. The other
potential source was duodenitis. Urinanalysis was not suggestive
of urosepsis, and the patient denied symptoms consistent with a
urinary tract infection. There was no evidence of new pulmonary
emboli on CTA. Portocath was removed on [**3-27**] by surgery given
concern for it being the bacterial source or a secondarily
seeded site of infection. Per surgery, patient should wait a
minimum of 2 weeks while on antibiotics before considering
getting another port placed. Blood cultures grew Klebsiella
sensitive to levafloxacin and so ceftazidine was switched to
levofloxacin for a 4 week course since last positive blood
culture ([**3-25**]). Sedimentation rate was normal while CRP was
elevated. Transthoracic echo was negative for vegetations and
transesophageal echo was deferred given likelihood portacath was
source of infection. Abdominal CT was negative abscess. OF NOTE:
Since discharge, patient has grown stenotrophomonas maltophilia
in [**12-2**] bottles from [**3-25**] that is sensitive to Bactrim. Unclear
if this strain was sensitive to levofloxacin. Per [**Hospital1 18**]
documented anti-microbial susceptibilities for isolates of S.
maltophilia (<50% of 75 known isolates total at [**Hospital1 **]), 53% are
sensitive to levofloxacin and 90% are sensitive to Bactrim.
However no subsequent blood cultures after [**3-25**] had any growth
and only klebsiella was isolated from the cultured
porta-catheter tip. Patient was discharged with a PICC line on
IV levaquin to complete a 4 week course.
.
2) Duodenitis: Soft tissue stranding on Abd CT around antrum and
duodenum. Could suggest infectious duodenitis vs Crohn's flare.
Patient had a benign abdominal exam and no diarrhea/abdominal
pain. GI was consulted and felt there was a low suspicion for
flare. Patient resumed his outpatient bowel medications and was
advised to follow-up with his outpatient gastroenterologist as
needed.
.
3) TBili elevation: Associated with a mild [**Last Name (LF) **], [**First Name3 (LF) **]
have been caused by mild shock liver in the setting of
hypotension. No evidence of liver abscess on Abd CT. Indirect
bilirubin and haptoglobin were wnl not suggestive of hemolysis.
There was no evidence of significant biliary disease on CT.
Resolved to TB 1.4 (wnl) by day of discharge.
.
4) Thrombocytopenia: Plt ct 68K. Likely related to sepsis. No
evidence of DIC by coags. Thrombocytopenia preceded the
initiation of heparin SC. Heparin products were discontinued and
HIT Ab was negative. No evidence of bleeding during hospital
cours.
.
5) Right Hand swelling: Left LENI (-) for DVT. Review of CTA
chest with radiology reveals SVC is patent. Hand was kept
elevated. Right UE U/S was negative for DVT (given Right SC
line).
.
6) ARF: Now resolved (Cr 1 from 1.8 on admission). Likely
pre-renal vs mild ATN in the setting of sepsis.
.
7) F/E/N: Low residue diet, TPN, monitor electrolytes and
replete as needed in TPN
.
8) Ppx: pneumoboots, PPI, PICC line was placed prior to
discharge
.
9) Dispo: discharged home with PICC line IV levaquin
.
10) FULL CODE
Medications on Admission:
Coumadin 2 mg 3 x a week - for portocath
Imodium 2 mg 3 a day
DTO 10-15 drops x 3 per day
B-12 injection once monthly
TPN
.
Meds (on transfer)
Morphine Sulfate 2 mg IV Q4H:PRN
Acetaminophen 1000 mg PO Q6H:PRN
Ceftazidime 2 gm IV Q12H
Heparin 5000 UNIT SC BID
Vancomycin HCl 1000 mg IV Q 12H
Levofloxacin 500 mg IV Q24H Order date: [**3-26**] @ 0933
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
4. Opium Tincture 10 mg/mL Tincture Sig: 10-15 Drops PO TID (3
times a day).
Disp:*1 month* Refills:*0*
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
6. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: Five Hundred
(500) mg Intravenous Q24H (every 24 hours) for 25 days: until
[**4-22**].
Disp:*[**Numeric Identifier **] mg* Refills:*0*
7. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous SASH and PRN as needed.
Disp:*1 month* Refills:*5*
8. Saline Flush 0.9 % Syringe Sig: Five (5) mL Injection SASH
and PRN.
Disp:*1 month* Refills:*5*
9. PICC line care
PICC line care per protocol
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
primary diagnosis:
Klebsiella sepsis/line infection
.
secondary diagnosis:
Crohn's disease.
Short Gut Syndrome on TPN
Discharge Condition:
good
Discharge Instructions:
Please take your medications as prescribed.
Please keep your follow-up appointments.
If you have any fevers/chills, abdominal pain, worsening
Followup Instructions:
Please schedule an appointment to see your primary care
physician ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**], MD) within one week of discharge.
Please schedule an appointment to see Dr. [**Last Name (STitle) 519**] 2-3 weeks from
discharge. Phone: [**Telephone/Fax (1) 6554**]
Please schedule an appointment to see your Gastroenterologist in
[**11-28**] months.
Completed by:[**2158-4-26**]
|
[
"99592",
"78552",
"5849",
"2875"
] |
Admission Date: [**2178-2-15**] Discharge Date: [**2178-2-26**]
Date of Birth: [**2123-5-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tylenol
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Fevers and hypotension
Major Surgical or Invasive Procedure:
Operative removal of IM nail from the left tibia
PICC line placement
History of Present Illness:
Mr. [**Known lastname **] is a 54 year old male h/o chronic left lower
extremity (LLE) osteomyelitis [**3-16**] traumatic fx and hardware
placement, deep venous thrombosus on coumadin, and recently
diagnosed aortitis who presents from an OSH with persistent
fevers and worsening LLE pain/swelling.
Mr. [**Known lastname **] states he was in his usual state of good health early
last year when a tire truck fell and crushed his L lower leg on
[**2177-6-9**]. He was taken to [**Hospital1 18**] where he was found to have
a L tibial shaft comminuted fracture in the distal [**2-14**] of the
bone, as well as chronic bursitis of the L knee. Dr. [**Last Name (STitle) 1005**]
placed an intramedullary nail and removed a prepatellar mass
consistent w/ the bursitis.
One week following discharge, Mr. [**Known lastname **] was admitted for
persistent fevers to 101*F, sweats, malaise, and chills along w/
L leg swelling and pain. He was hospitalized for 11 d and
treated for cellulitis w/ Vanc and cipro via PICC, to be
followed by ID. Seven weeks after abx initiation, Mr. [**Known lastname 78409**]
inflammatory markers remained positive, including ESR and CRP,
though clinically he was improving. IV abx were d/c'd on
[**2177-8-28**], nine weeks after the decline of markers and the
resolution of the majority of symptoms (inc temp), with the
exception of some pain and swelling. He was started on PO
doxycycline. At the time, ID was concerned for hardware
infection given the temporal course of the fevers and infection
and plan was for IM nail removal in [**3-23**]/
On [**2178-1-5**], Mr. [**Known lastname **] came for f/u in [**Hospital **] clinic and
complained of recurrent fevers to 101*F over the past several
weeks despite continuation of oral abx. He also had inc pain w/
ambulation and L leg edema. Per ID, he was continued on oral
doxy. Leg u/s revealed DVT and Mr. [**Known lastname **] was started on
anticoagulation. CT chest was neg for PE, but suggestive of 4mm
aortic thickening, read as possible intramural hematoma or
aortitis. Rhematology was consulted for vasculitis workup. MRI
was not suggestive of thickening, though arch abnormality was
visualized. Also noted were small pericardial and pleural
effusions.
Outpatient work-up for vasculitis was negative for temporal
arteritis on biopsy and inflammatory markers remained mildly
elevated to a CRP 64. F/u chest CT on [**2-10**] was significant for
repeated visualization of aortic thickening, unchanged, as well
as increased pericardial effusion. TTE also revealed
pericardial effusion without signs of tamponade, but possible
aortic regurg.
On [**2178-2-14**], Mr. [**Known lastname **] presented to [**Hospital3 **] ED
with increased lower leg pain, swelling, and warmth, with 3d of
fevers of 103 per visiting nurse services. In the ED he was
found to have a temp of 102.2 and BP 84/52. WBC was 27.7.
Transfer to [**Hospital1 18**] was arranged along with initiation of
Vancomycin, Zosyn, and dopamine.
At [**Hospital1 18**], Mr. [**Known lastname **] was admitted to the ICU.
ROS: Significant for GI upset and nausea. Pt. denies syncope,
change in taste, sight, olfaction, or hearing, dysphagia, chest
pain, palpitations, hemoptysis, vomiting, constipation,
diarrhea, hematuria, hematochezia, melena, change in bladder
habits, change in skin, new palpable masses.
Past Medical History:
# Presumed chronic osteomyelitis as detailed above
# Hypertension
# L popliteal DVT [**2178-1-5**], on coumadin at home.
# Chronic bursitis s/p resection [**2177-6-9**]
# Scoliosis
#? Gout.
Social History:
Mechanic for NSTAR electric vehicles. Widowed 4 years ago (wife
passed away from cancer). Currently lives with 14 yo son.
Denies tobacco or EtOH use.
Family History:
Non-contributory
Physical Exam:
Upon transfer to medical service:
VS:100.9 100.1 112/80 103 20 92 RA Glu 199
Gen: Obese male with prominent rhinophima appearing
significantly older than stated age with raspy voice,
continually rubbing eyes, and having difficulty recalling his
medical hx who is not in any acute pain or SOB.
HEENT: H:No signs of trauma, asymmetry. E: Pupils with minimal
reaction. 3->2.5mm. No scleral icterus. EOMs intact. N:
Prominent erythematous nose. No polyps or signs of ecchymosis.
T: Moist mucous membranes. No erythema or exudate.
CV: RRR. Audible S1, S2 with grade [**3-20**] diastolic murmur heard
best at UL sternal border. No radiation. No JVD appreciable.
No carotid bruits. No temporal bruits. Pulses [**Last Name (un) 55863**] in upper
and lower extremities, inc DP and PT. No delay in pulses.Pulsus
8mmHg. No splinter hemorrhages.
Pulm: Lungs clear to auscultation and percussion. Diaphragms
symmetric. No crackles, wheezes, rhonchi. Limited excursion on
inspiration.
Abd: Firm, non-tender to palp. Active bowel sounds. No liver
edge palp.
Extremities: Left lower extremity very warm to touch and with
edema and erythema from mid metatarsals to 3 inches below the
knee in comparison to R leg. Tender to palpation.
Neuro: Awake, alert, oriented x3. Language fluent, naming
intact, but easily distracted and tangential thought process at
times. CN II-XII grossly intact. [**6-16**] motor strength in all 4
extremities.
Pertinent Results:
ADMISSION LABS:
CBC:
[**2178-2-15**] 12:52AM BLOOD WBC-20.1*# RBC-4.18* Hgb-12.3* Hct-35.8*
MCV-86 MCH-29.5 MCHC-34.4 RDW-14.1 Plt Ct-537*#
[**2178-2-15**] 12:52AM BLOOD Neuts-83.7* Lymphs-12.8* Monos-2.8
Eos-0.5 Baso-0.2
[**2178-2-15**] 12:52AM BLOOD PT-19.5* PTT-26.5 INR(PT)-1.8*
[**2178-2-16**] 07:30PM BLOOD WBC-13.6* Lymph-14* Abs [**Last Name (un) **]-[**2073**] CD3%-60
Abs CD3-1150 CD4%-48 Abs CD4-920 CD8%-12 Abs CD8-233
CD4/CD8-3.9*
CHEMISTRIES:
[**2178-2-15**] 12:52AM BLOOD Glucose-123* UreaN-20 Creat-1.2 Na-133
K-4.0 Cl-97
HCO3-25 AnGap-15
CARDIAC ENZYMES:
[**2178-2-15**] 12:52AM BLOOD cTropnT-<0.01
[**2178-2-15**] 05:13AM BLOOD CK-MB-4 cTropnT-<0.01
[**2178-2-19**] 12:53PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2178-2-15**] 12:52AM BLOOD CK(CPK)-115
[**2178-2-15**] 05:13AM BLOOD CK(CPK)-105
[**2178-2-19**] 12:53PM BLOOD CK(CPK)-58
THYROID:
[**2178-2-16**] 07:30PM BLOOD TSH-1.5
ADRENAL:
[**2178-2-16**] 07:30PM BLOOD Cortsol-27.1*
INFLAMMATORY MARKERS:
[**2178-2-17**] 02:57AM BLOOD CRP-199.4*
[**2178-2-18**] 09:30AM BLOOD CRP-184.9*
[**2178-2-21**] 03:45PM BLOOD CRP-146.4*
ADDITIONAL SEROLOGIES AND TESTING:
[**2178-2-17**] 10:42AM BLOOD HIV Ab-NEGATIVE
DISCHARGE LABS:
CBC:
[**2178-2-26**] 05:02AM
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
10.5 3.39* 9.8* 29.0* 86 28.8 33.6 15.5 429
INR: 1.8
------------
MICROBIOLOGY:
[**2178-2-15**] 12:52 am BLOOD CULTURE SET1.
**FINAL REPORT [**2178-2-21**]**
Blood Culture, Routine (Final [**2178-2-21**]): NO GROWTH.
--------
[**2178-2-19**] 9:35 am SWAB Site: TIBIA
SWAB OF TIBIAL NAIL (LEFT) (SAVE FOR FUTURE USE).
GRAM STAIN (Final [**2178-2-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2178-2-21**]): NO GROWTH.
ACID FAST SMEAR (Final [**2178-2-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (HAIR/SKIN/NAILS) (Final
[**2178-2-19**]):
TEST CANCELLED, PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(KOH).
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
----------
[**2178-2-19**] 9:30 am TISSUE INTRAMEDULARY BONE LEFT TIBIA.
GRAM STAIN (Final [**2178-2-19**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2178-2-22**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
--------
[**2178-2-19**] 9:40 am TISSUE INTRAMEDULARY BONE REAMINGS LEFT
TIBIA.
GRAM STAIN (Final [**2178-2-19**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2178-2-22**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2178-2-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2178-2-19**]):
NO FUNGAL ELEMENTS SEEN.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
-------
[**2178-2-19**] 9:05 am SWAB DISTAL SCREWS SWAB.
GRAM STAIN (Final [**2178-2-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2178-2-21**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2178-2-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2178-2-19**]):
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(KOH).
---------
IMAGING:
L ANKLE XRAY [**2178-2-15**]: Four films are submitted of the tibia and
fibula showing an intramedullary rod
with fixation proximally and distally. The oblique fractures
through the
tibia and fibula have healed with callus formation more dense
than on the
prior films of [**2177-11-12**]. Some periosteal new bone formation
is seen
running down the medial aspect of the tibia below the old
fracture line, which could indicate an area of osteomyelitis.
Transthoracic ECHO [**2178-2-16**]:
Overall left ventricular systolic function is normal
(LVEF>55%). RV with borderline normal free wall function. The
aortic valve leaflets are moderately thickened. There is a
moderate sized pericardial effusion. Stranding is visualized
within the pericardial space c/w organization. There are no
echocardiographic signs of tamponade.
Transthoracic ECHO [**2178-2-20**]:
The patient was imaged, sitting up at 45 degrees. There is a
small pericardial effusion. The effusion is circumferential and
echo dense, consistent with blood, inflammation or other
cellular elements. There is little to no free-flowing fluid
around the heart. Left ventricular function is globally
preserved.
Compared with the prior study (images reviewed) of [**2178-2-16**], the
effusion appears substantially more consolidated and is overall
slightly smaller. The other findings are similar.
Transesophageal ECHO [**2178-2-23**]:
No spontaneous echo contrast or mass/thrombus is seen in the
left atrium/left atrial appendage or the right atrium/right
atrial appendage. The interatrial septum is intact to 2D and
color Doppler. There are simple atheroma in the descending
thoracic aorta to 40cm from the incisors. The aortic valve
leaflets are moderately thickened. A ~2 mm mobile echo density
(clips 34-36) is seen on the non-coronary leaflet of the aortic
valve consistent with possible vegetation vs focal calcium. No
aortic root abscess is seen. There is moderate (2+) aortic
regurgitation. The mitral valve leaflets are mildly thickened
but without focal vegetation or abscess. Mild [1+] mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Moderately thickened aortic valve leaflets with 2mm
mobile echodensity as described above and c/w vegetation (vs.
calcium). Moderate aortic regurgitation.
Brief Hospital Course:
This is a 54 year old man with a complicated history of presumed
chronic osteomyelitis and new diagnosis of aortitis who presents
with recurrent fevers and increased left lower extremity pain.
#Recurrent fevers: Following admission to the ICU, hypotension
resolved with fluid resucitation and breif course of pressors.
Vancomycin and Zosyn were continued and infectious disease,
rheumatology and cardiology consults were called. On the fourth
day on broad spectrum abx, Mr. [**Known lastname **] [**Last Name (Titles) 14976**]. Despite
extensive blood and bone cultures as well as testing for
syphilis, tuberculosis, HIV, aerobic, anaerobic, mycobacterial,
and fungal causes, the source of infection remains unclear. On
exam, his left lower extremity appeared suspicious for
osteomyelitis given swelling and pain though intraopertively the
bone did not appear infected and intra-operative tissue and
wound cultures have not grown anything. Patient had TEE to
assess for vegetations which showed a questionable vegetation on
the aortic valve. Plan is for patient to receive a [**5-18**] week
course of antibiotics:Ceftriaxone for a total of 4 weeks (last
dose on [**2178-3-14**]) and Vancomycin for a total of 6 weeks (last
dose [**2178-3-28**]). He has a repeat TEE scheduled in 4 weeks. At time
of discharge, patient remained afebrile with a normal white
blood cell count and downward trending CRP. He is to follow up
in infectious disease clinic on [**2178-3-12**]. Outpatient Lab Work
Weekly blood draws for CBC with Differential, BUN/Cr, AST, ALT,
Akl Phos, Total Bili, Chemistry 7, CRP, Vanco trough - results
to be faxed to [**Telephone/Fax (1) 78410**] atten Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D.
# Pericardial effusion: Pericardial effusion, first noted as an
outpatient, has been followed as an inpatient by transthoracic
echocardiogram and clinical exam. ECHO indicates consolidation
of effusion. A pericardial tap was considered but given the
small amount of pericardial fluid the cardiology consult service
did not feel this procedure would be high yield and would be
high risk. Patient remained hemodynamically stable without and
without concerning events on telemetry.
# Status Post Intramedullary Nail Removal: Patient tolerated
operative procure well and has had an uncomplicated course
post-op. Pain has been well controlled with oxycodone. He is
currently able to partial weight bear on the LLE. Plan is for
patient to follow up with orthopedic surgery 1 week from
discharge to have staples removed.
#Aortitis ?????? Stable during this admission. Blood pressure
remained stable. Plan is for patient to follow up with Dr.
[**Last Name (STitle) 914**] in 6 months and have repeat CT scan. If patient's fevers
were to return would consider re-imaging aorta sooner.
# History of DVT: Coumadin held while an inpatient and started
on a heparin drip given need for procedures. Coumadin restarted
at time of discharge with lovenox bridge. He is scheduled to
have outpatient lab work following discharge.
# Mental Status - Patient had distracted affect and has
tangential thought process throughout stay on medicine service.
Per patient's family this is his baseline. Patient had a Head CT
also showed no evidence of acute intracranial abnormalities
without contrast that did not indicate an acute intracranial
process. A Head CT with contrast was also showed no evidence of
acute intracranial abnormalities(patient unable to complete MRI
head due to claustrophobia).
# Anemia of Chronic Disease: Iron studies consistent with anemia
of chronic disease. Hematocrit remained stable during this
admission.
Patient was a FULL code during this admission.
Medications on Admission:
Medications on transfer:
Vancomycin 1000 mg IV Q 12H
Piperacillin-Tazobactam Na 4.5 g IV Q8H
Heparin IV Sliding Scale
Niacin 500 mg PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Insulin SC (per Insulin Flowsheet)
Nitroglycerin SL 0.3 mg SL PRN chest pain
Morphine Sulfate 1-2 mg IV Q4H:PRN pain
Metoprolol Tartrate 25 mg PO BID
Bisacodyl 10 mg PR HS:PRN constipation
Oxycodone 5-10 mg PO Q4H:PRN pain
Docusate Sodium 100 mg PO BID:PRN constipation
Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: You
will need to have your INR checked by home health. Your dose of
this med will be adjusted by your doctor.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
5. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours): To continue until INR therapuetic on coumadin.
[**Last Name (Titles) **]:*60 syringes* Refills:*0*
6. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every four (4)
hours as needed for pain: Do not drive or operate heavy
machinery while taking this medication.
[**Last Name (Titles) **]:*15 Capsule(s)* Refills:*0*
7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
8. Indomethacin 50 mg Capsule Oral
9. Niacin 500 mg Tablet Sig: One (1) Tablet PO once a day.
10. Calcium Carbonate Oral
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Vancomycin 1,000 mg Recon Soln Sig: 1500 (1500) mg
Intravenous twice a day for 41 days: Stop Date: [**4-7**]
To complete a 6 week course
Please give over 2 hours. .
[**Month/Year (2) **]:*41 QS* Refills:*0*
13. Ceftriaxone 2 gram Recon Soln Sig: One (1) Intravenous once
a day for 27 days: Stop Date [**3-24**] to complete a 4 week course.
[**Month/Year (2) **]:*27 QS* Refills:*0*
14. Outpatient Lab Work
Weekly blood draws for CBC with Differential, BUN/Cr, AST, ALT,
Akl Phos, Total Bili, Chemistry 7, CRP, Vanco trough - results
to be faxed to [**Telephone/Fax (1) 78410**] atten Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D.
15. Outpatient Lab Work
Please check INR on [**2178-2-26**] and fax to ([**Telephone/Fax (1) 78411**] Attn: Dr.
[**Last Name (STitle) 59771**]
16. Saline Flush 0.9 % Syringe Sig: One (1) Injection six times
daily for 6 weeks.
[**Last Name (STitle) **]:*240 QS* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 32036**] Home care
Discharge Diagnosis:
PRIMARY: Presumptive culture-negative endocarditis , status post
intra-medullary nail removal
SECONDARY: Pericardial effusion, Aortitis, History of deep
venous thrombosis
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were transferred to this hospital to determine why you were
having recurrent fevers and to treat your low blood pressure.
Blood cultures could not identify a specific type of bacteria.
However, while you were here, you were given antibiotics which
helped to reduce your fever. Your left leg also appeared
inflammed and we were concerned for infection from the leg. You
underwent surgery to remove the nail from your bone. Though it
does not appear that your bone was the source of infection. You
were also noted to have fluid around your heart, which is now
stable. You had a procedure to look at your heart valves that
indicated a question of an infection involving one of your
valves. As noted above, you will be treated with antibiotics
that should treat this type of infection. There has been no
change in the inflammation in your aorta. At time of discharge
you remained without fever. You will be discharged on a 6 week
course of antibiotics.
You have been started on the following NEW medications:
-Vancomycin: this is an intravenous antibiotic that you need to
infuse twice a day.
-Ceftriaxone: this is an intravenous antibiotic that you need to
infuse once daily.
-Oxycodone: this is a pain medication that you can take by mouth
up to every 4 hours as needed for pain. Do NOT drive or operate
heavy machinery while using this medication.
If you experience fevers, chills, chest pain, shortness of
breath or passing out please contact your primary care physician
or go to the emergency department for evaluation.
Followup Instructions:
Please follow up with your Primay Care Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 59771**] in
[**2-13**] weeks. Please call ([**Telephone/Fax (1) 78412**] to schedule an
appointment.
[**Hospital **] CLINIC: Provider: [**Name10 (NameIs) **] XRAY (SCC 2)
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2178-3-12**] 8:20
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2178-3-12**] 8:40
Visiting nursing should remove your staples on [**2178-3-5**]
.
INFECTIOUS DISEASE CLINIC:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2178-3-12**]
11:00am
CARDIOLOGY CLINIC: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] on [**2177-3-22**] at 3:00 pm in the
[**Hospital Ward Name 23**] Building. His office phone number is ([**Telephone/Fax (1) 1987**].
TRANSESOPHAGEAL ECHOCARDIOGRAM: You will need a follow up echo
to evaluate for endocarditis - you are scheduled for [**2178-3-27**] in
[**Hospital Ward Name **] 4 on the [**Hospital Ward Name 517**] of [**Hospital1 18**] at 7:30am. Please do not eat
anything starting at midnight on [**2178-3-26**] until after your
procedure.
CARDIOTHORACIC SURGERY: Dr.[**Name (NI) 9379**] office will schedule you
for a repeat CT scan to assess your aorta and will schedule you
for an appointment. If you do not hear from his office within
the next 4 weeks please call them at ([**Telephone/Fax (1) 1504**].
Completed by:[**2178-3-1**]
|
[
"0389",
"5119",
"V5861",
"4019"
] |
Admission Date: [**2112-4-18**] Discharge Date: [**2112-4-28**]
Date of Birth: [**2034-6-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 77-year-old male who
has been experiencing dyspnea on exertion since last Fall and
needs to rest for 15 minutes to resume his normal breathing
pattern.
He denies rest pain. A stress echocardiogram on [**2112-3-28**] was stopped secondary to fatigue and was uninterpretable
for ischemia. An echocardiogram showed mild left ventricular
hypertrophy and mild mitral regurgitation. There was new
hypokinesis in the anterior and lateral walls status post
exercise.
PAST MEDICAL HISTORY:
1. History of hypertension.
2. History of hypercholesterolemia.
3. History of insulin-dependent diabetes.
4. History of peripheral vascular disease.
5. Status post abdominal aortic aneurysm repair.
MEDICATIONS ON ADMISSION:
1. Accupril 20 mg p.o. twice per day.
2. Lipitor 40 mg p.o. once per day.
3. NPH 40 units subcutaneously twice per day.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: His family history was unremarkable.
SOCIAL HISTORY: His smoked one and a half packs for 15 years
and quit 20 years ago. He drinks alcohol rarely. He is a
retired civil engineer and lives with his wife.
REVIEW OF SYSTEMS: Review of systems was unremarkable.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, this was a well-developed, well-nourished
elderly male in no apparent distress. Vital signs were
stable, afebrile. Head, eyes, ears, nose, and throat
examination revealed normocephalic and atraumatic.
Extraocular movements were intact. The oropharynx was
benign. The neck was supple with full range of motion. No
lymphadenopathy or thyromegaly. Carotids were 2+ and equal
bilaterally without bruits. The lungs were clear to
auscultation and percussion. Cardiovascular examination
revealed a regular rate and rhythm. No murmurs, gallops, or
rubs. Normal first heart sounds and second heart sounds.
The abdomen was soft and nontender with positive bowel
sounds. No masses or hepatosplenomegaly. Extremity
examination revealed no clubbing, cyanosis, or edema. Pulses
were 2+ and equal bilaterally throughout. Neurologic
examination was nonfocal.
PERTINENT RADIOLOGY/IMAGING: The patient underwent cardiac
catheterization on [**2112-4-18**] which revealed the left
main had mild diffuse disease. The left anterior descending
artery had a calcified origin with an 80% to 90% stenosis.
The left circumflex had an 80% stenosis at the origin, 80%
stenosis before the first obtuse marginal, and diffuse distal
60% to 70% stenosis. The posterior descending artery was
small and diffusely diseased. The right coronary artery was
nondominant with an ostial 80% lesion and mid diffuse 80% to
90% lesion. Left ventriculography revealed an ejection
fraction of 45% with inferior severe hypokinesis and
akinesis.
HOSPITAL COURSE: He was admitted, and Dr. [**Last Name (STitle) 1537**] was
consulted. On [**4-19**], the patient underwent a coronary
artery bypass graft times three with a left internal mammary
artery to the left anterior descending artery, reversed
saphenous vein graft to the first obtuse marginal and second
obtuse marginal sequentially. The cross-clamp time was 87
minutes. Total bypass time was 105 minutes.
He was transferred to the Cardiothoracic Surgery Recovery
Unit in stable condition and was extubated. He then
developed stridor and required reintubation. He was also
very agitated and remained intubated and on propofol. He was
extubated on postoperative day three and had his chest tubes
discontinued on postoperative day two.
He was transferred to the floor on postoperative day six and
did well except for evening agitation which eventually
resolved.
DISCHARGE STATUS: He was discharged to rehabilitation on
postoperative day nine.
CONDITION AT DISCHARGE: Condition on discharge was stable.
PERTINENT LABORATORY VALUES ON DISCHARGE: His discharge
laboratories revealed hematocrit was 29.4, white blood cell
count was 10,200, and platelets were 288,000. Sodium was
138, potassium was 4.6, chloride was 104, bicarbonate was 25,
blood urea nitrogen was 28, creatinine was 1.1, and blood
glucose was 78.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice per day.
2. Aspirin 325 mg p.o. once per day.
3. Lasix 20 mg p.o. twice per day (times seven days).
4. Potassium chloride 20 mEq p.o. twice per day (times seven
days).
5. Lopressor 75 mg p.o. twice per day.
6. Haldol 5 mg p.o. q.h.s.
7. Quinapril 10 mg p.o. twice per day.
8. NPH insulin 10 units subcutaneously twice per day.
9. Lipitor 40 mg p.o. once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to be
followed by Dr. [**Last Name (STitle) 39354**] in one to two weeks, and by Dr. [**Last Name (STitle) **]
in two weeks, and by Dr. [**Last Name (STitle) 1537**] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Dictator Info 39355**]
MEDQUIST36
D: [**2112-4-28**] 14:41
T: [**2112-4-28**] 16:50
JOB#: [**Job Number 39356**]
|
[
"41401",
"4280",
"4019",
"2720",
"V1582",
"4168"
] |
Admission Date: [**2187-11-8**] Discharge Date: [**2187-11-28**]
Date of Birth: [**2112-9-17**] Sex: M
Service: MEDICINE
Allergies:
Oxacillin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
ICD removal
History of Present Illness:
75 yo man w/ h/o chronic atrial fibrillation, hypertension,
transient ischemic attack, nonischemic cardiomyopathy (EF
30-40%) s/p ventricular fibrillation arrest [**6-29**], with clean
coronaries at that time and s/p AICD placement who presents as a
transfer from OSH for management of bacteremia. During [**7-3**],
patient was admitted with large LGIB [**7-3**], complicated by MSSA
bacteremia, thought to be related to central line. At that time,
patient was treated with Vanco x 4 days, then oxacillin x 10
days. He was sent to rehab, then discharged home on [**2187-9-3**]. He
was doing well until [**2187-11-3**], when c/o fever to 102 and chills.
He is also reporting mild non-productive cough. Denies dyspnea,
PND, orthopnea. He was admitted to [**Hospital 1474**] Hosp on [**11-3**] and
blood cultures found to be positive for Staph aureus x 2 (MSSA,
penicillin resist). He was treated with Rifampin/Gent/Ancef but
repeat blood cultures [**2187-11-5**] remained positive for Staph, blood
cx from [**11-6**], [**11-7**], [**11-8**] have no growth to date. TTE was done
there with no evidence of vegetations or abscess. CXR without
infiltrate. Bone scan showed abnl uptake in L ankle, L shoulder
and L spine. TEE was delayed due to respiratory secretions.
Given recurrent bacteremia patient was transferred to [**Hospital1 18**] for
TEE and ICD system extraction. Pt is currently without
significant complaints other than diffuse body aches (mostly
Left shoulder, low back).
Past Medical History:
CHF (EF 30-40%)
Atrial fibrillation
Cardiac arrest [**6-29**] with V-fib s/p AICD placement (dual chamber
[**Company 1543**] Gem III AT DR (V:6945, A:5076))
HTN
Diverticulosis (s/p signif LGIB [**7-3**])
Colon polyps s/p polypectomy 3 yrs ago
Radiation proctitis
Left frozen shoulder
Subdural bleed after fall [**2184**] -> keppra PPX
S/P TIA
Depression
Prostate CA
Basal cell CA
C5-7 fracture s/p decompression laminectomy and c-spine fusion
[**2137**]
h/o Polio
oral HSV
Social History:
Pt lives in [**Location 1475**] with his wife. [**Name (NI) **] is a retired
pharmacist (previously Chief Pharmacist at [**Hospital1 **]). He does
not smoke or drink, though previously drank [**6-6**] drinks/day. No
drug use.
Family History:
Mother with hypertension, died of pulmonary embolism. Father
died of renal disease.
Physical Exam:
VS: T 98.6 ;BP 135/80 ; HR 60; RR 16; Sat 98% 2L
GEN: Pleasant man in bed lying on back at 30degrees in NAD with
wife at bedside.
HEENT: OP clear. MMM. Sclerae anicteric. PERRL.
NECK: JVP not elevated.
CV: Normal S1/S2, irrer irreg. II/VI HSM at LSB.
RESP: rare exp wheeze
Abd: NABS, Soft, obese, non-tender.
Ext: No edema.
Back: no spinal tenderness
Skin: 3 x 3 cm area of clustered papules + small amt of eschar.
Rectal: yellow, guaiac (-) stool
Pertinent Results:
[**2187-11-8**] 09:49PM BLOOD WBC-10.1# RBC-3.17* Hgb-10.5* Hct-29.4*
MCV-93 MCH-33.1* MCHC-35.7*# RDW-14.4 Plt Ct-217
[**2187-11-12**] 12:30PM BLOOD WBC-11.1* RBC-2.36* Hgb-7.7* Hct-22.5*
MCV-96 MCH-32.8* MCHC-34.4 RDW-14.2 Plt Ct-344
[**2187-11-25**] 09:00AM BLOOD WBC-6.6 RBC-3.03* Hgb-9.5* Hct-28.2*
MCV-93 MCH-31.3 MCHC-33.6 RDW-16.6* Plt Ct-313
[**2187-11-8**] 09:49PM BLOOD Neuts-85.2* Lymphs-9.0* Monos-2.2 Eos-3.0
Baso-0.5
[**2187-11-20**] 06:20AM BLOOD Neuts-78.5* Lymphs-15.0* Monos-3.4
Eos-2.6 Baso-0.5
[**2187-11-8**] 09:49PM BLOOD PT-14.7* PTT-27.4 INR(PT)-1.5
[**2187-11-8**] 09:49PM BLOOD Plt Ct-217
[**2187-11-25**] 09:00AM BLOOD Plt Ct-313
[**2187-11-8**] 09:49PM BLOOD ESR-80*
[**2187-11-17**] 06:33AM BLOOD ESR-58*
[**2187-11-24**] 05:26AM BLOOD Glucose-77 UreaN-76* Creat-3.2* Na-131*
K-4.9 Cl-100 HCO3-22 AnGap-14
[**2187-11-8**] 09:49PM BLOOD Glucose-123* UreaN-21* Creat-0.9 Na-132*
K-4.7 Cl-99 HCO3-26 AnGap-12
[**2187-11-12**] 05:00AM BLOOD Glucose-81 UreaN-32* Creat-1.4* Na-130*
K-4.5 Cl-98 HCO3-25 AnGap-12
[**2187-11-13**] 04:24AM BLOOD Glucose-113* UreaN-38* Creat-1.6* Na-130*
K-5.1 Cl-101 HCO3-22 AnGap-12
[**2187-11-14**] 04:07AM BLOOD Glucose-84 UreaN-45* Creat-2.0* Na-133
K-4.7 Cl-101 HCO3-22 AnGap-15
[**2187-11-18**] 05:04AM BLOOD Glucose-72 UreaN-57* Creat-2.8* Na-132*
K-5.1 Cl-100 HCO3-23 AnGap-14
[**2187-11-18**] 10:08PM BLOOD Glucose-86 UreaN-60* Creat-3.0* Na-132*
K-4.9 Cl-101 HCO3-23 AnGap-13
[**2187-11-19**] 01:31AM BLOOD Glucose-76 UreaN-61* Creat-3.2* Na-132*
K-4.5 Cl-100 HCO3-23 AnGap-14
[**2187-11-22**] 07:16AM BLOOD Glucose-67* UreaN-72* Creat-3.3* Na-133
K-5.2* Cl-101 HCO3-22 AnGap-15
[**2187-11-8**] 09:49PM BLOOD ALT-8 AST-28 LD(LDH)-164 AlkPhos-333*
TotBili-1.1
[**2187-11-10**] 05:30AM BLOOD ALT-5 AST-24 CK(CPK)-10* AlkPhos-290*
TotBili-0.5
[**2187-11-13**] 04:24AM BLOOD ALT-1 AST-17 AlkPhos-168* Amylase-68
[**2187-11-20**] 06:20AM BLOOD ALT-3 AST-16 LD(LDH)-162 AlkPhos-146*
TotBili-0.5
[**2187-11-8**] 09:49PM BLOOD Albumin-2.3* Calcium-8.6 Phos-3.5 Mg-1.8
[**2187-11-24**] 05:26AM BLOOD Calcium-8.2* Phos-6.1* Mg-2.0
[**2187-11-13**] 12:11AM BLOOD Hapto-104
[**2187-11-8**] 09:49PM BLOOD CRP-162.4*
[**2187-11-17**] 06:33AM BLOOD CRP-96.9*
[**2187-11-18**] 05:04AM BLOOD C3-31* C4-24
[**2187-11-8**] 09:49PM BLOOD Genta-1.2*
[**2187-11-10**] 08:38PM BLOOD Genta-5.4
[**2187-11-10**] 08:39PM BLOOD Genta-2.5*
[**2187-11-13**] 09:44PM BLOOD Genta-1.1*
[**2187-11-12**] 11:44AM BLOOD Glucose-155* Na-127* K-4.2
[**2187-11-12**] 11:44AM BLOOD Hgb-9.3* calcHCT-28
[**2187-11-12**] 11:44AM BLOOD freeCa-1.17
[**2187-11-26**] 03:22AM BLOOD WBC-7.8 RBC-2.85* Hgb-9.0* Hct-27.2*
MCV-95 MCH-31.4 MCHC-33.0 RDW-16.7* Plt Ct-313
[**2187-11-28**] 05:27AM BLOOD WBC-6.4 RBC-2.94* Hgb-9.1* Hct-26.9*
MCV-92 MCH-31.2 MCHC-34.0 RDW-17.0* Plt Ct-263
[**2187-11-25**] 09:00AM BLOOD WBC-6.6 RBC-3.03* Hgb-9.5* Hct-28.2*
MCV-93 MCH-31.3 MCHC-33.6 RDW-16.6* Plt Ct-313
[**2187-11-25**] 07:45AM BLOOD WBC-6.3 RBC-2.83* Hgb-8.9* Hct-26.9*
MCV-95 MCH-31.5 MCHC-33.2 RDW-16.6* Plt Ct-318
[**2187-11-20**] 06:20AM BLOOD Neuts-78.5* Lymphs-15.0* Monos-3.4
Eos-2.6 Baso-0.5
[**2187-11-28**] 05:27AM BLOOD Plt Ct-263
[**2187-11-27**] 03:51AM BLOOD PT-13.6* PTT-34.2 INR(PT)-1.2
[**2187-11-17**] 06:33AM BLOOD ESR-58*
[**2187-11-28**] 05:27AM BLOOD Glucose-79 UreaN-75* Creat-2.7* Na-130*
K-4.6 Cl-101 HCO3-23 AnGap-11
[**2187-11-27**] 03:51AM BLOOD Glucose-86 UreaN-75* Creat-2.8* Na-132*
K-4.6 Cl-100 HCO3-22 AnGap-15
[**2187-11-26**] 03:22AM BLOOD Glucose-73 UreaN-74* Creat-2.8* Na-133
K-4.8 Cl-101 HCO3-22 AnGap-15
[**2187-11-25**] 09:00AM BLOOD Glucose-82 UreaN-74* Creat-3.0* Na-134
K-4.8 Cl-103 HCO3-22 AnGap-14
[**2187-11-25**] 07:45AM BLOOD Glucose-99 UreaN-74* Creat-3.2* Na-132*
K-5.6* Cl-105 HCO3-19* AnGap-14
[**2187-11-23**] 06:20AM BLOOD Glucose-75 UreaN-75* Creat-3.2* Na-133
K-4.9 Cl-105 HCO3-22 AnGap-11
[**2187-11-22**] 07:16AM BLOOD Glucose-67* UreaN-72* Creat-3.3* Na-133
K-5.2* Cl-101 HCO3-22 AnGap-15
[**2187-11-21**] 07:15AM BLOOD Glucose-66* UreaN-67* Creat-3.2* Na-131*
K-4.7 Cl-100 HCO3-22 AnGap-14
[**2187-11-20**] 06:20AM BLOOD Glucose-68* UreaN-64* Creat-3.2* Na-131*
K-4.6 Cl-100 HCO3-21* AnGap-15
[**2187-11-19**] 01:31AM BLOOD Glucose-76 UreaN-61* Creat-3.2* Na-132*
K-4.5 Cl-100 HCO3-23 AnGap-14
[**2187-11-18**] 05:04AM BLOOD Glucose-72 UreaN-57* Creat-2.8* Na-132*
K-5.1 Cl-100 HCO3-23 AnGap-14
[**2187-11-17**] 06:33AM BLOOD Glucose-69* UreaN-53* Creat-2.6* Na-130*
K-4.7 Cl-99 HCO3-23 AnGap-13
[**2187-11-16**] 06:02AM BLOOD Glucose-76 UreaN-47* Creat-2.3* Na-134
K-4.7 Cl-102 HCO3-24 AnGap-13
[**2187-11-15**] 05:16AM BLOOD Glucose-82 UreaN-48* Creat-2.2* Na-133
K-4.5 Cl-102 HCO3-23 AnGap-13
[**2187-11-13**] 12:11AM BLOOD K-5.2*
[**2187-11-12**] 08:15PM BLOOD Glucose-75 UreaN-35* Creat-1.5* Na-132*
K-5.2* Cl-102 HCO3-22 AnGap-13
[**2187-11-12**] 12:30PM BLOOD Glucose-103 UreaN-32* Creat-1.3* Na-131*
K-4.6 Cl-102 HCO3-21* AnGap-13
[**2187-11-12**] 05:00AM BLOOD Glucose-81 UreaN-32* Creat-1.4* Na-130*
K-4.5 Cl-98 HCO3-25 AnGap-12
[**2187-11-11**] 06:21AM BLOOD Glucose-81 UreaN-28* Creat-1.2 Na-133
K-4.4 Cl-98 HCO3-25 AnGap-14
[**2187-11-10**] 05:30AM BLOOD Glucose-90 UreaN-23* Creat-0.9 Na-133
K-4.6 Cl-98 HCO3-25 AnGap-15
[**2187-11-9**] 05:49AM BLOOD Glucose-89 UreaN-22* Creat-0.9 Na-135
K-4.7 Cl-101 HCO3-27 AnGap-12
[**2187-11-8**] 09:49PM BLOOD Glucose-123* UreaN-21* Creat-0.9 Na-132*
K-4.7 Cl-99 HCO3-26 AnGap-12
[**2187-11-20**] 06:20AM BLOOD ALT-3 AST-16 LD(LDH)-162 AlkPhos-146*
TotBili-0.5
[**2187-11-13**] 04:24AM BLOOD ALT-1 AST-17 AlkPhos-168* Amylase-68
[**2187-11-10**] 05:30AM BLOOD ALT-5 AST-24 CK(CPK)-10* AlkPhos-290*
TotBili-0.5
[**2187-11-8**] 09:49PM BLOOD ALT-8 AST-28 LD(LDH)-164 AlkPhos-333*
TotBili-1.1
[**2187-11-28**] 05:27AM BLOOD Calcium-8.1* Phos-4.6* Mg-1.8
[**2187-11-27**] 03:51AM BLOOD Calcium-8.5 Phos-5.5* Mg-1.9
[**2187-11-26**] 03:22AM BLOOD Calcium-8.2* Phos-5.8* Mg-1.8
[**2187-11-25**] 09:00AM BLOOD Calcium-8.2* Phos-5.6* Mg-1.9
[**2187-11-25**] 07:45AM BLOOD Calcium-10.2 Phos-5.7* Mg-2.7*
[**2187-11-24**] 05:26AM BLOOD Calcium-8.2* Phos-6.1* Mg-2.0
[**2187-11-23**] 06:20AM BLOOD Calcium-8.1* Phos-6.7* Mg-1.9
[**2187-11-22**] 07:16AM BLOOD Calcium-8.2* Phos-7.0* Mg-2.0
[**2187-11-21**] 07:15AM BLOOD Calcium-8.0* Phos-6.5* Mg-2.0
[**2187-11-20**] 06:20AM BLOOD Calcium-8.2* Phos-6.3* Mg-1.9
[**2187-11-19**] 01:31AM BLOOD Calcium-7.9* Phos-6.3* Mg-1.9
[**2187-11-13**] 12:11AM BLOOD Hapto-104
[**2187-11-17**] 06:33AM BLOOD CRP-96.9*
[**2187-11-24**] 06:28PM BLOOD C3-4* C4-23
[**2187-11-18**] 05:04AM BLOOD C3-31* C4-24
[**2187-11-13**] 09:44PM BLOOD Genta-1.1*
[**2187-11-10**] 08:39PM BLOOD Genta-2.5*
[**2187-11-10**] 08:38PM BLOOD Genta-5.4
[**2187-11-8**] 09:49PM BLOOD Genta-1.2*
[**2187-11-12**] 11:44AM BLOOD freeCa-1.17
Femoral Vascular Ultrasound [**2187-11-26**]:
In the anterior subcutaneous tissues of the left groin, there is
a sizable localized hematoma which measures up to 9.5 cm
transverse x 12.3 cm sagittal x up to 4.8 cm in maximal AP
dimension. (Marginally larger than on the previous ultrasound of
[**11-13**]).
