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Admission Date: [**2167-1-27**] Discharge Date: [**2167-1-30**]
Service: MEDICINE
Allergies:
Vasotec / Niacin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 86 y.o. male with pmh significant for CAD s/p
PCI to LAD, LMCA and LCX in [**2163**], chronically occluded RCA with
L->R collaterals, dilated cardiomyopathy of [**11-5**]% presenting to
his outpatient Cardiologist with several weeks of lethargy, and
found to be bradycardic with HR in the 30's. EKG in office
showed Junctional bradycardia at a rate of 30, blood pressure
60/palp. He was given atropine 2mg with increased Hr to 40's,
and then transferred to the ED. In the ED his HR remained in the
30-40's with blood pressure of 110/50. He developed an increased
oxygen requirement with O2 saturation 60-70% on NRB. Head CT was
performed to rule out CVA as cause of bradycardia and was found
to be negative for acute bleed. Patient was also found to be in
acute renal failure with creatinine of 5.5 from baseline 2.5.
His potassium was also initially found to elevated at 9.0 in a
hemolyzed sample. Repeat K was 5.0. Diqoxin level was found to
be 0.7. Repeat K was 5.0. Given his progressive hypoxia he was
intubated with O2 saturation of 100% on FiO2 100%. In the ED his
rhythm alternated between sinus and junctional bradycardia.
His vitals were HR 37-39, blood pressure (77-116)/(33-46). He
was given aspirin, atropine, sodium bicarbonate, insulin 10
units, an amp of D50, albuterol nebs.
Per medical records, the patient has been hospitalized several
times in the past for both acute on chronic congestive heart
failure and acute renal failure attributed to poor forward flow
from CHF. he was most revcently admitted from [**2166-12-18**] through
[**2166-12-25**], during which he was diuresed 10L in the CCU on a lasix
drip with BP support from milrinone and phenylephrine. Upon
discharge, bumex was added and torsemide was discontinued. On
[**1-13**] the patient had increased creatinine detected on routine
labs, which resulted in a decrease of his bumex from 4mg to 3mg
PO BID. He then experienced a 5lb increased weight gain and had
his bumex increased to 4mg PO BID on [**2167-1-23**].
.
Per wife, patient has had increased confusion over past three
days, in addition to abdominal pain and diahrrea.
Past Medical History:
1 CAD: s/p PCI to LAD, LMCA and LCX in [**2163**]; chronically
occluded RCA with L->R collaterals
2 History of Colon cancer - last scope [**2162**] with polyp
3 Atrial fibrillation/flutter - on coumadin
4 History of Basal cell carcinoma
5 Mitral valve replacement [**1-/2164**] - (#29 Perimount Thermafix
pericardial valve).
6 Hypertension
7 Gout
8 Peripheral vascular disease (PVD)
9 Mild aortic stenosis
10 History of deep venous thrombosis - IVF filter placed [**2163**]
11 Hypercholesterolemia
12 Spinal stenosis
13 Familial hand tremor
14 Hernia repair, R-side inguinal
15 Cataract repair, last [**2165-8-14**]
16 Nephrolithiasis
17 Chronic kidney disease ( baseline Cr 2-2.7 per recent labs)
Social History:
- Former orthodontist.
- Smoked until early 40s at 1-1.5 packs/day since age 22. Denies
smoking since. Denies drinking.
- Lives with wife in [**Location (un) 55**].
Family History:
- Father had heart attack at age 60.
- Denies history of CA, diabetes in family.
Physical Exam:
BP : 95 / 46 mmHg
Weight: 70.2 kg
T current: 94 C
HR: 45 bpm
RR: 12 insp/min
O2 sat: 100 % on Supplemental oxygen: FiO2 .40
Eyes: Conjunctiva and lids: WNL
Ears, Nose, Mouth and Throat: Oral mucosa: left pupil dilated
5cm, reactive. right pupil 3mm, minimally reactive
Neck: Jugular veins: JVP, 9cm
Respiratory: Effort: Abnormal, intubated, Auscultation:
Abnormal, crackles
Cardiac: Rhythm: Regular, Auscultation: S1: WNL, S2: normal,
Murmur / Rub: Absent
Abdominal / Gastrointestinal: bowel sounds: WNL, Pulsatile mass:
No, Hepatosplenomegaly: No
Extremities / Musculoskeletal: Dorsalis pedis artery: Right:
dopplerable, Left: dopplerable, Posterior tibial artery: Right:
dopplerable, Left: dopplerable, Edema: Right: 2+,
Pertinent Results:
Admission labs:
[**2167-1-27**] 02:40PM WBC-7.7 RBC-4.19* HGB-10.4* HCT-32.5* MCV-78*
MCH-24.7* MCHC-31.9 RDW-22.1*
[**2167-1-27**] 02:40PM NEUTS-69.1 LYMPHS-16.7* MONOS-7.3 EOS-6.5*
BASOS-0.4
[**2167-1-27**] 02:40PM GLUCOSE-101 UREA N-109* CREAT-5.5*#
SODIUM-130* POTASSIUM-9.5* CHLORIDE-100 TOTAL CO2-18* ANION
GAP-22*
[**2167-1-27**] 02:40PM CALCIUM-8.8 PHOSPHATE-6.9*# MAGNESIUM-3.0*
Cardiac labs:
[**2167-1-27**] 02:40PM CK(CPK)-217*
[**2167-1-27**] 02:40PM CK-MB-6
[**2167-1-27**] 02:40PM cTropnT-0.12*
[**2167-1-27**] 08:03PM proBNP-[**Numeric Identifier 101895**]*
[**2167-1-28**] 03:05AM BLOOD CK-MB-NotDone cTropnT-0.13*
Brief Hospital Course:
**The patient expired on [**2167-1-30**].**
An 86 man with a history of CAD, dilated cardiomyopathy with
LVEF 15%, presented with junctional bradycardia, hypoxia,
hypothermia, hypotension.
.
#Hypotension: MAP on admission was 55. Recent vitals from
outpatient records show baseline BP 95/40. Hypotension was
likely secondary to systolic congestive heart failure. BNP
elevated at >24 000 was consistent with this. Sepsis was also
on the differential, and vancomycin and zosyn were initially
started. No arterial line or central line was placed because of
elevated INR 7.9 on admission. Peripheral dopamine and fluid
boluses were initially given to maintain MAP >60. He became
hypertensive with frequent ectopy. Dopamine was weaned off and
levophed briefly added as a bridge to milrinone which was also
started. After conversation with his wife, the decision was
made to pursue comfort measures only. All pressors were
stopped. The patient became progressively more hypotensive and
expired.
.
#Bradycardia: On admission he was fluctuating between sinus and
junctional bradycardia. Contributions likely included hypoxia,
hypothermia, and acute renal failure. Cardiac ischemia was on
the differential as well, but EKG without ischemic changes and
elevated troponin likely [**2-23**] renal failure. Pressors were
initiaed as above. Peripheral dopamine was initially started to
maintain MAP >60. This was changed to milrinone as above.
.
#Respiratory Status: He was intubated for hypoxic respiratory
failure in ED, was 70% on NRB. CXR with pulmonary infiltrates
suggestive of CHF. He was not diuresed because of hypotension.
He oxygenated well on the ventilator with 100% FiO2. After
comfort measures were initiated, the decision was made in
conversation with his wife to extubate. Shortly after
extubation he expired.
.
#Acute renal failure: Creatinine was 5.5, up from baseline of
2.5. This was likely secondary to exacerbation of congestive
heart failure with low cardiac output with a possible component
of overdiuresis. [**Month/Day (2) **] lytes showed a pre-renal state. Renal
was consulted and saw no need for CVVH or HD.
.
#Hypothermia: A bear hugger was placed. Infection was suspected
as a cause. His wife was reporting three days of confusion,
abdominal pain and diahrrea. Sputum grew staph aureas. Blood
and [**Month/Day (2) **] cultures as well as stool for c diff were negative.
He was initially treated with vancomycin and levofloxacin.
These were stopped when comfort measures only was initiated.
.
# Coronaries: History of CAD s/p PCI to LAD, LMCA and LCX in
[**2163**], and chronically occluded RCA with L->R collaterals. EKG
was without ischemic changes, troponin was elevated, likely
secondary to renal failure, but CK was normal and there was low
suspicion for acute ischemia.
.
#Bullous Pemphigoid: Minocycline and hydroxyzine were in setting
of acute illness. Sarna cream was continued.
Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Digoxin 125 mcg Tablet Sig: [**1-23**] Tablet PO DAILY (Daily).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*2 tubes* Refills:*0*
6. Minocycline 50 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*0*
8. Bumetanide 2 mg Tablet Sig: 2 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
9. Hydroxyzine HCl 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for itchiness.
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2167-1-31**]
|
[
"51881",
"5849",
"4280",
"41401",
"42789",
"40390",
"5859"
] |
Admission Date: [**2189-5-18**] Discharge Date: [**2189-5-27**]
Service: Cardiac Surgery
CHIEF COMPLAINT: Syncopal episodes.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 33754**] is a 78-year-old
male with a known history of aortic stenosis, non-insulin
dependent diabetes mellitus and hypertension who was
transferred from an outside hospital for cardiac
catheterization. They evaluated aortic stenosis after he
sustained a syncopal episode while driving. He was admitted
under the medical team for a cardiac catheterization.
PAST MEDICAL HISTORY: Aortic stenosis, asbestosis,
non-insulin dependent diabetes mellitus, hypertension,
arthritis.
PAST SURGICAL HISTORY: Status post appendectomy.
ALLERGIES: None known.
MEDICATIONS: On admission, Glyburide 5 mg q d, Prednisone 5
mg q d, Albuterol, Lisinopril 2.5 mg q d, Protonix 40 mg q d,
Aspirin 81 mg q d.
HOSPITAL COURSE: The patient was admitted on the cardiac
medicine service and [**Known lastname 1834**] a cardiac catheterization
which revealed severe three vessel disease and mild aortic
stenosis. Cardiac surgery was consulted at this point and
the decision to take him to the operating room was made. Mr.
[**Known lastname 33754**] [**Last Name (Titles) 1834**] a CABG times three on [**2189-5-21**] with LIMA to
LAD, RSVG to right RCA PD, RSVG to ramus. He tolerated the
procedure well and was taken to the CSRU in a stable
condition, intubated and on intra-aortic balloon pump. He
was slowly weaned off his pressors and extubated on
postoperative day #1. His chest tubes were discontinued on
postoperative day #2. On postoperative day #3 he was
considered stable for transfer to the floor. His subsequent
hospital stay was uneventful. His pacing wires were
discontinued on postoperative day #4. He was ambulated to a
level V and was ready for discharge on postoperative day #6.
Pain was well controlled with po analgesics and his chest
incision was healing well.
DISCHARGE MEDICATIONS: Lasix 20 mg q d times one week, KCL
20 mEq q d times one week, Colace 100 mg [**Hospital1 **], Aspirin,
enteric coated 325 mg q d, Glyburide 5 mg q d, Protonix 40 mg
q d, Amiodarone 400 mg q d times one month, Lopressor 25 mg
[**Hospital1 **], Percocet 1-2 tablets q 4-6 hours prn, Prednisone 5 mg q
d, Albuterol inhaler.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2189-6-4**] 16:13
T: [**2189-6-5**] 09:01
JOB#: [**Job Number **]
|
[
"41401",
"4241",
"25000",
"4019"
] |
Admission Date: [**2109-3-28**] Discharge Date: [**2109-4-5**]
Date of Birth: [**2041-12-10**] Sex: F
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
stridor
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with baloon dilation of tracheal stenosis
History of Present Illness:
67 yo woman with DM, HTN, myasthenia [**Last Name (un) 2902**] initially admitted
to Neurology for stridor, now being transferred to the MICU for
continued management of stridor.
.
The patient was recently admitted to [**Hospital1 18**] [**Date range (3) 89696**] for
management of a myasthenic crisis. During that admission, the
patient was in the Neuro ICU. She was intubated for eight days
during that stay. She was treated with plasmapheresis and
immunomodulators, cellcept, mesthinon and prednisone. Her
symptoms improved and she was discharged to rehab. She was
discharged from rehab on Saturday and felt in her normal state
of health until Tuesday night. On Tuesday, she felt acutely
short of breath.
.
In the ED, ENT was consulted who was able to rule out upper
respiratory source of stridor. They thought that she had
evidence of mild edema from reflux. She was admitted to the
Neuro service for observation. She was treated with racemic
epinephrine, however did not have complete relief. As her
stridor did not improve, Pulmonary was consulted. They were
concerned about her respiratory status and thought she should be
monitored more closely in the MICU.
.
Before the patient arrived in the MICU, a CT neck/chest was
performed which showed evidence of severe tracheal narrowing
distal to the vocal cords. She feels persistent dyspnea, worse
with expiration.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
.
Past Medical History:
- MG - diagnosed about 3 years ago with body weakness, diplopia,
dysarthria, has only been on Mestinon 60 mg QID
- DM
- HTN
- HLD
Social History:
Lives at home with a husband but she indicated that
their relationship was strained. She is a long term smoker,
smoked 1PPD for 50
years, has cut down to 1/4 pack over last few years. No etoh,
no
drugs
Family History:
No family history of MG or other neurological
diseases. Some DM in the family.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: significant stridor, louder with inspiration than
expiration, MMM
Lungs: stridor heard through all lung fields, no wheezes,
rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2109-4-5**] 07:35AM BLOOD WBC-9.8 RBC-3.73* Hgb-12.0 Hct-35.4*
MCV-95 MCH-32.0 MCHC-33.8 RDW-15.5 Plt Ct-302
[**2109-3-28**] 01:15PM BLOOD WBC-8.5 RBC-3.72* Hgb-11.6* Hct-34.8*
MCV-93 MCH-31.1 MCHC-33.2 RDW-15.2 Plt Ct-546*
[**2109-3-28**] 01:15PM BLOOD Neuts-55.1 Lymphs-35.1 Monos-7.2 Eos-1.7
Baso-0.9
[**2109-4-4**] 06:30AM BLOOD PT-11.4 PTT-34.7 INR(PT)-0.9
[**2109-3-28**] 01:15PM BLOOD PT-12.8 PTT-24.0 INR(PT)-1.1
[**2109-4-5**] 07:35AM BLOOD Glucose-161* UreaN-23* Creat-0.7 Na-140
K-4.6 Cl-103 HCO3-26 AnGap-16
[**2109-3-28**] 01:15PM BLOOD Glucose-133* UreaN-18 Creat-0.6 Na-140
K-4.1 Cl-101 HCO3-27 AnGap-16
[**2109-3-28**] 01:15PM BLOOD CK(CPK)-18*
[**2109-3-28**] 01:15PM BLOOD cTropnT-<0.01
[**2109-4-4**] 06:30AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.2
[**2109-3-28**] 01:15PM BLOOD Calcium-8.8 Phos-4.4 Mg-2.0
[**2109-3-28**] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2109-3-28**] 03:15PM BLOOD Type-ART pO2-206* pCO2-43 pH-7.45
calTCO2-31* Base XS-5
.