Normal arterial flow demonstrated with Doppler in the common
femoral artery, common normal phasic venous flow within the left
common femoral vein. No evidence of pseudoaneurysm or an
atriovenous fistula.
Right upper extremity ultrasound [**2187-11-26**]:
The right upper limb veins are patent and compressible with
normal phasic venous flow demonstrated. There is a PICC line
within the right brachial vein, no adjacent thrombus
demonstrated on the current study. (The patient has had interval
treatment with heparin. Clinical improvement in the arm swelling
since the previous ultrasound of [**2187-11-24**]).
Right upper extremity ultrasound [**2187-11-24**]:
Examination of the right IJ, subclavian, axillary and brachial
veins was performed. Exam was limited by positioning. No
evidence of thrombus in the right internal jugular, subclavian,
and axillary veins. One of the paired brachial veins appears
patent with no evidence of thrombus. The second brachial vein,
the vein containing the PICC demonstrates incomplete
compressibility and echogenic material consistent with thrombus.
Venous flow was demonstrated through this area of likely
thrombus.
Tagged WBC study [**2187-11-20**]:
Mild increased uptake at T12 is concerning for presence of
infection.
MRI Lumbar Spine [**2187-11-17**]
IMPRESSION:
1. Increased STIR signal abnormalities within several
intervertebral discs as described, with corresponding increased
signal intensity throughout the T12, severely compressed L1, L3,
and L4 vertebral bodies. These findings could be indicative of
multifocal discitis/osteomyelitis of the lumbar spine. No
paraspinal or epidural masses are otherwise found.
2. Heterogeneously low T1 signal abnormality of the lumbar spine
and focal dark T1 signal abnormality of the T12 vertebral body
also raise the possibility of metastatic disease, although
corresponding increased STIR signal intensity, particularly
within the T12 vertebral body would be atypical for osteoblastic
metastases tyipcally seen from prostate cancer. However, a
repeat bone scan is recommended for complete anatomical survey
and further evaluation of this possibility.
3. Multilevel disc degenerative change with severe spinal
stenosis at L3-4; moderate stenosis at L2-3.
Brief Hospital Course:
Mr. [**Known lastname 7749**] is a 75 yo man with history of chronic atrial
fibrillation, hypertension. transient ischemic attacks,
nonischemic cardiomyopathy (EF 30-40%) status post ventricular
fibrillation arrest [**6-29**], with clean coronaries at that time and
status post AICD placement who presents as a transfer from an
outside hospital for management of bacteremia. During [**7-3**],
patient was admitted with large LGIB [**7-3**], c/b MSSA bacteremia,
thought to be related to central line placement. At that time,
patient was treated with Vanco x 4 days, then oxacillin x 10
days. He was sent to rehab, then discharged home on [**2187-9-3**]. He
was doing well until [**2187-11-3**], when c/o fever to 102 and chills.
He was admitted to [**Hospital 1474**] Hosp on [**11-3**] and blood cultures
found to be positive for Staph aureus x 2 (MSSA, penicillin
resist) on [**11-3**] and [**11-4**]. He was treated with
Rifampin/Gent/Ancef, and blood cx from [**11-6**], [**11-7**], [**11-8**] have
been NGTD. TTE was done there with no evidence of vegetations
or abscess. CXR without infiltrate. Bone scan showed abnl
uptake in L ankle, L shoulder and L spine. TEE was delayed due
to respiratory secretions. Given recurrent bacteremia patient
was transferred to [**Hospital1 18**] for TEE and ICD system extraction.
.
In-house, serial blood cultures showed no additional growth,
with no new growth on blood cultures done at the outside
hospital. He did, however, become febrile to 101F on hospital
day #2. He was treated with cefazolin 2gm IV q8h per ID recs.
Gentamicin temporarily added for synergy, and was eventually
discontinued as surveillance cultures failed to show growth. Mr.
[**Known lastname 7749**] was also treated with acyclovir for HSV rash (HSV-1
positive on DFA and viral cultures).
.
Given results of outside hospital bone scan, Mr. [**Known lastname 7749**] had
several imaging studies to rule out osteomyelitis as etiology of
MSSA bacteremia. Plain films of L ankle, L shoulder, and
C-spine, and non-contrast CT of L-spine showed no evidence of
osteomyelitis. Contrast head CT showed no evidence of mets or
septic emboli.
.
Mr. [**Known lastname 7749**] was taken to OR on [**11-12**] for TEE and explantation of
ICD. TEE showed 1.1cm TV vegetation with tricuspid valve
regurgitation. Intra-op, ICD pocket appeared infected, but
culture eventually had no growth. Explantation was complicated
by a left groin hematoma, and hct drop to 22.5 from 26.5.
Immediately post-op, the patient's systolic blood pressure
dropped to the 80s, he was treated with neosynephrine to keep
MAP>60, given 2 units of PRBC, with inadequate hematocrit
response. Femoral ultrasound showed evidence of large left
hematoma. His lower extremities were cool, but dopplerable
pulses were noted in the lower extremities bilaterally.
Due to unstable hemodynamics and dropping hematocrit, Mr. [**Known lastname 7749**]
was transferred to the CCU for more intensive monitoring. He was
transfused a total of six units over first 24 hours, hematocrit
stabilized at 30 (baseline hct), he was weaned off
neosynephrine, and started on low dose isosorbide mononitrate
and hydralazine once blood pressure had been stable for over 24
hours. He underwent noncontrast CT scan which ruled out
retroperitoneal bleed. Repeat ultrasound showed hematoma, but
adequate flow; no signs or symptoms of compartment syndrome were
noted. Patient also had rising creatinine (to 2.2 from admission
creatinine of 0.9), rising phos (as high as 6.2), elevated K to
5.3, and decreased urine output. This acute renal failure was
thought to be secondary to hypovolemia and likely
gentamycin-induced renal toxicity. The renal service was
consulted, and they suspected gentamycin-induced toxicity vs
acute interstitial nephritis, and recommended diuresis with
lasix for elevated K, renally dosed meds, and TUMS for elevated
phos. The pt was started on Cefazolin (renally dosed) for
treatment of bacteremia. Nutrition consult also placed as
patient's albumin on transfer was 1.9 and he was edematous. teh
nutrition team suggested a full liquid diet with shake
supplements. ID recommended continung acyclovir for total 7
days, which was done, and cefazolin for total 6 weeks. Patient
transferred back to [**Hospital Unit Name 196**] on [**11-15**] for further management.
On [**Hospital Unit Name 196**] service, renal function continued to deteriorate.
Creatinine climbed to 3.3 by [**2187-11-22**]. Rare positive urine
eosinophils were noted, but there was no peripheral eosinophilia
that would suggest acute interstitial nephritis. Spot
protein/creatinine ratio was 2.2, C3 was 4 and C4 was noted to
be 24. FEUrea was noted to be 34%, so the lasix dose was
titrated to a ensure gentle diuresis due to concerns of prerenal
component of ARF and the likelihood that diuresis may be
contributing to hyponatremia. Through discussions with
infectious diseases team and renal services, decided that
evidence was not sufficiently strong for acute interstitial
nephritis. However, to address the possibility of Cefazolin as a
contributing [**Doctor Last Name 360**] for possible AIN, the antibiotic was switched
to Daptomycin. The urine creatinine plateaued and then trended
downward as a consequence of this change and was 2.7 on the day
of discharge. The patient will need to be continued on lasix for
active diuresis, given his siginificant edema. During his
hospitalization he was relatively refractory to lasix and was
diuresed with 120mg IV lasix. From admission to date, Mr. [**Known lastname 7749**]
has had a nett gain of 10kg. The lasix will need to be titrated
to achieve a diuresis goal of 0.5 to 1 kg daily (corresponding
to nett output of 500 to 1000cc daily) with a targeted weight
loss of 5 to 10kg or until edema has significantly resolved. The
patient's electrolytes and creatinine will need to be measured
daily and the electrolytes need to be repleted as needed.
.
During his hospital stay, the pt also started complaining of
lower back pain. A L-spine MRI and R shoulder MRI were obtained,
which demonstrated increased signal intensity throughout the
T12, severely compressed L1, L3, and L4 vertebral bodies. This
study was followed up by a tagged WBC study, per infectious
disease team recommendation. The WBC scan showed mildly
increased uptake at T12 that was concerning for presence of
infection, suggestive of osteomyelitis. Based on the infectious
diseases team's recommendation the patient will be continued on
Daptomycin for a 10 week duration with weekly monitoring of CBC,
Creatinine, liver function tests and CK at the rehabilitation
facility and then as an outpatient. The patient needs to be
followed up as an out-patient 5 weeks after discharge with the
Infectious Disease clinic.
.
Mr. [**Known lastname 16127**] hospital stay was also complicated by a
non-obstructive clot around the right PICC line ([**2187-11-24**]) that
was treated with heparin. The non-occlusive clot was not present
on a repeat right upper extremity ultrasound on [**2187-11-26**]. While
on heparin, Mr. [**Known lastname 7749**] was noted to have a recurrence of his
previous left groin hematoma. An ultrasound of the left groin
showed normal arterial flow with Doppler in the common femoral
artery, common normal phasic venous flow within the left common
femoral vein. There was no evidence of pseudoaneurysm or an
atriovenous fistula. The groin has been marked and needs to be
followed up at the rehabillitation facilility. Mr. [**Known lastname 7749**] also
had a traumatic foley placement with some clots. The clots
subsequently resolved and the patient's foley drained clear
urine. The patient will need close monitoring of his hematocrit
(daily) in teh setting of a groin hematoma and a few clots in
his foley.
.
Mr. [**Known lastname 7749**] was also noted to have a positive urine culture (yeast
10,000-100,000/ml) that was suggestive of a likely colonization.
He was treated with a 7 day course of Fluconazole and his foley
was changed.
.
While in hospital, Mr. [**Known lastname 16127**] coumadin was held in the setting
of dropping hematocrit (see above). While off coumadin, he was
noted to occasionally revert back into his baseline atrial
fibrillation. The risks and benefits of being off coumadin have
been discussed extensively with the patient and his family and
they would like the coumadin to be held until the hematoma
resolves and the patient has been reevaluated by the physicians
at the rehabilitation facility and the patient's cardiologist
Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**] (Phone:[**Telephone/Fax (1) 902**]).
.
Due to his extended hospital stay Mr. [**Known lastname 7749**] became physically
deconditioned. It is anticipated that he will need extensive
physical rehabilitation at the rehab facility to resume his
baseline functional status.
Medications on Admission:
Ultram
Nystatin
Guaifenisen
Rifampin 300mg q8
Albuterol
Lisinopril 40 [**Hospital1 **]
Lopressor 50 [**Hospital1 **]
Allopurinol 100 daily
lasix 40 daily
spirinolactone 25 daily
protonix 40 daily
tylenol prn
cefazolin 2g q8
famvir 500 [**Hospital1 **]
gentamicin 92mg q 8
zofran prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q DAY (12 HOURS ON,
12 HOURS OFF) () as needed for R shoulder pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
4. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
Disp:*30 ML(s)* Refills:*0*
5. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours) as needed
for back pain.
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
Disp:*3600 ML(s)* Refills:*0*
13. Daptomycin 500 mg Recon Soln Sig: One (1) Intravenous Q48H
for 9 weeks: To be continued for a total of 10 weeks for
osteomyelitis. Daptomycin started on [**2187-11-18**]. Dose to be
re-evaluated by infectious diseases specialist as an out-patient
5 weeks after discharge. .
Disp:*qs * Refills:*0*
14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
Disp:*30 ML(s)* Refills:*0*
15. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day): For elevated phosphate levels. The dose is to be
titrated by the physicians at the rehabilitation facility. .
Disp:*270 Tablet(s)* Refills:*2*
16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days: Total 7 day course.
Disp:*4 Tablet(s)* Refills:*0*
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): SC Heparin for DVT prophylaxis.
Disp:*30 * Refills:*2*
18. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: 0.5 Tablet Sustained Release 24HR PO DAILY (Daily): Hold
for systolic blood pressure <100 and heart rate <60.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
19. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea
20. lasix Sig: One [**Age over 90 **]y (120) Intravenous (only)
once a day: The physicians at the rehabilitation facility will
titrate the dose of lasix based on nett urine output and
creatinine levels. .
Disp:*7 * Refills:*0*
21. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Methicillin sensitive staph aureus bacteremia
Endocarditis
Urinary tract infection (yeast)
Osteomyelitis
Acute renal failure
Nonocclusive thrombus (PICC)
Hematoma (groin)
Atrial fibrillation
Hypertension
Nonischemic cardiomyopathy
Compression fracture
Discharge Condition:
Stable
Discharge Instructions:
You will need to weight yourself daily. If you note an increase
in weight of >3lbs, please report to your primary care physician
for evaluation.
Please follow a low-salt, heart healthy diet.
Please restrict total fluid intake to 1000cc daily.
If you have any chest pain, fever, chills,
nausea/vomiting/diarrhea, blood in bowel movements, abdominal
pain or increased swelling of your feet or body, please report
to the nearest Emergency Department.
You will need to follow-up with the renal (kidney) and
infectious diseases specialists (indicated below). You will also
need to see your primary care physician within the next two
weeks.
.
There have been some changes to your medication regimen. Please
carefully read the medication list and follow the instructions.
Followup Instructions:
PROVIDER: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] D.:[**Telephone/Fax (1) 3329**]
Date/Time:[**2187-12-7**] 1.30PM
.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] TAN (Infectious Diseases Specialist)
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2187-12-21**] 10:00am.
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) **] (Renal specialist at the [**Last Name (un) **]
Diabetes Center) Phone: [**Telephone/Fax (1) 3637**]. Date/time: [**2187-1-9**] at 9AM.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2187-11-28**]
|
[
"99592",
"5849",
"2851",
"42731",
"4280",
"4019"
] |
Unit No: [**Numeric Identifier 66138**]
Admission Date: [**2171-10-8**]
Discharge Date: [**2171-12-25**]
Date of Birth: [**2171-10-8**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is the former
1.43 kg product of a 29 and [**2-28**] week gestation pregnancy,
born to a 31 year-old, Gravida II, Para 0 woman.
Prenatalscreens: Blood type 0 positive, antibody negative,
Rubella immune, RPR nonreactive, hepatitis B surface antigen
negative. Group beta strep status unknown. Antepartum course
was notable for twin pregnancy. The mother developed
pregnancy induced hypertension which prompted admission to
[**Hospital6 3872**]. She received betamethasone and was
beta complete on [**2171-10-6**]. She was transferred to [**Hospital1 1444**] due to worsening
hypertension. She was treated with magnesium sulfate.
Decision was made to deliver by Cesarean section under spinal
anesthesia for worsening pregnancy induced hypertension.
This twin #1 emerged with Apgars of 8 at 1 minute and 8 at 5
minutes. She was admitted to the NICU for treatment of
prematurity.
PHYSICAL EXAMINATION: Physical examination upon admission to
the Neonatal Intensive Care Unit: Weight 1.43 kg. Head
circumference 27.5 cm. General: Pink infant in mild
respiratory distress, on continuous positive airway pressure.
HEENT: Soft anterior fontanel, normal facies. Palate
intact. Chest: Mild retractions, fair air entry.
Cardiovascular: No murmur. Present femoral pulses. Abdomen:
Soft and flat, nontender, no hepatosplenomegaly.
Genitourinary: Normal female external genitalia.
Musculoskeletal: Hips stable. Spine straight and normal.
Skin: Normal perfusion. Neuro: Normal tone and activity
for gestational age.
HOSPITAL COURSE:
1. Respiratory: [**Known lastname **] was initially placed on continuous
positive airway pressure. Upon admission to the Neonatal
Intensive Care Unit, she had worsening distress and an
increasing oxygen requirement and was subsequently
intubated and received 2 doses of Surfactant. She was
extubated to continuous positive airway pressure on day
of life 5. She transitioned to nasal cannula oxygen on
day of life #9 due to clinical decompensation. On day of
life #20, she was reintubated and ventilated for the next
week. On day of life 27, she was again extubated and
transitioned to room air and continued in room air
through the remainder of her Neonatal Intensive Care Unit
admission. She was initially treated for apnea of
prematurity with caffeine which was discontinued due to a
cardiac arrhythmia. She has had rare episodes of apnea
and none for the 3 weeks prior to discharge. At the time
of discharge, she is breathing comfortably, 30 to 40
breaths per minute. One episode of brief bradycardia was
noted during her eye exam yesterday but she has no further events
since then.
2. Cardiovascular: A murmur was noted on day of life #2 and
clinically presenting as a presumed patent ductus
arteriosus. She was treated with Indomethacin. Cardiac
echo was obtained on day of life #3 showing no PDA and a
patent foramen ovale versus an atrioseptal defect. On
day of life 18, she had a spontaneous episode of
supraventricular tachycardia. An EKG at that time showed
premature atrial beats and atrial bigeminy, normal
indices, no ventricular hypertrophy. She continued to
have runs of supraventricular tachycardia. She was
treated briefly with propranolol and digoxin. The
episodes resolved spontaneously and she has not had any
episodes since [**2171-11-3**]. No murmurs are noted at the
time of discharge. Baseline heart rate is 150 to 170
beats per minute with a recent blood pressure of 76 over
54 with a mean of 62 mmHg. Cardiology follow-up is
recommended one month after discharge.
3. Fluids, electrolytes and nutrition: [**Known lastname **] was initially
n.p.o. and maintained on IV fluids. She had a double
lumen umbilicus venous catheter, a percutaneously
inserted central catheter was placed on day of life 5.
Enteral feeds were started on day of life 5 and gradually
advanced to full volume. On day of life #20, she
presented with abdominal distention and tenderness and
frank blood per rectum. She was made n.p.o. and treated
with 3 weeks of bowel rest. A contrast enema was
performed on [**2171-11-16**] and [**2171-11-27**], both studies were
within normal limits with no strictures or abnormalities
noted. An upper gastrointestinal series was obtained on
[**2171-11-28**] and was within normal limits. [**Known lastname **] was refed
slowly with breast milk and again on day of life #60, she
had reccurrence of bloody stools. Her formula was
changed to Nutramigen without improvement and on day of
life #63, she was changed to Neocate elemental formula.
At the time of discharge, she is taking 150 to 240 cc per
kg per day of Neocate, exhibiting good weight gain.
Weight on the day of discharge is 3.05 kg with a
corresponding length of 50 cm and a head circumference of
34.25 cm. Serum electrolytes were checked repeatedly and
were within normal limits.
4. Infectious disease: [**Known lastname **] was evaluated for sepsis upon
admission to the Neonatal Intensive Care Unit. A white
blood count and differential were within normal limits. A
blood culture was obtained prior to starting intravenous
Ampicillin and Gentamycin. The blood culture was no
growth at 48 hours and the antibiotics were discontinued.
With the onset of her presumed necrotizing enterocolitis
on day of life #20, she was once again recultured and
started on ampicillin, gentamicin and clindamycin. She
received a total 21 day course of antibiotics. A lumbar
puncture was performed on day 10 of this antibiotic
course and was concerning with a CSF white blood cell
count of 40 which prompted elongation of her course to 3
weeks of antibiotics. All cultures were negative.
5. Hematology: [**Known lastname **] is blood type 0 positive. She
received 2 transfusions of packed red cells on [**2171-10-28**]
and [**2171-12-5**]. Her most recent hematocrit is 34.5% on [**2171-12-25**]
with a reticulocyte count of 1.9%.
6. Gastrointestinal: As previously mentioned, [**Known lastname **] had
presumed necrotizing enterocolitis and also concern for
cow's milk protein allergy. She will be followed up by the
pediatric gastroenterology service at [**Hospital3 1810**]
one month after discharge. Appointment will be with [**First Name8 (NamePattern2) 2795**]
[**Last Name (NamePattern1) 65196**], MD who can be reached at [**Telephone/Fax (1) 46320**]. The plan
had been to reintroduce breast milk 1 week prior to that
gastroenterology appointment to determine whether [**Known lastname **]
will tolerate breast milk. Her mother has been on a
modified restricted dairy and soy diet for the last month.
Her mother has expressed reservations about this plan
preferring to wait a longer period before trying breastmilk
again. This should be reviewed with Dr. [**Last Name (STitle) 65196**].
7. Neurology: Head ultrasounds were obtained on [**10-15**] and
[**2171-11-7**] and were within normal limits. [**Known lastname **] has
maintained a normal neurologic exam during admission and
there were no neurologic concerns at the time of
discharge.
8. Sensory: Audiology: Hearing screening was performed with
automated auditory brain stem responses. [**Known lastname **] passed in
both ears.
Ophthalmology: Eyes were initially examined on [**2171-11-22**]
showing stage I, zone II retinopathy of prematurity. Two
subsequent exams showed similar findings. Most recent exam
was on [**2171-12-24**] showing immature retina to zone II with
recommended follow-up in 3 weeks.
9. Psychosocial: [**Hospital1 69**] social
work has been involved with this family. The family has
been very involved in [**Known lastname 66139**] care.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66140**], MD, Child Health
Associates, [**Location (un) 66141**], [**Hospital1 **], [**Numeric Identifier 66142**].
Phone number [**Telephone/Fax (1) 38488**].
CARE AND RECOMMENDATIONS:
1. Feeding: Neocate p.o. ad lib. Reintroduce breast milk
after you and parents have discussed the plan further with
Dr. [**Last Name (STitle) 65196**]. If the baby continues to take large volumes -
>200ml/kg/d of Neocate, the protein intake will more than with
standard infant formulas. This should be well tolerated, however
our dietician recommends checking a BUN and creatinine in the
next 2-3 weeks to ensure this.
2. No medications at discharge.
3. Recommend starting supplemental iron 2 weeks after
discharge to provide total of 4mg/kg/d of elemental iron -
Neocate provides 2mg/kg/d of Fe when baby is taking 150ml/kg/d.
4. Car seat position screening was performed. [**Known lastname **] was
observed in her car seat for 90 minutes without any
episodes of bradycardia or oxygen desaturation.
5. State newborn screens were sent on [**11-21**],
[**2171-11-19**]. The last screen on [**2171-11-19**] was not on full
enteral feedings. Therefore, a repeat screening was sent
on [**2171-12-25**] with results pending at the time of discharge.
6. Immunizations: Hepatitis B vaccine was administered on
[**2171-11-10**].
Pediarix, HIB and Prevnar were administered on [**2171-12-14**].
Synagis was administered on [**2171-12-19**].
Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
7. Follow-up appointments:
a.) Appointment with Dr. [**Last Name (STitle) 66140**] within 3 days of discharge.
b.) Pediatric gastroenterology, Dr. [**First Name8 (NamePattern2) 2795**] [**Last Name (NamePattern1) 65196**], [**Hospital3 18242**], phone number [**Telephone/Fax (1) 46320**] - date [**2172-1-27**] 9:30 AM.
c.) Pediatric Cardiology, Dr. [**Last Name (STitle) 65613**], [**Hospital3 1810**], phone
number [**Telephone/Fax (1) 37115**], date [**2172-2-11**] 4:30PM.
d.) Pediatric Ophthalmology in 3 weeks with Dr.[**Name (NI) **] [**Name (STitle) 56687**] on
[**1-15**] at 1:30PM.
[**Known lastname 66139**] [**Hospital3 1810**] medical record number is [**Numeric Identifier 66143**].
DISCHARGE DIAGNOSES:
1. Prematurity at 29 and 4/7 weeks gestation.
2. Twin #1 of twin gestation.
3. Respiratory distress syndrome.
4. Suspicion for sepsis, ruled out.
5. Presumed meningitis (CSF pleocystosis but culture neg).
6. Presumed patent ductus arteriosus.
7. Supraventricular tachycardia.
8. Necrotizing enterocolitis.
9. Cow's milk protein allergy.
10. Anemia.
11. Apnea of prematurity.
12. Stage I retinopathy of prematurity.
13. Unconjugated hyperbilirubinemia.
DR.[**First Name (STitle) 1877**],[**First Name3 (LF) **] 50-466
Dictated By:[**Last Name (NamePattern1) 66144**]
MEDQUIST36
D: [**2171-12-25**] 01:00:38
T: [**2171-12-25**] 05:17:30
Job#: [**Job Number 66145**]
|
[
"7742",
"V053",
"V290"
] |
Admission Date: [**2154-6-10**] Discharge Date: [**2154-7-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath, fever, hypoxia to 80% on RA.
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central venous line placement
History of Present Illness:
84 yo woman with dementia at [**Doctor Last Name **] presented to ED [**2154-6-10**] with
fever to 101, cough and hypoxia to 80s on RA. On arrival in the
ED VS: 97.5 127/61 107 30 80% RA BG 260. The ED confirmed full
code with family given dementia, so proceeded with intubation
out of concern for airway protection more than hypoxia. 1 hour
after intubation she was itnermitently hypoensive to 50s
systolic (?versed related) so a central line was placed and she
was started on minimal levophed (on arrival 0.06 mcg/kg/min).
She was given zosyn 4.5gm/vanco 1gm/levaquin 750mg iv, versed
2mg iv and got a CT torso/head. She was given total 3L NS. CVP
noted to be 16-19, her ekg showed STEMI in V2-V3 with tn of 0.12
so cardiology was consulted, no cath at this time, no heparin.
Cardiology did bedside TTE: Normal LV function, no WMA.
ROS: Per children she c/o fatigue on saturday, was noted to
frequently clear her throat recently, but no other complaints
specifically.
Past Medical History:
dementia: alzheimer's disease
hypertension
rectal surgery?
Social History:
Lives in [**Hospital3 **] in [**Location (un) **]: [**Telephone/Fax (1) 17732**], long-standing
dementia, thought to be Alzheimer's. Per children was out with
them to lunch last week, gets assistance with ADL's/iADL's and
has short term memory deficits but still very interactive, no
difficulty with aspiration when eating. No history of tobacco
use, etoh, or illicit drug use.
Family History:
Unknown.
Physical Exam:
VS: T: 97.1 BP 107/54 HR 82 RR 16 Sat 100% on AC 500/15/.[**5-11**]
GEN: NAD, intubated, responds to name, grimaces to pain, does
not follow commands
HEENT: AT, NC, PERRLA 4->3mm B, no conjuctival injection,
anicteric, OP clear, MMM
Neck: supple, no LAD, no carotid bruits, JVP to angle of jaw
CV: RRR, nl s1, s2, no m/r/g
PULM: diffusely rhonchorus throughout, rales left base
ABD: soft, NT, ND, + BS, no HSM
EXT: cool LE, dry, +2 distal pulses BL, trace B edema
NEURO: 1+ DTR's patellar, biceps, triceps, bracioradialis
bilaterally, grimaces to pain, conjugate gaze, PERRL
Pertinent Results:
Admission labs:
[**Age over 90 **]|98|35 AG 9
-----------<279
4.3|34|1.1
estGFR: 47/57 (click for details)
CK: 100 MB: 7 Trop-T: 0.12
ALT: 140 AP: 122 Tbili: 0.4 AST: 162
13.4
7.4>--<200
40.5
N:75 Band:7 L:7 M:10 E:0 Bas:0 Myelos: 1
central venous o2 sat 96
PT: 12.5 PTT: 26.6 INR: 1.1
Micro:
blood cx [**6-10**] x4, no growth
stool cx [**6-10**] negative
urine culture negative
urine legionella antigen neg
sputum no growth [**6-10**], [**6-11**]
CXR PA and lat [**6-10**] FINAL: Hyperinflation with bilateral
hemidiaphragm flattening is not changed in appearance. No
effusion, consolidation or other opacity is identified within
the lungs. The aortic arch again demonstrates calcifications,
and there is no change in appearance of thoracic kyphosis with
vertebral body wedging.
.
ECG [**2154-6-10**]: Sinus tach (103), nl axis, nl intervals, 1mm ST
elevation V2-V3, Q III, TWI III, 1mm STE III, TW flattening aVF
(new). Improved on subsequent ECG's with slower rate.
CTA Chest, CT torso [**6-10**]: 1. No evidence of PE or thoracic or
abdominal aortic aneurysm.
2. No evidence of intra-abdominal abscess.
3. Some delay of passage of contrast from the great vessels,
which may represent pulmonary edema.
4. There is emphysema bilaterally. There is some atelectasis at
the bases.
5. There is a large non-obstructing gallstone in the
gallbladder.
CT Head [**6-10**]: 1. No evidence of infarction or hemorrhage. 2.
Likely chronic right maxillary sinusitis.
MRI Head ([**6-30**]):
1. No acute infarction.
2. Moderately extensive bilateral white matter FLAIR
hyperintense areas likely representing sequelae of chronic small
vessel occlusive disease, increased since [**2149**].
3. Patent major intracranial arteries, without focal
flow-limiting stenosis, occlusion, or aneurysm more than 3 mm,
within the resolution of MR angiogram.
4. Moderate diffusely increased signal, in the mastoid air
cells, representing fluid versus mucosal thickening.
Brief Hospital Course:
A/P: Mrs. [**Known lastname 12347**] is an 84F w/PMH dementia who initially
presented with fever, hypoxic respiratory failure, transient
hypotension, transaminitis, ARF and NSTEMI admitted to the
intensive care unit and intubated for respiratory distress. Her
course was complicated by NSTEMI, transaminitis and ARF, all of
which thought to be secondary to hypotensive shock in the
setting of sepsis. Patients mental status remained poor and
neurology as well as geriatric services were involved in
evaluation and treatment of her condition. All her psychotropic
medications were held (memantine, razadyne, risperdal) and her
mental status significantly improved. She remained alert and
cooperative, however with some confusion which remained stable.
.
Hospital course by problem:
.
.
# Pneumonia/Septic shock/VAP: Respiratory failure on admission
due to pneumonia in the setting of fever, cough, RLL infiltrate.
Course complicated by ventilator associated PNA. She had BAL on
[**2154-6-16**], no microorg identified. Levophed briefly required for
significant hypotension post intubation. Vancomycin was d/c'd
[**6-19**] and she completed 10 day course of levofloxacin on [**6-20**] and
8 days of zosyn on [**6-23**]. She has completed all of her abx
courses.
.
# Respiratory failure:- Initially requiring intubation as above.
Patient with pneumonia as above. Respiratory status also
complicated by a component of pulmonary edema after aggressive
fluid resuscitation in the setting of sepsis. She was extubated
[**6-18**]. No formal diagnosis of COPD but emphysema on CXR, airway
resistance. Once on the floor, she again required MICU transfer
due to hypercarbic respiratory failure and somnolence, likely
due to a combination of pulmonary edema, mucous plugging, and
oversedation. Now with good respiratory function on RA (O2Sat
97-100%)
.
# Paroxysmal Atrial fibrillation: She has been in and out of
Afib with RVR, rate to 150's since her admission. Seems to be
triggered by hypoxic episodes as above as well as by albuterol
neb treatments. CHADS2 score [**3-10**]. Afib seems also to trigger
pulm edema. Albuterol/xopenex held. Metoprolol uptitrated
significantly with improved rate control. Aspirin continued.
.
# ARF: Baseline creatinine 0.5, ARF on admission most likely due
to hypovolemia/pre-renal in setting of acute illness. Creatinine
came down and normalized. Lisinopril can be resumed in Rehab
with lower dose (2.5) and monitoring of renal function.
.
# Delirium/Dementia: Baseline dementia with intermittent
agitated delirium in the setting of acute illness and infection.
During her ICU stay she was tried on haldol with no effect,
zyprexa with short lasting effect, seroquel with best effect.
Memantine and razadyne restarted but pt became somnolent, hence
all psychotropic were held. Geriatrics was consulted for
recommendations for behavioral control. Required 1:1 sitter at
times for safety. Her post-discharge agitation plan includes
use of 0.25 mg haldol prn.
.
# NSTEMI: Troponin bump up to 0.12 with CK/CKMB not elevated,
most likely demand ischemia in the setting of relative
hypoperfusion from septic shock. Managed medically. Aspirin,
statin, beta blocker continued and cardiology followed. Stress
test as outpatient can be considered. TTE initially showed
severe hypokinesis of the distal half of the inferior wall which
subsequently appeared to resolve on echo during MICU stay. Again
ruled out for MI with most recent episode of resp distress
requiring MICU transfer.
.
# FEN: seen by speech and swallow, approved for nectar thickened
liquids and ground solids, thin liqids between meals only,
replete lytes prn, speech and swallow re-eval in Rehab to clear
pt for solids.
.
# CODE: DNR, intubation okay.
.
# COMMUNICATION: Patient, son [**Name (NI) **] [**Name (NI) 12347**] (c) [**Telephone/Fax (1) 17733**]
(h)[**Telephone/Fax (1) 17734**] and daughter [**Name (NI) **] (c) [**Telephone/Fax (1) 17735**] and (h) [**Telephone/Fax (1) 17736**]-5400 (co-HCP's).
Medications on Admission:
lisinopril 5 daily
aspirin 81mg daily
memantine 10mg [**Hospital1 **]
razadyne ER 16mg daily
risperdal 0.5mg qhs
toprol xl 50mg daily
vitamin E 1,000u twice daily
Discharge Medications:
1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 160 mg/5 mL Solution Sig: One (1) Acetaminophen
(Oral) 160 mg/5 mL Solution PO Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) puffs Inhalation [**Hospital1 **] (2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
13. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Septis
Respiratory failure
.
Ventilator associated pneumonia
Non ST elevation myocardial infarction
Agitation
Dementia
Afib with rapid ventricular response
COPD
Acute renal failure
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with severe pneumonia and respiratory
difficulties with acute mental status changes. We treated you
with antibiotics and you required a stay in the intensive care
unit. Your hospital course was complicated by mild myocardial
infarction (heart attack) and renal failure which recovered.
.
We changed and stopped some of you medication (see instructions
below).
.
Please return to the hospital or call your doctor if you or your
caregivers notice fever >101, further breathing difficulties,
agitation or difficult to control behavior, fast heart rate,
chest pain, or any new symptoms that you are concerned about.
.
Since you were admitted we have made the following changes to
your medications:
*
Followup Instructions:
Please see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**], within 2
weeks of discharge.
|
[
"0389",
"51881",
"5180",
"5849",
"78552",
"486",
"41071",
"2760",
"4019",
"99592",
"42731",
"4280"
] |
Admission Date: [**2128-4-13**] Discharge Date: [**2128-4-16**]
Date of Birth: Sex:
Service:
NOTE: The date of discharge is yet to be determined. She is
being transferred to the hematology/oncology floor, out of
the Intensive Care Unit.
HISTORY OF PRESENT ILLNESS: This is a 44 year old female
with immigrated from [**Country 4194**] three years ago with essentially
no past medical history. She presented to [**Hospital3 1280**] on
[**2128-3-18**] with fever, cough, headache, nine pound weight
loss over four months, abdominal pain, and is being
transferred here for a second opinion and further management.
On admission to [**Hospital3 1280**], she was found to be pancytopenic
with an ANC of 150; hematocrit of 20 and platelets of 56,000
and febrile to 101.6 degrees F. She was started on Ceptaz
and transfused packed red blood cells and platelets. She
underwent bone marrow biopsy on [**3-17**]. Results were
positive for B cell antigen; positive DBA44, positive CD-4 5
RO, hypercellular marrow with 5% fat composed almost entirely
of infiltrating small lymphoid cells, all consistent with the
diagnosis of hairy cell leukemia. Before starting any therapy
for her leukemia, a PPD was placed which was grossly
positive, despite the patient reporting a negative PPD two
months prior for work. She was placed on quadruple
tuberculosis medications on [**3-23**] that included
Isoniazid, Ethambutol, Rifabutin, Imperazinamide. A CT of
the abdomen was obtained which showed massive splenomegaly.
A CT of the chest showed mediastinal adenopathy and multiple
nodules.
She was bronchoscoped on [**3-23**] and had acid fast bacilli
sputum negative times three. The bronchoscopy showed no
endobronchial lesions and washings were obtained. The
patient was persistently febrile throughout her
hospitalization course. Blood cultures eventually grew
atypical microbacterium on [**3-17**] of one bottle; [**3-21**]
two bottles; [**3-24**] one bottle and [**3-26**], one bottle.
On [**3-25**], she was also noted to have a rash which worsened
on [**4-9**], spreading to her face, chest and extremities.
One skin biopsy showed a pathology report consistent with a
vasculitis. A repeat biopsy was performed on [**4-11**].
Cultures are pending at this time. This was all at the
outside hospital.
Medications started around that time included Fluconazole on
[**4-8**]. However, the rash seemed more likely to
correspond with the starting and stopping of Ceftazidime.
This patient was on multiple antibiotics throughout her four
weeks at [**Hospital3 1280**].
From [**3-29**] through [**4-8**], the patient was given GCSF.
She underwent radiation therapy to her spleen on [**3-30**],
[**4-2**], [**4-6**] and [**4-9**] and Interferon Alpha three
million units, three times a week, q. Monday, Wednesday and
Friday on the following dates: [**4-3**], [**4-5**], [**4-7**],
[**4-10**] and [**4-12**], in an attempt to stabilize her blood
count. Anti-tuberculin medications were stopped on [**4-10**].
Her blood cultures were sent to the state laboratory which
determined that the microbacterium growing from her blood
were not tuberculosis and not [**Doctor First Name **] and likely some type of
rapid grower. This patient was also noted to have diarrhea
at the outside hospital.
At the outside hospital, she had a TTE on [**3-31**] which
showed trace mitral regurgitation, trace tricuspid
regurgitation, normal ejection fraction, normal wall motion,
no vegetations. Her other past medical history is
significant for a history of stomach problems in [**Name (NI) 4194**]. She
is status post appendectomy and cesarean section 17 years
ago. She has a history of low back pain and headache. Her
home medications include Motrin for headache.
SOCIAL HISTORY: She moved to [**State 350**] from [**Country 4194**]
three years ago. She is Portuguese speaking. She has two
daughters, ages 17 and 20. She is married. This is her
second husband. She has stepchildren.
ALLERGIES: She has an allergy to Piroxicam and ANSAID and
also now an allergy to Ceftazidime. She has a desquamating
rash. She has tolerated other Penicillin in the past.