CHEST XRAY IMPRESSION: No acute cardiopulmonary abnormality.
.
CT TRACHEA
IMPRESSION:
1. Focal, fixed stenosis of the trachea at the level of the
thoracic inlet as characterized above.
2. Secretions in the right main stem bronchus as well as in the
right lower lobe bronchus, with resultant air trapping in the
right lower lobe.
3. Coronary arterial calcification.
Brief Hospital Course:
HOSPITAL COURSE
67 yo female with history of myasthenia [**Last Name (un) 2902**], DM, HTN, HLD,
Glaucoma and cataracts with recent hospitalization for MG crisis
s/p intubation, admitted for stridor, found to have significant
tracheal narrowing. Underwent ballowing for tracheal narrowing.
Pt was discussed with neurology attending Dr. [**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **]
who agreed to coordinate follow up during a rapid prednisone
taper in preparation of reconstructive tracheal surgery in the
near future. Pt was ultimately scheduled to follow-up in
musculoskeletal neurology clinic for management of taper.
.
ACTIVE ISSUES
# Tracheal Narrowing: Likely secondary to intubation during
recent hospitalization. The patient's symptoms improved with
heliox, likely because of improvement in turbulent flow. IP
consulted and took patient to OR she was foujnd to have tracheal
narrowing to 5mm. Balloon dilation was completed post procedure
diameter was 1.2cm. Her stridor returned with exertion the
following day. A second bronchoscopy revealed 1.0cm and stable.
Her stridor was stable for the duration of the hospital stay.
Combined follow-up with IP and thoracic surgery arranged for 2
weeks post discharge for discussion of recontructive surgery. A
rapid prednisone taper was initiated to prepare for surgery.
.
# Myasthenia [**Last Name (un) **]: Well controlled after recent crisis.
Continued on prednisone, Mycophenolate Mofetil 500 mg PO BID,
Pyridostigmine Bromide 60 mg PO/NG Q6H, (per neurology will need
to be on this medication for prolonged period of time until
cellcept is therapeutic). Prednisone was tapered in preparation
for future surgery. Follow-up with outpatient neurology was
arranged to manage medication therapy in setting of recent
crisis and plan for prednisone taper.
# HLD: Continued Pravastatin 10 mg PO DAILY
.
# DM: Continued metformin and insulin, when restart diet will
give diabetic
.
# HTN: Continued valsartan.
.
# Glaucoma: Lumigan *NF* (bimatoprost) 0.03 % OU QHS
.
TRANSITIONAL ISSUES
Medical Management: Rx for albuterol given for symptoms of
wheeze, prednisone taper
Follow-up: PCP, [**Name10 (NameIs) 1092**] Surgery and IP
Medications on Admission:
Aspirin 81 mg PO/NG DAILY
Pravastatin 10 mg PO DAILY
Docusate Sodium 100 mg PO BID
Acetaminophen 650 mg PO/NG Q6H:PRN pain, temp > 100.4
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Mycophenolate Mofetil 500 mg PO BID
traZODONE 50 mg PO/NG HS:PRN insomnia
Pyridostigmine Bromide 60 mg PO/NG Q6H
Pantoprazole 40 mg PO Q24H
MetFORMIN (Glucophage) 500 mg PO BID
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Nicotine Patch 7 mg TD DAILY
Valsartan 40 mg PO/NG DAILY
Lumigan *NF* (bimatoprost) 0.03 % OU QHS
Insulin SC (per Insulin Flowsheet) Sliding Scale
Ipratropium Bromide Neb 1 NEB IH Q4H:PRN wheezing
PredniSONE 60 mg PO/NG DAILY Start: In am
Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
Calcium Carbonate 500 mg PO/NG TID W/MEALS chewable
Vitamin D 400 UNIT PO/NG [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, temp > 100.4.
5. ibuprofen 100 mg/5 mL Suspension Sig: Four (4) mL PO every
six (6) hours as needed for headache.
6. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-9**]
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. pyridostigmine bromide 60 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
10. sennosides 12 mg Capsule Sig: One (1) Capsule PO twice a day
as needed for constipation.
11. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
13. latanoprost 0.005 % Drops Sig: One (1) both eyes Ophthalmic
at bedtime.
14. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. prednisone 10 mg Tablet Sig: Take 5 tablets for 3 days, then
take 4 tablets for 3 days, take 3 tablets for 3 days, take 2
tablets for 3 days and then take 1 tablet for 3 days, then STOP
Tablet PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*0*
18. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-9**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing for 10 months.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Tracheal Stenosis
Secondary
1. Myasthenia [**Last Name (un) 2902**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of stridor. You were admitted
to the medical intensive care unit. Imaging revealed focal
narrowing in your trachea, tracheal stenosis. This occured
likely as an unfortunate complication of your recent intubation
while hospitalized previously for myasthenia [**Last Name (un) 2902**]. Our
interventional pulmonologists performed a brochoscopy and were
able to balloon open this stenosis. Your stridor improved
however did not resolve. You were evaluated by a our thoracic
surgeons who will plan with interventional pulmonology surgical
reconstruction of your trachea. Before surgery, we will need to
discontinue your prednisone as this medication interferes with
wound healing. We discussed management of your myasthenia [**Last Name (un) 2902**]
with your neurology team. We discussed your admission with
neurology. Neurology will arrange follow-up with you as you
transition off prednisone.
It is safe for you to go home. It is important that you monitor
your symptoms closely. You will have stridor and some shortness
of breath with exercise as your tracheal stenosis still exists.
If you have any worsening of your symptoms, including acute
shortness of breath please return to the emergency department or
clinic depending on the severity of your symptoms.
The following changes were made to your medication list:
1. DECREASE prednisone by ten milligrams every 3 days:
Prednisone taper is 50mg x 3 days, 40mg x 3 days, 30mg x 3 days,
20mg x 3 days, 10mg x 3 days.