MEDICATIONS ON TRANSFER:
1. Vancomycin.
2. Alpha-Interferon.
3. Protonix.
4. Bactrim for PCP [**Name Initial (PRE) 1102**].
5. Amikacin.
6. Levofloxacin.
7. PRN Ativan,
8. Fioricet,
9. Tylenol.
PHYSICAL EXAMINATION: Upon admission to the Intensive Care
Unit, her systolic blood pressure was in the 80's. Her
oxygen saturation was around 96% on one liter nasal cannula.
Heart rate was slightly tachycardiac in the 120's.
Respiratory rate around 20. In general, she appeared acutely
ill, rigoring, although she was afebrile at that time. Skin
examination: She has a diffuse, erythematous plaque-like,
confluent rash, over her entire body, sparing the mucous
membranes and the palms and the soles. There is desquamation
as well. Pupils are equal, round, and reactive to light and
accommodation. Anicteric sclera. Moist mucous membranes.
No cervical lymphadenopathy. She did have some small lymph
nodes under the right axilla. Chest examination was notable
for rhonchi in the left upper lobe posteriorly and rales at
the bases bilaterally. Heart examination was tachycardiac,
soft, 2/6 systolic murmur at the apex. Belly was soft,
nontender, nondistended. Positive bowel sounds. She had
approximately 2+ lower extremity edema. Her pulses were all
2+. Neurologic: She is alert and oriented times three.
Cranial nerves 2 through 12 intact. Deep tendon reflexes
were 2+ in the upper extremities and 3+ in the lower
extremities with clonus bilaterally; down going toes
bilaterally. Gait not tested.
LABORATORY DATA: Please refer to the hospital course for
pertinent laboratory studies.
HOSPITAL COURSE:
1. Atypical mycobacterium bacteremia: The patient was
borderline septic. Her hypotension upon admission resolved
with a fluid bolus. Her lactate was less than 2. She failed
the [**Last Name (un) 104**]/stim test and thus, she was started on intravenous
steroids. A right internal jugular central line was placed.
On [**4-13**], to monitor her CVP and to allow for
intravenous antibiotics and intravenous fluids as needed. The
state laboratory was called regarding blood cultures
sensitivities. Their number is [**Telephone/Fax (1) 47555**]. The results of
the speciation and sensitivity will not be ready until next
week. However, they did mention that her sputum culture has
been negative at 14 days and the next read will be on [**0-0-0**]. The next blood culture read for acid fast
bacilli will be [**2128-4-23**]. No need to call before then.
The infectious disease doctor that was treating her at [**Hospital3 6454**] is named Dr. [**Last Name (STitle) 37454**] and his phone number is
[**Telephone/Fax (1) 54722**]. Infectious disease was consulted and this
patient was started on Moxifloxacin, Clarithromycin, Amikacin
and Linezolid. She was also started on Clinda for post
obstructive pneumonia (please see the next issue) and
Ambazone to cover for fungals as she has been neutropenic for
a prolonged amount of time. She should be pan cultured with
spikes, including fungal and acid fast bacilli blood
cultures.
A TTE was performed on [**4-14**] and no vegetations were
seen. The patient does have a soft murmur that was
appreciated. A body CT was performed to rule out abscess or
other sources of infection and no abscesses were seen;
however, she does have a left upper lobe pneumonia, possibly
post obstructive. No abnormalities in her belly despite
elevated transaminase.
Left upper lobe infiltrate with bronchus compression. She is
on the above antibiotics to cover for atypical mycobacterium.
She is also on Ambazone to cover for fungals and Clinda to
cover for anaerobes. There was a pulmonary nodule seen on
the CT scan from the outside hospital. Could this be the
source of mycobacterium?
Additional sources of fever: The patient was noted to have a
vaginal yeast infection on [**4-16**] and was started on
Monistat treatment for seven days. She was reportedly HIV
negative at [**Hospital3 1280**] as well and she is on Ambazone 3
mcg/kg for empiric fungal coverage as the patient has been
neutropenic for weeks and persistently febrile.
Hypotension: A central line was placed and she responded to
fluid boluses. Goal CVP is approximately 10.
Hairy cell leukemia: Hematology/oncology was consulted.
They reviewed the bone marrow biopsy slide and agreed that
this was consistent with hairy cell leukemia.
Hematology/oncology recommends no treatment at this time. No
Neupogen, chemotherapy or XRT, which were all received at the
outside hospital. We will hold off for now, although
infectious disease and hematology/oncology have agreed to
start GMCFF on [**4-16**] for a total of a 14 day course.
She should be treated supportively with transfusions, keeping
her hematocrit above 25 and platelets above 10,000 or above
20,000 plus bleeding. She was originally on Bactrim for PCP
[**Name Initial (PRE) 1102**]. However, this was discontinued as this could be
contributing to her rash. It is unclear of her prognosis at
this time. The CT scan of the torso that she had showed
extensive lymphadenopathy in her chest.
Question of cord compression: this patient developed urinary
retention, clonus and hyper reflexes in her lower extremities
on [**4-15**] and a large bladder was seen on the CT of her
torso. A magnetic resonance scan of the spine was obtained
which showed no compression in the thoracic or lumbar spine.
However, the cervical spine was imaged but not read. We are
waiting for Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] to complete his read of the magnetic
resonance scan of the cervical spine. She did have disc
protrusion at T8-9 and L5-S1.
Pancytopenia: She was on neutropenic precautions; keep
hematocrit above 25; guaiac all stools. She received one
unit of blood on admission. She was started on Sargramostim
or GMCSF on [**4-16**] for a 14 day course.
Desquamating raised plaque-like skin rash, sparing the mucous
membranes: Dermatology was consulted and a biopsy was
performed showed preliminary no growth. There is a question
as to whether or not this is a drug rash, most likely
secondary to Ceftazidime, leukemic infiltration into the skin
or mycobacterium infiltration into the skin. HTLV-1 could
also explain this rash and this laboratory is currently
pending.
Diarrhea leading to malabsorption: This could be secondary
to splenic XRT. She is being ruled out for Clostridium
difficile. It was negative for Clostridium difficile at the
outside hospital. Will hold off on giving Lomotil until she
rules out for Clostridium difficile.
Coagulopathy: She has a high INR. Originally, she had a high
PTT which has now resolved and low platelets. DIC laboratory
studies were checked. Her D-dimers were high but fibrinogen
and FDP were within normal limits. This is consistent with
low grade DIC. She was given Vitamin K, as her high INR was
likely secondary to malabsorption. Vitamin K was given for
three days.
Transaminitis: Supposedly medication induced per discharge
summary from the outside hospital. This coincided with
Amphotericin and anti-tuberculin medications. Here, she has
a high alkaline phosphatase and GGT. CT of the abdomen
showed no liver masses or abscesses, unclear etiology.
Headaches: This patient currently doesn't have headaches
here but had multiple headaches at the outside hospital. We
performed a CT of the head, which was negative for bleed or
masses. This was reassuring.
Fluids, electrolytes and nutrition: We obtained a nutrition
consult, put her on high protein Boost three times a day and
neutropenic diet. We repleted lytes prn. She has an albumin
of 1.5 which is unfavorable. We are giving her fluid boluses
based on her CVP's. Once diarrhea work-up is done, we will
start Imodium or Lomotil to decrease output. Nutrition is
suggesting TPN although this is not optimal due to her
infection, so we will hold off for now.
Hyperglycemia, likely secondary to steroids: She was started
on NPH on [**4-16**] with a regular insulin sliding scale.
Lines: She has a PICC from the outside hospital, placed on
[**4-12**], a right internal jugular placed here in the
Intensive Care Unit on [**4-13**], prophylaxis Pneumoboots,
neutropenic food and a PPI.
CODE: She is full. This needs to be addressed with the
family based on her prognosis.
PROGNOSIS: Poor, given her mycobacterial bacteremia in the
setting of leukemia.
Communication was kept with her sister, [**Name (NI) 54723**],
[**Telephone/Fax (1) 54724**]; her daughter, [**Name (NI) 32348**], [**Telephone/Fax (1) 54725**] and
husband, [**Telephone/Fax (1) 54726**]. She is to be transferred to the
oncology service. The rest of this dictation will be
dictated at a later time.
DR.[**Last Name (STitle) **],[**Doctor First Name 6337**] 12-871
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2128-4-16**] 04:21
T: [**2128-4-16**] 16:57
JOB#: [**Job Number 54727**]
|
[
"486",
"5119"
] |
Admission Date: [**2149-9-18**] Discharge Date: [**2149-10-17**]
Date of Birth: [**2112-5-23**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Head trauma s/p fall from motorcycle
Major Surgical or Invasive Procedure:
PARTIAL RIGHT TEMPORAL LOBECTOMY
PARTIAL RIGHT FRONTAL LOBECTOMY
RIGHT HEMICRANIECTOMY
History of Present Illness:
37 yo F thrown off motorcycle, helmeted with helmet intact, LOC
unknown but combative with all 4 extremities at time of arrival
of EMS, GCS E4M5V4 @1.35AM. Vital signs stable, has been able to
maintain own airways open with sufficient respiratory drive.
2.30AM GCS E4M6V4, infused with 2L NS and 1L RL. +Etoh. No
pain medications administered.
Past Medical History:
Unknown
Social History:
Married, 7 yo daughter [**Name (NI) **]
+EtOH
Family History:
unknown
Physical Exam:
ON ARRIVAL [**2149-9-18**]
PE:
HR82, BP 108/54, RR 22, sat 100%/FM Etoh fetor.
Neurologically, GCS at 2.37 E3-4, M6, V4. Opens eyes to verbal
stimuli, follows some commands briefly, says name and answers
some questions with 1-3 word-sentences (e.g. tetanus shots "two
years ago"). Short attention span, After ending stimulation
immediately asleep again. PERRL, EOMI, face symmetric.
Motorically moves all limbs full strength, sensory withdraws all
4's forcibly to noxious.
Reflexes 2+ symmetric, downgoing toes.
ON DISCHARGE [**2149-10-17**]
PE:
99.3 104 96/62 18 98%RA
comfortable, NAD
Neurologically, GCS 15. Opens eyes to verbal stimuli, follows
simple commands, answers questions appropriately.
PERRLA, EOMI, face symmetric, facial sensation intact
bilaterally.
Moves all 4 extremities against gravity.
Toes downgoing bilaterally.
Pertinent Results:
CT HEAD W/O CONTRAST [**2149-9-18**] 8:47 AM
Reason: PLEASE DO ON [**2149-9-18**] AT 5PM; eval change in SDH/SAH and
midli
[**Hospital 93**] MEDICAL CONDITION:
37F s/p passenger MCC, + helmet, + etoh, LOC unknown, combative
with all 4 extremities at time of EMS arrival. +TBI, R frontal
contusions, R frontal SDH and sml amts tSAH, L occipital fx.
REASON FOR THIS EXAMINATION:
PLEASE DO ON [**2149-9-18**] AT 5PM; eval change in SDH/SAH and midline
shift 24 hours after previous CT.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 37-year-old female, status post MCC, for
reevaluation of change in subdural hemorrhage, subarachnoid
hemorrhage, and shift of midline structures.
COMPARISON: [**2149-9-18**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: Right convexity subdural hematoma is not significantly
changed in size or configuration, with continued evidence of
radiodense material within, suggestive of acute hemorrhage.
Multifocal areas of intraparenchymal hemorrhage, predominantly
involving the right inferior frontal lobe, but also the left
inferior frontal lobe and right temporal lobe have increased in
size since previous exam, with increased surrounding edema and
effacement of right frontal and parietal sulci. There is
increased leftward subfalcine herniation, currently
approximately 9-10 mm, previously 8 mm. There is slightly
increased compression of the frontal and occipital horns of the
right lateral ventricle, but ventricular and sulcal size and
configuration is otherwise unchanged. There is no hydrocephalus.
Osseous structures are again notable for oblique, minimally
displaced fracture through the left occipital bone, extending
into the temporal bone and left jugular foramen, and small foci
of air are again seen within the jugular foramen and along the
inner table deep to the left occipital bone. There is high
density, reflecting thrombosis, in the left tranverse and
sigmoid sinus. Fluid is again seen within the sphenoid air
sinuses, with air- fluid level in the left sphenoid air cells,
unchanged.
Fracture to the left petrous bone, involving the carotid canal
also appears unchanged. Please note that these fractures are
better evaluated, and will be fully detailed and reported
separately in skull base CT performed [**2149-9-18**], 05:40.
IMPRESSION:
1. Increased intraparenchymal hemorrhage, particularly in the
right frontal region, with surrounding mass effect, sulcal
effacement, compression of the right lateral ventricle, and
increased leftward subfalcine herniation.
2. Unchanged moderate right subdural hematoma.
3. Unchanged appearance of fractures involving the left
occipital bone, temporal bone, and left jugular foramen, and
fracture of the left petrous bone involving the left carotid
canal.
RADIOLOGY Preliminary Report
CT HEAD W/O CONTRAST [**2149-9-29**] 8:23 AM
CT HEAD W/O CONTRAST
Reason: assess for new bleed vs edema
[**Hospital 93**] MEDICAL CONDITION:
37 year old woman with b.l frontal contusion 10 days ago now
with decreased MS
REASON FOR THIS EXAMINATION:
assess for new bleed vs edema
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Decreasing mental status, parenchymal contusions
seen previously.
NON-CONTRAST HEAD CT: Comparison with multiple previous
examinations, the most recent being [**2149-9-24**]. Large
intraparenchymal hemorrhage and edema is seen in the right
frontal lobe; no new foci of hemorrhage are seen. However, there
is increased leftward transtentorial herniation, and near
complete effacement of the midbrain cisterns, with only a small
amount of the fourth ventricle visible. Left lateral ventricle
has slightly increased in size, representing increased
hydrocephalus compared to the previous exam. Fracture of the
left occiput again noted. Fluid in the left mastoid sinuses and
nearly completely opacified right sphenoid sinus is again noted.
Hardware in the left naris, probably nose ring, again noted.
Other paranasal sinuses are clear.
IMPRESSION: Increased edema in right frontal lobe with increased
resultant herniation and compression of mid brain, as compared
to [**2149-9-24**]. Findings discussed with Dr. [**Last Name (STitle) **] by
telephone at time of interpretation.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
RADIOLOGY Preliminary Report
CTA HEAD W&W/O C & RECONS [**2149-9-29**] 3:24 PM
CTA HEAD W&W/O C & RECONS
Reason: Ct and CTV post op hemicraniectomy - eval for venous
thrombo
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
37 year old woman with tbi s/p hemicraniectomy right frontal
partial lobectomy right temoral partial lobectomy
REASON FOR THIS EXAMINATION:
Ct and CTV post op hemicraniectomy - eval for venous thrombosis
and / as well as post op changes - pt has left jugular vein
occlusion on admission 12 days ago - s/p motorcycle accident
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: A 37-year-old woman status post hemicraniectomy and
right frontal partial lobectomy. Evaluate for venous thrombosis.
TECHNIQUE: 1.25-mm axial images through the brain obtained after
uneventful intravenous contrast administration _____ head CTV.
Sagittal and coronal reformatted images.
Comparison made to prior study dated [**2149-9-18**].
FINDINGS: Since the prior study, the patient has undergone right
hemicraniectomy. As given in the history, the patient has had
partial frontal and temporal lobectomy. There is pneumocephalus
which is likely postoperative. Since the prior head CT scan
dated [**2149-9-29**] at 8:26 a.m., there has been slight interval
decrease in the shift of the normally midline structures.
However, there is persistent residual. On the current study, the
basal cisterns are now patent. There is persistent hypodensity
in the right frontal lobe from a known contusion. There is
hypodensity in the right temporo-occipital lobe which appears to
be present on the head CT done earlier this morning but not on
the prior head CTA and likely represents an infarct in the
territory of the right posterior cerebral artery. There are
blood products noted in the _____ the tentorium and along the
midline which were present on the prior study.
Again seen is the fracture extending from the left occipital
bone into the left temporal bone. There is persistent
opacification of the left mastoid air cells, likely the result
of blood products. The fracture line appears to extend into the
left jugular bulb, possibly into the carotid canal. There is no
contrast extravasation. There is non-opacification of the distal
left transverse sinus, the sigmoid sinus, and the proximal
internal jugular vein consistent with vessel thrombosis. This,
however, is unchanged since the prior study.
There is persistent opacification of the right sphenoid sinus
which could be the result of blood products.
The visualized arteries of the circle of [**Location (un) 431**] appear to be
within normal limits. No new hemorrhage is identified.
IMPRESSION:
1. Status post right-sided craniectomy with interval improvement
of the subfalcine herniation and shift of the normally midline
structures. There is mild persistent residual.
2. New infarct in the region of the right posterior cerebral
artery territory.
3. Stable appearance of the venous thrombosis extending into the
distal transverse sinus, the sigmoid sinus, and the proximal
internal jugular vein on the left side.
4. Asymmetric opacification of the cavernous sinus with less
opacity of the left cavernous sinus which could be the result of
slow flow or perhaps venous thrombosis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 42068**]
DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
VIDEO OROPHARYNGEAL SWALLOW [**2149-10-14**] 1:15 PM
Reason: eval for swallow / diet
[**Hospital 93**] MEDICAL CONDITION:
37 year old woman with traumatic brain injury / right
hemicraniectomy
REASON FOR THIS EXAMINATION:
eval for swallow / diet
VIDEO OROPHARYNGEAL SWALLOW
HISTORY: 37-year-old woman with traumatic brain injury, right
hemicraniectomy. Evaluate for swallow.
ORAL AND PHARYNGEAL VIDEO FLUOROSCOPIC EXAMINATION: An oral and
pharyngeal video fluoroscopic swallowing evaluation was
performed in collaboration with the speech and language
pathology division. Various consistencies of barium were
administered.
The oral phase demonstrated normal bolus control without
evidence of premature spillover into the pharynx. There was a
slight decrease in palatal elevation.
The pharyngeal phase demonstrated normal swallow initiation with
normal laryngeal elevation and epiglottic deflection. There is a
mild degree of residue within the valleculae. No penetration or
aspiration was seen.
IMPRESSION: There is no evidence of penetration or aspiration.
RADIOLOGY Preliminary Report !! Wet Read !!
G/GJ TUBE CHECK [**2149-10-15**] 6:57 PM
Reason: check gtube positioning
[**Hospital 93**] MEDICAL CONDITION:
37 year old woman with ? pulled at gtube free air seen on CXR
REASON FOR THIS EXAMINATION:
check gtube positioning
G-tube in place with contrast traversing to descending colon. No
extravastation or obstruction seen.
CT HEAD W/O CONTRAST [**2149-10-16**] 10:55 AM
CT HEAD W/O CONTRAST
Reason: R pronator drift on exam this am
[**Hospital 93**] MEDICAL CONDITION:
37F 17d s/p R hemicraniectomy/partial R temporal/frontal
lobectomy
REASON FOR THIS EXAMINATION:
R pronator drift on exam this am
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: CT OF THE HEAD WITHOUT CONTRAST.
CLINICAL INDICATION: A 37-year-old female, status post right
hemicraniectomy, partial right temporal frontal lobe lobectomy.
TECHNIQUE: Contiguous axial images were obtained to the brain,
no contrast was administered.
COMPARISON: This study was compared with multiple prior CTs of
the head, the last one dated [**2149-10-8**].
FINDINGS: In comparison with the prior examination, again
post-surgical changes consistent with right hemicraniectomy are
noted, low-attenuation areas as well as edema and blood products
are identified in the surgical bed, there is interval
improvement of the previously observed left subdural collection,
at the moment of the study no significant effacement of the
ventricular system is detected and the sulci appears preserved.
There is no evidence of intraventricular hemorrhage. The right
parietal lobe demonstrates uniform hyperdense pattern, which may
represent small amount of residual blood products. There is also
decrease in size of the previously detected amount of air
adjacent to the anterior aspect of the craniectomy and frontal
lobe. The left occipital fracture is again detected. No
significant changes are observed.
The orbits, paranasal sinuses appear grossly normal. The tip of
the left mastoid air cells appears slightly dense, which may
represent small amount of fluid.
IMPRESSION: Interval improvement of the previously observed
subdural collection on the left side. Decrease in size in the
amount of air detected adjacent to the frontal craniotomy. No
significant effacement of the sulci or ventricular narrowing is
observed at the moment of this examination.
Brief Hospital Course:
Mrs. [**Known lastname 73557**] was admitted to the Trauma ICU after initial eval
in the ED s/p motorcycle accident. Initial examination revealed
bifrontal and bitemoral contusions with associated skull
fracture. CTA revealed asymmetric opacification of the
cavernous sinuses with less opacification of the left cavernous
sinus. Soft tissue density within the left transverse sinus as
well as non-visualization of the left sigmoid and proximal left
internal jugular vein which could be a result of vessel
thrombosis. Stroke neurology team was consulted.
Recommendations were followed and included holding of
anticoagulation. Mannitol was started on HD 1. Na levels
flucuated and the pt was on 3% normal saline infusions
periodically. Endocrine team was consulted for assistance in
controlling sodium balance. Recommendations were followed. Her
exam improved over the first week of hospitalization ultimately
becoming alert and oriented/ without focal neurological deficit.
On hospital day #7 ([**9-24**]) pt had altered exam with dilated L
pupil / Na was 135 / CT was unchanged. She had good response to
Narcan and 3% NS. 3% drip was weaned / and salt tabs were given
via NGT.
Fluid balance was controlled by ICU team. On HD 12 Pt was noted
to have altered mental status. Electrolytes were stable. Stat
head CT was obtained and showed increased MLS with effacement of
basilar cysterns. PT was bolus'd mannitol, 23% saline bolus of
20cc was ordered, and pt was intubated for airway protection.
She was taken to the OR emergently after her exam continued to
worsen. She was extensor posturing pre-operatively with
bilateral dilated/trace reactive pupils. A right
hemicraniectomy with partial right frontal and partial right
temporal lobectomies was performed. A CT and CTV were obtained
poetoperatively. The venous thrombis in the Left IJ and
proximal left transverse sinus were unchanged. New Right PCA
infarct was noted. Stroke neurology team was asked to re-eval
the patient,and she was thought to have a R PCA distribution
stroke.
She was put on Aspirin on [**10-1**], with the plan of starting a
heparin drip in 5 days to maintain her PTT between 50-70 and
repeating the head CT. Her PTT has fluctuated around the
therapeutic range of 50-70 over the past few days, and coumadin
was re-started after her PEG tube was placed on [**2149-10-8**].
Hematology was consulted for leukocytosis, thrombocytosis, and
large heparin requirement. They thought that her leukocytosis
was a stress response, followed her thrombocytosis with a
peripheral smear and thought that her large heparin requirement
was related to her head injury and increased level of
thromboplastins. They conclude that her hematologic concerns do
not require further work-up. She has been receiving her heparin
gtt at 1050/hr and she was planned to receive coumadin 7.5mg the
evening of [**2149-10-16**], but her afternoon PTT came back >150. This
was thought to be laboratory error, and a repeat PTT was also
>150. As a result, her heparin drip was stopped, and her pm
coumadin dose held. She will require a reassessment of her
anticoagulation with coumadin and heparin drip when she arrives
at rehab.
Extubation was held on post op day 1 as pt was with fever on
Post op day 0 and continues to spike. Her blood cultures, urine
cultures and bone flap cultures came back positive for
methicillin sensitive staph aureus for which she is receiving
Nafcillin. Today is day #15 of 28 of Nafcillin for her MSSA.
She had mild anemia Hct 24.7, and was started on multivitamins
(Fe, B12, FA) in lieu of transfusion.
Pt had a PEG tube placed on [**2149-10-8**] due to 2 failed speech and
swallow evaluations. She is now able to tolerate thin liquids
with soft solids, and PEG feedings are being used to supplement
her po intake. A radiologist's wet [**Location (un) 1131**] on [**2149-10-15**] confirmed
that the PEG was in place with contrast traversing to descending
colon. No extravastation or obstruction seen.
On that same CXR pt was noted to have free air in the abdomen.
She had [**Male First Name (un) 73558**] her G-tube the day prior and so a general surgery
consult was obtained for evaluation. They performed a dye study
which showed that the PEG tube was in place and safe to use. An
additional radiologist'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] of this dye study was read as
her PEG tube tip as potentially in the correct position, but the
balloon may not be in the stomach. On [**2149-10-16**] general surgery
was re-consulted to evaluate her PEG tube placement prior to her
hospital discharge. To be safe, an additional abdominal CT was
performed to evaluate the placement of her PEG tube. The
general surgery service that initially placed her PEG reviewed
the abdominal xrays and CT abdomen and in the morning of [**2149-10-17**]
said that her PEG is in good placement, and that it is safe to
use. She will continue to take thin liquids with soft solids,
and her PEG will be used to supplement her po intake to ensure
adequate nutrition.
PICC line was originally placed on [**10-8**] and replaced on [**10-15**]
after the patient had pulled out her original one overnight.
This was re-adjusted in Interventional radiology after CXR
showed that the proximal end of the catheter needed to be
adjusted.
The am of [**2149-10-16**] she was noted to have a right pronator drift
which seems to be new - a CT scan of the brain was done that
showed interval improvement of her prior left subdural
collection. The air detected adjacent to the frontal craniotomy
is decreased in size compared to the previous study, and there
was no significant effacement of the sulci or ventricular
narrowing observed.
She has been fitted for a helmet, and she is to wear this helmet
whenever oob, and she has been reminded not to sleep on her
right side. Her right temporal skull flap is being stored in a
freezer at [**Hospital1 18**]. When her blood cultures are completely
negative, she will return for a repeat head CT and CTV, and we
will plan for skull flap replacement at that time.
She is being discharged from [**Hospital1 18**] to rehab in stable condition
with her vital signs within normal limits.
Medications on Admission:
unknown
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 * Refills:*2*
6. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): titrate prn to keep INR 2.0-3.0.
Disp:*90 Tablet(s)* Refills:*2*
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Disp:*200 ML(s)* Refills:*0*
11. Nafcillin 2 gm IV Q4H
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN
14. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*30 Suppository(s)* Refills:*2*
16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for fever, headache.
Disp:*qs Tablet(s)* Refills:*0*
19. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*qs Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Traumatic intraparenchymal hemorrhage.
2. Right subdural hematoma.
3. Fracture of left occipital bone, temporal bone, and left
jugular foramen, and left petrous bone.
4. Hyponatremia.
5. right hemicraniectomy.
6. partial right temporal lobectomy.
7. partial right frontal lobectomy.
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 3 MONTHS. YOU WILL NEED TO HAVE A HEAD CT
WITHOUT CONTRAST/CTV PERFORMED PRIOR TO THIS APPOINTMENT.
YOU WILL REQUIRE FOLLOW UP OF YOUR MASTOID AND TEMPORAL BONE
FRACTURES WITH THE OTOLARYNGOLOGY (ENT) DEPARTMENT IN 4 WEEKS.
CALL ([**Telephone/Fax (1) 6213**] TO SCHEDULE THIS APPOINTMENT.
|
[
"5990",
"2761",
"2859",
"2449"
] |
Admission Date: [**2146-12-1**] Discharge Date: [**2146-12-12**]
Date of Birth: [**2076-8-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2146-12-6**] Aortic Valve Replacement(21mm Pericardial) and Two
Vessel Coronary Artery Bypass Grafting(saphenous vein grafts to
diagonal and obtuse marginal arteries)
History of Present Illness:
This 70 year old male with 3 weeks of progressive shortness of
breath and productive cough. Presented to OSH in heart failure,
treated with Lasix, nebulizers and Prednisone with improvement.
With further workup, echocardiogram showed severe aortic
stenosis and cardiac catheterization revealed coronary artery
disease, additionally he had nonsustained ventricular
tachycardia. He was transferred for surgical evaluation.
Past Medical History:
insulin dependent Diabetes Mellitus
Hypertension
Chronic obstructive pulmonary disease
Acute systolic and diastolic heart failure
Anxiety
Aortic Stenosis
s/p Appendectomy
s/p Tonsillectomy
s/p Left wrist plating
Social History:
Lives with:significant other
[**Name (NI) 1139**]:3ppdxmany years
ETOH:none in 8 months-recovering
Family History:
non contributory
Physical Exam:
admission:
Pulse:87 Resp:20 O2 sat: 97% on 3L NC
B/P Right:122/47
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs rhonchi and expiratory wheezes bilat R>L
Heart: RRR [x] distant heart sounds [**3-19**] SEMurmur
Abdomen: Soft [x] obese, non-distended [x] non-tender [x] bowel
sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema1+ Varicosities:
None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right:+ecchymosis, no hematoma 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2146-12-12**] 04:50AM BLOOD WBC-11.8* RBC-2.69* Hgb-8.5* Hct-25.2*
MCV-94 MCH-31.7 MCHC-33.8 RDW-14.9 Plt Ct-207
[**2146-12-1**] 08:50PM BLOOD WBC-10.2 RBC-3.78* Hgb-11.8* Hct-35.8*
MCV-95 MCH-31.2 MCHC-32.9 RDW-14.0 Plt Ct-264
[**2146-12-12**] 04:50AM BLOOD Glucose-114* UreaN-30* Creat-1.1 Na-138
K-3.7 Cl-102 HCO3-32 AnGap-8
[**2146-12-11**] 04:50AM BLOOD Glucose-65* UreaN-38* Creat-1.3* Na-140
K-3.6 Cl-104 HCO3-28 AnGap-12
[**2146-12-1**] 08:50PM BLOOD Glucose-289* UreaN-31* Creat-0.9 Na-136
K-4.2 Cl-99 HCO3-28 AnGap-13
[**2146-12-1**] 08:50PM BLOOD ALT-35 AST-20 LD(LDH)-197 CK(CPK)-42*
AlkPhos-80 Amylase-29 TotBili-0.6
[**2146-12-4**] 11:15AM BLOOD %HbA1c-8.0* eAG-183*
[**2146-12-3**] 04:08PM BLOOD Type-ART Temp-37.2 pO2-85 pCO2-44 pH-7.44
calTCO2-31* Base XS-4 Intubat-NOT INTUBA
Brief Hospital Course:
Following transferred from the outside hospital for surgical
evaluation he underwent preoperative workup, including a
pulmonary consult due to his tobacco history. His steroids
started at the outside hospital were stopped and he was started
on Lasix for diuresis.
On [**2146-12-6**] he was taken to the Operating Room and underwent
aortic valve replacement and coronary artery bypass graft
surgery. Please see operative report for details, in summary he
had aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna Ease
pericardial tissue valve, coronary artery bypass grafting x2,
with reverse
saphenous vein graft to the second diagonal artery and the
obtuse marginal artery.
His bypass time was 118 minutes with a crossclamp of 97 minutes.
He tolerated the opration and was transferred to the cardiac
surgery ICU. He received vancomycin for perioperative
antibiotics.
He remained stable in the immediate post-op period, awoke
neurologically intact and was extubated. He remained in the
cardiac surgery ICU for several days post-operatively because
there were no beds available on the stepdown floor. All tubes,
lines, and drains were removed per cardiac surgery protocol.
Once on the stepdown floor he worked with Physical Therapy to
improve his strength and endurance. The remainder of his
hospital course was uneventful. His progress was somewhat slow
and it was felt he would benefit from a short rehabilitation
stay. On [**12-12**] he was cleared to be transferred to [**Hospital3 15644**]
Health Care Center for rehab. Lasix was continued at discharge
and can be discontinued when edema clears.
Medications on Admission:
Medications at home:
Temazepam 30 mg at bedtime
Lisinopril 40 mg daily
Symbicort 160 2 puffs [**Hospital1 **]
Spiriva inh 1 cap daily
Procardia 90 mg daily
Buspar 10 mg 4x day
Paxil 40 mg daily
Metformin 500 mg [**Hospital1 **]
Actos 40 mg daily
ativan 0.5mg prn
Outside hospital
Prednisone 60 mg daily
Metoprolol 12.5 mg TID
ASA 162 mg daily
Insulin NPH 12 units [**Hospital1 **], regular 5 units with each meal
Doxycycline 100 mg [**Hospital1 **]
Buspar 10 mg daily
Albuterol nebs
Atrovent nebs
Lisinopril 40 mg daily
Paxil 40 mg daily
Metformin 500 mg [**Hospital1 **]
Nicotine patch 21 mg daily
Procardia 90 mg daily
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day for 10
days.
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 4 weeks.
10. buspirone 10 mg Tablet Sig: One (1) Tablet PO four times a
day.
11. pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
14. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): two tablets (400mg) twice daily for two weeks,
then one tablet (200mg) twice daily for two weeks, then one
tablets (200mg) daily until discontinued by physician.
15. NPH insulin human recomb 100 unit/mL Cartridge Sig: 12 units
Subcutaneous breakfast and dinner.
16. Humalog KwikPen 100 unit/mL Insulin Pen Sig: Five (5) units
Subcutaneous breakfast, lunch, dinner.
17. Humalog KwikPen 100 unit/mL Insulin Pen Sig: as directed
Subcutaneous ac & HS: 120-160-2 units ac, none HS;161-200-4
units ac,2units HS;201-240-6units ac,4unitsHS,241-280 ac,4units
HS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Care - [**Location (un) 47**]
Discharge Diagnosis:
Aortic Stenosis
Coronary artery disease
s/p aortic valve replacement/coronary artery bypass grafts
Acute systolic and diasystolic heart failure
insulin dependent Diabetes Mellitus
Hypertension
Chronic obstructive pulmonary disease
Anxiety
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 2+ legs
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] (for Dr [**Last Name (STitle) **] at [**Hospital1 **] Heart Center
([**Telephone/Fax (2) 6256**]) on Thursday, [**12-29**] at 9:15am
Cardiologist: Dr [**Last Name (STitle) 4610**] at [**Hospital1 **] Heart Center
([**Telephone/Fax (2) 6256**]) on [**1-10**] at 10am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 8593**] [**Name (STitle) 8592**] in [**5-16**] weeks ([**Telephone/Fax (1) 26318**])
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2146-12-12**]
|
[
"4241",
"41401",
"4280",
"496",
"25000",
"3051"
] |
Admission Date: [**2195-5-3**] Discharge Date: [**2195-5-4**]
Date of Birth: [**2117-3-26**] Sex: M
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Subdural hematoma
Major Surgical or Invasive Procedure:
-
History of Present Illness:
78 year-old male with hypertension, ITP on Rituximab transferred
from OSH for further management of SDH. Felt poorly yesterday.
Woke up this morning with severe HA. Unresponsive in EMS.
Went to [**Hospital1 **], found to have decerebrate posturing, fixed
and dilated pupils. CT head with large left-sided SDH with 2mm
shift, and transtorial herniation. Intubated (succ/etomidate),
mannitol. Also received atropine for unknown reason.
.
On arrival at [**Hospital1 18**] ED, 76, 170/86, 14, 100% on ventilator
(settings below) Still ventilated on Propofol. Propofol
stopped briefly; noted to have 5mm nonreactive pupils, equal;
decerbrate posturing. Laboratory data significant for
hematocrit 36.2, platelet count 20. 7.36 // 50 // 89 on above
settings. CXR - tube in good position. Discussed with
neurosurg, radiology; determined to benefit in intervention at
this point. Per report from ED resident, patient converted to
CMO, and awaiting arrival of family prior to extubation.
Propofol restarted for comfort. On transfer to ICU, 67, 151/65,
10, 100% AC 10/500 PEEP 5, FiO2 100%.
.
On the floor, patient is intubated and not responsive.
Past Medical History:
ITP
Hypertension
Social History:
Married. Several children.
Family History:
Non-contributory
Physical Exam:
97.2, 67, 140/53, 97% on A/C (500x15, PEEP 5, FiO2 100%)
General: Intubated; not responsive
HEENT: Sclera anicteric, dry mucous membranes, pupils
dilated/fixed
Skin: Diffuse petechiae
Neck: No appreciable lymphadenopathy
Lungs: Clear to auscultation bilaterally on anterior
auscultation; no wheezes, rales, rhonchi
CV: RRR; normal S1/S2; no murmurs, rubs, gallops
Abdomen: Hypoactive bowel sounds; soft, non-tender,
non-distended
GU: Foley in place
Ext: Warm, well-perfused; 2+ pulses [**Last Name (un) **], no clubbing, cyanosis
or edema
Neuro: Pupils equal without reactivity; no response to verbal
stimulation (off of Propofol); triple flexion response
bilaterally lower extremities.
Pertinent Results:
Imaging ([**2195-5-3**], OSH; per neurosurg note): Significantly sized
left convexity acute subdural hematoma. The is profound
associated sub falcine herniation, with obliteration of the CSF
spaces of basal cisterns. There is also mass effect, and
displacement of the basal cisterns.
Brief Hospital Course:
78M with hypertension, ITP with subdural hematoma complicated by
mass effect. Expired shortly after admission.
.
#. Subdural hematoma: In context of thrombocytopenia and known
hypertension. Complicated by mass effect. Patient noted
intially to be decorticate. Unresponsive with fixed/dilated
pupils off of sedation. With downtitrating ventilatory support,
patient with rare breaths and with low tidal volumes. Discussed
with family; plan for comfort.
.
#. ITP: Thrombocytopenic. Held off on platelet transfusion as
would not change outcome.
.
#. Hypertension: Held anti-hypertensives.
Medications on Admission:
Prednisone
Avodart
Norvasc
Discharge Disposition:
Expired
Discharge Diagnosis:
Subdural hematoma;
Discharge Condition:
Expired;
Discharge Instructions:
Expired;
Followup Instructions:
Expired;
Completed by:[**2195-5-7**]
|
[
"4019",
"2449"
] |
Admission Date: [**2195-5-24**] Discharge Date: [**2195-6-5**]
Date of Birth: [**2116-7-4**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
male with known aortic stenosis who has been complaining of a
1-year history of increased dyspnea on exertion.
An echocardiogram performed in [**2194-12-21**] revealed
aortic stenosis with an aortic valve area of 0.6. Another
echocardiogram performed in [**2195-2-19**] was consistent with
aortic stenosis and aortic insufficiency.
The patient presented to [**Hospital1 69**]
for catheterization on [**2195-4-16**] in preparation for aortic
valve replacement surgery. The catheterization performed on
[**2195-4-16**] revealed normal coronary arteries and severe
aortic stenosis, with a mean gradient across the aortic valve
of 50 mmHg.
The patient was then admitted to an outside hospital on [**2195-5-23**] with complications of dizziness and near syncope and
was subsequently transferred to [**Hospital1 188**] on [**5-24**] for aortic valve replacement.
PAST MEDICAL HISTORY: The patient is a 78-year-old gentleman
with a past medical history significant for hypertension,
hypercholesterolemia, gastroesophageal reflux disease (with a
history of a bleeding ulceration), thrombophlebitis (status
post an inferior vena cava filter), and rheumatoid arthritis.
PAST SURGICAL HISTORY: He also status post pancreatic
surgery with removal of mass (status post stent). He is also
status post appendectomy, status post transurethral resection
of the prostate, status post bilateral cataract surgery,
status post correction of a deviated septum, status post
bilateral vein stripping of the legs.
SOCIAL HISTORY: He is a current smoker.
ALLERGIES: His allergies include a sensitivity to ASPIRIN
(causing gastrointestinal bleed).
PREADMISSION MEDICATIONS:
1. Diovan 160 mg by mouth once per day.
2. Protonix 40 mg by mouth once per day.
3. Atenolol 25 mg by mouth once per day.
4. Lipitor 10 mg by mouth once per day.
5. Folate 1 mg by mouth once per day.
6. Prednisone 5 mg by mouth once per day.
7. Methotrexate 10 mg by mouth every week and injection.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient underwent
aortic valve replacement on [**2195-5-26**] with a number 23-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] bovine pericardial valve. Total
cardiopulmonary bypass time was 71 minutes. The total cross-
clamp time was 52 minutes.
The patient was transferred in stable condition to the
Cardiothoracic Intensive Care Unit from the Operating Room on
propofol and aprotinin. The patient was extubated at 5:30
p.m. on the same day of surgery without incident.
The patient was transferred to the floor on postoperative day
one in stable condition. He was making good urine. The
patient was in a normal sinus rhythm, in first-degree
atrioventricular block. The patient then went into rapid
atrial fibrillation and was treated with Lopressor and was
started on amiodarone drip, with his heart rate remaining in
the range of 100 to 120 beats per minute. The patient
converted back to a normal sinus rhythm at 7:30 p.m. on [**5-28**]. The patient was changed to amiodarone by mouth 400 mg
twice per day. The patient went back into a rapid atrial
fibrillation on postoperative day five; for which he was
again administered Lopressor, with his heart rate in the low
100s. The patient then had several runs of ventricular
tachycardia on postoperative day five, for which he was
administered a bolus of amiodarone -which converted him back
to a normal sinus rhythm at 65 beats per minute, with a
stable blood pressure.
On postoperative day six, the patient was found to have an
erythematous right forearm and was found to right arm
thrombophlebitis - for which she was continued on Kefzol.
The patient continued to go in an out of atrial fibrillation
while he was on the floor - being treated with heparin for
anticoagulation.
The Electrophysiology Laboratory consulted on the patient on
[**6-3**] for his episodes of paroxysmal atrial fibrillation -
at which time they recommended increasing metoprolol to 37.5
mg by mouth three times per day if the blood pressure
tolerated it and then to 50 mg by mouth three times per day
as well as continuing amiodarone. They also recommended a
Coumadin load and a heparin drip, since they felt the heparin
was subtherapeutic. They also recommended to arrange for [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] of Hearts monitor upon discharge.
The Electrophysiology Service came back for another
consultation on [**6-4**], at which time they recommended
changing the amiodarone to 400 mg twice per day and
continuing a Coumadin and heparin combination with a goal INR
of 2 to 3. They recommended followup with Dr. [**First Name (STitle) **]
[**Name (STitle) 1911**] in four to six weeks. Heparin was discontinued,
as the INR was now therapeutic, and the patient was
administered Coumadin.