Followup Instructions:
Pt is scheduled to be seen in [**Hospital 7817**] Clinic on [**2109-4-10**]
Campus: EAST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Last Name (LF) 89697**],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
Address: 5 INDUSTRIAL DR [**Last Name (STitle) **], [**Location (un) **],[**Numeric Identifier 84441**]
Phone: [**Telephone/Fax (1) 89698**]
Appointment: Friday [**2109-4-12**] 2:00pm
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2109-4-23**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2109-4-23**] at 9:00 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Department: NEUROLOGY
When: THURSDAY [**2109-6-6**] at 2:30 PM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD [**Telephone/Fax (1) 541**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"25000",
"2859",
"4019",
"2724",
"V5867",
"V1582"
] |
Admission Date: [**2122-8-3**] Discharge Date: [**2122-8-21**]
Date of Birth: [**2050-4-7**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy by GI on [**2122-8-5**]
History of Present Illness:
72 year old female with history of COPD on home O2, ovarian CA
s/p TAH/BSO in [**2120**], recently discharged from [**Location (un) 620**] for
diarrhea and orthostasis, p/w continued diarrhea, dizziness and
abdominal pain.
Went to PCPs office on [**7-29**] with one month of watery diarrhea
and shortness of breath typical of her COPD flares. She was
admitted to [**Location (un) 620**] where she tested negative for C. Diff, was
hydrated with IV NS, and treated for a COPD flare with azithro
and a prednisone taper. Discharged [**8-1**] with referral to GI.
Called PCPs office day of admission requesting pain medication
for [**9-18**] abdominal pain. She had been taking ibuprofen for pain,
On BRAT diet and had been able to keep fluids and some food
down.
In the ED, initial VS: T 100.6 HR 136 BP 93/54 RR 20 SpO2
93%/RA. Labs significant for negative U/A, WBC 15, 11% bands, Na
128. Lactate 2.2. CXR shows bibasilar atelectasis ?
consolidation at bases. Abdominal pain resolved. Treated
empirically for CAP with azitho/ceftriaxone. Admitted for
hyponatremia, fever, leukocytosis.
Started on flaygl as the diarrhea was initially thought to be
caused by c. diff toxin. CT showed colitis/edema in ascending
and descending colon likely responsible for abdominal pain. GI
recommended flex sig and transfer to MICU for the procedure (see
below). During the course of hospital day 1, patient had
increasing oxygen requirement with a trigger at 1620 hours for
88% O2 sat on 4L NC. Resolved with nebs. Overnight patient had a
fever of 100.7, tachycardia to 140s and BP of 90/50s while on
albuterol nebs. VS reassuring nebs d/c'ed and vitals repeated.
Tachycardia and leukocytosis was concerning for sepsis and
antibiotics was broadened to Zosyn, Vancomycin, and
Azithromycin. COPD managed with predisone, nebs, and
fluticasone-salmeterol diskus.
Past Medical History:
- COPD, on home oxygen 3L
- ovarian CA (carcinosarcoma) s/p TAH/BSO [**3-20**], chemotherapy
- Anxiety
- compression fx t7-t8
- Hypertension
Social History:
- Smoked 40 pack years. One pack per day. Drinks approximately
ten drinks a week. Denies substance abuse. Lives with her
daughter.
Family History:
Negative for breast, ovarian, colon, or uterine cancer.
Physical Exam:
Physical Exam:
VS: T99.8, P117, BP114/65, RR35, O2Sat92% on 4L NC.
General: in mild pain
HEENT: sclerae anicteric, MMM, PERRL
Neck: supple, JVP not elevated, no LAD
CV: regular rate and rhythm, no rubs, murmurs, or gallops
Lungs: clear bilaterally, no wheezing, no crackles.
Abdomen: +BS, distended. painful to palpation diffusely. no
organomegaly.
Extremities: 2+ edema to calf
Neuro: awake, A&Ox3, moving all extremities
Discharge exam:
VS: T98.0, P96, BP152/76, RR18, O2Sat95% on 2L NC.
General: NAD, A&Ox3
HEENT: sclerae anicteric, MMM, PERRL
Neck: supple, JVP not elevated, no LAD
CV: regular rate and rhythm, no rubs, murmurs, or gallops
Lungs: clear bilaterally, rare fine crackles at bases
Abdomen: +BS, Soft, non-tender, non distended
Extremities: 1+ edema to knees bilaterally; R PICC site healing
well with palpable thin cord in R upper arm
Neuro: awake, A&Ox3, moving all extremities
Pertinent Results:
ADMISSION LABS:
[**2122-8-3**] 06:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2122-8-3**] 06:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2122-8-3**] 06:45PM URINE RBC-3* WBC-3 BACTERIA-FEW YEAST-NONE
EPI-3
[**2122-8-3**] 06:45PM URINE HYALINE-24*
[**2122-8-3**] 06:45PM URINE CA OXAL-RARE
[**2122-8-3**] 06:45PM URINE MUCOUS-RARE
[**2122-8-3**] 05:13PM LACTATE-2.2*
[**2122-8-3**] 05:10PM GLUCOSE-127* UREA N-12 CREAT-0.8 SODIUM-128*
POTASSIUM-3.9 CHLORIDE-91* TOTAL CO2-23 ANION GAP-18
[**2122-8-3**] 05:10PM estGFR-Using this
[**2122-8-3**] 05:10PM CA125-37*
[**2122-8-3**] 05:10PM WBC-15.5*# RBC-4.03* HGB-12.7 HCT-38.8 MCV-96
MCH-31.6 MCHC-32.9 RDW-12.9
[**2122-8-3**] 05:10PM NEUTS-80* BANDS-11* LYMPHS-6* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2122-8-3**] 05:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2122-8-3**] 05:10PM PLT SMR-VERY HIGH PLT COUNT-684*#
[**2122-8-3**] 05:10PM PT-14.8* PTT-26.5 INR(PT)-1.4*
[**2122-8-3**] EKG: Sinus tachycardia. Left anterior fascicular block.
Delayed precordial R wave
transition as a consequence. Compared to the previous tracing of
[**2122-3-11**] the
rate has increased. Otherwise, no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
139 146 82 292/430 63 -45 50
Discharge labs:
[**2122-8-21**] 08:20AM BLOOD WBC-7.2 RBC-3.12* Hgb-9.5* Hct-30.8*
MCV-99* MCH-30.6 MCHC-31.0 RDW-15.6* Plt Ct-832*
[**2122-8-13**] 03:35AM BLOOD PT-12.4 PTT-29.5 INR(PT)-1.1
[**2122-8-21**] 08:20AM BLOOD Glucose-88 UreaN-15 Creat-1.8* Na-136
K-4.3 Cl-101 HCO3-28 AnGap-11
[**2122-8-21**] 08:20AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9
Pertinent Micro:
Blood cultures neg ([**8-3**], [**8-4**])
Urine cultures neg, urine legionella Ag neg [**2122-8-3**]
Stool culture, O&P neg [**2122-8-4**]
c diff [**2122-8-16**] neg
MRSA screen [**2122-8-5**] neg
[**2122-8-9**] 3:12 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2122-8-11**]**
GRAM STAIN (Final [**2122-8-9**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2122-8-11**]):
SPARSE GROWTH Commensal Respiratory Flora.
Pertinent Imaging:
[**2122-8-5**] CTA abdomen
IMPRESSION:
1. Minimal improvement in pancolonic bowel wall thickening
consistent with
colitis.