The patient was felt stable for discharge on [**6-5**]. His
physical examination at that time revealed vital signs with a
temperature of 97.3, his heart rate was 68 (in sinus rhythm),
his blood pressure was 110/63, and he was saturating 98
percent on room air. Neurologically, the patient was awake
and alert times three. His heart was regular in rate and
rhythm. There were no rubs or murmurs. The lungs were
clear. There were decreased breath sounds at the bilateral
bases. His sternal incision was clean, dry, and intact with
intact staples. There was no erythema. His abdomen was
soft, nontender, and nondistended. There were normal bowel
sounds. He was tolerating a regular diet.
DISCHARGE DISPOSITION: The patient was discharged home.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg by mouth twice per day.
2. Aspirin 81 mg by mouth once per day.
3. Percocet one to two tablets by mouth q.4-6h. as needed
(for pain).
4. Lipitor 10 mg by mouth once per day.
5. Protonix 40 mg by mouth once per day.
6. Prednisone 5 mg by mouth once per day.
7. Lasix 20 mg by mouth once per day (for five days).
8. Potassium chloride 20 mEq by mouth once per day (for five
days).
9. Amiodarone 400 mg by mouth twice per day (for seven days)
and then 400 mg by mouth once per day.
10. Lopressor 50 mg by mouth three times per day.
11. Keflex 500 mg by mouth q.6h. (for 10 days).
12. Coumadin 1 mg by mouth (for the next three days with
an appointment to have prothrombin time and INR checked
with a goal INR of 2 to 2.5).
DISCHARGE INSTRUCTIONS-FOLLOWUP: The patient was instructed
to follow up with Dr. [**First Name (STitle) 518**] in one to two weeks, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in three to four weeks, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13175**] in one to
two weeks, and Dr. [**First Name (STitle) **] [**Name (STitle) 1911**] on [**7-2**].
DISCHARGE DIAGNOSES: Aortic stenosis; status post aortic
valve replacement.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 28488**]
MEDQUIST36
D: [**2195-6-5**] 10:02:32
T: [**2195-6-5**] 11:54:44
Job#: [**Job Number 28489**]
|
[
"4241",
"9971",
"42731",
"25000",
"4019"
] |
Admission Date: [**2195-2-10**] Discharge Date: [**2195-2-10**]
Date of Birth: [**2119-8-13**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Darvon / Atenolol / Bactrim / Sulfa
(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 year old female with known CAD, diastolic CHF, HTN, DM,
dyslipidemia, p/w acute dyspnea on her home BiPap machine,
called 911. EMS found her in respiratory distress unable to
speak, requiring BVM ventilation, gave her Lasix 80 mg IV, nitro
patch. She has been in and out of hospitals for the past year,
and has been intubated three times over that period. During a
[**Month (only) **] hospitalization she was diagnosed with CHF and
reportedly had an EF of 30%, though her last documented Echo is
of 55%. She has been out of rehab from that hospitalization for
3 weeks, and since arriving home she was started on BiPap at
night, a low-salt diet, and has a home health nurse 4 days/week.
Over the past 3 days her nurse tracked a 2-lb weight gain.
Past Medical History:
1. Coronary artery disease s/p NSTEMI and Taxus stent to LAD in
[**2189**] in [**State 108**] and failed attempt to stent OM1 in [**2187**]
2. Hypertension.
3. Diabetes mellitus type 2 (last A1C 9.0 in [**2192-5-18**])
4. Hyperlipidemia.
5. Anemia with baseline hematocrit approximately 30.0.
6. Carotid stenosis.
7. Breast cancer, status post lumpectomy and radiation
therapy.
8. Chronic Diastolic CHF
9. Status post cholecystectomy.
10. Obstructive Sleep Apnea on CPAP at home
11. Bakere's cyst
12. Osteoarthritis
Social History:
The patient lives in [**Location 3146**] by herself. She smoked 0.5-1 ppd
for 30 years but quit 20 years ago. She does not currently
drink alcohol. She denies illicit drug use. Ambulates with
walker and needs assistance with ADLs.
Family History:
Father had stomach cancer and died of a MI at age 62. Her
mother had [**Name2 (NI) 499**] cancer and died in her 60s. She had two
brothers, one died of an MI at age 39, the other at age 65. She
has a sister who had breast cancer. She has three children, one
of whom is deceased. The other two children are healthy. She
has three healthy grandchildren.
Physical Exam:
On admission:
Vitals: T: 70. BP 158/67. RR 26-30. O2 98% on BiPap.
General: Alert, oriented, speaking full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles in bases
CV: S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding
GU: Foley
Ext: warm, well perfused, 2+ pulses. Nonpitting edema in legs.
Pertinent Results:
Admission Labs:
[**2195-2-10**] 02:25AM WBC-18.3* RBC-3.68* Hgb-10.7* Hct-32.1* MCV-87
MCH-29.0 MCHC-33.3 RDW-15.3 Plt Ct-491*
[**2195-2-10**] 02:25AM Neuts-83.8* Lymphs-11.7* Monos-3.0 Eos-1.2
Baso-0.4
[**2195-2-10**] 02:25AM PT-23.5* PTT-30.2 INR(PT)-2.2*
[**2195-2-10**] 02:25AM Glucose-178* UreaN-44* Creat-1.7* Na-139 K-4.0
Cl-100 HCO3-29 AnGap-14
[**2195-2-10**] 02:25AM CK(CPK)-77
[**2195-2-10**] 02:25AM cTropnT-0.02*
[**2195-2-10**] 03:39AM Type-ART FiO2-80 pO2-106* pCO2-51* pH-7.39
calTCO2-32*
Brief Hospital Course:
74 year old female with CAD, diastolic CHF, HTN, DM,
dyslipidemia, p/w acute dyspnea. EMS found her in her home with
respiratory distress unable to speak, requiring BVM ventilation,
gave her Lasix 80 mg IV, nitro patch. When she arrived in the
[**Hospital1 18**] ED she was 88% on room air and 100% on Bipap. She was
started on a Nitro gtt, given Aspirin 600 mg PR. Labs notable
for WBC of 18.9 and so concern for pneumonia she received
Ceftriaxone 1 gram and Levaquin 750 mg. It was felt her physical
exam, CXR and clinical course c/w CHF exacerbation/acute flash
pulmonary edema was felt to be most likely though trigger
unknown. Patient was is NSR so arrythmia was not felt likely to
be contributing to flash. Patient was therapeutic on Coumadin,
and while her left leg is more swollen than her right this is
chronic so PE was felt to be unlikely trigger.
.
When she arrived in the ICU, she arrived on BiPap at FiO2 40%
5/5 had a rate of 30, Vt 600, and on a Nitro gtt 2
mcg/kg/minute. She was able to speak full sentences and no
longer appeared to be in acute respiratory distress. She was
given 80 IV lasix, nitro gtt was stopped at 2AM and she was
weaned to 02 via NC by the morning. Repeat CXR showed
improvement of the signs suggesting pulmonary edema. As she had
a low grade temperature of 100.1, her antibiotics (azithromycin
& ceftriaxone) were continued presumptively for
community-acquired pneumonia. Transthoracic echocardiogram was
negative for ventricular pathology. Her chest x-ray reportedly
showed bilateral extensive focal parenchymal opacities persist,
some of which appear mass-like or nodular (notably in the left
lung). It was suggested that these nodules may undergo CT
evaluation.
- sputum cx pending
- LENIs ordered but not yet done
- PT consult for early mobilization ordered but not yet done
.
Her other chronic medical problems were managed as below:
# A Fib: Patient in NSR, INR therapeutic at 2.2, she was
continued on coumadin 6mg po qhs and monitored on telemetry. Of
note, her troponin level increased from 0.02 to 0.07, but only
non-specific changes were seen on the ECG. This was communicated
by telephone to your accepting physician prior to transfer.
.
# OSA: Continued on CPAP overnight.
# HTN: Written for her home Imdur, Metoprolol, Hydralazine
# GERD: Home Pantoprazole
# DM: Continued on (unable to confirm as patient didn't know her
dose) Novolin NPH 20 units QAM, and sliding scale.
.
# Pulmonary Nodules: CXR read " left more than right, extensive
focal parenchymal opacities persist, some of which appear
mass-like or nodular (notably in the left lung). As suggested on
the previous examination, these lesions could undergo CT
evaluation. "
-CT not yet ordered or done, will need assessment at [**Hospital1 34**] (where
patient is being transferred today).
.
# Prophylaxis: Subcutaneous heparin, home PPI
.
# Access: peripherals
.
# Communication: Patient and son [**Name (NI) 429**] (HCP) [**Telephone/Fax (1) 23433**]
Medications on Admission:
Nexium 40 mg QD
Hydralazine 30 mg TID
Novolin NPH 20 units in AM
Novolog SS
Fluticasone 50 mcg Spray
Imdur 120 mg QD
Lopressor 100 mg [**Hospital1 **]
Lasix 60 mg QD
Warfarin 4 mg QD
Alb/Atrovent nebs Q4
Ergocalciferol 1,000 unit QD
Discharge Medications:
1. Hydralazine 10 mg Tablet Sig: Three (3) Tablet PO Q8H (every
8 hours).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
5. Albuterol Sulfate Inhalation
6. Ipratropium Bromide Inhalation
7. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days: Start on [**2-11**], as [**2-10**] dose already given.
Last dose on [**2-14**].
8. Ceftriaxone 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 4 days: [**2-10**] dose already given. Last dose will
be on [**2-14**].
9. Insulin Regular Human Injection
10. Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day: To
be adjusted as according to INR levels.
11. Novolin R 100 unit/mL Solution Sig: Twenty (20) Units
Injection once a day.
12. Ergocalciferol (Vitamin D2) Oral
13. Fluticasone Nasal
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Acute on chronic diastolic congestive heart failure
Fever
Secondary: Coronary artery disease
Hypertension
Hyperlipidemia
Diabetes Mellitus, Type 2
Anemia
Obstructive Sleep Apnea
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:
Ms. [**Known lastname **],
You were admitted to [**Hospital1 69**] for
respiratory distress. You were given medications to control your
blood pressure and to treat any possible pneumonia, and you were
given supplemental oxygen. You were given diuretic medications
to remove fluid from your body, and your condition improved. An
echocardiogram of your heart showed that your heart is still
pumping blood effectively.
We made the following changes to your medications. Your
medication list will be communicated to the hospital you are
going to.
- Stopped NEXIUM. Instead, you are receiving PANTOPRAZOLE 40 mg
by mouth, once daily, to reduce stomach acid.
- Your FUROSEMIDE was increased to an 80 mg dose through the IV,
to remove fluid from your body. Your new providers will decide
how much of this medication to give you, going forward.
- AZITHROMYCIN 500 mg today (already given), then 250 mg by
mouth once daily, for the next four days. Last dose 2/27
- CEFTRIAXONE 1 g through the IV for a total of 4 days, for the
next four days. Last dose 2/27
- Your WARFARIN will be re-dosed as according to your blood
tests at the new hospital.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You are being transferred to a different hospital, for further
care
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"486",
"4280",
"42731",
"4019",
"25000",
"32723",
"2724",
"412",
"41401",
"V4582",
"2859"
] |
Admission Date: [**2180-9-9**] Discharge Date: [**2180-10-13**]
Date of Birth: [**2148-11-12**] Sex: F
Service: SURGERY
Allergies:
Nafcillin / Peanut
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Abdominal pain and fever
Major Surgical or Invasive Procedure:
Colonoscopy ([**2180-9-11**])
History of Present Illness:
31yoF with h/o IVDA, cirrhosis [**1-19**] autoimmune hepatitis c/b
portal HTN w/ ascites, variceal bleed s/p TIPS on [**2180-7-17**], and
hepatic encephalopathy, as well as hyperglycemia [**1-19**] TIPs and
steroids represents with abd pain. Of note, the patient was just
admitted Thurs->Friday for N/V/abd pain. During that admission,
she had a CT scan which showed no cause for her pain.
Gastroenteritis was presumed and she was discharged home after
her symptoms improved with zofran and dilaudid.
.
She reports that after discharge on Friday, she felt well. Then,
this morning ~ 5 AM, abd pain woke her from sleep. The pain was
diffuse, sharp and intermittent. She was able to get back to
sleep after 45 minutes. Then, when her mom woke her to check her
fsbg ~ 10, she again noticed the abd pain. She slept most of the
day, but did have 1 episode of nbnb emesis and felt persistently
nauseated. She also took her temperature during the course of
the day and it trended from 101 to 99.0. Her mother thought she
should go to the hospital because of the pain and vomiting so
she went to Addison-[**Doctor Last Name **].
.
At OSH ED, she received zofran 4 mg, dilaudid 1 mg x 3, and 1L
NS. Her pain improved. She was transferred to [**Hospital1 18**] because she
was concerned she needed imaging, which couldn't happen quickly
there. At [**Hospital1 **] ED, initial VS 99.9 82 109/57 14 99% on RA. First
set of labs was inaccurate. 2nd set of labs significant for
baseline pancytopenia, Na 137, Cr 0.6, and INR 2.2 (bl = 1.8)
(though INR was from first draw). LFTs were near baseline. RUQ
U/S showed cirrhotic liver, stable splenomegaly, unchanged
gallbladder wall edema and new to-and-fro flow in the left
portal vein. She was given 2L NS, 0.5 mg IV dilaudid x2, and 4
mg IV zofran. Stool guaiac was negative.
.
Currently, VS 97.4 126/74 87 20 100% on RA. She states that she
feels much better now though still has [**5-26**] diffuse, sharp abd
pain. Her nausea has resolved and she ate 2 box meals in the ED
today. She says that she feels silly to have come to the ED
again with most of the tests being negative and asks if she is
expected to have abd pain/nausea/vomiting with her disease. She
wasn't sure whether or not she should have come to the hospital
and didn't know who to call to ask.
.
ROS: + low-grade fevers, abd pain, n/v, fatigue
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
.
Finally, this patient has had a complicated course over the past
3 months. Briefly, she was admitted on [**6-12**] for a GI bleed -
grade 1 varices without bleeding seen on EGD. She represented on
[**7-1**] again with GI bleeding - EGD showed non-bleeding varices,
gastritis, and portal gastropathy. She was admitted again on
[**7-12**] for a third GI bleed - this admission she had TIPS
procedure performed. Course was complicated by high-grade MRSA
bacteremia requiring 6 weeks of IV vancomycin (at rehab, d/t
concern of IVDA and PICC line). She was then admitted from rehab
on [**8-8**] for hepatic encephalopathy and again on [**8-25**] for hepatic
encephalopathy and hyperglycemia.
Past Medical History:
# Autoimmune hepatitis: [**Doctor First Name **]+, AMA-, [**Last Name (un) 15412**]+
# Cirrhosis, complicated by varices, hepatic encephalopathy, and
ascites s/p TIPS [**2180-7-17**]
# Hep C: Genotype 3. most recent viral load undetectable
# high grade S aureus bacteremia on vancomycin
# hematemesis in [**5-/2180**] and EGD with + grade I esophageal/
duodenal varices noted
# Rheumatoid Arthritis
# Herpes zoster
# Compartment syndrome in R arm s/p surgical decompression
[**11/2178**]
# C section in [**2175**]
# Osteomyelitis [**2177**]
Social History:
Currently lives at home with her mother. She is single, has 2
children (one living with father, one with paternal grandma).
active smoker ([**12-19**] PPD x 15yrs). denies recent EtOH, drugs. Per
rehab records, she has a hsitory of marijuana and heroin use.
Used to work as a CNA.
Family History:
Father died of overdose when the patient was only 7. Mother has
hypothyroidism. A paternal aunt has diabetes mellitus.
Physical Exam:
EXAM ON ADMISSION:
VS - 97.4 126/74 87 20 100% on RA
GENERAL - well-appearing woman w/ moon facies, pleasant, NAD
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, mildly TTP diffusely, no masses or HSM,
no rebound/guarding
EXTREMITIES - WWP, no c/c, 1+ PE in bil. ankles, 2+ peripheral
pulses (radials, DPs)
SKIN - spider angiomas on chest, multiple small excoriations on
arms and legs -> pt states that she has pruritis and itches at
these lesions constantly
NEURO - no asterixis, grossly intact
.
EXAM ON DISCHARGE:
Same as above, except ...
Pertinent Results:
LABS ON ADMISSION:
[**2180-9-10**] 12:42AM BLOOD WBC-3.4* RBC-2.10*# Hgb-8.1*# Hct-24.1*#
MCV-115* MCH-38.7* MCHC-33.7 RDW-16.2* Plt Ct-60*
[**2180-9-10**] 06:42AM BLOOD WBC-2.7* RBC-1.95* Hgb-7.4* Hct-21.5*
MCV-111* MCH-38.2* MCHC-34.5 RDW-15.9* Plt Ct-46*
[**2180-9-10**] 09:30PM BLOOD Hgb-8.8* Hct-25.0*
[**2180-9-10**] 12:42AM BLOOD Neuts-60.5 Lymphs-28.0 Monos-6.2 Eos-4.6*
Baso-0.8
[**2180-9-10**] 06:42AM BLOOD PT-19.4* PTT-39.8* INR(PT)-1.8*
[**2180-9-10**] 12:42AM BLOOD Glucose-192* UreaN-8 Creat-0.6 Na-137
K-3.3 Cl-107 HCO3-22 AnGap-11
[**2180-9-10**] 12:42AM BLOOD ALT-48* AST-73* AlkPhos-155* TotBili-3.8*
[**2180-9-10**] 06:42AM BLOOD ALT-40 AST-54* AlkPhos-142* Amylase-53
TotBili-3.3*
[**2180-9-10**] 06:42AM BLOOD Lipase-70*
[**2180-9-10**] 06:42AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.7
[**2180-9-10**] 06:42AM BLOOD VitB12-1238* Folate-14.5
[**2180-9-10**] 02:32PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
MICROBIOLOGY:
.
DIAGNOSTICS:
DUPLEX DOPP ABD/PEL [**2180-9-9**]
DUPLEX DOPPLER ULTRASOUND OF THE LIVER: The liver demonstrates
heterogeneous
echogenicity, findings consistent with patient's known history
of cirrhosis.
No focal hepatic lesion is identified. The visualized portions
of the
pancreatic head, neck, and body are within normal limits.
Evaluation of the
tail is limited by overlying bowel gas. The spleen remains
enlarged measuring
15.7 cm. There is unchanged diffuse gallbladder wall edema,
findings
consistent with patient's underlying chronic liver disease.
However, no focal
gallstones are visualized. The common bile duct measures 5 mm
and is not
dilated. There is a mild amount of perihepatic and left upper
quadrant
ascites, which is new compared to prior ultrasound though
similar compared to
recent CT examination.
LIVER DOPPLER: Color and pulse wave Doppler examination of the
hepatic
vasculature demonstrates a patent main portal vein with a peak
systolic
velocity of 44 cm/sec compared to 59 cm/sec on recent prior. The
TIPS is in
unchanged position with wall-to-wall flow throughout and typical
respiratory
variations. The velocity in the proximal TIPS ranges from
167-196 cm/sec
compared to 150-190 cm/sec on recent prior. The range of
velocities in the
mid TIPS ranges from 144-164 cm/sec, decreased compared to prior
when it
measured 177-231 cm/sec. The peak systolic velocity in the
distal TIPS
measures 134 cm/sec compared to 121 cm/sec on the prior. The IVC
is patent
with usual directional flow. The left portal vein demonstrates
some to- and
fro- flow which appears new compared to prior examination,
though centrally
flow is in the direction of the TIPS. The main hepatic artery
demonstrates
normal arterial Doppler waveform with a peak systolic velocity
of 85 cm/sec.
IMPRESSION:
1. Patent TIPS with wall-to-wall flow and respiratory
variability. Stable
velocities in the proximal and distal TIPS with slightly
decreased velocities
in the mid TIPS compared to recent prior examination.
2. Newly identified to and fro flow within the left portal vein,
though
centrally flow appears hepatofugal towards the TIPS stent.
3. Stable cirrhotic-appearing liver, diffuse gallbladder wall
edema and
splenomegaly.
4. Small amount of perihepatic and left upper quadrant ascites,
which is new
compared to prior ultrasound though similar compared to recent
CT examination.
.
PERTINENT LABS ON DISCHARGE:
Brief Hospital Course:
31 y.o. F with h/o IDDM, IVDA, cirrhosis [**1-19**] autoimmune
hepatitis c/b portal HTN w/ ascites, variceal bleed s/p TIPS on
[**2180-7-17**], and hepatic encephalopathy, presented with abd pain and
occult anemia. Hct drop from 24 to 21. PRBC transfusion was
given. She underwent endoscopy on [**2180-9-12**] complicated by a GI
bleed when a previously placed coil in the duodenum became
dislodged. The pt's Hct dropped to 16.9 and she was taken to IR
to embolize the bleeding duodenal varix and subsequently
transferred to the CCU.
Transplant surgery was consulted and on [**2180-9-13**] she was taken to
the OR for exploratory laparotomy, ligation of duodenal varix,
duodenotomy, and retrieval of embolic coils. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was
placed. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative
note for details.
Postop course was complicated by high ascites drain output
requiring IV fluid replacements and albumin. Diet was slowly
advanced. Lactulose and Rifaximin were started to prevent
encephalopathy. She had high pain med requirements for
persistent abdominal pain. Drain fluid was sent for cell count
and culture on [**9-22**]. Culture of fluid isolated 2 species of
Acinetobacter Baumanii pan-sensitive except Bactrim. She was
started on Cetriaxone. Fluid was re-sent on [**9-25**] demonstrating
94 WBC and 21 polys. Culture was negative.
On postop day 13, she was re-started on Lasix and Aldactone. On
postop day 14, the [**Doctor Last Name 406**] drain was removed. Incision and old
drain site remained dry. However, abdominal girth increased.
Creatinine started to rise.
On [**9-29**], a liver donor offer was available. Patient accepted
and underwent Liver Transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Please refer to operative note for details. She was sent to SICU
immediately postop for management where she was extubated. LFTs
increased as anticipated. Liver US/Duplex demonstrated patent
arteries with resistive index in the right hepatic artery 0.7
to 0.78, main hepatic artery was 0.78 to 0.79, and left hepatic
artery was 0.68. The middle, right, and left hepatic veins were
patent with normal waveforms. The main, right anterior, right
posterior and left portal veins are patent with normal
waveforms. No intrahepatic or extrahepatic biliary ductal
dilatation was seen. Repeat liver duplex was unchanged. LFTs
trended down.
Creatinine continued to rise to 3.2 then decrease. Lasix was
given for generalized edema.
Diet was advanced and tolerated. Insulin gtt was initially
started then switched to sliding scale. She remained
hemodynamically stable and was transferred out of the SICU.
LFTs decreased. [**Last Name (un) **] was consulted and Lantus with sliding
scale ordered. She was assisted out of bed to ambulate. Pain
medication was switched to po Dilaudid. Dose was increased for
c/o abdominal pain. Lateral JP was removed on [**10-3**] and site
sutured. This remained dry. On [**10-9**], a liver biopsy was
performed for rising alk phos. Biopsy demonstrated bile duct
proliferation. An ERCP was then done on [**10-11**] noting CBD
stricture; duct was stented. Alk phos decreased after stenting.
She tolerated the procedure fairly well. She complained of
abdominal pain and severe headache. She was also hypertensive.
This was treated with IV Lopressor and IV Morphine. Head CT was
normal. Norvasc was stopped for potential etiology of headache.
Headache and abdominal pain resolved.
Immunosuppression consisted of Cellcept which was well
tolerated, steroids were tapered per protocol. Prograf was
initiated and doses adjusted. The plan was for Prednisone to
continue permanently after taper for Autoimmune hepatitis. Lasix
was continued for 2+ leg edema. Creatinine normalized.
She was cleared by PT for home safety and was discharged to her
mother's home with VNA services. She demonstrated good knowledge
of medications and insulin management.
Of note, she experienced developed diffuse itching and burning
of the skin
and sensation of shortness of breath after eating a peanut
butter [**Location (un) 6002**]. She was given Benadryl for this and was
evaluated by Dr. [**First Name (STitle) 2602**] Sheik, who felt that she could have
acquired passive transfer of food specific IgE antibodies with
a organ transplant. She was instructed to avoid all peanut
products strictly for the next month and/or until seen in
[**Hospital 9039**] Clinic in followup. Serum specific IgE to peanuts and
other common food allergens were sent, and she was given an
EpiPen script on discharge. Administration technique was
provided. She will followup in the outpatient [**Hospital 9039**] Clinic n
two to four weeks. Results of blood tests were to be reviewed
at that time.
Medications on Admission:
MEDICATIONS: (from prior discharge summary)
# lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q2H
(every 2 hours) as needed for see additional instructions:
Please titrate to [**2-18**] BMs/day. [**Month (only) 116**] take 30 ml Q2 hr for BM <3. .
# azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
# magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
# sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
# spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Please give with furosemide .
# furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please give with spironolactone .
# metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Please hold for systolic blood pressure <90.
# pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
# rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
# prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
# insulin glargine 100 unit/mL Cartridge Sig: Thirty (30) units
Subcutaneous qam: Please take 30 units of glargine insulin in
the morning.
# ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea for
5 doses.
# clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
5X/DAY (5 Times a Day).
# fluconazole 150 mg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS
(Every 3 Days).
# insulin lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous per sliding scale: Please take insulin lispro as
directed by your home sliding scale three times a day before
meals and before bedtime.
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
follow sliding scale taper.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
7. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO once a
day.
8. tacrolimus 1 mg Capsule Sig: Five (5) Capsule PO Q12H (every
12 hours).
9. insulin lispro 100 unit/mL Solution Sig: follow sliding scale
Subcutaneous four times a day.
Disp:*1 bottle* Refills:*2*
10. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
Disp:*60 Capsule(s)* Refills:*2*
13. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*28 Tablet Extended Release(s)* Refills:*0*
14. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*20 Tablet(s)* Refills:*1*
16. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous once a day.
Disp:*1 bottle* Refills:*2*
17. Insulin Syringes
Low dose U-100 syringes
25-26 gauge [**12-19**] inch needle for [**Hospital1 **] NPH and sliding scale qid
humalog
supply: 1 box
refill:2
Discharge Disposition:
Home With Service
Facility:
vna carenetwork
Discharge Diagnosis:
Allergic reaction likely due to peanuts (passive transfer from
donor liver)
history of MRSA bacteremia
cirrhosis secondary to autoimmune hepatitis status post TIPS
Hyperglycemia secondary to medications
HCV
peritonitis
HRS, ATN
VRE UTI
biliary stricture
DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the following:
fever (temperature of 101 or greater), shaking chills, nausea,
vomiting, inability to take any of your medications, jaundice,
increased abdominal pain, incision redness/bleeding/drainage,
abdominal distension or decreased urine output.
-You will need to have blood drawn every Monday and Thursday for
lab monitoring
-do not lift anything heavier than 10 pounds/no straining
-no driving while taking pain medication
-you may shower
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9978**] MD [**Telephone/Fax (1) 2378**] ([**Last Name (un) **] Endocrinology)
[**Location (un) 551**] [**Last Name (un) **] , [**Last Name (un) 3911**], [**Location (un) 86**], MA
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2180-10-20**] 3:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2180-10-27**] 1:30
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2180-10-27**] 2:50
Completed by:[**2180-10-16**]
|
[
"5845",
"5990",
"2761"
] |
Admission Date: [**2156-7-26**] Discharge Date: [**2156-9-3**]
Date of Birth: [**2104-3-28**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Ciprofloxacin / Morphine Sulfate / Ativan
/ Piperacillin Sodium/Tazobactam
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Transfer from Outside Hospital with sepsis and bowel leakage
after two laparotomies
Major Surgical or Invasive Procedure:
Exploratory laparotomy, extensive lysis of adhesions, small
bowel resection with enteroenterostomy, cecal primary closure,
abdomen washout and gastrojejunostomy tube placement.
History of Present Illness:
[**Known firstname 17**] is a 52-year-old female who was transferred from an
outside hospital after being admitted inearly [**Month (only) 205**] with
diverticulitis. The patient was treated withantibiotic therapy
and then underwent exploratory laparotomy
and segmental colectomy with primary anastomosis on [**2156-6-30**]. She spent 10 days in the hospital postoperatively and
was discharged home. She returned shortly thereafter with
increasing abdominal pain and fevers. The patient had a
pelvic abscess with an anastomotic leak and was taken to the
operating room a second time on [**2156-7-20**] for
exploratory laparotomy and abscess drainage. Enterotomies
were made during this exploration and they were repaired with
interrupted silk sutures. The patient was given an end
colostomy and mucous fistula.
Postoperatively on [**2156-7-26**], succus was actively drainging
from the wound. A CT scan was performed which showed
extravasation of contrast from the bowel into the pelvis and out
the wound. The patient was transferred to the [**Hospital1 346**] for tertiary care after that finding.
The patient was initially accepted by Dr. [**Last Name (STitle) **] and
then transferred to Dr. [**First Name (STitle) 2819**] on the Blue Surgery service.
The patient was seen in the surgical intensive care unit in
on arrival. There was bilious drainage from the abdominal
incision and feculent drainage from [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain
that had been placed in the pelvis by the previous surgeon.
The patient was explained the risks and benefits of operative
procedure and it was deemed appropriate to operate as there
was significant drainage and it probably would not be
controlled adequately with nonoperative therapy. The grave
situation was explained to the patient and the patient's
daughter, and the patient agreed to proceed and signed a
surgical consent for exploration. Bowel resection, diverting
ostomy and requirement to leave the abdomen open were all
discussed and a consent was signed.
Past Medical History:
Recurrent Diverticulitis
HTN
Benign colon polyp
h/o EtOH abuse
Fiberoid uterus s/p TAH BSO
s/p Laproscopic cholecystectomy
Social History:
quit smoking in [**6-/2156**] at the time of her admission for
diverticulitis
1.5ppd X 30 yrs
History of EtOH and marijuana abuse
Family History:
non-contributory
Physical Exam:
temp:101.6, HR 123, BP 125/47, RR 19, SaO2 97%
Gen: frail thin caucasion woman in NAD,
HEENT: NCAT EOMI
CV: RR, tachy, nl S1, S2
Pulm: CTA b/l
Abd: BS present, tender to palp, drains intact, midline
inscision
Ext: no pedal edema, MAE
Pertinent Results:
[**2156-7-26**] 07:58PM GLUCOSE-83 UREA N-10 CREAT-0.5 SODIUM-131*
POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-24 ANION GAP-15
[**2156-7-26**] 07:58PM ALT(SGPT)-9 AST(SGOT)-16 LD(LDH)-212 ALK
PHOS-142* AMYLASE-103* TOT BILI-0.3
[**2156-7-26**] 07:58PM WBC-15.6* RBC-3.44* HGB-10.3* HCT-31.3*
MCV-91 MCH-30.0 MCHC-33.0 RDW-14.7
[**2156-7-26**] 07:58PM NEUTS-72.6* LYMPHS-16.1* MONOS-5.6 EOS-5.5*
BASOS-0.2
[**2156-7-26**] 07:58PM PLT SMR-VERY HIGH PLT COUNT-645*
Brief Hospital Course:
The patient was admitted to the Blue surgery service and
underwent an emergent operation on [**2156-7-27**] (see Dr.[**Name (NI) 11471**] op
note). Postoperatively, her wound healed secondarily with wet to
dry dressing changes twice daily. She underwent CT-guided
drainage of a pelvic abscess with placement of a pigtail
catheter. A G tube and JP drain were also placed. She was
administered antibiotics for organisms isolated from her wound
cultures. One week [**Last Name (LF) **], [**Known firstname 17**] developed a fever/rash and
renal failure thought to be a reaction to an antibiotic, most
likely Zosyn. She also developed a severe skin rash and was
briefly transferred to the SICU for fluid resuscitation. She
recovered from the drug reaction, was transferred back to the
floor. Repeat CT scans of her abdomen showed no new collections,
and she continued to improve. The JP drain was removed on [**8-31**].
She was deemed ready for discharge to rehab on [**9-3**].
Medications on Admission:
Atenolol
vancomycin
levofloxacin
metronidazole
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Disp:*qs x 1 month packet* Refills:*0*
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*qs x 1 month packet* Refills:*0*
3. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
4. Sodium Chloride 0.9% Flush 10 ml IV DAILY:PRN
PICC line - Inspect site every shift
5. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
6. Diazepam 2.5 mg IV BID PRN
7. Hydromorphone 0.5-4 mg IV Q3-4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Small bowel leakage and cecal leakage enterocutaneous fistula
Allergic reaction to pipericillin with severe rash/renal failure
Sepsis
Discharge Condition:
Stable.
Discharge Instructions:
Please call your doctor if you experience fever >101.5, redness
or purulent drainage from wounds, persistent nausea/vomiting, or
any other concerns. No heavy lifting for 8 weeks. Please take
all medications as prescribed.
Followup Instructions:
Please see Dr. [**First Name (STitle) 2819**] in 1 week. Upon discharge, please call Dr. [**Name (NI) 63323**] office at [**Telephone/Fax (1) 2998**] for an appointment.
Completed by:[**2156-9-3**]
|
[
"5849",
"99592"
] |
Admission Date: [**2156-7-8**] Discharge Date: [**2156-7-12**]
Date of Birth: [**2086-1-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aortic stenosis/regurgitation
Major Surgical or Invasive Procedure:
Aortic valve replacement (927mm Mosaic tissue) [**2156-7-8**]
History of Present Illness:
This 70 year old white male has a long standing history of
aortic stenosis. recent echocardiograms have shown worsening
stenosis ([**Location (un) 109**] 0.8 cm2 and >100 gradient)with new regurgitation
with dilatation of the aortic root. He was admitted now for
elective replacement.
Past Medical History:
hypertension
hyperlipidemia
aortic stenosis/regurgitation
Remote history of sternal fracture
Social History:
Race: Caucasian
Last Dental Exam: 1 month
Lives with: wife
Occupation: Counselor
Tobacco: Never
ETOH: one-two drinks per day
Family History:
father died age 65 of MI
Physical Exam:
admission:
Pulse: 74 Resp: 16 O2 sat: 98%
B/P Right: 147/83 Left: 139/87
Height: 66" Weight: 178
General: WDWN in NAD
Skin: Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X] Anicteric sclera
Neck: Supple [X] Full ROM [X] No JVD[X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, IV/VI harsh systolic ejection murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X] No HSM/CVA tenderness
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Mild bilateral spider veins
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit- Murmur radiates bilaterally
Pertinent Results:
[**2156-7-12**] 05:13AM BLOOD WBC-9.8 RBC-3.89* Hgb-11.5* Hct-33.5*
MCV-86 MCH-29.4 MCHC-34.2 RDW-13.2 Plt Ct-315#
[**2156-7-12**] 05:13AM BLOOD Plt Ct-315#
[**2156-7-12**] 05:13AM BLOOD UreaN-10 Creat-0.7 Na-139 K-4.0 Cl-105
[**2156-7-10**] 04:40AM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-134
K-4.2 Cl-100 HCO3-27 AnGap-11
[**2156-7-12**] 05:13AM BLOOD Mg-2.2
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The number
of aortic valve leaflets cannot be determined. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POSTBYPASS
Biventricular systolic function remains normal. There is a well
seated, well functioning bioprosthesis in the aortic position.
No AI is visualized. The MR is now trace. The study is otherwise
unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2156-7-8**] 10:49
Brief Hospital Course:
Following admission he went to the Operating Room where aortic
valve replacement was undertaken. he weaned from bypass on Neo
Synephrine and Propofol. he remained stable, was weaned and
extubated and came off pressor easily. See operative note for
details.
He was in complete heart block immediaitely after surgery, but
in sinus rhythm by POD 1. He developed atrial fibrillation with
a ventricular response of 130 on POD 2 and beta blockade was
begun. He was diuresed towards his preoperative weight.
Physical therapy worked with him for mobility and strengthening.
CTs were discontinued on POD 1 and temporary wires per protocol.
Made good progress and was cleared for discharge to home with
VNA on POD #4. All f/u appts were advised.
Medications on Admission:
amlodipine 5 mg daily
lipitor 10 mg daily
ASA 81 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day) as needed for post op.
Disp:*90 Tablet(s)* Refills:*1*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of S.E Ct.
Discharge Diagnosis:
s/p aortic valve replacement
aortic stenosis/regurgitation
hypertension
hyperlipidemia
postop A Fib
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema -none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on Tuesday [**8-10**] @ 1:15 pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17811**] in [**11-29**] weeks[**Telephone/Fax (1) 85193**]
Cardiologist: Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 9241**] [**Last Name (NamePattern1) 85194**] in [**11-29**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2156-7-12**]
|
[
"4241",
"9971",
"42731",
"4019",
"2724"
] |
Admission Date: [**2157-6-21**] Discharge Date: [**2157-6-27**]
Date of Birth: [**2120-1-29**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
MVC, abdominal pain
Major Surgical or Invasive Procedure:
1)Splenectomy
2)Small Bowel resection
History of Present Illness:
37 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] with MVC rollover, presented next day with severe
abdominal pain to OSH. CT scan showed splenic laceration with
free fluid/blood in the peritoneum. Pt was transfered to [**Hospital1 18**]
for difinitive care.
Past Medical History:
None
Social History:
+tobacco/occasional EtoH/ denies IVDA
Family History:
noncontributory
Physical Exam:
upon arrival:
Vitals: 100.8 117/67 106 20 100%sat
General: GCS 15, obviously in pain
HEENT: PERRL 3-2mm BL, c-collar in place, no hemotypanum, no
oropharyngeal trauma, trachea midline
Chest: RRR no m/r, CTABL with equal BS
Back: left flank echymosis/abrasion, right hip/flank
abrasion/echymosis
Ab: distended, firm, diffusely tender, pos guarding
Pelvis: no instability
Ext: left shoulder abrasion, right anterior leg abrasion, 2+DPP
BL
Rectal : good tone, heme neg
Pertinent Results:
[**2157-6-21**] 10:24PM TYPE-ART PO2-170* PCO2-49* PH-7.28* TOTAL
CO2-24 BASE XS--3
[**2157-6-21**] 10:24PM LACTATE-1.0
[**2157-6-21**] 10:24PM O2 SAT-98
[**2157-6-21**] 10:13PM GLUCOSE-140* UREA N-15 CREAT-1.0 SODIUM-139
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-21* ANION GAP-12
[**2157-6-21**] 10:13PM CALCIUM-7.6* PHOSPHATE-3.9 MAGNESIUM-1.5*
[**2157-6-21**] 10:13PM WBC-19.3*# RBC-4.77# HGB-14.1# HCT-41.2#
MCV-86 MCH-29.5 MCHC-34.1 RDW-14.0
[**2157-6-21**] 10:13PM FIBRINOGE-226
Brief Hospital Course:
Pt taken to OR where a distal illeum mesenteric injury was
appreciated in addition to the splenic laceration. Pt's spleen
and small bowel was resected and he was transfered to the SICU
intubated and in stable condition. After an uncomplicated SICU
stay pt was extubated and transfered to the floors in good
condition. On the floors pt did well aside from some episodes
of hypoxia secondary to a small infiltrate/area of atelectasis
in the RLL which resolved with Lasix and aggressive pulmonary
toilet. Pt was slowly advanced to a regular diet, his pain was
well controlled throughout. On the day of discharge pt was
educated about the risks of being asplenic and the neccesary
precautions he would need to take. He also recieved H. flu,
meningicoccal, and pneumovax vaccines. He also recieved a
prescription for a MedAlert bracelet.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain for 3 days.
Disp:*36 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
3 days.
Disp:*6 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1)Splenic Laceration
2)Asplenia
3)Motorvehicle Crash
4)small bowel ischemia
Discharge Condition:
Good
Discharge Instructions:
1)You had your spleen removed and as a result you are at risk
for serious infections especially in these initial days after
your operation. It is therefore imperative that you call a
physician immediately if you have a fever or chills.
2)We have given you 3 vaccines which correspond to 3 types of
bacteria that you are at particular risk for serious infection
with now that you no longer have a spleen. These vaccines do
not last forever. You must follow up with your PCP as soon as
possible to discuss a plan for further vaccination in the
future.
3)You should also wear a MedAlert bracelet for which you have
been given a prescription so that other physicians are aware
that you do not have a spleen in the case that you cannot tell
them that yourself.
4)You have had abdominal surgery and your small bowel removed.
As such you should call a physician immediately if you have any
persistent abdominal pain, diarrhea, constipation, nausea,
vomiting, chest pain, or shortness of breath, or any other
concerning symptoms.
5)You will need to follow up in the Trauma clinic next week as
instructed below.
Followup Instructions:
1)Call your PCP as soon as possible to discuss your hospital
course, health status, need for future follow up, vaccinations.
2)Follow up at the Trauma clinic one week from tomorrow. Call
[**Telephone/Fax (1) 56358**] as soon as possible to make an appointment. You
will have your staples removed at that time.
|
[
"5180"
] |
Admission Date: [**2146-1-17**] Discharge Date: [**2146-1-24**]
Date of Birth: [**2106-1-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hyperglycemia, hypernatremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
40 yo M with presumptive diagnosis of UC (dx by colonoscopy at
OSH), hospitalized [**Date range (3) 57353**] with BRBPR attributed to UC
flare c/b RF (Cr as high as 3.9, with baseline creatinine now
1.5), liver U/S findings of nodularity and heterogenous
echotexture suggestive of cirrhosis, anemia w/findings
suggestive of chronic disease, and thrombocytopenia in the
setting of not having taken his chronic prednisone for two
months.
.
Four days prior to the current admission his prednisone had been
tapered from 60 to 30 mg daily. At the same time he developed
lighheadedness, polyuria, polydypsea, and blurred vision. He
denied fevers, chills, chest pain, cough, SOB, abdominal pain,
nausea, vomiting, diarrhea, or dysuria, or any recurrent BRBPR.