2. Sigmoid diverticulosis without evidence of diverticulitis.
3. Moderate celiac artery and SMA ostial stenosis. The
mesenteric vessels
are patent. No thrombus identified.
4. Left lower lobe collapse/consolidation with possible mucus
plug within the
left lower lobe bronchus.
5. Note is made of an accessory left hepatic artery arising
from the left
gastric artery.
6. New moderate right hydronephrosis and hydroureter without
definite cause
identified.
[**8-5**] CTA chest
IMPRESSION:
1. Minimal improvement in pancolonic bowel wall thickening
consistent with
colitis.
2. Sigmoid diverticulosis without evidence of diverticulitis.
3. Moderate celiac artery and SMA ostial stenosis. The
mesenteric vessels
are patent. No thrombus identified.
4. Left lower lobe collapse/consolidation with possible mucus
plug within the
left lower lobe bronchus.
5. Note is made of an accessory left hepatic artery arising
from the left
gastric artery.
6. New moderate right hydronephrosis and hydroureter without
definite cause
identified.
[**2122-8-5**] Flex Sig
Impression: Granularity, erythema and congestion in the splenic
flexure compatible with ischemic colitis (biopsy)
(biopsy)
Procedure done in ICU. Retained stool was washed away and bowel
wall was well seen. When the area of colitis was seen in the
splenic flexure we did not advace further so as to lesson chance
of complications so extent could not be assessed
Otherwise normal sigmoidoscopy to splenic flexure
[**2122-8-6**] TTE
The left atrium is elongated. No intracardiac right-to-left
shunting seen on 2D, color Doppler or saline contrast with
maneuvers. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF 60%). The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with normal free wall contractility. There is
abnormal systolic septal motion/position consistent with right
ventricular pressure overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a very small pericardial effusion. There
are no echocardiographic signs of tamponade.
[**2122-8-8**] pCXR
FINDINGS: Heterogeneous opacities in the left upper lobe have
progressed in
the interval and are now accompanied by confluent airspace
opacities in the
left perihilar region. Heart remains enlarged, and there is
also marked
enlargement of the central pulmonary arteries, likely due to
pulmonary
hypertension in the setting of severe upper lobe predominant
emphysema.
Small-to-moderate bilateral pleural effusions are also present
and may have
increased in the interval.
IMPRESSION: Worsening left upper lobe and juxta-hilar
opacities, concerning
for evolving infectious pneumonia in the appropriate clinical
setting.
[**2122-8-17**] Renal US
IMPRESSION:
1. Interval resolution of prior right hydronephrosis. No
suspicious renal
mass or stones.
2. Minimal right perinephric free fluid.
[**2122-8-17**] KUB
Dilated colon and small bowel likely due to ileus. Ahaustral
bowel consistent
with chronic colitis.
Brief Hospital Course:
72 yo F with COPD, ovarian CA, presented with persistent
diarrhea, abdominal pain and SOB was found to have colitis,
complicated by pneumonia.
# Ischemic colitis- Patient presented with severe abdominal pain
and persistent diarhea and was found to have ischemic colitis on
flexible sigmoidoscopy and CTA of the abdomen which showed
narrowing of the SMA and celiac arteries. Patien was in the MICU
for several days during this admission for hypotension, but did
not require intubation. She was evaluated by both ACS and GI and
surgery was not felt to be necessary. She had 4-6 episodes of
loose stools (c.diff and stool culture negative) daily after
tranfer to the MICU which was controlled with loperamide until
the development of an ileus as described below. She was
hemodynamically stable after transfer from the MICU. Upon
discharge to rehab she was having [**3-14**] bowel movements per day,
not on loperamide, no nausea with regular diet.
-Colonoscopy scheduled with GI in [**Month (only) **] for follow up
-Loperamide as needed, conservatively
#Ileus- Several days prior to discharge patient developed nausea
and was not passing flatus or having bowel movements. Upright
KUB on [**2122-8-17**] was consistent with ileus, lactate was not
elevated, no changes on EKG, cardiac enzymes negative, LFTs
normal. Resolved by keeping pt NPO and off loperamide for a day
with maintenance IVF.
-Conservative use of loperamide as outpatient
# Tachycardia- Etiology inclear. Initial presentation likely
related to hypovolemia, anxiety, and pain. Following transfer
from the MICU, she had occasional episodes of sinus tachycardia
to the 120's noted on telemetry. She remained HD stable and
asymptomatic throughout. Started on metoprolol with better rate
control of HR in 90s.
-Lisinpril, felodipine replaced with metoprolol succinate 50mg
daily
-Should be followed by PCP
# Pneumonia: Patient was dyspneic with new O2 requirement on
admission, CXR consistent with pneumonia, possible component of
COPD exacerbation. Following transfer from the MICU, she was
weaned to her home O2 requirement of 2L (erroneously noted on
admission to be 3L) with oxygen saturations in the high 90's.
She was treated with a 14 day course of antibiotics
(vanc/zosyn), ended on [**2122-8-17**].
She did not complain of discomfort or increased work of
breathing on discharge.
# [**Last Name (un) **]- Contrast induced nephropathy and ATN most likely, vs.
vancomycin-induced nephrotoxicity. Renal consult followed
patient and recommended continuing to hold ACEI on discharge. Cr
peaked at 2.5, was 1.8 at discharge (0.3-0.4 at baseline).
Improved with IVF and good PO intake.
-Continue to follow Cr outpatient with PCP
[**Name10 (NameIs) **] dose all medications, avoid nephrotoxins
-Lisinpril discontinued
# Coagulopathy: INR was elevated on presentation to the
hospital. Most likely secondary to antibiotics and poor
nutritional status. INR normalized following vitamin K
administration in the ICU.
# Depression/anxiety: Stable on this admission. She was
maintained on her home regimen of Buspar, and was additionally
given ativan PRN, about 0.5mg PO daily.
# Documented history of hypertension, lisinopril stopped for
[**Last Name (un) **], felodipine held, started on metoprolol for BP and rate
control in setting of tachycardia of unclear etiology.
-BP med changes and tachycardia should be followed by PCP
# Transitional issues for this patient include: Following
creatinine, rehabilitation with physical therapy, GI follow up
for full colonoscopy.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler [**2-9**] PUFF IH Q6H:PRN wheezing/sob
2. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
3. Felodipine 5 mg PO DAILY
hold for sbp < 90
4. Lisinopril 20 mg PO DAILY
hold for sbp < 90
5. Tiotropium Bromide 1 CAP IH DAILY
6. Aspirin 81 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. BusPIRone 10 mg PO BID:PRN anxiety
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BusPIRone 10 mg PO BID:PRN anxiety
3. Multivitamins 1 TAB PO DAILY
4. Albuterol Inhaler [**2-9**] PUFF IH Q6H:PRN wheezing/sob
5. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
6. Tiotropium Bromide 1 CAP IH DAILY
7. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
epigastric pain
8. Famotidine 20 mg PO DAILY
9. Nystatin Oral Suspension 5 mL PO QID thrush
10. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 533**] Centre for Extended Care
Discharge Diagnosis:
Primary: Ischemic colitis complicated by ileus
Secondary: health care-associated pneumonia
Chronic Obstructive Pulmonary Disease Exacerbation
acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were hospitalized for treatment of your diarrhea, abdominal
pain, and shortness of breath. While you were in the hospital,
you had trouble breathing and your blood pressure became low. As
a result of these issues, you were transferred to the intensive
care unit (ICU). While in the ICU, you intermittently required
more oxygen but did not need to be intubated. You were treated
for pneumonia and COPD exacerbation, and you received
antibiotics, and nebulizer treatments. You breathing improved,
and we were able to transfer you to the regular medicine floor,
where you were weaned to your home oxygen requirement.
While you were in the hospital you underwent a CT scan of your
abdomen, and a flexible sigmoidoscopy, both of which showed that
you have ischemic colitis, which was most likely the cause of
your diarrhea. This occurs when there is not enough blood flow
to the bowel. The surgeons did not feel you needed surgery. Your
symptoms were much improved over your stay here. It is important
that you have your full colonoscopy in [**Month (only) **], and that you
tell your doctor if your symptoms worsen.
During your stay you developed severe nausea, and an xray showed
an ileus, or slowing of the bowel, that was likely a result of
inflammation from colitis as well as the loperamide you were
taking for diarrhea. We stopped the loperamide and kept you from
eating and your symptoms resolved after a day.
Upon discharge, it was felt that you would benefit from a stay
at a rehabilitation center. We wish you the best at rehab.
Followup Instructions:
Department: DIGESTIVE DISEASE CENTER - colonoscopy
When: MONDAY [**2122-10-19**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5085**], 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
Department: GYN SPECIALTY
When: FRIDAY [**2122-10-23**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] [**Telephone/Fax (1) 5777**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2122-8-21**]
|
[
"486",
"5849",
"2851",
"4019"
] |
Admission Date: [**2189-3-14**] Discharge Date: [**2189-3-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Peri-orbital pain and swelling
Major Surgical or Invasive Procedure:
Incision and drainage of left nasal bridge mass
.
Biopsy of left nasal bridge mass
History of Present Illness:
[**Age over 90 **]yo M with h/o CAD, CHF, presenting from [**Hospital3 10310**]
hospital with possible periorbital cellulitis with question of
intracranial spread.
.
Mr. [**Known lastname 11286**] first presented to OSH with L nasal and
periorbital swelling over the 2-3 days prior to admission. His
son also notes that he has had some confusion over the last
week, which is atypical. He denies any recent trauma, denies
F/C/NS, headaches, dizziness, CP or SOB. His son does note
decreased appetite over the last few months, with 20lb weight
loss, and has started Ensure supplements. A CT was done, which
demonstrated a 2cm x 1.5cm mass or area of infection. Concerning
was the radiologist's read of air in the orbit, cavernous sinus,
and L jugular. AP CXR done, which was reportedly unremarkable.
He was also noted to be in AF (unclear chronicity - pt and son
unaware of AF diagnosis). He was started on meropenem, and
transferred to [**Hospital1 18**] ED for neurosurgical evaluation.
.
In the [**Hospital1 18**] ED, initial VS were T: 97.4F, BP: 116/79, HR: 122,
RR: 25, SaO2: 98% RA. On exam he was noted to have erythema and
nasal swelling and fluctuance along the L nasal bridge. He was
given a dose of vancomycin, and, on the recommendation of
neurosurgery, sent for a repeat head CTA. The CT demonstrated a
peripherally enhancing 2.1cm x 1.4cm soft tissue mass, which
could be neoplastic, infectious, or both. There were clear
paranasal sinuses, no erosion of the nasal bone, and no evidence
of intracranial involvement. Also seen were small air bubbles of
unclear etiology, in the right orbit, bilateral IJs, adjacent to
the R IJ at level of clavicle, R cavernous sinus, and in
subcutaneous tissues posterior to the left orbital well. While
in the ED, he was also noted to be in AF with RVR to 140s,
remained hemodynamically stable, and received diltiazem 15mg IV,
which lowered HR to 90s.
.
After reaching the floor, NF resident attempted needle
aspiration - obtained tiny amount thick, purulent fluid in
needle, but insufficient to send to lab. Plastics was
consulted, I and D was performed and [**3-18**] swab from the wound
grew coag negative staph. Dermatology biopsied lesion and
pathology is still pending.
.
On [**2189-3-19**] patient experienced increasing respiratory distress
in the setting of known CM w/ EF <20%, and was receiving IVFs
for contrast induced nephropathy (ARF post CT w/ contrast), and
a. fib w/ RVR. He was transferred to the CCU for further
management. Lasix drip was started as was digoxin with good
effect. He was transferred back to the floor on [**2189-3-22**] off
lasix drip and maintaining O2 sats on room air.
Past Medical History:
CAD - silent MI 30ya.
HTN
Cardiomyopathy
Congestive heart failure, EF <20%
Alcohol abuse
Emphysema
Gout
BPH
h/o PUD s/p gastrectomy [**2174**]
Subdural hematoma [**2176**] [**1-30**] MVA, c/b DVT
Dementia
Social History:
Former fisherman. Quit smoking 50ya. 1-2 drinks/day.
Family History:
NC
Physical Exam:
T: 96.0F BP: 115/83 HR: 73 RR: 18 SaO2: 97% RA
Gen: Gaunt, Caucasian gentleman, lying comfortably in bed, NAD
HEENT: Notable for 2x3cm erythematous, fluctuant area along L
nasal bridge and extending supperiorly to periorbital region
above L eye, and L superior lid. PERRL, EOMI, no conjunctival
injection, no pain on eye motion. Area is slightly warm and
tender to touch. As above, attempted needle aspiration yielded
tiny amount thick, yellow fluid.
Neck: Supple, no LAD
CV: [**Last Name (un) **] [**Last Name (un) 3526**], no m/r/g
Chest: Barrel chest, distant BS, no w/r/r
Abd: Scaphoid, soft, NT/ND, +BS
Extr: No pedal edema, DPs 1+ bilaterally
Neuro: A&Ox3, strength 5/5 throughout
Pertinent Results:
CTA brain [**3-14**]:
2.1X1.4 cm soft tissue mass on the left side of the nose with
peripheral enhancement, which is non-specific, and can be
infectious or neoplastic or neoplasm with infection. Soft tissue
swelling in front of left orbit, which may be due to spread of
infection. Clear paranasal sinues and no erosion to the nasal
bone. No evidence of spread of infection in the brain on this
CTA.
.
Small air bubbles in the rt orbit, in the bilateral internal
jugular veins, adjacent to the rt IJV at the level of clavicle
(which may be outside of vessels or in the small branches),
right side of the cavernous sinus, and in the subcutaneous
tissue posterior to the left orbital wall, of unknown etiology.
Clinical correlation is recommended. Emphysema. Dr. [**Last Name (STitle) 11287**] was
informed. Official read awaits for 3D reformats.
.
TTE [**3-18**]: The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is markedly dilated. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated with severe global hypokinesis. No
masses or thrombi are seen in the left ventricle. The right
ventricular cavity is dilated with severe global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild to moderate ([**12-30**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate to severe (3+) mitral regurgitation
is seen. The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
.
CXR [**3-22**]: stable, no PNA/CHF
.