.
In the ED, vital signs were stable. Initial labs showed Na+ 162
(corrected for hyperglycemia 171.4), K+ 4.5, Glucose 928, pH
7.38, Ca 10.5, Phos 7.7, creatinine 3.1. WBC elevated to 14.8
with 86%N. He was given 4L NS, 10units iv insulin, started on
an insulin gtt and transferred to the [**Hospital Unit Name 153**].
.
Previous work-up:
1) Abdominal CT and ultrasound: demonstrating echogenic liver
c/w cirrhosis without any masses or lesions, sigmoid bowel wall
thickening.
2) Renal biopsy: suggestive of ATN, no evidence of
immune-complex glomerulonephritis.
3) HIV negative
4) [**Doctor First Name **] positive 1:40 speckled
5) Anti-SM negative
6) antimitochondrial antibody negative
7) hepatitis serologies negative
8) AFP negative
9) SPEP without significant monoclonal elevation
10) ceruloplasmin wnl
11) low positive ASO titer.
Past Medical History:
1. Ulcerative colitis: diagnosed 1.5 years ago by colonoscopy
in NJ after a relatively acute presentation over a 2 week time
span, hospitalized [**3-2**] prior, treated with steroids and Pentasa
as an outpatient
2. CRI (baseline creatinine 1.5)
3. Cirrhosis
4. Anemia of chronic disease
5. Thrombocytopenia
Social History:
Married Nigerian immigrant.
Works as instructor for autistic children.
Lived in NJ for five years. Educated in [**Country 532**] with medical
degree.
No known HIV exposure, no history of blood transfusions, no
known exposures to active TB, no recent travel.
Denies tobacco, alcohol or drug use.
Family History:
Denies any family history of diabetes, autoimmune disease, renal
disease, thyroid disease, gastrointestinal diseases
Physical Exam:
BP123/90, T96.9, HR70-90, RR15, O2sat100%RA
Gen: thin male, NAD
HEENT: EOMI, PERRL, MMdry, cracked lips, no lad
CV: RRR, no mrg, nl s1s2, PMI slightly laterally placed
Lungs: CTAB
Abd: thin, soft, NT, ND, +BS, no masses, no HSM
Back: no CVAT, no spinal tenderness
Ext: no C/C/E, 2+ radial/DP/PT
Skin: no rashes, multiple oval shaped scars on both shins and
one on abdomen
Neuro: A&O x3, strength 5/5 throughout, sensation intact
grossly to fine touch + pain, nl tone, reflexes 2+ throughout B
biceps/patellar
Pertinent Results:
LABS ON ADMISSION:
[**2146-1-17**] 07:05PM URINE RBC-0 WBC-0 BACTERIA-OCC YEAST-NONE
EPI-0
[**2146-1-17**] 07:05PM URINE BLOOD-NEG NIT-NEG PROT-NEG GLUC-1000
KET-TR BILI-NEG UROBIL-NEG PH-5.0 LEUK-NEG
[**2146-1-17**] 07:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.031
[**2146-1-17**] 07:40PM PT-14.3* PTT-23.3 INR(PT)-1.3
[**2146-1-17**] 07:40PM PLT COUNT-174#
[**2146-1-17**] 07:40PM NEUTS-86.2* LYMPHS-12.4* MONOS-1.3* EOS-0
BASOS-0.1
[**2146-1-17**] 07:40PM WBC-14.8*# RBC-4.74# HGB-14.0# HCT-44.3#
MCV-94 MCH-29.5 MCHC-31.6 RDW-17.9*
[**2146-1-17**] 07:40PM ALBUMIN-4.7 CALCIUM-10.5* PHOSPHATE-7.7*#
MAGNESIUM-3.6*
[**2146-1-17**] 07:40PM LIPASE-61*
[**2146-1-17**] 07:40PM AST(SGOT)-28 ALK PHOS-335* AMYLASE-266* TOT
BILI-0.9
[**2146-1-17**] 07:40PM GLUCOSE-978* UREA N-77* CREAT-3.1*#
SODIUM-162* POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-26 ANION
GAP-28*
[**2146-1-17**] 09:30PM GLUCOSE-814* UREA N-74* CREAT-2.9*
SODIUM-162* POTASSIUM-7.7* CHLORIDE-120* TOTAL CO2-20* ANION
GAP-30*
###########################################
LABS ON DISCHARGE:
[**2146-1-23**] 06:50AM BLOOD WBC-6.6 RBC-3.44* Hgb-10.0* Hct-29.7*
MCV-87 MCH-29.2 MCHC-33.8 RDW-17.7* Plt Ct-69*
[**2146-1-23**] 06:50AM BLOOD Glucose-86 UreaN-26* Creat-1.4* Na-139
K-3.1* Cl-108 HCO3-24 AnGap-10
[**2146-1-23**] 06:50AM BLOOD ALT-142* AST-139* LD(LDH)-247
AlkPhos-285* Amylase-142* TotBili-0.8
[**2146-1-23**] 06:50AM BLOOD Lipase-73*
[**2146-1-23**] 06:50AM BLOOD Albumin-3.3* Calcium-8.2* Phos-2.1*
Mg-1.6
###########################################
Head CT: no hemorrhage or mass effect
###########################################
CXR: no acute cardiopulmonary disease
###########################################
MRCP: 1. Cirrhotic liver with confluent fibrosis. There are
no arteriorly enhancing lesions or dominant masses. 2. There is
no biliary ductal dilatation or imaging features to suggest
cholangitis. 3. Small amount of ascites.
###########################################
PENDING LABS:
--C-PEPTIDE CA [**60**]-9
--HEPARIN DEPENDENT ANTIBODIES
--INSULIN ANTIBODIES
--ISLET CELL ANTIBODY
--PARVOVIRUS B19 ANTIBODIES (IGG & IGM)
Brief Hospital Course:
40 yo M with presumptive history of UC, hospitalized in
[**11-7**] with BRBPR attributed to UC flare c/b ARF,
cryptogenic cirrhosis, anemia, and thrombocytopenia, presenting
[**2146-1-17**] with nonketotic hyperosmolar hyperglycemia and
hypernatremia.
.
1. HYPERGLYCEMIA: patient presented with nonketotic
hyperosmolar hyperglycemia, which may be due to his recent
steroid course. He had been treated in house with iv steroids
for his presumed UC flare and was discharged to home on a slow
prednisone taper. In the setting of lasix use, steroids can
cause nonketotic hyperosmolar hyperglycemia. However, given his
hepatic and renal issues, an autoimmune or infectious process
was also considered. The patient's previous work-up to this end
was negative. He was initially started on an aggressive fluid
rehydration with 1/2NS for free water deficit + insulin gtt and
eventually switched to glargine, and a sliding scale
humaloginsulin regimen on the second day of admission. [**Last Name (un) **]
was consulted and recommended the above regimen and a panel of
autoantibody studies to determine if the pt has type I or II DM.
His humalog sliding scale was optimized while on the medicine
floor. He was discharged on glargine 10 units at bedtime and
humalog sliding scale for breakfast, lunch and dinner.
.
2. HYPERNATREMIA: most likely due to osmotic diuresis in
hyperglycemic patient. Sodium corrected for elevated serum
glucose was 171.4mEq/dl. Free water deficit was 7.4L +
insensible losses. 1/2 NS was used for intravascular fluid
repletion. Na is 146 on day of transfer.
.
3. HYPERCALCEMIA: likely due to acute renal failure vs.
dehydration. No signs of GI, cardiac, psychiatric, or muscular
affects. corrected with IVFs
.
4. HYPERPHOSPHATEMIA: as above, likely due to dehydration and
corrected with IVFs.
.
5. ARF on CRI: baseline creatinine 1.6. ARF likely prerenal
in setting of hypovolemia secondary to osmotic diuresis,
improved from 3.1 to 1.4 with IVFs.
.
6. ELEVATED WBC: WBC 14.6 with left shift. Most likely due to
steroid use vs stress response. Pt remained afebrile with no
evidence of infection on UA or CXR, and his WBC returned to
[**Location 213**].
.
7. THROMBOCYTOPENIA: ranged from 49 to 91 after a decrease from
174 with IVF at admission. Thought possibly secondary to
unintentional heparin exposure, but continued to be in "double
digits" despite no heparin. A HIT antibody test was performed
and was pending at the time of discharge. Steroids and liver
disease may both be affecting thrombocyte generation.
.
8. UC: questionable diagnosis based on colonoscopy reports.
Patient is now follwed by Dr. [**First Name (STitle) 572**] who was notified of his
admission. UC stable for now. On 30 mg prednisone QD w/o
symptoms. To be reassessed as outpt by Dr. [**First Name (STitle) 572**] in one week
from discharge.
.
9. Cirrhosis: Etiology unknown but U/S on previous study
suggestive of cirrhosis. Pt declined liver biopsy at that time.
His LFTs, alkphos, amylase and lipase remained mildly elevated.
A MRCP was performed the day before discharge, and a
preliminary report showed: 1. Cirrhotic liver with confluent
fibrosis. There are no arterially enhancing lesions or dominant
masses. 2. There is no biliary ductal dilatation or imaging
features to suggest cholangitis. 3. Small amount of ascites.
The Pt refused a liver biopsy. No clear etiology for his
cirrhosis was elucidated.
.
10. FEN: renal, diabetic/carbohydrate controlled diet
.
11. Communication: with the patient and his cousin [**Name (NI) 57354**] Aru
[**Telephone/Fax (1) 57355**])
.
12. Code: Full
Medications on Admission:
Prednisone (60mg changes to 30mg daily)
Folate
Vit B complex
Lasix 40mg daily (discontinued recently)
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. glargine
take 10 units at bedtime every day,
two months supply,
3 refills
3. humalog
take as directed by sliding scale; breakfast, lunch and dinner;
roughly two month supply (assuming 5-10 units per ml);
3 refills
4. insulin syringes
two month supply;
3 refills
5. blood test lancets
two month supply;
3 refills
6. blood glucose test strips
two months supply, 3 refills
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Diabetes Mellitis c/b Hyperosmalar Non-ketotic Syndrome.
2. Acute Renal Failure.
3. Hypernatremia.
4. Acute on chronic thrombocytopenia.
Secondary:
1. Chronic Renal insufficiency - biopsy with probable ATN.
2. Cryptogenic Cirrhosis.
3. Ulcerative Colitis.
4. Anemia - chronic disease.
Discharge Condition:
stable
Discharge Instructions:
1) Seek immediate medical attention if experiencing blurred
vision, increased thirst, increased urination, fever, chills,
abdominal pain, vomiting, diarrhea.
2) Take all medications as prescribed
3) Follow-up all appointments
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (PCP) [**2145-1-30**] 2:00 pm, phone
[**Telephone/Fax (1) 250**]
.
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Last Name (un) **] Diabetes Center, [**2145-2-7**]
1:00 pm, phone [**Telephone/Fax (1) 2378**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Where: LM [**Hospital Unit Name 22399**] Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2146-1-31**] 4:15 pm
|
[
"5845",
"2875",
"2761"
] |
Admission Date: [**2151-9-17**] Discharge Date: [**2151-9-21**]
Date of Birth: [**2151-9-17**] Sex: M
Service: NB
HISTORY: This was a full-term male prenatally
diagnosed with a question of a Dandy-Walker malformation.
This infant was born at 37-5/7 weeks to a 37-year-old gravida
3, para 0 now 1, O-positive, hepatitis surface antigen
negative, RPR nonreactive, group B Strep negative woman. The
OB history was remarkable for 2 previous losses. Antepartum
was remarkable for hypertension at 32 weeks, but requiring no
treatment. An ultrasound at 20 weeks diagnosed Dandy- Walker
malformation. Mother was evaluated with MRI. The results
showed, in addition to Dandy-Walker malformation, unilateral
right ventriculomegaly, but no midline shift. The corpus callosum
and cavum septum pellucidum appeared to be normally formed.
Amniocentesis revealed normal male karyotype. Prenatal FISH
results also were unremarkable. The fetal echocardiogram also
performed was also unremarkable. No hydrocephalus was noted on
serial ultrasounds prior to delivery. Parents met with
Neurology, Neurosurgery, and Genetics prenatally.
The baby was delivered by cesarean section for failure to
progress.
PHYSICAL EXAMINATION: Baby [**Name (NI) **] [**Known lastname 62372**] Apgar scores were 8 and 8
at 1 minute and 5 minutes respectively. His birth weight was
3545 grams, in the 75th-90th percentile. His head
circumference was 36.5 cm in the 90th percentile and his
length was 52 cm or 20.5 inches greater than the 90th
percentile. The examination was notable for the following:
Pink, well-appearing term infant, normal facies, large head,
soft anterior fontanel, intact palate, clear breath sounds,
no grunting, flaring, or retracting. Regular rate and rhythm
without murmurs. Femoral pulses 2+ and symmetric. Flat, soft,
nontender abdomen without hepatosplenomegaly. Normal phallus.
Testes and scrotum were normal. Stable hips. Normal tone and
normal perfusion.
DIAGNOSIS: Term average for gestational age male, currently
asymptomatic newborn with Dandy-Walker malformation.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: Remained on room air throughout admission
without issues.
2. Cardiovascular: No issues.
3. Fluids and electrolytes: Ad-lib breast feeding,
tolerating feedings well, no issues. [**First Name8 (NamePattern2) 319**] [**Last Name (NamePattern1) 3236**], RN,
IBCLC of the Lactation Service saw mom and baby. Discharge
weight is 3220 grams (7 pounds, 2 ounces). Weight remains in
the 75th percentile.
4. Gastrointestinal: The baby's color was jaundiced. The
initial bilirubin on [**2151-9-19**] was
11.9/0.2/11.7. A subsequent level on [**2151-9-21**] was
15.2/0.2/15.
5. Hematology: The infant is O-positive, Coombs negative,
and has not received any blood products.
6. Infectious disease: The infant was well appearing and
without sepsis concerns.
7. Neurology: A head ultrasound was performed on [**9-20**], [**2151**] revealing a Dandy-Walker malformation without
associated hydrocephalus. The baby was noted to be
neurologically intact with normal tone and reflexes.
8. Sensory: Audiology: Hearing screen was performed with
automated brainstem responses. Results were reported as
normal prior to discharge on [**2151-9-21**].
9. Psychosocial: [**Hospital1 69**] social
work involved with family. Follow up not reported as
needed. The social worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Location (un) 37380**], [**Location (un) 5176**], [**Numeric Identifier 55215**]. Phone ([**Telephone/Fax (1) 58589**].
CARE AND RECOMMENDATIONS:
1. Breast feeding on demand.
2. State screening done [**2151-9-19**], results are
pending.
3. Immunizations received: Hepatitis B vaccine given on
[**2151-9-19**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 3 criteria: 1. Born at less than 32 weeks; 2.
Born between 32 and 35 weeks with 2 of the following:
Daycare during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school-
age siblings; or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS:
1. The patient needs appointment with primary pediatrician
by [**2151-9-23**]. The pediatrician is Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], [**Location (un) 40647**], [**Location (un) 5176**], [**Numeric Identifier 55215**], ([**Telephone/Fax (1) 62373**].
2. Magnetic resonance scan appointment needed at [**Hospital1 62374**] [**Location (un) 86**], phone ([**Telephone/Fax (1) 62375**].
3. Neonatal [**Hospital 878**] clinic at CHB ([**Telephone/Fax (1) 37121**]. Needs
appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], who will schedule an
outpatient ultrasound as well.
4. [**Hospital **] clinic at CHB, ([**Telephone/Fax (1) 62376**]. Needs appointment in
[**3-12**] weeks after discharge.
[**First Name11 (Name Pattern1) 6177**] [**Last Name (NamePattern4) **], [**MD Number(1) 61488**]
Dictated By:[**Doctor Last Name 55781**]
MEDQUIST36
D: [**2151-9-21**] 07:52:24
T: [**2151-9-21**] 08:17:32
Job#: [**Job Number 62377**]
|
[
"V053"
] |
Admission Date: [**2141-11-16**] Discharge Date: [**2141-11-23**]
Date of Birth: [**2082-10-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**11-16**]: DCD Renal Transplant
History of Present Illness:
59 year old male with ESRD [**1-3**] DM and
HTN. Currently on peritoneal dialysis. He does urinate large
amounts daily (>2L). He had not had any recent infections or any
fevers, chills or night sweats. He also denies any chest pain,
SOB, claudication, urinary symptoms, nausea, vomiting or
abdominal pain. He denies any constipation or diarrhea and his
last bowel movement was at midnight.
Past Medical History:
minor stroke with loss temp sensation R hand
HTN
Diabetes mellitus
Coronary artery disease status post CABGx2 '[**32**], NSTEMI [**7-10**]
End-stage renal disease on HD (2nd to DM/HTN)
Gout
Colonoscopy 4yrs ago normal per pt report.
Social History:
works as plumber, no ETOH/drug/tobacco use
Family History:
signif for HTN and DM, father with [**Name2 (NI) 499**] cancer
Physical Exam:
Gen: NAD
HEENT: MMM no lesions
CV: RRR no MRG
RESP: CTAB no WRR
ABD: soft, NT, slight distention but no tympany. No G/R
WOUND: LLQ incision with staples intact, clean and dry
EXT: 2+ PE up to the knees b/l
Pertinent Results:
[**2141-11-16**] 03:27PM GLUCOSE-187* UREA N-105* CREAT-12.0*
SODIUM-139 POTASSIUM-6.5* CHLORIDE-104 TOTAL CO2-15* ANION
GAP-27*
[**2141-11-16**] 03:27PM PHOSPHATE-10.0* MAGNESIUM-1.6
[**2141-11-16**] 03:27PM WBC-7.6 RBC-2.74* HGB-8.6* HCT-26.9* MCV-98
MCH-31.5 MCHC-32.0 RDW-15.8*
[**2141-11-17**] 03:30PM BLOOD CK-MB-57* MB Indx-7.1* cTropnT-1.81*
[**2141-11-17**] 10:45PM BLOOD CK-MB-49* MB Indx-5.9 cTropnT-1.97*
[**2141-11-18**] 04:20AM BLOOD CK-MB-44* MB Indx-5.0 cTropnT-1.81*
[**2141-11-19**] 04:59AM BLOOD CK-MB-16* MB Indx-1.9 cTropnT-2.30*
[**2141-11-20**] 05:20AM BLOOD CK-MB-10 MB Indx-1.9 cTropnT-2.24*
TTE [**11-20**]:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild to moderate regional left ventricular systolic dysfunction
with severe hypokinesis of the distal half of the septum and
anterior wall and basal inferior wall. The apex is not well
seen. The remaining segments contract normally (LVEF = 35-40 %).
The right ventricular cavity is mildly dilated with moderate
global free wall hypokinesis. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Symmetric left ventricular
hypertrophy with regional systolic dysfunction suggestive of
multivessel CAD. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2140-7-18**],
inferior wall hypokinesis is now suggested c/w ischemia.
Brief Hospital Course:
Pt was admitted electively on [**2141-11-16**] for DCD renal tranplant.
The operation was notable for a donor kidney cold ischemia time
of ~22 hours. The patient tolerated the procedure well with no
complications. He was admitted to the SICU because he required
BIPAP overnight for hypoxemia, but was weaned off by the
morning. Of note, the patient's SBP remained in the mid 90's on
POD1, and this prompted troponin analysis. His initial troponin
was found to be elevated to 1.97. The patient's EKG showed
evidence of ST segment depression, similar to his previous
episode of demand ischemia seen in [**7-10**]. This picture was
confounded, however, by the patient's continued renal failure in
the immediate post operative period. He required hemodialysis
on POD 0 for fluid overload, and he tolerated temoval of 1.5 L.
Early in the am of POD2, the patient was found to be recovering
well, with no need for hemodynamic or respiratory support. He
was transferred to F10 in good condition.
Over the weekend, his hospital course was notable for difficult
to control FBG's in the setting of post operative
methylprednisolone. He was placed on an insulin drip, which was
weaned off the next day with the aid of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult and the
administration of a strict fixed and sliding scale insulin
regimen. On POD 3, the patient's troponin was found to be
persistently elevated to 2.3, after briefly decreasing to 1.8
from 1.97. Based on this information and his past medical
history of CABG and NSTEMI, a cardiology consult was obtained.
A TTE showed a new area of hypokinesis consistent with a new
ischemic event. The cardiology staff recommended medical
management considering his recent renal transplant; a
contraindication to cardiac catherization. He was discharged on
aspirin/plavix, carvedilol, imdur, and hydralazine.
By POD 4, the patient's graft function appeared to be picking
up, with a doubling in urine output from the day prior. The
transplant nephrology staff was impressed with this finding, and
suggested that the patient may not need outpatient dialysis. In
fact, they suggested that his residual volume overload could be
treated with lasix instead of hemodialysis. Because he was set
to leave on Thursday before a holiday weekend, the patient was
dialyzed prior to discharge and given a laboratory appointment
on Sunday. He was instructed to take Lasix 100mg PO BID on days
he was not going to have dialysis.
He was deemed safe to discharge home on post operative day 7.
By this time he had received medication and insulin teaching,
and had received treatment and follow up recommendations from
the cardiology staff. He is fully ambulatory, and is eating and
voiding without difficulty. His post operative pain is well
controlled on oral medications.
Medications on Admission:
Atorvastatin 80', VitB/VitC/Folic ac 1',
Phoslo 1334 after meals, Carvedilol 25", Cinacalcet, Plavix 75',
Colchicine prn, protronix 20', sevelamer 1600''', Valsartan 240'
Discharge Medications:
1. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*2 bottles* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO prn: every
8 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
Disp:*60 Tablet(s)* Refills:*2*
8. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. lamivudine 10 mg/mL Solution Sig: 2.5 ml PO DAILY (Daily).
Disp:*2 bottles* Refills:*2*
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
14. hydralazine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
15. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
16. tacrolimus 1 mg Capsule Sig: Six (6) Capsule PO Q12H (every
12 hours).
Disp:*360 Capsule(s)* Refills:*2*
17. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*120 Tablet(s)* Refills:*2*
18. furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day): ONLY ON DAYS WHEN NOT GETTING DIALYSIS.
Disp:*150 Tablet(s)* Refills:*2*
19. Outpatient Lab Work
Sunday [**11-26**] at 9:30 at [**Hospital1 18**] [**Hospital Ward Name 516**]
Felberg [**Location (un) **]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
ESRD
S/P Renal Transplant
Perioperative Myocardial Infarction
Discharge Condition:
Alert and oriented to all spheres, ambulating without difficulty
Discharge Instructions:
You were admitted for an elective DCD Renal Transplant. Your
operation went well with no complications.
You need to have blood drawn for labs on Sunday [**11-26**] at the
[**Hospital Ward Name 516**] lab located in the [**Hospital Ward Name 1826**] building [**Location (un) **] Lab ,
9:30AM
While you were in the immediate post operative period, your
cardiac enzymes were elevated. This may have been due to a
myocardial infarction, likely due to the strain on your heart
during surgery. The Cardiologists saw you and recommended
medical management instead of cardiac cath, because of the risk
of contrast damaging your new kidney.
You also had elevated blood sugars after your surgery. The
specialists from the [**Hospital **] clinic helped us, and recommended
that you go home on insulin. Please follow the instructions and
teaching given to you by the nursing staff. Record your blood
sugars at mealtime and before bed. Keep track of them in a
notebook, and bring them to your next appointment.
Please take all of the medications prescribed to you exactly as
they are written, and remember to avoid all over the counter
medications, especially if the transplant team has not ok'd them
first. You will likely need HD for a short while until your new
kidney is at full speed. Make sure to keep all your
appointments and to notify the transplant team of any changes.
Follow your urine output at home, and make sure to keep track of
your weight. Your staples from your incision will come out at
your follow up appointment.
Followup Instructions:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2141-11-27**] 2:40
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2141-12-4**]
10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2141-12-11**] 1:00
Please follow up with your outpatient cardiologist, Dr. [**Last Name (STitle) **]
on [**12-25**] at 1240pm.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: [**Numeric Identifier **] Office Phone: ([**Telephone/Fax (1) 10857**]
Office Location: W/[**Hospital Ward Name **] 4 Department: Medicine Organization:
[**Hospital1 18**]
|
[
"40391",
"9971",
"2851",
"4280",
"2767",
"2724",
"412",
"V4581"
] |
Admission Date: [**2195-10-8**] Discharge Date: [**2195-10-20**]
Date of Birth: [**2146-8-20**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
DKA vs hyperosmolar hyperglycemic state
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49 yo M with DM2, HLD, HTN & HIV w/associated IgA nephropathy,
found to have glucose greater than 600 at routine nephrology
appointment on [**10-8**]. He was admitted to the ICU for an insulin
drip although did not have DKA. In the ICU he was seen by
[**Last Name (un) **] consult who recommeneded sc insulin dosing and his
insulin was titrated. He states prior to admission he had some
URI symptoms including rhinorrhea. Currently feels well, no URI
symptoms, no cough, no SOB, no chest pain, no abd pain, no
diarrhea. No F/C. No night sweats. No pain anywhere, rest of
ROS is negative.
Of note he was recently discharged from [**Hospital1 18**] on [**9-15**]; during
this admission he was diagnosed with HIV and acute renal failure
secondary to HIV-associated IgA nephropathy. At this time he was
noted to have bilateral periureteral stranding and bladder wall
thickening.
Past Medical History:
DM, type II, last HA1C of 7.6 in [**6-18**]
Hyperlipidemia
HTN
Proteinuria
Social History:
riginally from [**Country 3587**], is not a documented citizen. He lives
with 5 other friends in [**Location (un) 686**] and is currently not working,
but has worked as a janitorial cleaner. Has not traveled out of
the country. Has a son in his 20's in [**Country 3587**], but no
immediate family in the US. He sniffs tobacco occasionally for
the last 5-6 years. No alcohol or illicit drug use. Has only
slept with women, sometimes unprotected. Has had sexual contacts
with prostitutes, but cannot say when last exposure was.
Family History:
Father with DM. Denies any family history of kidney disease or
kidney failure. No family history of malignancies.
Physical Exam:
[**Hospital Unit Name 153**] Admission:
GEN: NAD
HEENT: MMM, no OP lesions, JVP ??cm, neck is supple, no
cervical, supraclavicular, or axillary LAD
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or HSM, no stigmata of chronic
liver disease
LIMBS: No LE edema, no tremors or asterixis, no clubbing
SKIN: No rashes or skin breakdown
NEURO: CNII-XII nonfocal, strength 5/5 of the upper and lower
extremities, reflexes 2+ of the upper and lower extremities,
toes down bilaterally
Pertinent Results:
[**2195-10-11**] 06:00AM BLOOD WBC-11.5* RBC-3.80* Hgb-11.0* Hct-34.7*
MCV-91 MCH-28.8 MCHC-31.6 RDW-17.9* Plt Ct-284
[**2195-10-8**] 04:10PM BLOOD WBC-11.3*# RBC-3.85* Hgb-11.6* Hct-35.4*
MCV-92 MCH-30.0 MCHC-32.6 RDW-17.6* Plt Ct-234
[**2195-10-8**] 04:10PM BLOOD Neuts-89.6* Lymphs-8.6* Monos-1.2*
Eos-0.2 Baso-0.3
[**2195-10-20**] 05:35AM BLOOD UreaN-79* Creat-2.8* Na-138 K-5.3* Cl-104
HCO3-24 AnGap-15
[**2195-10-19**] 05:48AM BLOOD UreaN-85* Creat-3.3* Na-133 K-5.0 Cl-97
[**2195-10-14**] 06:00AM BLOOD Glucose-151* UreaN-47* Creat-2.6* Na-135
K-4.4 Cl-100 HCO3-23 AnGap-16
[**2195-10-8**] 04:10PM BLOOD Glucose-739* UreaN-58* Creat-3.0* Na-126*
K-5.1 Cl-92* HCO3-18* AnGap-21*
[**2195-10-8**] 04:10PM BLOOD Lipase-90*
[**2195-10-8**] 04:10PM BLOOD cTropnT-0.02*
[**2195-10-8**] 08:56PM BLOOD CK-MB-2 cTropnT-<0.01
[**2195-10-19**] 05:48AM BLOOD Mg-1.6
[**2195-10-8**] 08:56PM BLOOD Albumin-2.9* Calcium-7.2* Phos-3.3
Mg-1.4*
[**2195-10-8**] 08:56PM BLOOD ASA-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
[**2195-10-9**] 04:06AM BLOOD Lactate-1.3
[**2195-10-8**] 10:15PM BLOOD Lactate-2.9*
[**2195-10-8**] PORTABLE CXR:
Grossly no acute pulmonary process. Due to various limitations,
consider PA and lateral views of the chest once clinically
feasible to better establish a new baseline.
[**2195-10-8**] ECG:
Sinus bradycardia. Left axis deviation. Left anterior fascicular
block.
Compared to the previous tracing left axis deviation and left
anterior
fascicular block are new.
[**2195-10-8**] 3:00 pm URINE Site: NOT SPECIFIED OLD S#
1840V.
**FINAL REPORT [**2195-10-9**]**
URINE CULTURE (Final [**2195-10-9**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**2195-10-9**] 3:33 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2195-10-15**]**
Blood Culture, Routine (Final [**2195-10-15**]): NO GROWTH.
Brief Hospital Course:
49 yo M with PMH of DM2, HTN, HLD and recent diagnosis of HIV
with HIV-associated IgA nephropathy who presents with
hyperglycemia.
DM II uncontrolled with complications: admitted with
hyperosmolar hyperglycemic state. BG improved uptitration of
insulin per the recommendations of the [**Last Name (un) **] consult service.
It was stressed to the patient that when his prednisone
decreases in dose he will need adjustments to his insulin to be
made and he should seek counseling from his physician regarding
this issue to make sure his insulin decreases when his
prednisone dose decreases.
HIV/AIDS: CD4+ = 237. [**9-29**] HIV-1 Viral Load = 752 copies/ml.
Mode of transmission heterosexual intercourse. He was continued
on his outpatient HAART regimen.
HIV-associated IgA nephropathy: creatinine stable upon
discharge, will continue on prendisone 50mg po daily until renal
followup.
Bladder inflammation NOS: consider repeat cystoscopy (UA w/trace
blood) or CT pelvis to further eval for source of infection as
an outpatient.
Bilateral periureteral stranding: the patient should follow up
with urology outpatient for further workup.
HYPERKALEMIA: mild. the patient will have his potassium
rechecked on Thursday [**10-22**] with his PCP.
Medications on Admission:
ABACAVIR [ZIAGEN] - 300 mg Tablet - 2 Tablet(s) by mouth DAILY
(Daily)
CALCIUM ACETATE - 667 mg Capsule - 1 Capsule(s) by mouth three
times a day take with meals
EPOETIN ALFA [EPOGEN] - 10,000 unit/mL Solution - 0.5
Solution(s)
three times a week, every Monday, Wednesday, Friday You will get
this at the [**Hospital **] clinic which is scheduled for you.
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth 1X/WEEK (WE) fridays
FUROSEMIDE - 80 mg Tablet - 1 Tablet(s) by mouth daily
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 30
Solution(s)
qam
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - 2 - 10
Solution(s) based on the sliding scale
LAMIVUDINE [EPIVIR HBV] - 100 mg Tablet - 1 Tablet(s) by mouth
DAILY (Daily)
LOPINAVIR-RITONAVIR [KALETRA] - 200 mg-50 mg Tablet - 4
Tablet(s)
by mouth DAILY (Daily)
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a
day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth DAILY (Daily)
PENTAMIDINE [NEBUPENT] - 300 mg Recon Soln - 1 300 mg INH once a
month (Last Dose: [**2195-9-18**])
PRAVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily
PREDNISONE - 20 mg Tablet - 2.5 Tablet(s) by mouth DAILY (Daily)
SODIUM POLYSTYRENE SULFONATE - 15 gram/60 mL Suspension - 120
Suspension(s) by mouth once a day
ASPIRIN - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth
once a day
OMEGA-3 FATTY ACIDS [FISH OIL] - 1,000 mg Capsule - 2 Capsule(s)
by mouth twice a day
PROCRIT injections (Last Dose: [**2195-10-8**])
Discharge Medications:
1. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (FR).
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Four (4) Tablet PO
DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Pentamidine 300 mg Recon Soln Sig: One (1) INH Inhalation
once a month.
10. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Omega-3 Fatty Acids Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
14. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous qam.
Disp:*qs bottle* Refills:*2*
15. Humalog 100 unit/mL Solution Sig: as directed units
Subcutaneous qac and qhs: per sliding scale.
Disp:*qs bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Diabetes II Uncontrolled with complications- Hyperosmolar
hyperglycemic state
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 worsened control of your
diabetes. Please use your new insulin regimin as was used in
the hospital and please adhere to a diabetic diet.
Please make your appointments as scheduled for you.
Followup Instructions:
***Before you can book an appointment at [**Last Name (un) **], you must call
their financial counselor and apply for insurance. Your Health
Safety Net will not pay for a visit at that facility. Please
call [**Telephone/Fax (1) 21217**] to talk to a counselor. Then you may call
[**Telephone/Fax (1) 2384**] to set up an appointment***
Department: [**Last Name (un) **] Diabetes Center
When: WEDNESDAY [**2195-10-28**] at 11:00AM
With: [**Name6 (MD) 1052**] NEEDLE, RN [**Telephone/Fax (1) 2384**]
Building: [**Last Name (un) **] ([**Location (un) 86**],MA) 2ND FL
Department: WEST [**Hospital 2002**] CLINIC
When: FRIDAY [**2195-10-23**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 10084**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: THURSDAY [**10-22**] AT 11:00 A.M.[**2195-10-26**] at 2:30 PM
With: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2195-11-5**] at 1 PM
With: DR. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"2767",
"4019",
"2724",
"V5867"
] |
Admission Date: [**2182-7-16**] Discharge Date: [**2182-7-17**]
Date of Birth: [**2122-5-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest pain and palpitations
Major Surgical or Invasive Procedure:
Cardiac cath s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] to LAD
History of Present Illness:
60-year-old female with HTN, hyperlipidemia, and multinodular
goiter who presented to the ED with progressive chest pains and
palpitations over the past 4 months. She reports that she has
had intermittent chest pressures associated with palpitations
that usually last 2-3 minutes and occur mostly at rest. They are
not associated with exertion, and stressful/emotional situations
tend to exacerbate her symptoms. She was recently admitted to
[**Hospital1 2177**] over the weekend (although per ED resident, no record of
this at [**Hospital1 2177**]) with chest pains and, per pt, they wanted to do a
cardiac cath but she was not comfortable with the facilities
there. She presents here now with chest pressures and
palpitations since 5 AM this morning that woke her from sleep.
They are a bit more severe than usual, and have been
intermittent throughout the morning. Patient also had excrcise
stress test in [**2182-7-4**] ischemic EKG changes in the absence of
anginal symptoms at a high cardiac demand good exercise
tolerance.
.
In the ED, initial vitals were T 97.0, HR 99, BP 159/81, RR 16,
and SpO2 100% on RA. EKG showed SR at 72 bpm with NA, NI, and
TWI in III similar to prior EKG. Initial Troponin was negative.
Labs were otherwise unremarkable. Cardiology consult was
called and recommended Aspirin 325 mg PO, Nitroglycerin SL PRN,
and urgent coronary catheterization.
.
Patient was taken directly to the cath lab, with no heparin.
Patient was loaded with prasugrel and started on integrillin. In
the cath lab patient was found to have single vessle CAD with
moderate LAD lesion at the takeoff of the D2. The diag ostial
lesion was 80-90% stenosis. She had successful POBA of the D2
and then successful stening of LAD with [**Date Range **]. During the
procedure patient became diaphoretic and dropped BPs to the
70-80s with HR in the 60s treated with atropine and rewuired
dopamine which was weaned off over few minutes with improvemnt
in BP to 110s-110s. Limited echo showed no effusion. Patient
was admitted to CCU for monitoring.
.
In the CCU, patient denies any chest pain, shortness of breath,
lightheadedness, dizziness, fevers. No diaphoresis or
nausea/vomiting. Also denies orthopnea, PND. All other ROS
negative.
Past Medical History:
1. CARDIAC RISK FACTORS: (Pre)Diabetes, +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
# PERCUTANEOUS CORONARY INTERVENTIONS:
3. OTHER PAST MEDICAL HISTORY:
# Multinodular goiter -- negative FNA per notes
# Borderline diabetes-- per patient was told she had elevated
sugars at recent admission.
Social History:
# Tobacco: None
# ETOH: None
# Illicit: None
Family History:
No family history of early MIs.
Physical Exam:
GENERAL: Appears well in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with flat JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: 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.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No lesions
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission/Relevant Labs:
[**2182-7-16**] 08:25AM BLOOD WBC-6.6 RBC-4.18* Hgb-13.7 Hct-39.9
MCV-96 MCH-32.7* MCHC-34.3 RDW-13.5 Plt Ct-257
[**2182-7-16**] 08:25AM BLOOD Neuts-57.2 Lymphs-33.3 Monos-7.0 Eos-1.9
Baso-0.6
[**2182-7-16**] 08:25AM BLOOD PT-11.6 PTT-29.1 INR(PT)-1.1
[**2182-7-16**] 08:25AM BLOOD Glucose-139* UreaN-10 Creat-0.6 Na-142
K-3.6 Cl-105 HCO3-27 AnGap-14
[**2182-7-16**] 08:25AM BLOOD cTropnT-<0.01
[**2182-7-17**] 06:15AM BLOOD CK-MB-10
[**2182-7-16**] 08:25AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.1
.
Discharged Labs:
[**2182-7-17**] 06:15AM BLOOD WBC-9.7 RBC-3.69* Hgb-11.8* Hct-35.3*
MCV-96 MCH-32.0 MCHC-33.5 RDW-13.3 Plt Ct-242
[**2182-7-17**] 06:15AM BLOOD Glucose-104* UreaN-8 Creat-0.5 Na-140
K-3.7 Cl-104 HCO3-30 AnGap-10
[**2182-7-17**] 06:15AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.2
.
Cath: [**2182-7-16**]:
1. Coronary angriography in this right dominant system
demonstrated single vessel disease. The LMCA was a long vessel
with a 10% mid-vessel lesion. The LAD had mild luminal
irregularities proximally and 60% hazy mid vessel at the take
off of the D2. The D2 had an 80% ostial lesion. The distal LAD
was otherwise patent and long, wrapping around the apex. The LCx
had mild luminal irregularities and gave a large bifurcating OM
with relatively large upper and lower poles. The RCA was patent
with mild luminal irregularities.
2. Resting hemodynamics revealed normal left sided filling
pressures and mild systemic arterial systolic hypertension with
SBP 146 mmHg.
3. FFR of the LAD lesion 0.82 with [**Month (only) **] showing the MLA at
2.7-2.8m2
4. Successful POBA of D2
5. Succesful stenting of mid LAD with 3.0 x 12 [**Month (only) **]
6. Likely vagal reaction following LAD stenting requiring
fluids, atropine and transient dopamine infusion.
7. Non flow limiting dissection of D2 with antegrade flow.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease with moderate hazy mid LAD
lesion at the takeoff of the D2. D2 ostial lesion was 80-90%.
2. FFR of mid LAD lesion of 0.82 and [**Month (only) **] showing the LAD lesion
area of 2.7-2.8m2.
3. Successful POBA of D2 with 2.0mm balloon.
4. Succesful stenting of LAD with 3.0 X 12mm Promus element [**Month (only) **]
5. Vagal reaction following LAD stent post dilation treated with
atropine, fluids and brief dopamine gtt with normalization of
hemodynamics
6. Non flow limiting ostial D2 dissection with normal antegrade
flow
7. Closure of right radial artery access site with TR band.
.
CXR: [**2182-7-16**]
FINDINGS: Frontal and lateral views of the chest were obtained.
The heart is of normal size with normal cardiomediastinal
contours. The pulmonary vasculature is unremarkable. The lungs
are clear without focal or diffuse abnormality. No pleural
effusion or pneumothorax is visualized. Osseous structures are
unremarkable. No radiopaque foreign body.
IMPRESSION: No acute cardiopulmonary process. No pneumothorax.
Brief Hospital Course:
60 yo F with HTN, hyperlipidemia presented with recurrent
progressively worsening chest pains with recent abnormal stress
test concerning for unstable angina and CAD. Negative troponins
and now s/p cath with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] to LAD.
.
# Coronary Artery Disease: Patient presented with 3-4 months of
worsening chest pains at rest lasting 2-3 minutes. Patient had
recent exercise tolerance test which showed ischemic EKG changes
without any symptoms. ON the day of admission patient was
awakened by [**6-4**] constant chest pain. In the ED, EKG showed
non-Specific ST changes, initial troponins were negative. Given
concern fro unstable angina and CAD, patient had cardiac cath
which showed single vessel CAD with moderate LAD lesion at the
takeoff of the D2. The diag ostial lesion had 80-90% stenosis.
She had successful POBA of the D2 and then successful stenting
of LAD with [**Month/Year (2) **]. During the procedure patient became
diaphoretic with drop in BP to 70s and HR 60s most likely vagal
reaction. She was briefly on pressors for BP support. Post cath
EKG was essentially unchanged. She was prasugrel loaded in the
cath lab and started on 18 hours of Integrilin. She was
transferred to CCU for further hemodynamic monitoring. During
her CCU stay her blood pressure stayed stable and she did not
have any chest pain or shortness of breath. She was continued
on aspirin, valsartan, prasugrel. Her simvastatin was changed
to atorvastatin. She will follow up with Dr. [**First Name (STitle) **] for
further care who will make decision regarding patient's
anti-platelet therapy and getting a follow up TTE in one month.
.
# Hypertension: Patient was hypotensive in the cath lab
requiring atropine and dopamine. Patient has remained stable in
the 120s-130s systolic in the CCU. She was discharged on her
home valsartan and HCT combination med.