[**2189-3-14**] 08:00PM GLUCOSE-107* UREA N-39* CREAT-1.4* SODIUM-140
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-18
[**2189-3-14**] 08:00PM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-2.6
[**2189-3-14**] 08:00PM WBC-8.3 RBC-4.60 HGB-14.0 HCT-42.7 MCV-93
MCH-30.3 MCHC-32.7 RDW-15.7*
[**2189-3-14**] 08:00PM PT-13.3* PTT-25.8 INR(PT)-1.2*
[**2189-3-14**] 08:00PM PLT COUNT-124*
Brief Hospital Course:
[**Age over 90 **]M with h/o CAD, emphysema, gout, presenting with 2-3 day onset
of L nasal swelling, hospital course c/b hypoxia [**1-30**] to flash
pulmonary edema in setting of atrial fibrillation w/ RVR, and
IVFs for contrast induced nephropathy.
.
1. Nasal swelling: Differential included infection vs neoplasm
vs neoplasm with superimposed infection. Patient was initially
on vanco and zosyn for one week for presumed periorbital
cellulitis. Head CT showed no evidence of sinus involvement, but
did show unusual air bubbles in contralateral orbit, cavernous
sinus, as well as intravenously. Fluid collection was incised
and drained by plastics, frank pus was expressed. Gram stain
showed 1+ PMNs and cultures grew coag negative staph and
presumtive peptostreptococcus. Swelling improved, no
reaccumulation of fluid, incision site was healing well. Patient
continued to be afebrile with no leukocytosis. Presence of pus
was suggestive of infectious process. After first week of IV
vanc and zosyn, abx were switched to PO. Pt was on augmentin
since [**3-23**] for a total of 7 days (until [**3-29**]). Pathology was
still pending upon discharge. It is necessary to follow up on
these results.
.
2. Periorbital and intravascular air bubbles: Unclear etiology,
unclear whether clinically relevant. Possibly introduced during
contrast injection for CT study. Neurosurgery evaluated the
patient. Given no sign of intracranial involvement they
initially did not feel that there was anything to do, however
given air in cavernous sinus there was a concern for risk of
thrombosis. However, neurology evaluated the patient as well and
determined that risk of thrombosis was low, so no need for
anticoagulation. The patient's infection was treated as above.
It was felt that no other interventions were necessary at this
point.
.
3. AF with RVR: New diagnosis for patient. After acute
management, now rate-controlled on metoprolol and digoxin.
Patient with CHF, HTN, Age >75, so CHADS score shows increased
risk of thromboembolic event. However, because of potential need
for surgical intervention for above processes, anticoagulation
was held initially. Eventually, patient was started on coumadin
on [**3-23**] with heparin gtt for brigding. INR goal is [**1-31**]. Prior
discharge patient was started on lovenox for brigding as his INR
was still 1.4. Heparin drip was switched off at this point. His
first dose of lovenox was given on [**2189-3-25**] at 1.30pm. He should
continue lovenox (renally dosed, 60mg sc qd) until his INR is in
the therapeutic range on coumadin. His INR should be checked [**1-31**]
days after discharge at rehab and at least weekly thereafter.
His PCP has been informed of the necessity to check his INRs
after rehab.
.
4. ARF: Baseline Cr ~1.8 per PCP, [**Name10 (NameIs) **] trended up steadily since
admission, especially following CT with contrast. Renal was
consulted. Urine lytes were suggestive of prerenal azotemia. In
addition, patient did receive dye load on [**3-14**] which is likely
contributing to ARF (contrast-induced nephropathy). Renal U/S
showed no obstruction or hydro. Creatinine has eventually
started to come back down from a max of 3.9. Cr remained around
baseline since [**3-23**] (Cr even down to 1.5 on [**3-24**]). Patient
should follow up with nephrology after discharge. He has an
appointment scheduled.
.
5. Hypoxia: Triggered on the floor for hypoxia into the 80s, CXR
c/w with pulmonary edema. Likely multifactorial in the setting
of known CHF EF <20%, and was getting IVFs for acute on chronic
renal failure (prerenal as well as contrast induced
nephropathy). In addition, atrial fibrillation w/ RVR was
contributing. TTE during this hospitalization showed significant
systolic dysfunction with EF 20% as well as valvular disease
with MR, TR and AR. Patient diuresed well in the ICU on lasix
drip. Rate with improved control as above. Hypoxia resolved
(95-98% on RA) soon after this event. Home dose of Lasix (40mg
PO bid) should be restarted after discharge. Patient should
follow up with Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] at the [**Hospital 1902**] clinic after discharge.
An appointment has been scheduled.
.
6. CHF: with significant systolic dysfxn as above and valvular
disease. Patient was continued on BB and digoxin. In addition,
his ACEI was restarted once his renal fxn improved. He should
also be restarted on his home lasix after discharge. Patient
should follow up with Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] at the [**Hospital 1902**] clinic after
discharge. An appointment has been scheduled.
.
7. CAD: No evidence of active ischemia, however, patient has h/o
ischemic cardiomyopathy. TTE during this hospitalization showed
significant systolic dysfunction with EF 20% as well as valvular
disease with MR, TR and AR. Patient was continued on his BB. He
was not started on ASA as it was felt that it was not necessary
since he received adequate cardiac protection from Warfarin. His
ACEI was restarted once his renal fxn improved.
.
8. Anemia: Normocytic. Recent hct in the 35s. B12, folate were
wnl. Ferritin was 128, TIBC was 207. Fe/TIBC approx 60%, thus
likely ACD. Further workup as an outpatient recommended.
.
9. Thrombocytopenia: Stable around 100 to 150 (all values from
[**2-/2189**]; none prior to that month in OMR). Unclear etiology. It
was considered to d/c heparin products if platelets would have
been trending down further. However, they remained stable and
further w/u as outpatient is recommended.
.
10. Gout: Serum uric acid level was normal. Patient was not
currently on allopurinol. No allopurinol was initiated given his
acute on chronic renal failure. Outpatient management is
recommended after discharge.
.
11. FEN: Heart-healthy diet. Ensure supplements with meals.
.
12. Proph: Initially s.c. Heparin. Later heparin gtt and
coumadin until therapeutic INR. Then heparin drip switched off
and lovenox started.
.
13. Code: DNR/DNI - and, after discussion with family [**3-19**] - no
escalation of care: no central lines, and they declined dialysis
if it was needed. If pt. agitated, in pain, treat pain even at
risk of worsening resp. status, BP.
.
14. Contact: HCP: [**Name (NI) 122**] [**Name (NI) 11288**] (son), [**Telephone/Fax (1) 11289**]
Medications on Admission:
Outpatient meds:
ASA 81mg PO daily
Toprol XL 12.5mg PO daily
Ramipril 2.5mg PO daily
Allopurinol 150mg PO daily
Lasix 40mg, [**1-31**] daily
.
Meds on transfer:
Zosyn 2.25mg IV q6h
Vancomycin 1gm IV dose by level for trough <20
Digoxin 0.0625mg PO daily
Metoprolol 25mg PO bid
Calcitriol 0.25mcg PO every other day
Morphine sulfate 1mg IV q4h prn
Heparin 5000 Units SC tid
Atrovent nebs q6h
Thiamine 100mg PO daily
Docusate 100mg PO bid prn
Tylenol 325-650 PO q4-6h prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours): To be continued until [**2189-3-29**].