- Continue HCTZ 12.5mg daily
.
# Hyperlipidemia: Her simvastatin was switched to atorvastatin
80mg daily
.
# Prediabetes: Patient blood sugars continued to be in the
120-130s. Patient will follow up with PCP who will check an A1C
level.
.
CODE: Full
EMERGENCY CONTACT: [**Name (NI) **] [**Name (NI) 18913**] [**Telephone/Fax (1) 18914**]
Transitions of Care:
- Patient will follow up with PCP who will check A1C level on
patient and start appropriate meds if indicated.
- Patient had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] placed in LAD and started on Prasugrel
10mg daily. She will follow up with Dr. [**First Name (STitle) **] who will make
further decision regarding patient's antiplatelet therapy and
consider TTE one month after cath.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. valsartan-hydrochlorothiazide *NF* 160-12.5 mg Oral Daily
2. Atenolol 50 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Aspirin 100 mg PO DAILY
Discharge Medications:
1. Prasugrel 10 mg PO DAILY
RX *prasugrel [Effient] 10 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*3
2. Aspirin 100 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. valsartan-hydrochlorothiazide *NF* 160-12.5 mg Oral Daily
5. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Coronary Artery Disease s/p cardiac catherization with
placement of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] to LAD.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 18915**],
It was a pleasure taking care of your during your
hospitalization at [**Hospital1 18**]. You had a procedure to place a stent
in your heart because of your recurrent chest pains. You did
not have a heart attack. You were admitted to cardiac intensive
unit because of brief episode of low blood pressure during the
procedure. You were monitored overnight in the cardiac
intensive unit and your blood pressures remained normal. On the
day of discharge you did not have any chest pain or shortness of
breath. Following your heart procedure you have been started on
a blood thinning medication called prasugrel which you should
continue to take for at least one year unless told otherwise by
Dr. [**First Name (STitle) **]. You should follow up with Dr. [**First Name (STitle) **]. (see
below) Your simvastain is also being replaced with atorvastain.
.
You can pick up your Prasugrel and atorvastatain medication from
CarePlus Pharmacy [**Hospital1 18916**]. Phone: [**Telephone/Fax (1) 18917**]
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: MONDAY [**2182-7-22**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: THURSDAY [**2182-8-15**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2182-7-17**]
|
[
"41401",
"4019",
"2724"
] |
Admission Date: [**2179-9-18**] Discharge Date: [**2179-10-27**]
Date of Birth: [**2179-9-18**] Sex: M
Service: NB
DICTATED BY:[**Last Name (NamePattern4) 62599**]
HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname **], delivered at 30-5/7 weeks'
gestation, weighing 1105 grams, and was admitted to the
newborn intensive care nursery for management of prematurity.
Mother is a 31 year old gravida 5, para 2 now 3 woman who was
living in [**Hospital1 6687**] for the previous two months on a work visa
with her home being in [**Country **]. She had prenatal care in
[**Hospital1 6687**], starting one month prior to delivery. Her
prenatal screens included blood type 0-positive, antibody
screen negative, hepatitis B negative, RPR nonreactive, group
B strep unknown. Her prenatal history was notable for
chronic hypertension, treated with methyl-dopa. Her
estimated date of delivery was [**11-22**] by LMP for an estimated
gestational age of 30-5/7 weeks at delivery. The pregnancy
was complicated by preeclampsia treated with Aldomet and by
IUGR. She was treated with magnesium sulfate and received
one dose of betamethasone several hours prior to delivery,
but proceeded to cesarean section for fetal decelerations.
There was no labor, no intrapartum fever, and no clinical
evidence of chorioamnionitis. Rupture of membranes occurred
at delivery for clear fluid. She did not receive intrapartum
antibiotic coverage. The infant emerged with good tone and
cried on transfer to the warmer. He was orally and nasally
bulb suctioned and dried and received free flow oxygen. The
Apgar scores were 8 at one minute and 8 at five minutes.
PHYSICAL EXAM ON ADMISSION: Well-appearing preterm infant
with examination consistent with a 30 week gestation. Birth
weight was 1105 grams (10-25th percentile). Head
circumference 26 cm (10th percentile), length 37.5 cm (10-
25th percentile). Anterior fontanel is soft and flat with
nondysmorphic appearing infant with palate intact. Neck and
ears normal. Initially mild nasal flaring. Mild intercostal
and subcostal retracting with good bilateral breath sounds.
He was well-perfused with normal pulses, no murmur. Abdomen
soft, nondistended. No organomegaly or masses. Patent anus.
Three-vessel umbilical cord. Normal penis. Testes descended
bilaterally. Active, responsive, tone appropriate for
gestational age. Skin intact. Hips stable. Spine straight
and intact. Sacral mongolian spot.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: He was placed on continuous positive airway
pressure of 6 cm without oxygen requirement on admission to
the nursery for transitional respiratory distress. He weaned
off the continuous positive airway pressure to room air at
around 18 hours of life and has remained on room air since
with comfortable work of breathing. He had mild apnea of
prematurity, not requiring methylxanthine therapy. His last
apnea-bradycardia event was on [**2179-10-3**].
CARDIOVASCULAR: He developed a murmur on day of life 10. An
echocardiogram showed no patent ductus [**Last Name (LF) 46976**], [**First Name3 (LF) **] atrial
septal defect and patent foramen ovale, mild peripheral
pulmonic stenosis, left aortic arch with aberrant right
subclavian artery. Cardiology does not recommend further
imaging or follow up unless he has clinical issues.
FLUIDS/ELECTROLYTES/NUTRITION: He started feeds on day of
life 1 and advanced to full volume feeds on day of life 9.
He developed medical necrotizing enterocolitis on day of life
9 and was made NPO for 10 days. He received total parenteral
nutrition during this time. He was restarted on feeds again
on day of life 19 and increased to full feeds without
problems. Presently he is taking Enfamil 26 cal/oz (by
concentration) ad lib, taking 140 to 150 ml per kg per day
with weight gain. Weight at time of discharge is 1775 grams.
GI: He was treated for medical NEC manifested by spitting
and abnormal abdominal gas pattern without pneumatosis and
guaiac positive stool.
He received phototherapy for indirect hyperbilirubinemia.
His peak bilirubin totaled 6.3, direct 0.4, on day of life 7.
HEMATOLOGY: He received a blood transfusions on [**10-26**]
for a hematocrit of 21.3 with retic 3.5% on [**10-25**].
INFECTIOUS DISEASE: He received a 48 hour rule out with
ampicillin and gentamicin after birth. His CBC was normal and
blood culture was negative. He received a 14 day course of
vancomycin and gentamicin for medical NEC.
NEUROLOGY: He has had two head ultrasounds at one week and
at one month of age and both were normal. Audiology hearing
screening passed.
OPHTHALMOLOGY: His eyes were initially immature with follow
up on [**2179-10-25**] showing mature retina. Follow up is due at 9
months of age per routine.
PSYCHOSOCIAL: This mother is from [**Name (NI) **] and her husband
and family are residing there. She has a visa to work in
[**Hospital1 6687**] every summer and is currently living in [**Hospital1 6687**]
due to the birth of this infant. She has been visiting as
often as possible, one or two times a week, and keeps in
touch by phone. Her visa is due to expire on [**2179-12-2**]. She
plans to return to [**Country **] soon after discharge. [**Hospital1 18**] social
worker is involved with the mother. The contact social worker
is [**Name (NI) 4457**] [**Name (NI) 36244**] and she can be reached at [**Telephone/Fax (1) 39086**].
CONDITION ON DISCHARGE: Infant is stable, ad lib feeding.
DISCHARGE DISPOSITION: Home with mother. Name of primary
pediatrician prior to traveling back to [**Country **] will be Dr.
[**Last Name (STitle) **] in [**Hospital1 6687**].
CARE AND RECOMMENDATIONS:
1. FEEDS: Enfamil 26 calories per ounce (by concentration).
2. MEDICATIONS: Ferrous sulfate 2 mg/kg per day.
3. CARSEAT TESTING: Passed
4. STATE NEWBORN SCREEN: Three state newborn screens have
been performed. The newborn screen on [**2179-10-2**] was all
normal except for cystic fibrosis, when the results are
arranged for category A. A followup screening was done
on [**2179-10-11**] and that was normal, including a cystic
fibrosis screen. Question regarding followup on that
should be addressed to the state lab. Their telephone
number is [**Telephone/Fax (1) 49919**].
5. IMMUNIZATIONS RECEIVED: Received hepatitis B
immunization, the first one on [**2179-9-18**], the second one
on [**2179-10-21**]. Synagis (RSV prophylaxis) vaccine given on
[**2179-10-27**].
6. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following criteria: 1) Born
at less than 32 weeks; 2) Born between 32 and 35 weeks
with two of the following: Daycare during RSV season,
smoker in the household, neuromuscular disease, airway
abnormalities or schoolage siblings, or 3) Chronic lung
disease. Influenza immunization is recommended annually
in the fall for all infants once they reach 6 months of
age. Before this age for the first 24 months of a
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
7. FOLLOWUP APPOINTMENTS: Followup appointments to be
arranged with Dr. [**Last Name (STitle) **] when infant is home in [**Hospital1 6687**];
thereafter, followup will be provided by the doctors [**First Name8 (NamePattern2) **]
[**Name5 (PTitle) **]. VNA will be arranged when he is discharged to
[**Hospital1 6687**].
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age preterm infant, born at
30-5/7 weeks.
2. Transitional respiratory distress, resolved.
3. Atrial septal defect.
4. Indirect hyperbilirubinemia, resolved.
5. Apnea of prematurity, resolved.
6. Necrotizing enterocolitis, resolved.
7. Anemia of prematurity, status post transfusion.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2179-10-23**] 18:59:46
T: [**2179-10-23**] 20:01:05
Job#: [**Job Number 62600**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2176-10-9**] Discharge Date: [**2176-10-16**]
Date of Birth: [**2113-4-24**] Sex: F
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10416**]
Chief Complaint:
post op for close monitoring
Major Surgical or Invasive Procedure:
s/p ventral hernia repair
History of Present Illness:
HPI: pt is a 63 yo lady w/ remote smoking history, obesity, who
is s/p extensive ventral hernia repair this evening w/ mesh
placment, who was transferred from PACU for close monitoring in
setting of mild hypoxia, tachycardia, and ?EKG changes. She had
an uneventful, intraoperative and postoperative course until she
was noted to be mildly hypoxic to 94% on 2L (no room air sat
recorded) in the PACU, tachycardic, with ?new q waves on her
EKG. She was transferred to the [**Hospital Unit Name 153**] for overnight observation.
She receieved approximately 500 cc of IVF intraoperatively. On
arrival to [**Hospital Unit Name 153**], patient had no complaints except for
post-operative, abdominal pain. She denies chest pain or
shortness of breath.
Past Medical History:
1. POD #0 -- Ventral hernia repair, Extensive lysis of
adhesions, Placement of mesh for abdominal wall reconstruction,
Closure of abdominal wall skin defect.
2. Nephrolithiasis [**2166**], multiple stones in the right lower pole
calyx
s/p Cystoscopy, stents, extracoporeal shock wave lithotripsy
3. ccy
4. longtime smoker- quit [**2166**]
5. obesity
6. h/o diverticulosis w/ resection and subsequent colostomy with
reversal
7. h/o ventral hernia repairs in past, last several years ago
8. depression
Social History:
Born in [**Country 2559**], moved here 40+years ago; lives in [**Location 10417**] w/
husband; has involved daughter. Phone numbers in chart. Remote
smoker-quit [**2166**]; denies every drinking alcohol "I don't even
drink the wine my husband makes."
Family History:
not elicited
Physical Exam:
PE: T 99.5 BP 91/50 HR 117 sinus tachy R 20 93% 4L
Gen: obese, Italian woman, pleasant, tired, no distress
HEENT: MM dry, NG tube in place with minimal drainage, NC in
place
CHEST: scant bibasilar crackles
CV: tachy, regular, distant heart sounds, no m/r/g
ABD: obese, binder in place with large abd dressing; 2 JP drains
in place, draining serosanguinous fluid, appropriately tender
abdomen
EXTRM: scant edema, warm and well perfused, strong peripheral
pulses
NEURO: intact, good historian; not fully assessed
Pertinent Results:
[**2176-10-9**] 06:30PM GLUCOSE-161* UREA N-23* CREAT-1.0 SODIUM-141
POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
[**2176-10-9**] 06:30PM CK(CPK)-51
[**2176-10-9**] 06:30PM CK-MB-2 cTropnT-<0.01
[**2176-10-9**] 06:30PM ALBUMIN-3.4 CALCIUM-8.6 PHOSPHATE-3.6
MAGNESIUM-1.5*
[**2176-10-9**] 06:30PM WBC-11.1* RBC-3.89* HGB-10.9* HCT-33.1*
MCV-85 MCH-27.9 MCHC-32.8 RDW-14.8
[**2176-10-9**] 06:30PM PLT COUNT-324
[**2176-10-9**] 04:09PM TYPE-ART TEMP-36.8 RATES-/20 O2-50 PO2-103
PCO2-38 PH-7.36 TOTAL CO2-22 BASE XS--3 INTUBATED-INTUBATED
VENT-SPONTANEOU
[**2176-10-9**] 11:19AM TYPE-ART PO2-158* PCO2-32* PH-7.45 TOTAL
CO2-23 BASE XS-0
[**2176-10-9**] 11:19AM GLUCOSE-183* LACTATE-2.3* NA+-136 K+-3.9
CL--114*
[**2176-10-9**] 11:19AM HGB-10.2* calcHCT-31
[**2176-10-9**] 11:19AM freeCa-1.07*
Brief Hospital Course:
63F s/p extensive ventral hernia repair. She tolerated the
sugery well. Post-operatively, she had persistent,mild hypoxia
post extubation. The Medical Service was immediately consulted
for low oxygen saturation. She was placed on supplemental
oxygen post-extubation and was eventually weaned off. On the
day of discharge, her oxygen sat was 96% on room air.
With respect to her wound, in continued to remained
clean/dry/intact. There was some erythema post-operatively,
which is now much improved with antibiotic treatment. She has
been afebrile with stable vitals, eating well, ambulating,
making good urine and stool. She will be discharged, in good
condition, to home with a visiting nurse to be by to evaluate
for possible home physical therapy services.
Medications on Admission:
celexa 10 mg po qd
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed: FOR NAUSEA
.
Disp:*30 Tablet(s)* Refills:*0*
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 2 weeks.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
EXTENSIVE VENTRA HERNIA
Discharge Condition:
GOOD
Discharge Instructions:
PLEASE TAKE MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS
CAREFULLY. IF SIGNS AND SYMPTOMS OF INFECTION, SUCH AS
FEVERS/CHILLS, PURULENT DISCHARGE FROM WOUND/INCISION SITE,
INCREASED REDNESS, INCREASED PAIN, PLEASE CALL OR GO TO THE
EMERGENCY ROOM. REMEMBER TO CALL TO SCHEDULE YOUR FOLLOW UP
APPOINTMENT (BELOW). LIGHT ACTIVITIES UNTIL SEEN IN CLINIC.
REMEMBER TO WHERE ABDOMENAL BINDER AS INSTRUCTED.
Followup Instructions:
PLEASE CALL [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10418**], M.D. ([**Telephone/Fax (1) 10419**] TO BEEN SEEN IN
1 WEEK.
Completed by:[**2176-10-16**]
|
[
"496",
"42789",
"V1582"
] |
Admission Date: [**2191-11-25**] Discharge Date: [**2191-12-2**]
Date of Birth: [**2117-7-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
light-headedness, anemia, GI bleed
Major Surgical or Invasive Procedure:
Balloon enteroscopy - [**2191-11-29**] by Drs. [**First Name (STitle) 908**] and [**Name5 (PTitle) 92552**]
Video capsule study - [**2191-12-1**]
History of Present Illness:
Mr. [**Known lastname **] is a 74yo male with h/o CKD, anemia of chronic
inflammation, BPH, and chronic foley catheter w/ recurrent UTIs,
who on [**11-21**] experienced acute onset of light-headedness while
walking through his house. His symptoms were associated w/
diaphoresis and weakness, but no chest pain, shortness of
breath, or syncope. He has been having black stools for at
least several months, initially thought to be related to iron
pills, but he denies any hematochezia. Also denies any
abdominal pain, nausea, vomiting, hematemesis, or weight loss.
On presentation to [**Location (un) 620**] ED his Hct was found to be 11.7, Hgb
3.7, and he was initially tranfused 2 units pRBCs. NG lavage
did not show any active bleeding. Of note, he had recently been
transfused 2 units as an outpatient in a "medical day care"
setting for a Hct of 18.8, approximately one week prior to
admission. Hct at [**Location (un) 620**] had previously been 29.4 on [**2191-11-7**].
He had never had an EGD or colonoscopy. No prior history of GI
bleeding. Does have signficant history of alcohol abuse, though
has been sober for the past 6 months. Until recently he had
been poorly complaint with outpatient medical follow-up.
.
During his admission to [**Location (un) 620**], he was transfused a total of 9
units pRBCs over 4 days, with last transfusion earlier today.
Despite this ongoing transfusion requirement, he remained
hemodynamically stable. He underwent EGD on [**11-22**] which was
normal. Colonoscopy [**11-23**] showed fresh and old blood throughout
his entire colon and distal terminal ileum, but no focal
bleeding sources. He did have scattered diverticuli throughout
the colon, and small internal hemorrhoids. He had a push
enteroscopy to 140cm which was unrevealing, and no active
bleeding or AVMs were noted. Small capsule endoscopy [**11-25**]
however showed a possible bleeding source in the small bowel.
The prolonged capsule time prohibited better localization, but
there was concern for a possible subtle lesion such as
Dieulafoy's. CT angiography was not obtained given his CKD.
He was transferred to [**Hospital1 18**] for full enteroscopy and potential
surgery. Of note he was also found to have a UTI positive for
MRSA and Enterococcus that was vancomycin sensitive, and he was
switched from ceftriaxone to vancomycin on [**2191-11-24**].
.
On arrival to the MICU, patient is comfortable and without
complaints. He denies any current nausea, vomiting, or
abdominal pain. Does report nausea while at [**Location (un) 620**], in the
setting of his bowel prep for the colonoscopy. Prior to
admission, he denies having any dyspnea on exertion. He is
being treated for a UTI and has a chronic Foley; denies any
symptoms associated with this infection including fever or
suprapubic pain.
.
Review of systems:
(+) Per HPI. Did have chills, now resolved. Has chronic
bilateral hip pain secondary to arthritis. Has psoriasis.
Occasional palpitations.
(-) Denies fever, night sweats, significant weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain or chest pressure. No myalgias.
Past Medical History:
- Chronic kidney disease stage IV, baseline creatinine 2.7.
- Iron deficiency and anemia of chronic disease.
- BPH, wearing chronic Foley catheter for 3-6 months
- Recurrent UTI, mostly Citrobacter and Proteus sensitive to
Rocephin.
- Hemorrhagic cystitis.
- Psoriasis.
- Alcohol abuse and withdrawal, sober for 6 months.
- DJD and psoriatic arthritis.
- Paroxysmal atrial fibrillation during a hospitalization.
- Osteoarthritis.
- Vitamin B12 deficiency.
- Hyperparathyroidism.
- Echocardiogram in [**2191-3-27**] showed EF of 65% to 70% with
moderate TR and LVH.
Social History:
Lives at home with his wife. Uses [**Name2 (NI) **] and walker sometimes.
Reports remote tobacco use, but none for past 50 years. Has
history of alcohol abuse (1 to 2 bottles of wine every day for
20 years), but has been sober 6-7 months. Denies illicit drug
use, including any IVDU.
Family History:
No family history of colon cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.2 BP: 136/84 P: 76 R: 11 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: PERRL, EOMI, sclera anicteric, MMM
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley in place
Ext: Warm, well perfused, 2+ DP pulses, no edema
Neuro: CNII-XII grossly intact, 5/5 strength upper/lower
extremities
Skin: Psoriatic plaques on arms and hands bilaterally
Pertinent Results:
ADMISSION LABS:
[**2191-11-25**] 07:13PM BLOOD WBC-10.8 RBC-3.25* Hgb-9.6* Hct-28.0*
MCV-86 MCH-29.7 MCHC-34.4 RDW-18.6* Plt Ct-314
[**2191-11-25**] 07:13PM BLOOD PT-11.3 PTT-28.9 INR(PT)-1.0
[**2191-11-25**] 07:13PM BLOOD Glucose-93 UreaN-42* Creat-2.3* Na-139
K-4.5 Cl-108 HCO3-21* AnGap-15
[**2191-11-25**] 07:13PM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0
.
ABDOMEN CT WITHOUT IV CONTRAST:
Small bilateral pleural effusions are present, greater on the
left (2:4), with mild adjacent compressive atelectasis. No
nodules or masses are detected. The heart size is normal, and
there is no pericardial effusion.
.
Oral contrast distributes throughout the stomach and proximal
small bowel. Thickening at the pylorus is likely peristalsis
(2:24). There is a small duodenal diverticulum (2:25). Tiny
duodenal diverticula are also present near the ligament of
Treitz (300B:27). There is no bowel obstruction. There is no
mesenteric or retroperitoneal lymphadenopathy, and no free air
or free fluid.
.
An endoscopic capsule is seen within the mid portion of the
descending colon (2:38). Diverticula are scattered across the
sigmoid colon and the ascending colon (300B:30) without evidence
of diverticulitis.
.
Tiny gallstones are present (2:21). The liver, spleen, adrenal
glands, and
pancreas are normal.
.
Both ureters are thickened (300B:33, 38); however, there is no
hydronephrosis. Both kidneys are slightly atrophic. Mild
perinephric stranding is symmetric and likely within normal
limits.
.
PELVIC CT WITHOUT IV CONTRAST:
A foley catheter resides within a collapsed bladder, which
demonstrates
markedly thickened walls measuring up to 1.3 cm (301B:41, 2:70).
These
features were also seen on the [**Hospital1 4086**] ultrasound
examination from [**2191-5-4**].
.
Scattered iliac and inguinal lymph nodes are at the upper limits
of normal in size (2:78). There is no intrapelvic free fluid.
.
OSSEOUS STRUCTURES:
There is no acute fracture. Severe osteoarthritic changes are
seen throughout both femoroacetabular joints, with central loss
of the joint space, with substantial subchondral cystic change
and sclerosis, with large hanging osteophytes (300B:39). There
is slight loss of disc heights of L5 (301B:41). Anterior disc
bulges at L4/L5 and L5/S1 are present. Extensive lateral
osteophytosis is seen throughout the lumbar spine (300B:37).
.
IMPRESSION:
1. No bowel mass detected on this non-contrast enhanced study.
An endoscopy capsule is located at the mid descending colon. If
there remains a need to localize bleeding, a tagged RBC study
could be considered; though if renal function improves, a
multiphase CT using VoLumen oral contrast and iodinated IV
contrast could also be helpful.
2. Duodenal, ascending colonic, and sigmoid diverticula, with no
evidence of diverticulitis.
3. Ureteral and bladder wall thickening, likely secondary to
chronic
obsrtuction. Correlation with any prior urological workup is
recommended.
4. Cholelithiasis.
5. Severe bilateral hip osteoarthropathy.
.
Single Balloon Enteroscopy [**2190-11-29**]:
Findings: Esophagus:
-Mucosa: Normal mucosa was noted.
Stomach:
-Mucosa: Normal mucosa was noted.
Duodenum:
-Mucosa: Normal mucosa was noted.
Jejunum:
-Mucosa: Normal mucosa was noted. SPOT tattooing with success.
Ileum: Not examined.
Impression: Normal small bowel enteroscopy to distal jejunum
No blood or bleeding lesions noted. SPOT tattooing with success
at the most distal point reached
.
GI Bleeding Study (Tagged RBC scan) [**2191-11-30**]:
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for minutes were obtained. A left lateral
view of the pelvis was also obtained.
.
Blood flow images show normal abdominal flow. There are no
abnormal areas of hyperemia.
.
Dynamic blood pool images show no evidence of bleeding during
the time of the study.
.
IMPRESSION:No evidence of bleeding during the time of the study.
.
Video Capsule Study [**2191-12-1**]:
Gastric passage time: 0h 17m, Small bowel passage time: 4h 45m,
.
Procedure info & findings
1)No active bleeding site seen in the small bowel.
2) A single non-bleeding angioectasia is seen in the distal
jejunum.
3)A few lymphangiectasias in the proximal jejunum.
4)Old blood seen in the cecum.
.
Summary & recommendations
Summary: No active bleeding site seen in the small bowel. A
single non-bleeding AVM in the distal jejunum. A few
lymphangiectasias. Old blood seen in the cecum.
Brief Hospital Course:
Primary Reason for Hospitalization:
74M with h/o CKD, anemia of chronic inflammation, BPH, and
chronic foley catheter w/ recurrent UTIs, transferred now from
[**Hospital1 **] [**Location (un) 620**] for further evaluation of GI bleeding and acute
blood loss anemia, with course also notable for MRSA and
enterococcal UTI.
.
Active Issues:
.
#. GI Bleed with acute blood loss anemia: Based on work-up at
[**Hospital1 **] [**Location (un) 620**] prior to transfer, GI bleed was felt to be most
likely secondary to small bowel etiology. GI and surgery were
consulted and followed closely. He had a CT abdomen/pelvis and
tagged RBC scan which were unrevealing. He had a video capsule
study which showed single non-bleeding angioectasia in the
distal jejunum, thought likely to be the source of his bleed.
Since he was no longer actively bleeding, and his Hct was
stable, it was felt that he could be safely discharged with
close monitoring at a rehab facility. He should have his Hct
monitored every other day (or more often if he experiences
melena or BRBPR), and transfused RBCs for Hct <21. Should he
experience re-bleeding, would recommend that he return to the
hospital for GI angiography and embolization to stop the bleed.
.
# UTI: Patient with h/o chronic Foley and recurrent UTIs. Urine
culture at [**Location (un) 620**] revealed MRSA and enterococcus sensitive to
vanco, and vanco started [**11-24**] at [**Location (un) 620**]. Patient was
afebrile, without leukocytosis, on transfer and vancomycin was
discontinued. However he spiked a temp to 100.6 on [**2191-11-27**] and
was restarted on IV vancomycin. He should complete a 14 day
course for complicated UTI, to end on [**2191-12-10**].
.
#. CKD: Patient's Cr elevated to 3.7 on admission to [**Location (un) 620**],
though subsequently returned to baseline of 2.6. Acute on
chronic kidney failure was likely seconary to pre-renal azotemia
in the setting of acute blood loss.
.
Chronic Issues:
#. BPH: Continued Flomax 0.4mg daily per outpatient regimen.
Continued finasteride per outpatient regimen.
#. B12 deficiency: Continued vitamin B12 1000 mcg PO daily per
outpatient regimen.
.
#. Paroxysmal atrial fibrillation: Was in normal sinus rhythm on
admission. Held metoprolol given GI bleeding, and he should
resume his metoprolol on discharge. Patient has not been on
anticoagulation, though CHADS2 score 0 based on available
history. He should start ASA 81mg daily in the future once GI
bleed has resolved.
.
Transitional Issues:
- He has a follow up appointment scheduled with the GI service
at [**Hospital1 18**]-[**Location (un) 620**].
- He should have his Hgb/Hct monitored closely after discharge
with a transfusion goal of Hct > 21. If any signs of GI bleed
he should be evaluated immediately.
- No medication changes during this hospitalization.
- He maintained full code status during this hospitalization.
Medications on Admission:
Home medications:
- Iron 325 mg p.o. b.i.d.
- Vitamin B12 1000 mcg p.o. daily.
- Flomax 0.4 mg p.o. daily.
- Finasteride 5 mg p.o. daily.
- Metoprolol 25 mg p.o. daily.
.
Medications on transfer:
Nexium 40mg IV BID
Vancomycin 1gm IV daily
Flomax 0.4mg PO daily
Vitamin B12 1000 mcg PO daily
Zofran prn
Maalox prn
Discharge Medications:
1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
5. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 24H (Every 24 Hours) for 8 days: Take until [**12-10**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary Diagnosis:
Acute blood loss due to GI bleed
Urinary tract infection
Secondary Diagnoses:
Chronic kidney disease
Benign prostatic hypertrophy
Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 18**] because you were anemic due to a
bleed in your GI tract. You had a video capsule study which
showed a small area that was bleeding in your small bowel, but
the bleeding has stopped. Your blood counts have remained
stable, and we feel it is safe for you to leave the hospital
with close monitoring of your blood counts. We have also
arranged for you to follow up with a gastroenterologist. If you
experience dark tarry stools or see blood in your stool, please
contact your physician immediately or go to the ED.
You were also treated for a urinary tract infection while you
were here. We started you on IV antibiotics, and you should
continue the antibiotic for a total of 2 weeks.
We made the following changes to your medications:
- START IV vancomycin 1g every 24 hours for urinary tract
infection. You should continue this antibiotic until [**2191-12-10**].
We made no other changes to your medications. Please continue
taking your medications as prescribed by your outpatient
providers.
We have scheduled appointments for you to follow up in the [**Hospital **]
clinic at [**Hospital1 18**] [**Location (un) 620**]. Please see below for your appointment
times. If you are unable to make an appointment, please call
and reschedule.
It has been a pleasure taking care of you at [**Hospital1 18**] and we wish
you a speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) **],[**Name (NI) **] MD
Address: [**Apartment Address(1) 58580**], [**Location (un) **],[**Numeric Identifier 18724**]
Phone: [**Telephone/Fax (1) 3259**]
Appt: [**12-23**] at 2:15pm
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
|
[
"2851",
"5849",
"5990",
"40390",
"42731",
"V1582"
] |
[**Numeric Identifier 47969**]
Admission Date: [**2103-6-11**] Discharge Date: [**2103-7-27**]
Date of Birth: [**2103-6-11**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Infant is a 2045 gram, 32 week,
male newborn, admitted to the Neonatal Intensive Care Unit
for management of prematurity. Infant was born to a 32 year
old, Gravida 5, Para 3, now 4 mother.
PRENATAL SCREENS: B negative, antibody negative, hepatitis
surface antigen negative, RPR nonreactive, Rubella immune.
GBS unknown.
PRIOR MATERNAL OBSTETRIC HISTORY: Previous cesarean section,
followed by two VBACs. This pregnancy complicated by uterine
dehiscence, seen on early fetal ultrasound. At 24 weeks,
mother was admitted to [**Hospital1 69**]
for expectant management with some concern for extension of
dehiscence. Mother received betamethasone at 24 weeks and 30
weeks gestation. Decision was made to deliver the infant by
cesarean section at 32 weeks gestation.
Neonatal Intensive Care Unit team at delivery. Infant
emerged with good tone, color and spontaneous crying. Apgars
were eight at one minute and nine at five minutes.
PHYSICAL EXAMINATION: On admission, birth weight was 2045
grams (75 to 90th percentile); length 42 cms (50th
percentile); head circumference 31 cms (75th percentile).
Anterior fontanel was open and flat; active, alert. Positive
red reflex both eyes. Palate intact. Mild grunting noted in
room air with mild subcostal retractions. Bilateral breath
sounds clear and equal with good aeration. No murmur.
Regular rate and rhythm. Abdomen: Soft, no
hepatosplenomegaly, three vessel cord. Testes: High in
canal but palpable; normal male genitalia. Anus patent.
Spine intact. No sacral dimples. Hips stable. Clavicles
intact. Tone and reflexes are appropriate for gestational
age.
At discharge, unremarkable exam. Circumcision healing well
one week post-op.
HOSPITAL COURSE: RESPIRATORY: Infant noted to have grunting
and mild subcostal retractions on admission. Infant was
placed on CPAP and received 25 to 30% FI02. Infant was
noted to have increased respiratory distress on day of life
two, was intubated and received two doses of
surfactant. He was extubated on day of life two to CPAP
and weaned to nasal cannula by day of life three. Infant was
weaned to room air by day of life five. Infant has remained
in room air with respiratory rate of 30-50 and oxygen
saturations greater than 95%. Caffeine was started on day of
life 13 for increased apnea and bradycardia and was
discontinued on day of life 20. The last episode of apnea and
bradycardia was on [**2103-7-21**].
CARDIOVASCULAR: Infant has remained hemodynamically stable
this hospitalization, no murmur. Heart rate 140 to 160 with
mean blood pressure 45 to 55.
FLUIDS, ELECTROLYTES AND NUTRITION: Infant was initially
nothing by mouth, receiving 80 cc per kg per day of D-10-W.
Infant was started on enteral feedings on day of life two and
advanced to full volume feedings by day of life seven.
Infant was advanced to maximum core density of 30 calories
per ounce with Promod by day of life 14. Infant tolerated
feeding advancement without difficulties. Calories were
eventually decreased for growth and the infant is currently
receiving minimum of 130 cc per kg per day of breast milk or
Enfamil 20 calories per ounce. He is nursing well and waking
for feedings. The most recent weight is 3395 grams. Length
is 50 cms. Head circumference 35 cms.
GASTROINTESTINAL: Infant received single phototherapy from
day of life four to day of life five; maximum bilirubin level
of 12.2 with a direct of 0.3. The most recent bilirubin
level on day of life seven was 8.4 with a direct of 0.3.
HEMATOLOGY: Infant did not receive any blood transfusions
this hospitalization. Most recent hematocrit on day of
admission was 50.6%. Baby's blood type is B positive, direct
Coomb's test negative. He is being discharged home on iron
supplementation due to his prematurity.
INFECTIOUS DISEASE: Infant received 48 hours of ampicillin
and gentamicin for rule out sepsis. Initial CBC showed a
white blood cell count of 12.6; hematocrit of 50.6%;
platelets 262,000; 51% neutrophils, 0 bands. Blood cultures
remained negative to date. The infant has not had any issues
with sepsis this hospitalization.
SENSORY: Hearing screening was performed with automated
auditory brain stem responses. Infant passed both ears.
OPHTHALMOLOGY: Infant did not meet criteria for eye
examination.
PSYCHOSOCIAL: Parents very involved with family. [**Hospital1 346**] social work involved with family.
The contact social worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Former 32 week gestation, stable in
room air, feeding well and growing.
DISCHARGE DISPOSITION: Home with parents and 3 older
brothers.
NAME OF PRIMARY PEDIATRICIAN: [**Hospital 620**] Pediatrics, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1728**], phone number [**Telephone/Fax (1) 37814**]. Fax #[**Telephone/Fax (1) 47970**].
CARE RECOMMENDATIONS: Feedings at discharge: Ad lib nursing
or Enfamil 20 calories per ounce, p.o.
minimum 130 cc per kg per day.
MEDICATIONS:
Fer-in-[**Male First Name (un) **] 25 mg per cc, dose 0.25 cc q. day by mouth.
Polyvisol 1 cc po daily.
STATE NEWBORN SCREEN: Sent on [**2103-6-14**] and showed an
elevated 17-OH, progesterone of 65 (range less than 60). A
repeat newborn screen was sent on [**2103-6-19**] and it was
within normal range.
IMMUNIZATIONS: Infant received hepatitis B vaccine on [**2103-6-23**].
IMMUNIZATIONS RECOMMENDED: Synagis-RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria:
1.) Born at less than 32 weeks.
2.) Born between 32 and 35 weeks with plans for day care
during the RSV season, with a smoker in the household or with
preschool siblings.
3.) With chronic lung disease.
FOLLOW-UP APPOINTMENTS: Follow-up appointment with primary
pediatrician early next week.
Early intervention: [**Location (un) 270**] Child Development Center.
Phone number [**Telephone/Fax (1) 43148**].
Visiting nurses association in [**Location (un) 1110**]. Phone number
[**Telephone/Fax (1) 46941**].
DISCHARGE DIAGNOSES:
Prematurity, former 32 week gestation.
Status post respiratory distress syndrome.
Status post rule out sepsis.
Status post apnea of prematurity.
Status post indirect hyperbilirubinemia.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 36532**]
Dictated By:[**Last Name (NamePattern1) 35945**]
MEDQUIST36
D: [**2103-7-27**] 01:29
T: [**2103-7-27**] 03:51
JOB#: [**Job Number 47971**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2117-1-16**] Discharge Date: [**2117-1-30**]
Date of Birth: [**2040-7-3**] Sex: F
Service: NEUROLOGY
Allergies:
Food Extracts
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Slurry speech, right arm weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76y/o RH lady with recent (8 days ago) Left frontal subcortical
stroke (slurred speech and right facial), hx of renal cancer,
lung mets, on chemotherapy (Nexavar), on Coumadine 2mg QD and
Aggrenox (for port and recent stroke) presented with worsening
in slurry speech and right arm weakness. She was admitted for a
night to [**Hospital6 2910**] for above CVA. She had
MRI, reportedly had "a stroke". She had drooped right face and
slurriness at that time, but no limb weakness. The detail
studies there is unknown at this point. She took Coumadine 1mg
QD to avoid clotting at her port, which has
been increased to 2mg QD since discharge. Last night, she might
have some unsteadiness in her gait. But she was able to walk by
herself. Otherwie, she has been doing well until this morning
(woke up 8:15AM), when husband noticed some worsening in
slurriness. At lunch time (around noon), her husband
noticed that she was not able to lift her right arm to feed her.
She finished her lunch at her left hand. EMT was called and
brought her to [**Hospital1 18**] ED.
ROS:
No change in comprehension. No change in mood, behavior. No
change in gait. No change in vision, hearing. No fever, rash. No
chest pain, palpitation. No chest pain, cough, SOB. No nausea,
vomiting, abdominal pain, diarrhea. No dysuria. No bladder/bowel
incontinence.
Past Medical History:
CVA (left sided stroke) a week ago.
s/p Right nephrectomy for renal cancer, had lung and brain
metastasis, on chemo.
Social History:
Lives with husband
Family History:
Unknown.
Physical Exam:
Vitals: T 98.2 HR 84, reg BP 14/58 RR 25 SO2 98% r/a
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear. Extra ear canals, ear drums
clear.
Neck: No Carotid bruits
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, flat, no tenderness
Ext: No arthralgia, no deformities, no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect
Orientation: Oriented to person, place, and date
Attention: Able to do recite the month of the year forward, but
unable to do it backward.
Registration: [**2-15**] at 30 secs
Recall: [**12-17**] at 5 minutes
Language: Slurred and dysarthric. Intact naming, [**Location (un) 1131**],
repeat. Unable to calculate 7 quarters (says seven dollars). No
apraxia, no neglect, no right left confusion
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 4 to 3mm
bilaterally. Visual fields are full to finger movement. Fundi
normal bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Shallower R NLF and slight droop at the right mouth
angle. Facial sensation intact. and symmetric.
VIII: Hearing intact to tuning fork bilaterally. No tinnitus. No
nystagmus.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk and tone bilaterally
No tremor, no asterixis
Full strength throughout
MMT [**Doctor First Name **] Tri [**Hospital1 **] WExt WFlx IO IP Quad HS TA GC [**Last Name (un) 938**] ToeExt ToeFlx
R 5- 5 5 5 5 5 5- 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Right pronation (no drift)
Sensation: Intact to light touch, pinprick, temperature (cold),
vibration, and propioception throughout all extremities.
Reflexes: B T Br Pa Ankle
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes were downgoing bilaterally
Coordination: Normal on finger-nose-finger, rapid alternating
movements normal, heel knee tapping normal.
Meningeal sign: Negative Brudzinski sign. No nucal rigidity.
Pertinent Results:
[**2117-1-16**] 02:23PM BLOOD WBC-6.6 RBC-3.30* Hgb-11.2* Hct-32.1*
MCV-97 MCH-34.0* MCHC-35.0 RDW-15.0 Plt Ct-149*
[**2117-1-18**] 02:47AM BLOOD WBC-9.4# RBC-3.22* Hgb-10.5* Hct-30.8*
MCV-96 MCH-32.7* MCHC-34.2 RDW-14.6 Plt Ct-202#
[**2117-1-20**] 11:35AM BLOOD WBC-6.8 RBC-3.18* Hgb-10.5* Hct-30.6*
MCV-96 MCH-33.1* MCHC-34.3 RDW-14.9 Plt Ct-201
[**2117-1-22**] 02:00AM BLOOD WBC-6.4 RBC-3.23* Hgb-10.5* Hct-30.6*
MCV-95 MCH-32.3* MCHC-34.1 RDW-14.8 Plt Ct-207
[**2117-1-16**] 02:23PM BLOOD Neuts-77.6* Lymphs-16.4* Monos-4.4
Eos-1.4 Baso-0.2
[**2117-1-16**] 02:23PM BLOOD PT-15.3* PTT-24.5 INR(PT)-1.3*
[**2117-1-18**] 02:23PM BLOOD PT-30.1* PTT-32.8 INR(PT)-3.1*
[**2117-1-18**] 04:36PM BLOOD PT-32.8* INR(PT)-3.4*
[**2117-1-19**] 02:37PM BLOOD PT-37.0* INR(PT)-4.0*
[**2117-1-20**] 03:20AM BLOOD PT-33.1* PTT-32.7 INR(PT)-3.5*
[**2117-1-21**] 03:15AM BLOOD PT-32.0* PTT-32.8 INR(PT)-3.3*
[**2117-1-16**] 02:23PM BLOOD Glucose-135* UreaN-15 Creat-1.1 Na-142
K-4.2 Cl-105 HCO3-28 AnGap-13
[**2117-1-22**] 02:00AM BLOOD Glucose-102 UreaN-14 Creat-0.9 Na-141
K-3.6 Cl-109* HCO3-23 AnGap-13
[**2117-1-16**] 02:23PM BLOOD ALT-17 AST-27 LD(LDH)-295* CK(CPK)-81
AlkPhos-68 Amylase-38 TotBili-0.4
[**2117-1-16**] 02:23PM BLOOD CK-MB-3 cTropnT-<0.01
[**2117-1-16**] 10:22PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2117-1-17**] 07:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2117-1-16**] 02:23PM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.3 Mg-2.2
[**2117-1-17**] 07:00AM BLOOD %HbA1c-5.6
[**2117-1-17**] 07:00AM BLOOD Triglyc-95 HDL-59 CHOL/HD-2.9 LDLcalc-92
[**2117-1-17**] 07:00AM BLOOD TSH-4.2
Head CT [**1-16**]:
No evidence of intracranial hemorrhage or edema. If there is
clinical concern for acute infarct, MRI with diffusion-weighted
imaging is recommended
MRI/MRA [**1-17**]:
1. Acute left-sided subcortical periventricular white matter
infarct.
2. Small less than 5 mm probable metastatic lesion at the right
posterior frontal subcortical region.
3. Small vessel disease.
4. Abrupt cutoff at the bifurcation of the left middle cerebral
artery.
CT Perfusion [**1-21**]:
No evidence of hemorrhage on head CT. CT perfusion demonstrates
a large area of delayed time to peak without large abnormality
on blood volume indicative of a large area of ischemia with a
small area of infarct.
Brief Hospital Course:
Ms. [**Known lastname 63847**] was admitted to the floor with tele. Over the course
of 24 hours her exam fluctuated from expressive aphasia and
plegia of the R arm to mild word finding difficulties and almost
full strength of the right arm.
She had an MRI and MRA which showed a L MCA watershed infarct
and very tight L MCA branch. She was therefore transferred to
the ICU for pressure support. Her SBP was kept elevated with
Neo. She was also started on Coumadin in the hopes to improve
blood flow through the narrow MCA. Aggrenox was stopped and she
was put on Atorvastatin. Her LDL was 92 and her A1c was 5.6.
After a few days, her exam remained labile and a CT perfusion
was done to evaluate the extent of her penumbra. This showed a
large area (most of the MCA territory) was affected. Therefore
her blood pressure goals were continued and she was started on
IVF with limited results. She was therefore given a trial of
albumin in an attempt to increase her intracerebral perfusion
without significant change.
She was continued on IVF at 150 cc/hr and her pressor support
was weaned. Even with intermittent drops in her SBPs to 110s,
she continued to have stable exam with continued expressive
aphasia, decreased R gaze, and R hemiparesis arm worse than leg.
She was weaned off her neosynephrine on [**1-26**].
Her INR remained low on coumadin of 2mg [**Last Name (LF) 244**], [**First Name3 (LF) **] her dose was
increased to 4 mg daily on [**1-29**].
The patient was noted to be anemic. This was felt to be mostly
dilutional. On the day of discharge her hematocrit was 23.4 up
from 21.8 on the previous day.
Importantly the patient's MRI also showed a small contrast
enhancing right sided parietal lesion. This likely represents
metastatic renal cell cancer, but is not biopsy proven.
The patient was seen by physical therapy who recommended a rehab
stay.
Medications on Admission:
Coumadin 2mg QD, Aggrenox 1 tab [**Hospital1 **], Nexavar 400mg [**Hospital1 **]
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Warfarin 2 mg Tablet Sig: 1-2 Tablets PO DAILY16 (Once Daily
at 16): Please check frequent INR and titrate to between 2 and
3. Most recent INR was 1.9 after getting 4mg on [**2116-12-29**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Stroke.
Metastatic renal cell carcinoma.
Discharge Condition:
Vital Signs stable. The patient has a presistent motor aphasia
with some difficulty repeating. She has a right facial droop.
She has right upper extremity weakness.
Discharge Instructions:
Please take your medications as prescribed.
Please follow up with your appointments as documented below.
Please return to the hospital if you have any concerning
symptoms. This includes, but is not limited to, weakness,
slurred speech or a facial droop.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2117-3-1**] 2:30
Please make an appointment to see your primary care doctor in
the next several days.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
Completed by:[**2117-1-30**]
|
[
"5990",
"2859"
] |
Admission Date: [**2192-9-28**] Discharge Date: [**2192-10-2**]
Date of Birth: [**2107-7-26**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Latex
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
From [**Hospital Unit Name 153**] admission note:
85 year old man with known history of cryptogenic cirrhosis with
hypersplenism, portal hypertension, and esophogeal varices along
with chronic LGIB due to known AVMs and pancytopenia presents
transferred from OSH for BRBPR. Patient has had chronic blood
per stool since [**Month (only) 116**], and has been followed closely with serial
hematocrits and transfusions. Previous colonoscopies have shown
bleeding AVM's treated with cauterization. Presents to OSH after
having 5 bloody bowel movements yesterday morning. Stools
decscribed as loose and dark with bright red blood mixed in.
Denies abdominal pain, nausea or vomiting. Denies dizziness or
syncope. No chest pain or SOB. Last bowel movement was this
morning with smaller amount of BRB mixed with stool.
.
Patient remained normotensive at OSH. HCT showed HCT 21.5
(baseline 25). Received 2 units pRBC with increase to 24.3.
Received one additional unit prior to transfer. On arrival to
the floor, patient is comfortable and without complaint except
for being hungry.
Past Medical History:
- recurrent GI bleeding (see above)
- Grade II esophageal varicies s/p endoscopic band ligation,
[**First Name9 (NamePattern2) 67469**] [**Last Name (un) 88105**] injection
- Diverticulosis
- Internal hemorrhoids
- CAD s/p CABG approximately 30 years ago
- Moderate to severe mitral regurgitation
- Severe pulmonary artery hypertension
- History of atrial fibrillation
- Biventricular Pacemaker (inserted ~[**2188**], unknown indication)
- Osteomyelitis at 8 y/o resulting in shortening of his left leg
- Hearing impairment
- Bilateral hip replacement
- Anti-K antibody. Patient should receive K-antigen negative
products for all red cell transfusions.
Social History:
Mr. [**Known lastname 88104**] is one of 9 children. Only he, his brother, and
his oldest sister are still living. He currently lives with his
wife in a senior apartment complex in [**Location (un) 38**]. He retired
10-15 years ago from a career as a professional accordian player
when his hearing began to decline. He shops for food, cooks, and
helps care for his wife who has spinal stenosis. He performs his
ADLs without problem and uses a cane at basleline.
TOBACCO: smoked cigarettes occasionally; last smoked 20-25 years
ago
ALCOHOL: denies
ILLICITS: denies
Family History:
His father had a history of alcohol abuse and died from heart
disease. His mother died from heart disease in her 90s. One of
his sons died at 52 y/o from sudden cardiac death. His other son
died at 53 y/o in [**Country 3992**], where he was working as a physician's
assistant. There is no family history of colon cancer.
Physical Exam:
Admission exam(from [**Hospital Unit Name 153**] note)
Vitals: T:97.9 BP:144/81 P:60 R:14 18 O2: 99%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI holosystolic
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. Notable posterior displacement of rt tibia from knee with
shortening of right leg.
Neuro: AAOx4. CNII-XII intact. 4+/5 strength throughout except
at rt knee, likely due to chronic deformity. FTN intact. Gait
deferred.
Discharge Exam
VSS
GEN: Patient lying comfortably in bed nad a+ox3
HEENT: MMM oropharynx clear
NECK: supple no thyromegaly
CV: rrr no m/r/g
RESP: ctab no w/r/r
ABD: soft nt nd bs+
EXTR: no le edema good pedal pulses bilaterally
DERM: no rashes, ulcers or petechiae
neuro: cn 2-12 grossly intact non-focal
PSYCH: normal affect and mood
Pertinent Results:
[**2192-9-28**] 07:56PM HCT-31.8*
[**2192-9-28**] 04:00PM GLUCOSE-85 UREA N-17 CREAT-1.0 SODIUM-144
POTASSIUM-3.3 CHLORIDE-111* TOTAL CO2-24 ANION GAP-12
[**2192-9-28**] 04:00PM estGFR-Using this
[**2192-9-28**] 04:00PM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2192-9-28**] 04:00PM WBC-2.3* RBC-3.68*# HGB-11.6*# HCT-33.5*#
MCV-91 MCH-31.4 MCHC-34.5 RDW-19.3*
[**2192-9-28**] 04:00PM NEUTS-63.5 LYMPHS-23.7 MONOS-8.8 EOS-3.7
BASOS-0.3
[**2192-9-28**] 04:00PM PLT COUNT-86*
Discharge labs
[**2192-10-2**] 11:15AM BLOOD WBC-2.1* RBC-3.13* Hgb-10.1* Hct-28.4*
MCV-91 MCH-32.4* MCHC-35.6* RDW-19.3* Plt Ct-77*
[**2192-10-2**] 11:15AM BLOOD PT-14.3* INR(PT)-1.2*
Colonoscopy [**10-2**]:
Impression: Angioectasia in the ascending colon (thermal
therapy)
Grade 1 internal hemorrhoids
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
.
#BRBPR/melena: Patient was initially transferred to the ICU and
monitored overnight. He did not require any further
transfusions(got three at OSH). He underwent colonoscopy on
[**10-2**] which showed an angioectasia in the ascending colon which
was coagulated. Diverticulosis was also noted. His hct on
[**10-2**] was 28.4. He was discharged on po iron and will f/u with
his PCP [**Last Name (NamePattern4) **] [**10-8**]. PLEASE REPEAT A CBC AT THIS VISIT.
.
#cryptogenic cirrhosis: no report of hemoptysis, coffee-ground
emesis. He will follow up with Dr. [**First Name (STitle) **] for an EGD on [**10-9**].
#afib: Patient was paced through hospitalization. His nadolol
was restarted on discharge.
.
Medications on Admission:
-Crestor 5 daily
-Nadolol 40 daily
- Flomax 0.4 daily
- Omeprazole 20 daily
- Ascorbic acid 500 daily
- Ferrous sulfate 325 daily
-MVI
Discharge Medications:
1. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
5. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for bloody and black stool. Initially you
required a blood transfusion, no further bleeding was noted. A
colonoscopy was performed and an abnormal blood vessel
(angioectasia) was found in your colon and treated. On
discharge your blood counts had been stable for >48 hours
without transfusion. Please follow up with your primary care
physician and your gastroenterologist.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 1730**] O.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
When: Monday, [**10-8**], 3:30PM
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2192-10-9**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage
*This appointment is for an Endoscopy. If you have not already
received preparation instructions from Dr. [**Last Name (STitle) 88107**] office, please
call the number above.
|
[
"V4581"
] |
Admission Date: [**2148-11-4**] Discharge Date: [**2148-12-11**]
Date of Birth: [**2148-11-4**] Sex: M
Service: Neonatology
PRESENTING HISTORY: Baby boy [**Known lastname 12129**] is a 1450 gram male
infant born at 30 and 6/7 weeks gestation to a 21-year-old G2
P0 to 1 mother by C. section for preeclampsia. Prenatal labs
were notable for blood type B positive, antibody negative,
RPR nonreactive, Rubella immune, Hep B surface antigen
negative and GBS unknown. The pregnancy was complicated by
history of maternal chronic hypertension plus the
preeclampsia but the mother was not on any medications. The
mother was admitted two days prior to delivery with headache
and proteinuria. She was betamethasone complete and delivered
secondary to unremitting preeclampsia. The infant emerged
vigorous. The Apgars were 8 and 9 at 1 and 5 minutes of life
respectively. The infant was brought to the NICU for further
management of prematurity and was placed on CPAP secondary to
grunting.
SOCIAL HISTORY: The mother lives in a shelter. The father of
the baby is reportedly involved. The mother is [**Name (NI) 7979**]
and requires an interpreter for communication.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Admission weight 1460 grams which is
in the 75th percentile. Length 38 cm which is in the 25th
percentile. Head circumference was 28 cm which is in the 50th
percentile. The exam was otherwise unremarkable.
HOSPITAL COURSE:
1. Respiratory: The infant was initially placed on CPAP and
was never intubated. He remained on CPAP until day of
life 4 at which time he was transitioned to room air and
tolerated that well. There have been no further issues.
2. Cardiovascular: The patient has been doing well. He did
have some intermittent tachycardia to the 190's that
self-resolved. There was never any ectopy on the EKG or
the monitor and the patient's baseline heart rates
returned to the 140's-160's.
3. Respiratory: The patient had some apnea of prematurity,
was never treated with caffeine and has been spell-free.
4. FEN and GI: The patient had some feeding immaturity but
was tolerating p.o. well with excellent weight gain
prior to discharge. The patient was discharged home on
EnfaCare mostly breast milk 24 calories per ounce
concentration. The maximum calories in the NICU were 28
calories per ounce including BeneProtein.
5. Hematology: The patient's last hematocrit was 36.7 on
[**2148-11-29**]. He was discharged home on iron 2
mg/kilogram/dose. The patient was on some phototherapy
for hyperbilirubinemia which has resolved.
6. ID: The patient received an initial rule out sepsis and
has not had any issues with infection since then.
7. Neurology: The patient had a normal head ultrasound on
[**2148-11-13**] which is day of life 10. However, on
[**348-12-10**], the head ultrasound at 36 weeks
corrected gestational age showed a collection a cysts
bilaterally in the caudothallamic notch. The
differential diagnosis includes a possible old grade 1
hemorrhage that was not seen on a prior episode or torch
infection. There is also a tiny incidental 2 mm choroid
plexus cyst on the right side that is of no
significance. Neurology was consulted to evaluate the
patient. Incidentally, the patient did not pass the
hearing screen bilaterally. A urine CMV was sent to
evaluate for congenital infection.
8. Sensory: Part A: Audiology hearing screen was performed
with automated auditory brain stem response. The infant
did not pass and was referred for followup testing. An
appointment has not yet been scheduled. Part B:
Ophthalmology. The patient had an exam on [**2148-12-4**] to look for retinopathy of prematurity OD immature
zone 3, OS immature zone 2 with recommended followup in
three weeks. The patient will have a followup
appointment.
9. Psychosocial: The [**Hospital1 18**] social worker was involved with
the family. The social worker can be reached through the
[**Hospital1 **] NICU at [**Telephone/Fax (1) **]. The patient will have ENA and
early intervention followup.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To home.
PRIMARY CARE PEDIATRICIAN: [**Doctor Last Name **]Health Center, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38832**]. The followup appointment is recommended in [**2-6**]
days after discharge.
CARE AND RECOMMENDATIONS:
1. Feeds at discharge were breast milk with EnfaCare powder
to make it to 24 K-cals per ounce recommended to [**7-13**]
months of age.
2. Medications: Multivitamins 1 ml p.o. daily and iron 4
mg elemental iron/kilo/dose daily which is 0.4 ml (25 mg/ml
solution) p.o. daily.
3. Iron and vitamin D supplementation: Part A: Iron
supplementation is recommended for preterm and low birth
weight infants until 12 months of corrected age. Part B:
All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 international units
daily until 12 months of corrected age.
4. Care seat positioning screen was passed.
5. Newborn screen was normal including a negative for
toxoplasmosis.
6. The patient received a hepatitis B immunization on
[**2148-11-28**] and the first Synagis shot at [**12-8**], [**2148**].
7. Immunizations recommended: Part A: Synagis RSV
prophylaxis should be considered from [**Month (only) **] through
[**Month (only) 958**] for all infants who meet any of the following 4
criteria: 1. Born at less than 32 weeks. 2. Born between
32 and 35 weeks with two of the following: Daycare
during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school
age siblings. 3. Chronic lung disease or 4.
Hemodynamically significant congenital heart disease.
Part B: Influenza immunization is recommended annually
in the fall for all infants once they reach 6 months of
age. Before this age and for the first 24 months of the
child's life, immunizations against influenza is
recommended for household contacts and out of home
caregivers. [**Name (NI) **] C: This infant has not received the
rotavirus vaccine. American Academy of Pediatrics
recommends initial vaccination of preterm infants at or
following discharge from the hospital if they are
clinically stable and are at least 6 weeks but fewer
than 12 weeks of age.
FOLLOWUP: Followup appointments are needed for the patient
with the primary care doctor, the ophthalmologist as well as
a hearing referral. We will follow up on urine CMV result and
contact Dr. [**Last Name (STitle) 38832**] if positive.
PHYSICAL EXAMINATION: On discharge, the weight was 2500
grams, head circumference was 29 cm, length 42 cm. In
general, the patient was alert, awake in no distress. HEENT
exam: Anterior fontanel open and flat. The red reflex was
present bilaterally. The extraocular movements were intact.
Cardiac: There was regular rate and rhythm, no murmurs,
gallops or rubs heard. Lungs are clear to auscultation
bilaterally. The abdomen is soft, nontender, nondistended, no
hepatosplenomegaly present. The extremities are warm and well
perfused. There was a small umbilical hernia present that is
reducible. The patient is circumcised. Testicles are
descended bilaterally. The circumcision site appears clear.
There is very mild swelling of the glans as the circumcision
was just done. Extremities are warm and well perfused. Cap
refill is less than 2 seconds. Femoral pulses are 2+ and the
radial pulses are 2+.
DISCHARGE DIAGNOSES:
1. Prematurity 30 and 6/7 weeks.
2. Respiratory distress syndrome.
3. Rule out sepsis.
4. Circumcision [**2148-12-9**].
5. Rule out CMV infection.
6. Bilateral caudothallamic cysts.
7. Failed hearing screen.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name8 (MD) 75068**]
MEDQUIST36
D: [**2148-12-10**] 18:45:28
T: [**2148-12-10**] 20:17:24
Job#: [**Job Number 75173**]
|
[
"7742",
"V053"
] |
Admission Date: [**2190-8-2**] Discharge Date: [**2190-8-12**]
Date of Birth: [**2109-3-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2190-8-3**] Urgent coronary artery bypass grafting x3 with left
internal mammary artery to left anterior descending coronary;
reverse saphenous vein single graft from the aorta to the first
diagonal coronary artery; reverse saphenous vein single graft
from the aorta to the first obtuse marginal coronary artery.
History of Present Illness:
This is an 81 year old male with a history of paroxysmal Atrial
Fibrillation who was recently admitted to OSH with chest pain.
Cardiac workup included a nuclear stress test that showed no
evidence of ischemia. He was discharged with planned follow up
with Cardiology in 2 weeks. However, he again had left sided
chest pain associated with a racing heart rate and presented to
the OSH ED. At that time he was cardioverted to NSR. Further
cardiac workup included cardiac angiogram that revealed
multivessel coronary artery disease. He presents to [**Hospital1 18**] for
further evaluation of coronary artery revascularization.
Past Medical History:
Coronary Artery Disease
Past Medical History:
Paroxysmal Atrial Fibrillation
Hypertension
Hypercholesterolemia
Gastro intestinal bleed (while on heparin)
Toxic-metabolic encephalopathy
ETOH withdrawal
Pilonidal cyst.
Past Surgical History:
s/p Appendectomy [**1-26**]
lumbar diskectomy [**2188**]
Social History:
Lives with: wife-[**Name (NI) **]
Contact: [**Name (NI) **](wife) Phone # [**Telephone/Fax (1) 88767**]
Occupation: retired construction worker
Cigarettes: yes [x] last cigarette [**2175**] Hx: 40 pack year hx
Other Tobacco use: denies
ETOH: none in last 6 months. Previously daily beers and shot
Family History:
Premature coronary artery disease - none
Physical Exam:
Pulse: 56 SB Resp: 16 O2 sat: 99 % RA
B/P Left: 132/77
Height: 69 inches Weight: 83.3 kg
General: Pleasant cooperative no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] anteriorly
Heart: RRR [x] Irregular [] Murmur [] grade
Abdomen: Soft[x] non-distended[x] non-tender[x] + bowel
sounds[x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Alert and oriented x3 nonfocal, unable to assess gait on
bedrest s/p cath
Pulses:
Femoral Right: mynx closure Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: + bruit Left: no bruit
Pertinent Results:
Admission labs:
[**2190-8-2**] 06:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2190-8-2**] 09:30PM PT-12.2 PTT-40.9* INR(PT)-1.0
[**2190-8-2**] 09:30PM PLT COUNT-159
[**2190-8-2**] 09:30PM WBC-5.6 RBC-3.64* HGB-11.1* HCT-32.6* MCV-90
MCH-30.6 MCHC-34.1 RDW-14.4
[**2190-8-2**] 09:30PM %HbA1c-5.4 eAG-108
[**2190-8-2**] 09:30PM ALBUMIN-3.6 CALCIUM-10.0 PHOSPHATE-2.4*
MAGNESIUM-2.1
[**2190-8-2**] 09:30PM CK-MB-2 cTropnT-<0.01
[**2190-8-2**] 09:30PM LIPASE-61*
[**2190-8-2**] 09:30PM ALT(SGPT)-11 AST(SGOT)-20 LD(LDH)-185
CK(CPK)-42* ALK PHOS-86 AMYLASE-144* TOT BILI-0.3
[**2190-8-2**] 09:30PM GLUCOSE-104* UREA N-23* CREAT-1.4* SODIUM-140
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
[**2190-8-2**] 10:45PM CK-MB-2 cTropnT-<0.01
[**2190-8-2**] 10:45PM CK(CPK)-36*
[**2190-8-3**] Intra-op TEE
PREBYPASS
No mass/thrombus is seen in the left atrium or left atrial
appendage. No spontaneous echo contrast is seen in the left
atrial appendage. No thrombus is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is moderately dilated. The descending thoracic
aorta is mildly dilated. There are complex (>4mm) atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trace mitral regurgitation
is seen.
An epiaortic scan was performed which confirmed dilated aorta
with no significant atheromatous disease at canullation or cross
clamp location.
POSTBYPASS
Biventricular systolic function remains normal. The study is
otherwise unchanged from prebypass.
Discharge Labs:
[**2190-8-12**] 06:15AM BLOOD WBC-6.6 RBC-3.31* Hgb-9.7* Hct-29.5*
MCV-89 MCH-29.4 MCHC-32.9 RDW-14.6 Plt Ct-284
[**2190-8-11**] 06:23AM BLOOD WBC-7.5 RBC-3.61* Hgb-10.6* Hct-31.4*
MCV-87 MCH-29.3 MCHC-33.7 RDW-14.5 Plt Ct-256
[**2190-8-9**] 06:50AM BLOOD WBC-5.3 RBC-3.27* Hgb-9.7* Hct-28.9*
MCV-88 MCH-29.6 MCHC-33.5 RDW-14.9 Plt Ct-201
[**2190-8-12**] 06:15AM BLOOD PT-19.4* INR(PT)-1.8*
[**2190-8-11**] 06:23AM BLOOD PT-16.5* PTT-29.9 INR(PT)-1.5*
[**2190-8-9**] 06:50AM BLOOD PT-16.3* PTT-30.4 INR(PT)-1.4*
[**2190-8-8**] 06:55PM BLOOD PT-21.8* INR(PT)-2.0*
[**2190-8-12**] 06:15AM BLOOD Glucose-85 UreaN-23* Creat-1.6* Na-142
K-4.2 Cl-106 HCO3-28 AnGap-12
[**2190-8-11**] 06:23AM BLOOD Glucose-96 UreaN-24* Creat-1.5* Na-141
K-4.1 Cl-104 HCO3-27 AnGap-14
[**2190-8-8**] 04:16AM BLOOD Glucose-91 UreaN-29* Creat-1.4* Na-144
K-3.5 Cl-106 HCO3-28 AnGap-14
[**2190-8-7**] 05:15AM BLOOD Glucose-83 UreaN-32* Creat-1.5* Na-142
K-3.4 Cl-105 HCO3-30 AnGap-10
[**2190-8-12**] 06:15AM BLOOD Mg-2.1
[**2190-8-10**] Chest x-ray:
As compared to the previous radiograph, there is no relevant
change. Minimal pericardial air inclusion might be present at
the level of the aortopulmonary window. Unchanged left rib
fractures and area of mild pleural thickening might have
increased in extent. Unchanged size of the cardiac silhouette.
Pre-existing retrocardiac atelectasis is improving. Unchanged
unremarkable right lung. No pulmonary edema. No evidence of
pneumonia.
Brief Hospital Course:
Following the routine pre-operative workup, the patient was
brought to the Operating Room on [**2190-8-3**] where the patient
underwent coronary bypass grafting with Dr. [**Last Name (STitle) 914**]. Please see
the operative note for details, in summary he had:
Urgent coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending coronary; reverse
saphenous vein single graft from the aorta
to the first diagonal coronary artery; reverse saphenous vein
single graft from the aorta to the first obtuse marginal
coronary artery. His bypass time was 62 minutes, with a
crossclamp of 46 minutes. Of note, 4.5cm Ascending Aortic
Aneurysm was noted on intra-op TEE. The patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring on
Propofol and phenylephrine infusions. He remained
hemodynamically stable in the immediate post-op period, woke
from anesthesia neurologically intact and was extubated. He
remained hemodynamically stable, was weaned from vasopressor
support and on POD1 was transferred from the ICU to the stepdown
floor for continued care and recovery. The patient was begun on
diuretics at that time as well. All chest tubes, invasive lines
and epicardial pacing wires were removed per cardiac surgery
protocol and without complication. He had intermittent atrial
fibrillation/flutter for which Amiodarone and Warfarin were
started. Warfarin was dosed for a goal INR between 2.0 - 2.5.
Amiodarone was titrated per Atrius cardiology. The patient
worked with the physical therapy service for assistance with
strength and mobility. By the time of discharge on
postoperative day nine, the patient was ambulating with
assistance, the wound was healing and pain was controlled with
Percocet. There was very minimal sternal drainage and PO
antibiotic was changed to a one week course of Keflex. The
patient was discharged to rehabilitation at [**Hospital **] Health Care
in good condition, he is to follow up with Dr [**Last Name (STitle) 914**] on
[**2190-8-31**] @1:45PM. Cardiology followup appt. was also arranged at
[**Location (un) 2274**] [**Location (un) 38**]. The cardiac surgery office will also arrange a
chest CT scan with contrast in approximately one year time to
re-evaluate his dilated ascending aorta. At discharge, he was in
a normal sinus rhythm with rate in the 60's.
Medications on Admission:
Nitroglycerin SL prn
Colace 100 mg [**Hospital1 **]
Ferrous Sulfate 325 mg daily
Imdur 30 mg daily
Lopressor 12.5 mg [**Hospital1 **]
Simvastatin 20 mg daily
ASA 81 mg daily
Omeprazole 20 mg daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO DAILY
(Daily) for 1 weeks: hold for K+ >4.5.
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 1 weeks.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 7 days: then drop to 1 tab(200mg) daily until
followup with cardiologist.
13. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Titrate for goal INR between 2.0 - 2.5. Daily dose may vary.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] health care center
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Paroxysmal Atrial Fibrillation/Flutter
Hypertension
Hypercholesterolemia
Dilated Ascending Aorta
Chronic Renal Insufficiency
Mild Postop Sternal Drainage(improved)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, with assistance
Sternal pain managed with Percocet
Sternal Incision - healing well, no erythema, minimal drainage
Edema: trace bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw day after discharge from hospital
****Please arrange for coumadin/INR follow up prior to discharge
from rehab
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) 914**] Date/Time:[**2190-8-31**] @1:45PM [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 88768**] [**Name (STitle) 42388**] [**2190-8-20**] @ 11:00 AM
[**Location (un) 38**] [**Hospital1 **] Medical Assoc.
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 17465**] in [**4-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw day after discharge from hospital
****Please arrange for coumadin/INR follow up prior to discharge
from rehab****
***Cardiac surgery office will arrange chest CT scan in
approximately one year to evaluate ascending aortic aneurysm***
Completed by:[**2190-8-12**]
|
[
"41401",
"42731",
"40390",
"5859",
"2720",
"V1582"
] |
Admission Date: [**2132-1-19**] Discharge Date: [**2132-1-21**]
Date of Birth: [**2062-5-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Phenytoin Sodium
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69 year old female with h/o metastatic melanoma originating on
the right arm with mets to the lung was with her family for
[**Holiday **] and she had a headache. She went to bed and woke up
confused and her husband reported that she became unconscious.
The family was able to catch her and help her to the ground so
she did not hit her head. She was shaking on her right side, had
loud respirations, and was intubated when EMS arrived. She went
to the OSH where a CT scan revealed 2 brain lesions. She was
given Ativan for presumed seizure and was loaded with 1 gram of
phosphenytoin. She was also given 8 mg of decadron. She was then
transferred to [**Hospital1 18**]. For transport she was on fentanyl and
versed. Upon arrival to [**Hospital1 18**] she was started on propofol.
Neurosurgery was consulted for the new brain lesions.
The patient was seen this week by hem-onc for her melanoma and
was waiting for tests to come back before possibly enrolling in
a clinical trial. She had a brain MRI that was negative 2 months
ago.
Past Medical History:
metastatic melanoma - originated on right arm, now has lung mets
Hypertension
Hyperlipidemia
Discoid lupus diagnosed 25 years ago based on a malar rash and
a back rash, finger stiffness. Doesn't know [**Doctor First Name **] or dsDNA status.
MI in [**2112**] with cardiac arrest, treated with TPA with full
resolution, no residual damage per the patient.
PMR 2-3 years ago, resolved with steroid course
Social History:
Lives in [**State 108**] with husband. Was in [**Location (un) 86**] for
[**Holiday **].
Family History:
Noncontributory
Physical Exam:
T:97.7 BP:155/73 HR:104 RR:16 O2Sats:100% vented
Gen: Intubated, off sedation for exam.
HEENT: Pupils: PERRL EOMs-unable to test
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Obese, Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic with brief eye opening. Does not follow
commands.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally.
III, IV, VI: unable to test
V-XII: unable to test
Motor: Moves all 4 extremities to sternal rub. Localizes and is
purposeful with both upper extremities. Briskly withdraws
bilateral lower extremities.
Sensation: unable to test
Toes mute bilaterally
Pertinent Results:
[**2132-1-20**] 02:03AM BLOOD WBC-16.6* RBC-4.02* Hgb-11.6* Hct-34.4*
MCV-85 MCH-28.9 MCHC-33.8 RDW-12.6 Plt Ct-248
[**2132-1-19**] 01:10AM BLOOD Neuts-94.9* Bands-0 Lymphs-3.3*
Monos-1.6* Eos-0.1 Baso-0.2
[**2132-1-20**] 02:03AM BLOOD Glucose-162* UreaN-15 Creat-0.6 Na-139
K-4.4 Cl-108 HCO3-23 AnGap-12
[**2132-1-20**] 02:03AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9
[**2132-1-19**] 03:41AM BLOOD Phenyto-11.1
[**2132-1-19**] 05:38PM BLOOD Type-ART pO2-151* pCO2-40 pH-7.37
calTCO2-24 Base XS--1 Intubat-INTUBATED
[**2132-1-19**] 05:38PM BLOOD Na-145 K-3.4*
Imaging:
MRI Head [**1-19**]:
Wet Read: NPw SAT [**2132-1-19**] 3:20 PM
Multiple lesions in the rbain- largest in the right parietal
lobe with
moderate surroudning edema. While most lesions are in the
cerebral parenchyma, i is noted in the right superior colliculus
and another one in the right cerebellar hemisphere.
Leptomeningeal spread cannot be excluded- consider further work
up. A tiny lesion is noted on the surface of left cerebellar
hemisphere.
(series 16, im 6)
Wet Read Audit # 1 NPw SAT [**2132-1-19**] 3:18 PM
Multiple lesions in the rbain- largest in the right parietal
lobe with
moderate surroudning edema. While most lesions are in the
cerebral parenchyma, i is noted in the right superior colliculus
and another one in the right cerebellar hemisphere.
Leptomeningeal spread cannot be excluded
Brief Hospital Course:
Ms [**Known lastname 3321**] was admitted to the ICU started on Dilantin and
Decadron. She underwent a MRI of her brain which showed multiple
lesions in the right [**Last Name (un) **]- largest in the right parietal lobe
with moderate surroudning edema. On hospital day one she was
extubated and found to have a normal neurological exam. On
hospital day two she was transfered to the surgical floor. Her
case was discussed in the brain tumor conference on [**1-21**] it was
decided that whole brain radiation would be the best treatment.
She was transferred to the [**Hospital Ward Name **] where the planning
session took place. She was discharged to home, with
instructions to return on [**1-22**] to have radiation.
Medications on Admission:
Simvastatin 20 mg each evening
Lisinopril 10 mg daily
Trimethoprim 100 mg - take [**1-26**] tablet QHS
Paroxetine 20 mg daily
Atenolol 50 mg daily
Hydroxycholoquine 200 mg daily
Discharge Medications:
1. Trimethoprim 100 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*21 Tablet(s)* Refills:*0*
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Brain masses presumed Metastatic Melanoma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
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:
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**1-28**],
at 11:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will be having whole brain radiation to treat your brain
masses on [**1-22**]. Please follow the instructions that were
provided to you during your planning session.
Completed by:[**2132-1-21**]
|
[
"4019",
"2724",
"412",
"V1582"
] |
Admission Date: [**2129-12-20**] Discharge Date: [**2129-12-24**]
Date of Birth: [**2062-6-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline Analogues
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67 y/o female PMH Asthma, TBM presented to ED with 3 weeks of
shortness of breath and cough. Patient reports "going downhill"
3 weeks ago - which she explains as increasing shortness of
breath at rest, cough and generally feeling unwell. Patient
began taking 20 mg prednisone [**2128-12-13**] and spoke to Dr. [**Last Name (STitle) **]
[**2128-12-16**] reported feeling better and was to re-start taking
prednisone 10 mg every other day but patient continued taking 10
mg prednisone every day. This past friday patient's cough began
to be productive of green sputum associated with rhinorrhea and
congestion. She reports fever and chills for the last 2 weeks -
but her temperature is 98.8-98.9. Patient denies recent
triggers, but did clean her house early [**Month (only) 404**]. Over the last 3
weeks patient never increased her albuterol and continued to
take only once a day, additionally she does not take Singulair.
She denies sick contacts. She denies recent travel, leg swelling
or pain. She has never been intubated for her asthma.
.
Patient followed by pulmonary clinic for asthma and requires 10
mg prednisone every other day. She received her flu vaccine this
year. She has frequent asthma flares - reveiw of OMR [**2129-12-16**],
[**2129-11-7**], [**2129-9-14**], [**2129-8-19**].
.
On arrival to ED VS 95, BP 144/69, HR 110, RR 24, O2Sat: 94% RA.
Tachycardia improved to 80s with 2 L NS. Patient given 3
combivent NEBs, 125 mg methylpred, 2 gram magnesium,
Levofloxacin, 2 L NS, tylenol and ASA. During her ED stay O2
ranged 92%-100% 2 L NC. Labs notable for ABG 7.42/41/74/28 on 2
L O2, lactate 1.0, negative troponin, HCT 34.9, WBC 10.2 with
81.9% neutrophils/no bands. Patient continued to tachypneic up
to 30s consequently is being admitted to ICU for close
monitoring. VS on transfer T 98.1, HR 89, BP 134/63, RR 26, O2
sat 97% 2 L NC.
Past Medical History:
#. Asthma - patient chronically on steroids 10mg qod - followed
by Dr. [**Last Name (STitle) **], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
#. History of tracheomalacia s/p tracheoplasty
#. History of multiple strokes: patent PFO, according to [**Last Name **]
problem list right MCA [**2122**].
#. Seizure disorder: no clear documentation of seizure disorder,
history of body jerking, followed by neurology.
#. Depression
#. Osteomalacia
#. Fibromyalgia
#. Gastroesophageal reflux disease
#. Subacute cutaneous lupus - no evidence of systemic lupus.
Followed by Dr. [**Last Name (STitle) **]
#. IBS
Social History:
The patient currently lives in [**Hospital1 8**]. She is divorced with 3
adult children. Her son [**Name (NI) **] lives in [**Name (NI) **]. The patient was
previously employed in Advertising but is not currently working
secondary to illness
Tobacco: Quit 25 years ago, [**12-11**] PPD x 20 years
ETOH: Once per month
Illicits: None
Family History:
Noncontributory
Physical Exam:
On Admission
VS: Temp: 98.7 BP: 141/73 HR: 84 RR: 30s O2sat: 96% 2 L.
GEN: pleasant, comfortable, mildy tachypneic but able to
complete full sentances. no respiratory distress.
HEENT: MMM, no supraclavicular or cervical lymphadenopathy, no
jvd.
RESP: Wheezes throughout.
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
Pertinent Results:
Admission:
[**2129-12-20**] 01:30AM BLOOD WBC-10.2# RBC-4.17* Hgb-11.5* Hct-34.9*
MCV-84 MCH-27.5 MCHC-32.8 RDW-15.4 Plt Ct-243
[**2129-12-20**] 01:30AM BLOOD Neuts-81.9* Lymphs-11.9* Monos-4.9
Eos-0.5 Baso-0.8
[**2129-12-20**] 01:30AM BLOOD PT-12.1 PTT-23.6 INR(PT)-1.0
[**2129-12-20**] 01:30AM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-140
K-3.7 Cl-100 HCO3-31 AnGap-13
[**2129-12-20**] 01:30AM BLOOD cTropnT-<0.01
.
Other labs:
[**2129-12-20**] 04:00AM BLOOD Type-ART O2 Flow-2 pO2-74* pCO2-41
pH-7.42 calTCO2-28 Base XS-1 Intubat-NOT INTUBA
[**2129-12-20**] 01:41AM BLOOD Lactate-1.0
.
.
Microbiology:
[**2129-12-20**] MRSA SCREEN MRSA SCREEN-PENDING
[**2129-12-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL [**2129-12-20**] BLOOD CULTURE Blood Culture,
Routine-PENDING [**2129-12-20**] BLOOD CULTURE Blood Culture,
Routine-PENDING
.
.
Radiology:
CXR [**2129-12-20**]
CHEST, PA AND LATERAL: The lungs are hyperexpanded, with
flattening of the
hemidiaphragms, widening of the anteroposterior diameter,
[**Hospital1 **]-apical
hyperlucency, and pleural-parenchymal scarring. There is no
focal
consolidation. There is a stable 1.6 x 1.1-cm calcified
granuloma in the left
upper lobe. The cardiomediastinal and hilar contours are normal.
There are
no pleural effusions or pneumothorax. The trachea is normal in
caliber.
Again noted is partial resection of the right posterior fifth
rib from prior
tracheoplasty procedure. The bones are diffusely demineralized,
with
multilevel degenerative changes.
IMPRESSION:
1. Chronic obstructive airways disease.
2. No evidence of pneumonia.
Brief Hospital Course:
67 year old F PMH Asthma, TBM who presents with shortness of
breath and cough.
Shortness of breath and cough: Probable COPD exacerbation in
setting of viral or environmental trigger. CXR without
infiltrate. The patient was initially admitted to the ICU where
she was started on Methylprednisolone 125 mg IV q 6hours and
nebulizer treatement. She had improvement back to her recent
baseline which is with persistent severe SOB with minimal
activity. She will complete a very slow taper of prednisone
eventually back to her chronic home dose for lupus of 10mg every
other day. She will complete 5 total days of azithromycin and
have ongoing nebulizer therapy. She will go to rehab for ongoing
physical therapy. She was started on bactrim prophylaxis dosing
because of the ongoing steroid use.
The patient has a very poor prognosis. She requires ongoing
counselling as an outpatient regarding code status and
expectations going forward. She will follow-up with her PCP and
pulmonologist.
All other medical issues were stable and she was continued on
her home medicatin regimen.
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 vial nebulizer four times a day as needed -
does not use
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inh four times a day prn - only takes once a day
ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly
CALCITONIN (SALMON) - 200 unit/dose Aerosol, Spray - 1 spray in
alternating nostrils daily
CELECOXIB [CELEBREX] - 200 mg Capsule - 1 Capsule(s) by mouth
twice a day as needed for pain
CLOPIDOGREL - 75 mg Tablet - 1 Tablet(s) by mouth once a day
CLORAZEPATE DIPOTASSIUM - 3.75 mg Tablet - 1 Tablet(s) by mouth
4
or 5 times per day as needed for seizures, anxiety
CYCLOBENZAPRINE - 10 mg Tablet - 1 Tablet(s) by mouth up to four
times a day as needed for prn for neck pain
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1
Capsule(s) by mouth weekly
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff inhaled daily rinse mouth after use
FUROSEMIDE - 20 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day as needed for swelling - typically does not take
HYDROCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by
mouth three times daily
HYDROXYCHLOROQUINE - 200 mg Tablet - 1 Tablet(s) by mouth twice
a
day - is taking once a day
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth once a day
MIRTAZAPINE - 15 mg Tablet - 1 Tablet(s) by mouth at bedtime
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day - not taking
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice daily prn
PRAVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
PREDNISONE - 10 mg Tablet - prescribed as every other day
PREGABALIN [LYRICA] - 50 mg Capsule - 2 Capsule(s) by mouth once
a day - No Substitution
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - one capsule inhaled daily - not taking
ZOLPIDEM - 5 mg Tablet - [**12-11**] Tablet(s) by mouth at bedtime only
as needed
Medications - OTC
ASPIRIN [ASPIRIN [**Hospital1 **]] - (Prescribed by Other Provider) -
81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day
DIPHENHYDRAMINE HCL [BENADRYL] - (OTC) - 25 mg Capsule - 2 tabs
at bedtime
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation four times a day as needed for shortness of
breath or wheezing.
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
4. calcitonin (salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal once a day.
5. celecoxib 200 mg Capsule Sig: One (1) Capsule PO twice a day
as needed for pain.
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. clorazepate dipotassium 3.75 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily) as needed for seizures/mood: For time period until
rehab pharmacy has in stock, then ongoing use.
Disp:*10 Tablet(s)* Refills:*0*
8. furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day as
needed for swelling.
9. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q8H (every 8 hours) as needed for fibromyalgia pain.
10. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO
twice a day.
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. pregabalin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): For time period until rehab pharmacy has in stock, then
ongoing use.
Disp:*5 Capsule(s)* Refills:*0*
16. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*120 neb* Refills:*5*
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily): For time period until rehab pharmacy
has in stock, then ongoing use.
Disp:*5 Capsule(s)* Refills:*0*
19. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
Disp:*100 ML(s)* Refills:*2*
20. Nebulizer machine
For COPD: Dispense 1 nebulizer machine. Zero refills.
21. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
Inhalation once a day.
22. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
23. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
24. prednisone 20 mg Tablet Sig: Per description Tablet PO DAILY
(Daily): 60mg daily for 2 days, then 50mg for 5 days, then 40mg
for 5 days, then 30mg for 5 days then 20mg for 5 days then 10mg
every other day ongoing.
25. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
26. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
COPD exacerbation
Prior stroke
Fibromyalgia
Depression
Hypertension
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted with shortness of breath due to a COPD
exacerbation. Please continue all breathing treatments and the
steroid taper with prednisone as prescribed.
Please follow-up with your outpatient pulmonologist and primary
care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
Stop using ambien and flexeril due to the risk of sedation
contributing to your shortness of breath.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2129-12-29**] at 11:20 AM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 4200**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2130-1-2**] at 1:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: MONDAY [**2130-1-2**] at 2:00 PM
Department: MEDICAL SPECIALTIES
When: MONDAY [**2130-1-2**] at 2:00 PM
With: DR. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"4019",
"311"
] |
Admission Date: [**2125-8-16**] Discharge Date: [**2125-8-24**]
Date of Birth: [**2051-8-25**] Sex: M
Service: NEUROSURGERY
Allergies:
Horse/Equine Product Derivatives
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
blurry vision on the left visula field.
Major Surgical or Invasive Procedure:
Right craniotomy for resection of right optic tract glioma.
Tissue biopsy
History of Present Illness:
73 year-old righ handed male who has noiced blurry vision on the
left visual field while doing his crossword puzzle and playing
golf.His visual problem got worse over time MRI -/+ gadolinium
in [**Hospital1 756**] and [**Hospital 63531**] Hospital [**2125-7-21**] showed an enhancing mass
in the optic chiasm and the right optic nerve. There was a spot
of enhancement as well as T2 and FL IR hyoerdensities in the
left cereberal peduncleand left insula.[**Doctor First Name **] any headcahe,
nausa, vomiting, seizure or fall. Patient was placed on a
dexamethasone without any imporovement on his vision. Patient
refeered to Dr [**Last Name (STitle) **] by Dr [**Last Name (STitle) 724**] for surgical evaluation. After
long discussion with patient benefits, risk of surgery by Dr
[**Last Name (STitle) **] patient and family decided to have an elective surgery.
Past Medical History:
HTN
Hyperlipidemia.
Social History:
lives with wife, fully independent with [**Name (NI) 5669**] at home prior to
surgery.
Tobacco: 1PPDx20 years.Quit in [**2090**].
ETOH:occ
Family History:
Strong family hsitory of esophageal CA.(grandmother, sister,
first cousin w/ esophageal CA).
Physical Exam:
Vital signs: 97.3 76 16 195/58 98% RA preo holding area.
GEN: elderly man NAD, [**Doctor Last Name **]=[**Doctor First Name **] in strecther.
SKIN:good turgor tonus, no ecchymosis.
HEENT: neck supple, no coratid bruits, sclera unicteric/no
hemorrhage.
CVS: RRR, S1/S2, No M/G/R.
CHEST: CTA A/P bilat.
ABD: soft, nontender, nondistended, bowel sounds present.
EXT: no edema, no clubbing, PP+/bilat.
NEURO: alert, awake, orientedx3.
Language fluent with good comprehension.
CN: pupils are equal reactive to light, 4 mm to 2 mm
bilaterally.
There is no afferent pupillary defect. Extraocular movements
are full. Visual field examination shows a left hemianopsia in
OS and a left upper quadrantaposia in OD. Funduscopic
examination reveals sharp disks margins bilaterally, but his
right optic nerve is a slightly pale. His face is symmetric.
Facial sensation is intact bilaterally. His hearing is intact
bilaterally. His tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: He does not have a drift. His muscle
strengths are [**4-26**] at all muscle groups. His muscle tone is
normal. His reflexes are 0-1 bilaterally. His ankle jerks are
absent. Sensory examination is intact. Coordination examination
does not reveal dysmetria. His gait is normal. He does not have
a Romberg.
Pertinent Results:
[**2125-8-16**] GLUCOSE-167* UREA N-28* CREAT-0.8 SODIUM-133
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-13
[**2125-8-16**] CALCIUM-7.0* PHOSPHATE-3.5 MAGNESIUM-1.8
[**2125-8-16**] WBC-14.0* RBC-4.38* HGB-13.5* HCT-40.6 MCV-93 MCH-30.8
MCHC-33.3 RDW-13.4
[**2125-8-16**] PLT COUNT-117*
[**2125-8-16**] PT-12.7 PTT-21.0* INR(PT)-1.1
Head MRI;[**2125-7-21**]
Showed an enhancing lesion in the
right optic nerve, right optic tract, and the optic chiasm.
There was also an enhancing spot in the left parietal white
matter, as well as increase FLAIR and T2 signals in the left
cerebral peduncle and the left insula.
EEG: [**2125-8-20**]
Markedly abnormal portable EEG due to the persistent and
somewhat rhythmic bursts of slowing with some sharp features
broadly
over the right hemisphere. This suggests a focal subcortical
abnormality, likely of a structural or distructive nature. The
rhythmic
appearance of slowing and occasional sharp features raises
concern for
the possibility of lateralized epileptogenesis, but there were
no clear
seizures during the recording. An atomic correlation would be of
interest if clinically indicated. Reflective of some drowsiness,
over the left side.
Tissu Pathology ; [**2125-8-16**]
#1, OPTIC TRACK LESION BIOPSY (including intraoperative smear):
ANAPLASTIC ASTROCYTOMA with gemistocytic features.
WHO ([**2119**]) grade III out of IV.
Brief Hospital Course:
73 year-old male underwent right craniotomy for resection of
right optic track glioma, and tissue biopsy under general
anesthesia on [**8-16**]/5.No intraoperative complications occurred.
easily extubated. Patient closely monitored in the PACU for Q1
hour neuro check and SBP goal of 100-140 mmHg ovenight.Star [**Male First Name (un) **]
to taper his Decadron POD#1 to mg [**Hospital1 **] until [**Doctor Last Name **] in the brain
tumor clinic. Postop Head MRI with/without gadolinium revealed
status post craniotomy, mass in the optic chiasm is visualized.
No evidence of hemorrhage, mass effect or hydrocephalus. Signal
abnormalities in the brain stem and left insular region. No
evidence of acute infarct.
Patient developed hyponatremia on POD#3, Na 121, started 3%
sodioum IV fluid restriction initiated and salt tabs able to
normolize sodium level.On [**8-24**] Na:132 borderline low, continue
fluid restriction to 1000ml a day. Check serum sodium level
periodically in rehab. Advanced his diet as tolareted, able to
void without any difficulty.POD#5 ([**8-20**]) Patient had a
whitnessed seizure activity by staff, potable EEG showed
abnormal EEG, dilantin 1 gm load then, 100mg TID
started.Dilantin 7.6 [**8-22**], [**8-23**] Dilantin level 18 on current
dose.Reloaded and dose increased to 200mg [**Hospital1 **].
On [**2125-8-23**] on morning rounds patient was slow to respond on
neuro exam , repeated Head CT was stable, later in the day neuro
exam was better. Spiked a low grade fever 101 pan cultures
obtained. Urine dipsitick showed trace blood, tr ketone, tarce
protein, glucose 250, urobil: 12, no leukocit. blod culutere an
durine cultures are pending, if they becaome postive will
contact with patient for treatment.Bilateral lower extremity
doppler study was negative for DVT. Stures removed on [**2125-8-24**].
Dr [**Last Name (STitle) 724**] from Neurooncology seen him postop. He will follow him
up on [**2125-9-3**] in brain tumor clinic along with
radiation oncology and Dr [**Last Name (STitle) **].
Pyhiscal therapy consulted for ambulation and need for rehab. Pt
recommended that patient needs rehab for to regain his strenght
to maxiamize his safety at home.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): D/C when is off Decadron.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
10. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Rigth frontal glioma
Discharge Condition:
Neurologically stable.
Discharge Instructions:
Monitor for redness, swelling, darinage. Report fever greater
than 101, chills, seizure activity or any other neurologic
sypmtoms.
Fluid restrict 1000ml/24 hours until Na level normal.Lasr Na:
132 ([**8-24**]). Check Na level periodically until normal.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) 724**] in Brain [**Hospital 341**] clinic on
[**2125-9-3**] at 1600. Brain tumor clinic phone number is
[**Telephone/Fax (1) 1844**].
Please repeat urine analysis for trace blood, trace keton, trace
protein, glucose 250, Urobil:12 on [**2125-8-24**].
Completed by:[**2125-8-24**]
|
[
"5180",
"2724",
"4019"
] |
Admission Date: [**2146-6-27**] Discharge Date: [**2146-7-7**]
Date of Birth: [**2097-5-28**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old
gentleman who presented to an outside hospital with stiff
neck and severe headache. He states that the headache
started about 6 pm on the day of admission, treated with
ibuprofen without relief, and a few hours later stated the
stiff neck came on suddenly like gang busters. He went to
[**Hospital6 2561**] where a CT showed a posterior
communicating artery aneurysm rupture, and the patient was
transferred to [**Hospital6 256**] for
further management.
MEDICATIONS ON ADMISSION: Lipitor 10 mg qd.
PAST MEDICAL HISTORY: Hypercholesterolemia.
ALLERGIES: No known allergies.
PHYSICAL EXAM: He was afebrile, BP 149/89, heart rate 97,
SATs 96 percent on room air.
HEENT: Pupils were equal, round and reactive to light. EOMS
were full.
NECK: Supple. No masses. He had a stiff neck. His
strength was [**6-8**] in all muscle groups. His sensation was
intact to light touch throughout. He had no drift. His fine
finger movements were intact.
STUDIES: He had a CTA which was inconclusive, unable to
localize the bleed.
HOSPITAL COURSE: Therefore, the patient was admitted to the
ICU and underwent an arteriogram on [**2146-6-27**] which showed
no evidence of intracranial aneurysm. He was transferred to
the regular floor on [**2146-6-29**]. He had a couple of episodes
of sinus tachycardia which resolved spontaneously. His vital
signs remained stable. His neurologic exam remained intact,
awake, alert, oriented x 3. Following commands x 4. Speech
was fluent with no weakness and still complains of stiff neck
and actually leg pain.
He did have Dopplers done on [**2146-7-5**] which were negative
for DVT. He had a repeat angiogram on [**2146-7-2**] which,
again, showed no evidence of aneurysm, but a small amount of
vasospasm. The patient was monitored for signs and symptoms
of vasospasm of which he developed none, and he was
discontinued of his IV fluid, remained neurologically intact,
and was discharged to home on [**2146-7-7**] in stable condition,
with follow-up with Dr. [**Last Name (STitle) 1132**] in 2 weeks.
MEDICATIONS AT TIME OF DISCHARGE:
1. Nimodipine 60 mg po q 4 h prn.
2. Hydromorphone 2-6 mg po q 4 h prn.
3. Colace 100 mg po bid.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2146-7-7**] 10:47:57
T: [**2146-7-7**] 11:20:22
Job#: [**Job Number 93681**]
|
[
"2720",
"42789"
] |
Admission Date: [**2153-10-21**] Discharge Date: [**2153-10-23**]
Date of Birth: [**2099-10-24**] Sex: F
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: This 53-year-old female fell
down a flight of wooden stairs after drinking alcohol that
evening, had positive LOC and incontinence, complained of
headache and back pain. The patient landed on her back and
hit her head on the wall.
PAST MEDICAL HISTORY:
1. Breast cancer.
2. Hypertension.
MEDICATIONS:
1. Tamoxifen.
2. Atenolol.
3. Paxil.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco, moderate alcohol use, no IV drug
use.
PHYSICAL EXAMINATION - VITALS: Temperature 98.7, heart rate
101, blood pressure 131/71, respirations 18, O2 saturation
96%.
GENERAL: Alert and oriented x 3. GCS 15.
HEENT: Hematoma over left occiput. Pupils equal, round and
reactive to light. TM clear. Trachea midline. No JVD.
LUNGS: Clear to auscultation bilaterally. Chest nontender.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft, nontender, nondistended.
PELVIS: Stable.
EXTREMITIES: Nontender, no deformity, palpable pedal pulses.
BACK: Tenderness over lumbar spine.
RECTAL: Normal tone, guaiac negative.
NEURO: No focal deficit. Cranial nerves II through XII
intact.
LABORATORIES: Sodium 143, potassium 3.6, chloride 110,
bicarb 29, BUN 17, creatinine 1.2, glucose 198, white blood
cell 5.4, hematocrit 34, platelets 152. [**Name (NI) 2591**] - PT 12, PTT
19, INR 1. Serum tox - ETOH 51. UA negative.
FILMS: CT head - right frontal subarachnoid hemorrhage
versus interparenchymal bleed, no mass effect. CT C-spine
negative. Chest x-ray negative. Pelvis negative. Thoracic
and lumbar spine negative.
HOSPITAL COURSE: The patient was transferred from the
Emergency Department to the Trauma SICU for q 1 h neuro
checks and observation. The patient remained stable in the
ICU overnight.
On hospital day #2, a repeat head CT was obtained which
showed a stable intracranial hemorrhage. The patient was
transferred to the floor, tolerating regular diet and full
activity. An MRI of the head was obtained which showed a
resolving hematoma. The patient was cleared by neurosurgery
for discharge with follow-up head CT and CT angiogram.
A neuro rehab consult was obtained, and it was determined
that the patient does not appear to have any need for neuro
rehabilitation. An addiction consult was obtained, and the
patient was counseled on her alcohol use. The patient was
discharged on [**2153-10-23**].
DISCHARGE DIAGNOSES:
1. Intracranial hemorrhage.
2. Status post fall.
3. Breast cancer.
4. Hypertension.
DISCHARGE MEDICATIONS:
1. Tylenol #3, [**2-8**] po q 4-6 h prn.
2. Ibuprofen 600 mg 1 po q 6-8 h prn.
3. Docusate 100 mg po bid prn.
Resume home medications:
4. Tamoxifen.
5. Atenolol.
6. Paxil.
FOLLOW-UP: The patient was advised to follow-up with Dr.
[**Last Name (STitle) 739**] (neurosurgery) in 1 month. Call ([**Telephone/Fax (1) 88**]
to arrange appointment. The patient was also advised that
she needs to obtain a head CT prior to this appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Name8 (MD) 50285**]
MEDQUIST36
D: [**2153-10-23**] 10:56
T: [**2153-10-23**] 10:01
JOB#: [**Job Number 50286**]
|
[
"4019"
] |
Admission Date: [**2154-10-30**] Discharge Date: [**2154-10-31**]
Date of Birth: [**2091-1-19**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Exercise intolerance
Major Surgical or Invasive Procedure:
Catheterization and stenting
History of Present Illness:
This is a 63 y.o. patient of Dr [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 7842**] and Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] with CAD s/p CABG x 3 [**11-6**] (LIMA-LAD, Lrad-OM1, and
sVG-PDA), HTN, Hypercholesterolemia, Gout, and a family history
of CAD (brother with MI and CABG in his 50's). He has done very
well since his surgery and a stress test in [**2153-4-4**] which
revealed mild anterolateral ischemia which did not impair his
LV.
He was asymptomatic at that time, continuing to be very active
running and swimming, and further work up was deferred.
He states that prior to CABG he did experience
with angina with reported chest discomfort with exertion. Since
his CABG, he has had rib cage tenderness and pain that occurs
with
any movement. When he palpates the area of tenderness it
resolves. He denies any true angina discomfort since his
surgery.
Two months ago the patient noted decreasing activity that his
times in running and swimming were increasing. He did not have
any difficulty breathing or special fatigue, but simply could
not keep up to his recent paces. The patient mentioned this to
his physician during his annual physical exam. He also recently
noted an increase in gastric reflux and burping,although he
denies any formal diagnosis of GERD. Because of his physician's
concern, he underwent a nuclear stress which revealed ST
depressions along with a drop in his blood pressure during
exercise. He did not experience any chest discomfort. He now
presents for cardiac catheterization.
.
Past Medical History:
Dyslipidemia, Hypertension
CABG: x3 [**11-6**] (LIMA-LAD, Lrad-OM1, and sVG-PDA)
CAD
HTN
Hyperlipidemia
Gout
Hemorrhoids
Abdominal aortic ulceration
Social History:
The patient lives with his wife in [**Name (NI) 932**], MA. He is a
professor [**First Name (Titles) **] [**Last Name (Titles) **] [**Location (un) 86**].
-Tobacco history: None
-ETOH: Prior history of heavy alcohol use , but sober more than
15 years
Family History:
Brother with MI and CABG in 50s.
Physical Exam:
Admission Exam
VS: BP 119/53 HR 54 100% sat on room air
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. CN III-XII grossly intact.
NECK: Supple, no JVD noted.
CARDIAC: RR, normal S1, S2. No murmurs, rubs, gallops
auscultated. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. No
accessory muscle use. CTA bilaterally; no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, bowel sounds positive
EXTREMITIES: No femoral bruit auscultated on right femoral cath
site. No hematoma felt.
PULSES: radial/pedal pulses 2+
Pertinent Results:
[**2154-10-30**] 03:47PM UREA N-12 CREAT-1.1 SODIUM-139 POTASSIUM-4.3
CHLORIDE-104 TOTAL CO2-30 ANION GAP-9
[**2154-10-30**] 03:47PM CK(CPK)-57
[**2154-10-30**] 03:47PM CK-MB-4
[**2154-10-30**] 03:47PM PLT COUNT-213
Cardiology Cath note pending
Brief Hospital Course:
This is a 63 y.o. M h/r CAD s/p CABG x 3 [**11-6**] (LIMA-LAD,
Lrad-OM1, and
sVG-PDA), HTN, Hypercholesterolemia, Gout, and a family history
of CAD (brother with MI and CABG in his 50's) who presents to
[**Hospital1 18**] with positive nuclear stress test and admitted for cardiac
cath. Pt noted 2 months of decreased activity tolerance and
underwent nuclear stress test which revealed ST depressions and
drop in BP during exersize.
.
# CORONARIES: Had cardiac cath procedure. The patient was
ballooned in circumflex, some dissection, unable to deliver
stents into distal OM1. Balloon/stented left main with 2.5 x 12
Endeavor (DES), small OM dissection, good flow. Patient received
integrillin for 18 hours.
He was then started on [**10-31**] with loading dose of 60 mg
Prasugrel, followed by a daily regimen of 10 mg for at least 30
days. Patient started on ASA once desensitized. Pt will follow
up with cardiology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to decide whether or not to
continue with Prasugrel or switch to plavix.
.
# Aspirin desensitization
Patient underwent aspirin desensitization protocol outlined by
Allergy. Patient received his daily dose of 325 mg ASA after the
end of the desensitization protocol (which also has a 325 mg
dose) and was asymptomatic of allergy before discharge.
Tryptase level sent, per Allergy recommendation, and will need
to be followed up outpatient.
.
# Hypertension
Continued atenolol from home medications.
.
# Hyperlipidemia
Continued Crestor therapy at home dose.
.
# Gout
Continued allopurinol therapy.
Medications on Admission:
ALLOPURINOL - (Prescribed by Other Provider) - 300 mg Tablet -
1
Tablet(s) by mouth DAILY (Daily)
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
CLOPIDOGREL - (Prescribed by Other Provider) - 75 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth at bedtime
Discharge Medications:
1. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
CAD s/p drug eluting stent in the left main artery
Aspirin Desensitization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after having an abnormal
stress test. A cardiac catheterization procedure was performed
and a stent was placed in a vessel of the heart to improve blood
flow. You tolerated the procedure well. You were desensitized of
your aspirin allergy and are now able to take aspirin every day.
Please make sure to take 325mg of aspirin every day. You will
also need to take Prasugrel 10mg every day to protect your heart
and to keep the stent open.
Please STOP your daily Plavix.
Please START: Prasugrel 10mg daily and START Aspiring 325mg
daily.
You will follow up with your cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Followup Instructions:
Please make sure to follow up with your cardiologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], within the next few days.
|
[
"41401",
"4019",
"2720",
"V4581"
] |
Admission Date: [**2146-1-21**] Discharge Date: [**2146-2-7**]
Date of Birth: [**2120-2-26**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Nausea and vomitting
Major Surgical or Invasive Procedure:
PICC
History of Present Illness:
This is a 25 year old female transferred from [**Hospital3 **]
for acute pancreatitis and nausea and vomiting. She presented to
the ED on [**2146-1-17**] with sudden onset of severe epigastric pain and
vomiting (several episodes of non-bloody,non-bilious). She
denied HA, CP, SOB, dizziness, changes in bowel or bladder
habits. At the OSH, she had a CT scan that was consitent with
moderate pancreatitis, without evidence of ductal dilation or
necrosis. A RUQ US showed no evidence of biliary
obstruction/sludge/stones. She developed acute mentl status
changes on the afternoon of [**2146-1-20**], possibly related to EtOH
withdrawl. She was then transferred here.
Past Medical History:
Ankle injury - takes Tylenol with codeine PRN
Social History:
Rare tobacco
1 glass wine daily
Family History:
Unknown
Physical Exam:
VS: 99.7, 127, 153/59, 31, 96% 2L
Gen: NAD
Neuro: A+O x 3
HEENT: PEERL, EOMI intact
CV: reg rhythm, tachy
Chest: CTA bilat
Abd: mod distended, TTP, min BS
Ext: WWP without C,C,E. +2 DP bilat.
Pertinent Results:
[**2146-1-21**] 01:25AM BLOOD WBC-9.8 RBC-3.40* Hgb-11.1* Hct-32.9*
MCV-97 MCH-32.7* MCHC-33.7 RDW-13.9 Plt Ct-88*
[**2146-1-25**] 05:10AM BLOOD WBC-28.4*# RBC-3.31* Hgb-10.7* Hct-31.9*
MCV-96 MCH-32.2* MCHC-33.4 RDW-14.5 Plt Ct-366#
[**2146-1-31**] 04:00PM BLOOD WBC-21.5* RBC-3.13* Hgb-9.8* Hct-29.6*
MCV-95 MCH-31.2 MCHC-33.0 RDW-14.4 Plt Ct-620*
[**2146-2-1**] 06:15AM BLOOD WBC-25.8* RBC-3.42* Hgb-10.5* Hct-32.7*
MCV-96 MCH-30.6 MCHC-32.0 RDW-14.4 Plt Ct-866*
[**2146-1-31**] 04:00PM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-133
K-4.5 Cl-96 HCO3-26 AnGap-16
[**2146-1-21**] 01:25AM BLOOD ALT-20 AST-32 AlkPhos-45 Amylase-90
TotBili-0.6
[**2146-2-1**] 06:15AM BLOOD ALT-36 AST-49* AlkPhos-96 Amylase-35
TotBili-0.4
[**2146-1-21**] 01:25AM BLOOD Lipase-118*
[**2146-1-27**] 11:43AM BLOOD Lipase-132*
[**2146-2-1**] 06:15AM BLOOD Lipase-93*
[**2146-1-21**] 01:25AM BLOOD Albumin-2.8* Calcium-7.6* Phos-1.9*
Mg-1.9 Iron-8*
[**2146-2-1**] 06:15AM BLOOD Albumin-3.3* Calcium-9.5 Phos-5.1* Mg-2.3
[**2146-1-31**] 04:00PM BLOOD calTIBC-183* Ferritn-942* TRF-141*
CT HEAD W/O CONTRAST [**2146-1-21**] 3:07 PM
[**Hospital 93**] MEDICAL CONDITION:
25 year old woman with confusion
REASON FOR THIS EXAMINATION:
unremarkable.
IMPRESSION: No acute intracranial pathology, including no sign
of intracranial hemorrhage. Please note if high suspicion for
intracranial mass, CT examination is not sensitive and an MRI
would be recommended.
.
CHEST (PA & LAT) [**2146-1-25**] 10:29 AM
INDICATION: 25-year-old female with pancreatitis and left
pleural effusion. ? pneumonia.
IMPRESSION:
1. Unchanged moderate left-sided pleural effusion.
2. Left lower lobe consolidation, most likely representing
atelectasis.
3. Small right-sided subpulmonic pleural effusion.
.
CHEST (PORTABLE AP) [**2146-1-27**] 9:11 AM
[**Hospital 93**] MEDICAL CONDITION:
25 year old woman with pancreatitis, fevers, room air sat 87%
REASON FOR THIS EXAMINATION:
Interval change. Assess for effusion/PNA?
IMPRESSION: AP chest compared to [**2146-1-25**]:
There has been no recent interval change. Moderate left pleural
effusion and large area of consolidation at the base of the left
lung and a smaller region of consolidation on the right medially
are unchanged. Small right pleural effusion may also be present.
Upper lungs are clear. The heart is normal size. Tip of the left
PIC catheter projects over the mid SVC. No pneumothorax.
[**2146-2-6**] 05:47AM BLOOD WBC-13.8* RBC-3.08* Hgb-9.5* Hct-29.4*
MCV-95 MCH-30.7 MCHC-32.2 RDW-14.3 Plt Ct-705*
[**2146-2-6**] 05:47AM BLOOD Glucose-88 UreaN-16 Creat-0.7 Na-138
K-4.8 Cl-103 HCO3-24 AnGap-16
[**2146-2-6**] 05:47AM BLOOD ALT-31 AST-27 AlkPhos-67 Amylase-31
TotBili-0.2
[**2146-2-6**] 05:47AM BLOOD Lipase-78*
[**2146-2-6**] 05:47AM BLOOD Calcium-9.2 Phos-5.6* Mg-2.1
IGG SUBCLASSES 1,2,3,4
Test Result Reference
Range/Units
IGG 1 [**Telephone/Fax (1) 70863**] MG/DL
IGG 2 181 35-477 MG/DL
IGG 3 46 15-135 MG/DL
IGG 4 36 4-158 MG/DL
IGG 648 L [**Telephone/Fax (1) **] MG/DL
Brief Hospital Course:
She was admitted to the ICU with pancreatitis. She was made NPO,
with IVF.
CV: She was tachycardic to the 130's and hypertensive in the
150's. She was hemodynamically stable. She was treated with
several boluses of fluid for hypovolemia and also placed on
Lopressor. She continued with Lopressor and her HR was WNL.
Resp: A CXR revealed left pleural effusion. Slight improvement
in right infrahilar consolidation. There was a question of
possible pneumonia as a source of her high fevers. She received
Levofloxacin for 3 days until a repeat CXR showed no evidence of
pneumonia. Her lungs cleared over the next few days.
Pancreatitis: She had moderate to severe pancreatitis and
experiencing lots of pain. She had no stone disease by U/S. Her
Lipase was as high as 143 and then decreased to 78 at time of
discharge. The other enzymes were WNL. She had a slow recovery
and was treated conservatively.
Fever + elevated WBC: She had fevers for several days, as high
as 103, and a WBC as high as 28,000. These persisted for several
days. All blood, stool, and urine cultures were negative. She
was treated with Tylenol. This was all likely due to the
pancreatitis. She was not treated with antibiotics, but instead
let the pancreatitis run its course and slowly she recovered.
FEN: She was NPO. a PICC line was placed and she was started on
TPN. She continued on TPN until [**2146-2-4**]. Her PO diet was slowly
advanced, starting with sips on [**2146-2-3**] and advanced to a
regular diet. She did not have a rise in her enzymes and so
continue to take a diet.
Pain: She was having lots of abdominal pain on admission. She
was treated with IV Dilaudid. A PCA Dilaudid was started and she
continued to need high doses of pain medications. A Pain Consult
was obtained and she received Tylenol, Ibuprofen, Amitriptyline.
Anxiety: She was very anxious on admission. She was placed on a
CIWA scale and received Ativan per the scale for possible EtOH
withdrawl. A Head CT was performed and showed No acute
intracranial pathology, including no sign of intracranial
hemorrhage. She reportedly had mental status changes at the OSH
prior to transfer to [**Hospital1 18**]. She received Valium for anxiety and
this was then switched to Ativan.
Pancreatology Consult: Dr. [**Last Name (STitle) 174**] saw and examined this patient.
Fevers were likely related to cytokine mediated inflammation.
Other differential included: increased triglycerides, CFTR
mutation mediated, autoimmune pancreatitis, sphincter of oddi
dysfunction. She will follow-up with Dr. [**Last Name (STitle) 174**] in [**8-26**] weeks.
Medications on Admission:
OCP, tylenol prn
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for 2 weeks.
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain and fever.
Disp:*qs Tablet(s)* Refills:*0*
4. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for pain and insomnia for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for 1 months.
Disp:*75 Tablet(s)* Refills:*0*
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Fevers
Tachycardia
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Please resume all of your regular medications and take any new
meds as ordered.
.
Continue to ambulate several times per day.
.
You should avoid all alcohol consumption.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 70864**] (GI - [**Hospital1 **]
Gastroenterology) in [**2-19**] weeks. Call ([**Telephone/Fax (1) 70865**] to schedule
an appointment.
Please follow-up with your PCP [**Last Name (NamePattern4) **] 2 weeks. You were started on
Lopressor for your HR. Discuss whether this needs to be
continued.
Please follow-up with Dr. [**Last Name (STitle) 174**] (Pancreatologist) in 8 weeks.
Call ([**Telephone/Fax (1) 22346**] to schedule an appointment.
Completed by:[**2146-2-7**]
|
[
"2875",
"4019"
] |
Admission Date: [**2166-6-11**] Discharge Date: [**2166-6-14**]
Date of Birth: [**2089-8-17**] Sex: F
Service: MED
CHIEF COMPLAINT: Short of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
Portugese speaking only female treated at [**Hospital6 36598**] with a history of prolonged intubation after sepsis
in [**11/2165**] status post multiple failed extubations,
complicated by laryngeal edema status post tracheostomy
discontinued two months ago. She reports two to three months
of shortness of breath on home O2, two liters nasal cannula.
On [**6-9**], she was acutely short of breath, gasping for air
and admitted to [**Hospital3 **] on [**6-9**]. She had a cough
productive for white sputum; no fevers or hemoptysis.
White blood cell count of 19.6 and no bands. She was
recently started on steroids on [**6-5**]. She was noted to have
inspiratory and expiratory stridor, hypercapnia on admission.
Temperature of 98.5 F.; pulse 101, respiratory rate 20, blood
pressure 118/70; O2 saturation 99 percent on 3.5 liters nasal
cannula and chest x-ray with mild congestive heart failure.
Neck film with normal epiglottis. EKG atrial fibrillation
with right ventricular strain patterns. [**Hospital3 **] course
with ABG at 07:06, 135, 98, 95 percent on 100 percent non
rebreather, placed on BiPAP at 10:04. ABG improved. Since
then, she has been transferred to [**Hospital1 190**] for a repeat bronchoscopy, CT scan of the
neck, possible repeat tracheostomy.
Here she had a bronchoscopy and was found to actually have
tracheal stenosis and since then has had a tracheal stent
placed by Interventional Pulmonary and has done well since.
She is now transferred back to the Medicine floor and now
being transferred back to [**Hospital6 14576**] for further
care.
PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease.
Diastolic dysfunction.
Multiple admissions for congestive heart failure.
Atrial fibrillation.
Diabetes mellitus.
Hyperlipidemia.
Osteoarthritis of the left knee.
History of pneumonia.
Hemicolectomy for benign mass.
History of laryngeal edema per extubation for bronchoscopies
in the past.
History of granulating wound infection in abdominal wall.
History of a left buttocks decubitus ulcer.
Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy, cholecystectomy, hemorrhoidectomy.
ALLERGIES: Penicillin.
SOCIAL HISTORY: No tobacco or ethanol. She lives in [**Location (un) 38520**], [**Location (un) 3844**]. Home one week prior to admission. At
baseline, she walks with a walker.
HOSPITAL COURSE: CENTRAL AIRWAY OBSTRUCTION: Since she has
been here, she had bronchoscopy and was found to have
tracheal stenosis which was stented without any
complications. The patient tolerated it well. Also, the
patient had a history of hypercapneic respiratory failure /
chronic obstructive pulmonary disease and is a known CO2
retainer from past admissions. Currently she is well
compensated on six liters and was weaned off of her O2.
Given that she is a chronic retainer her best O2 saturation
was to keep between 90 and 93 percent or the low 90s. She was
doing well and she has actually done well and was weaned off
the oxygen and is now having saturation in the low 90s on
room air. Also, her steroid was weaned down per Pulmonary
Team each day by about 25 percent. Further taper at the
discretion of the outside hospital. Continue with Albuterol,
ipratropium; discontinued theophylline given in narrow
therapeutic window. Her hypoxia has actually resolved since.
Given the history of atrial fibrillation, she was restarted
back on her Coumadin with the goal of 2.0 to 2.5 INR to be
adjusted at the outside hospital.
Congestive heart failure: Asymptomatic currently. Obtain
echocardiogram at the outside hospital.
Uncontrolled SVT, coronary artery disease: To continue
Lopressor, Imdur; no aspirin at the time.
Diabetes mellitus: Regular insulin sliding scale and
actually restarted back on her Metformin and her other
diabetic medications; see Page one.
Infectious Disease: Was discontinued off of Levofloxacin.
Psychiatric: Continued on Zoloft, BuSpar and Ativan.
Kept on diabetic diet, NPO. Vitals were stable.
CONDITION ON DISCHARGE: She is discharged to the outside
hospital in stable condition.
DISCHARGE INSTRUCTIONS:
1. Per Interventional Pulmonary, to continue guiafenesin 1200
twice a day.
2. Final recommendation to followup also anemia with outside
hospital for an anemia workup.
FINAL DIAGNOSIS: Tracheal stenosis status post bronchoscopy
and stent placement.
Chronic obstructive pulmonary disease.
Congestive heart failure with known diastolic dysfunction.
Diabetes mellitus.
Hyperlipidemia.
Eventual wound healing left buttocks decubitus ulcer, see
page one for further details.
DISCHARGE MEDICATIONS:
1. Warfarin 6 mg p.o. q day; INR between 2.0 and 2.5 goal.
2. Albuterol.
3. Ipratropium.
4. Sertraline.
5. Isosorbide 30 q day.
6. Metoprolol 25 twice a day.
7. Pantoprazole 40 q day.
8. Docusate 100 twice a day.
9. Magnesium hydroxide p.r.n.
10. Buspirone 10 mg p.o. twice a day.
11. Acetaminophen p.r.n.
12. Furosemide 40 mg p.o. twice a day.
13. Metformin 500 mg p.o. three times a day.
14. Replignoride 2 mg, one tablet p.o. twice a day with
meals only.
15. Insulin sliding scale to continue.
16. Dexamethasone now at 3 mg intravenously q. 12; taper
at the discretion of the outside hospital team.
17. Guaifenesin 1200 mg tablet q 12 hours per
Interventional Pulmonary.
The patient has a central line which is going to stay in
place and removed at the discretion of the outside hospital.
FOLLOW UP: Interventional Pulmonary will call the patient
for further followup. Also other followup with primary care
physician in [**Name Initial (PRE) **] week or two once discharged from the outside
hospital.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 2019**]
Dictated By:[**Name8 (MD) 12818**]
MEDQUIST36
D: [**2166-6-14**] 16:18:48
T: [**2166-6-14**] 18:25:30
Job#: [**Job Number 55832**]
|
[
"496",
"4280",
"42731",
"25000",
"2724"
] |
Admission Date: [**2133-1-21**] Discharge Date: [**2133-2-3**]
Date of Birth: [**2132-12-17**] Sex: F
Service: NBB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Name2 (NI) **] [**Known lastname 60258**] is the 1340
gram product of a 29 and [**5-16**] week gestation born to a 30 year
old gravida II, para 0, now [**Name (NI) 1105**], mother after Clomid induced
pregnancy. For further details of her prenatal and initial
postnatal history, please see interim discharge summaries
dated [**2132-12-20**], and [**2133-1-13**]. In short, Baby Girl [**Name2 (NI) **]
[**Known lastname 60258**]'s course has been complicated by a left colon
perforation which required ileostomy. The perforation
occurred on [**2132-12-20**], during a contrast enema and she
underwent her ileostomy at [**Hospital3 1810**] the same day.
She remained at [**Hospital3 1810**] postoperatively until
[**2133-1-12**], when she had been advanced to half feeds and was
felt to be stable for regular transfer to [**Hospital1 346**]. When she returned to [**Hospital1 346**] on [**2133-1-12**], she was noted to be
lethargic with increased apneic episodes. A sepsis
evaluation was performed which revealed gram negative rod
bacteremia. She was transferred back to [**Hospital3 1810**]
for potential further surgical management. During her stay
at [**Hospital3 1810**], she was treated with ten days of
Gentamicin and Zosyn for Enterobacter sepsis. She was felt
to have ileus in relation to her sepsis but once that had
improved, she was restarted on her feeds and advanced back to
full feedings. While there, she was also transfused once
with packed red blood cells and was continued on her caffeine
therapy for apnea of prematurity. She also had an eye
examination on [**2133-1-19**], which showed immature retina with
no retinopathy of prematurity. She was transferred back to
[**Hospital1 69**] on [**2133-1-21**].
PHYSICAL EXAMINATION: On admission, in general, the Baby
Girl [**Name2 (NI) **] [**Known lastname 60258**] was pink and comfortable in room air. Head,
eyes, ears, nose and throat examination revealed anterior
fontanelle that was soft and flat and nasogastric in place.
Her lungs were clear to auscultation bilaterally. Her heart
was regular rate and rhythm without a murmur and with two
plus femoral pulses. Her abdomen was soft, nondistended,
nontender, with bowel sounds present, and with a pink
ileostomy site covered by a bag with soft yellow stool. Her
extremities were well perfused.
HOSPITAL COURSE: Respiratory - Baby Girl [**Name2 (NI) **] [**Known lastname 60258**] has
remained in room air since her transfer back to [**Hospital1 346**] Neonatal Intensive Care Unit. She
was initially continued on her caffeine therapy for apnea of
prematurity, having 0-1 apneic episodes a day. The caffeine
was discontinued on [**2133-1-27**], as she had had no further spells.
Cardiovascular - Baby Girl [**Name2 (NI) **] [**Known lastname 60258**] has been hemodynamically
stable during this stay with normal perfusion and blood
pressure. She is routinely noted to have a soft intermittent
murmur which is consistent with peripheral pulmonic stenosis.
Fluids, electrolytes and nutrition - On return from
[**Hospital3 1810**], the infant was on full feeds of breast
milk 22 at 140 cc/kg/day, taking alternate p.o. and PG feeds.
Over her first week of hospitalization here, she was advanced
on calories to breast milk 30 with ProMod at 150 cc/kg/day.
She was weaned to breast milk or similac 26 cal/oz prior to
discharge. She was making good weight gain on those feeds. She
has been continued on her Reglan therapy to improve her motility
and she stools easily and regularly through her ileostomy.
Hematologic - Baby Girl [**Name2 (NI) **] [**Known lastname 60258**] has not had any blood
transfusions since returning from [**Hospital3 1810**] on
[**2133-1-21**]. Her hematocrit on [**2133-1-30**] was 29.4 with a
reticulocyte count of 2.
Ophthalmology - Baby Girl [**Name2 (NI) **] [**Known lastname 60258**] last underwent eye
examination on [**2133-1-19**], at [**Hospital3 1810**] where she
was revealed to have immature retina. She had a follow up exam
on [**2133-2-2**] at [**Hospital1 18**] which showed immature retina bilaterally.
She is due for a follow up exam in three weeks.
Neurologic - A thirty day head ultrasound was performed on
[**2133-1-28**], and was normal.
Condition at time of discharge- Good.
Condition at the time of discharge- Good.
Discharge disposition to home
Name of Primary care pediatrician [**First Name8 (NamePattern2) 24592**] [**Last Name (NamePattern1) 60260**] at [**Location (un) **]
Medical Group phone ([**Telephone/Fax (1) 60261**] FAX ([**Telephone/Fax (1) 60262**].
Feeds at discharge Similac 26 cal/oz or Breast Milk 26 cal/oz
(extra calories with Similac powder and corn oil)
Medications: Iron 0.2 ml of 25 mg/ml and reglan 0.2 mg po every 8
hours.
State Newborn Screen Sent [**2132-12-20**] and [**2133-1-28**]
Immunizations Received: Hepatitis B #1 [**2133-1-23**], Synagis [**2133-1-30**]
Immunization Recommendations: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] throught [**Month (only) 547**] for infants who meet any
of the following three criteria: 1) born at <32 weeks: 2) born
between 32 and 35 wks with 2 of the following: day care during
RSV season, a smoker in the household, neuromuscular disease,
anirway abnormalities, or shcool age siblings: or 3) with chronic
lung disease
Influenza immunization is recommended annually in the fall for
all infants once they reach 6 months of age. Before this age (and
for the first 24 months of the child's life), immunization
against influenza is recommended for housdhold contacts and
out-of-home caregivers
Follow up appointment: Primary care pediatricain [**2133-2-2**],
Opthamology Dr [**Last Name (STitle) 60268**] [**Name (STitle) 60269**] [**2133-2-19**].
Surgical follow up with Dr. [**Last Name (STitle) 60270**] at [**Hospital3 1810**] on
[**2133-2-10**] Phone ([**Telephone/Fax (1) 60271**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 60272**] Ostomy nurse at [**Hospital3 1810**] as needed phone
([**Telephone/Fax (1) 60273**].
DISCHARGE DIAGNOSES: Prematurity at 29 and 5/7 weeks
gestation.
Status post Apnea of prematurity.
Status post Immature feeding.
Status post colonic perforation with ileostomy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Doctor Last Name 56593**]
MEDQUIST36
D: [**2133-1-29**] 12:45:29
T: [**2133-1-29**] 19:20:55
Job#: [**Job Number 60274**]
|
[
"V053"
] |
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