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous once
a day: Until your INR is therapeutic on coumadin.
12. Digoxin 125 mcg Tablet Sig: [**12-30**] Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
golden livingcenter
Discharge Diagnosis:
Primary:
1. Left nasal abscess
2. Atrial fibrillation with RVR
3. Coronary artery disease
4. Systolic Congestive heart failure (EF <20%)
5. Emphysema
6. BPH
7. Hypertension
8. Dementia
.
Secondary:
1. Gout
2. Peptic ulcer disease
3. Benign prostatic hyperplasia
Discharge Condition:
Stable, tolerating PO.
Discharge Instructions:
You have been treated for an infection of the soft tissue near
your left eye. You are on oral antibiotics now. Your blood is
also being thinned with medications (warfarin and temporarily
also lovenox) for your newly diagnosed heart condition called
atrial fibrillation.
.
Please call your doctor if you develop fevers, chills, worsening
swelling of the left side of your nose or increased pain,
changes in your vision, chest pain, shortness of breath or any
other symptoms that concern you.
.
Please follow up as outlined below.
Followup Instructions:
Please follow up with your primary care doctor ([**Last Name (LF) 8494**],[**First Name3 (LF) **] C.
[**Telephone/Fax (1) 11290**]) within a few days after your discharge from rehab.
He was informed to follow up on the INR after rehab.
.
Please also follow up with:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2189-4-2**] 8:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD ([**Hospital 2793**] clinic) Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2189-4-28**] 11:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] ([**Hospital 1902**] clinic) Phone:[**Telephone/Fax (1) 3512**]
Date/Time:[**2189-4-27**] 10:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"42731",
"5849",
"4280",
"5859",
"2875",
"40390",
"41401",
"2724"
] |
Admission Date: [**2167-2-21**] Discharge Date: [**2167-3-6**]
Date of Birth: [**2103-11-18**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
headache, nauesa/vomiting, vertigo
Major Surgical or Invasive Procedure:
Cerebellar lesion resection x2
EVD
VPS placement
History of Present Illness:
The pt is a 63-year-old RH woman with a history of non-small
cell
lung CA (stage IIIa, s/p chemo, XRT, and L upper lobectomy), PE
35 yrs ago, rheumatic fever in childhood, prior tobacco use who
presents with headache, nausea/vomiting, dizziness, and blurry
vision for the last 2 weeks. She reports a holocephalic
headache,
extending from the back of her head up to the front bilaterally
starting about 2 weeks ago. The headache is constant, not
throbbing, and worsens with any movement particularly when she
stands up. It does not seem to worsen with lying down and has
not
woken her from sleep. She says she used to get migraines but has
not had one in years; thinks this headahce feels somewhat
similar
but is atypical in its duration. In addition she has has
worsening nausea with vomiting, and for the last two days has
not
been able to keep anything down. She has also noticed that her
vision appears "cloudy" over the last week and a half. Upon
further questioning she says she thinks it appears double
sometimes but is unsure if the images are vertically or
horizontally displaced. She has not tried covering one eye to
see
if it improves. She is not sure if it is worse when looking
toward one direction or the other. Currently her vision seems a
little blurry but denies diplopia at the moment.
Within the last two days she has also begun to experience
dizziness, which she describes as the room spinning. She has
also
had difficulty walking and says she feels very unsteady on her
feet. Unsure if she is falling toward one side or the other. She
came into the ED today because she was continuing to feel worse
and was unable to keep down anything by mouth.
On neuro ROS, the pt reports headache, blurred/double vision,
vertigo, difficulty walking as above. Denies difficulty
speaking,
loss of vision, focal weakness, numbness/tingling, bowel or
bladder incontinence or retention.
On general review of systems, the pt reports frequent chills but
does not think she has had any fevers. Denies recent weight loss
or gain. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. +Nausea/vomiting, no abdominal pain.
has
not had a bowel movement over the last few days which she
attributes to not eating. No dysuria. Denies rash.
Past Medical History:
Lung cancer, stage IIIa (T1b, N2, M0)
- [**4-1**] persistent nonproductive cough, chest x-ray at that time,
which demonstrated a hilar mass
- [**2166-4-14**] chest CT confirmed the presence of a lobulated, left
suprahilar pulmonary mass with a large, left hilar and
aorticopulmonary window nodal conglomerate
- [**2166-5-1**] PET scan demonstrated FDG avid left upper [**Month/Day/Year 3630**] mass
and
2 FDG-avid left hilar masses, and left mediastinal
lymphadenopathy as well. No other sites of disease were noted.
- [**2166-4-30**] head CT negative for evidence of metastatic disease.
-- [**2166-5-9**] mediastinoscopy --> two left-sided (2L and the 4L
),
ipsilateral lymph nodes were positive for metastatic
undifferentiated carcinoma. Tumor cells stained positive for
TTF-1, cytokeratin 7, synaptophysin, were focally positive for
chromogranin and negative for CK20 and LCA, consistent with a
carcinoma of lung origin.
- [**Date range (3) 100411**] concurrent XRT and cisplatin/etoposide
- [**2166-8-28**] Left thoracotomy with left upper lobectomy, mediastinal
lymph node dissection, intercostal muscle flap buttress
PE 35 years ago in the setting of oral contraceptive use
History of rheumatic fever in childhood
Status post appendectomy many years ago
Left ORIF of the humerus following an MVC (was told she could
not
have an MRI due to metal in her arm)
Social History:
Single, lives with her brother in [**Name (NI) **]. Has a daughter and
a
grandson who live in [**Location (un) 5131**]. Used to work as a social
worker
for the state, has recently stopped working. She smoked one pack
a day for 40 years but quit on [**2166-5-2**]. She drinks
alcohol socially, but recently stopped.
Family History:
Mother had breast cancer in her 70s and heart
disease. She had three maternal aunts with breast cancer.
Father had diabetes. She has five siblings, no history of
cancer
in any of her siblings.
Physical Exam:
Admission Physical Exam:
Vitals: T 98.2 P 104 BP 113/71 RR 18 O2 100%
General: Awake, cooperative, appears somewhat uncomfortable.
HEENT: NC/AT, no scleral icterus noted, mucous membranes dry
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Awake and alert, appears tired and somewhat
uncomfortable. Oriented to place, initially says date is
[**2067-8-21**] but then corrects to [**2167-2-19**]. Unsure of day of
month, says 2nd and then 25th. Knows current president. Able to
relate history without difficulty. Language is fluent with
intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Speech was not dysarthric. Able to follow
both
midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch or pinprick throughout. No
extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
+?Mild dysmetria R>L on FNF initially.
-Gait: Deferred due to severe nausea, vertigo
Exam on Discharge:
Mental status varries, patient on and off confused
CN 2-12 grossly intact
Moves all extremities with good strength
Pertinent Results:
[**2167-2-21**] 12:50PM GLUCOSE-95 UREA N-22* CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
[**2167-2-21**] 12:50PM estGFR-Using this
[**2167-2-21**] 12:50PM CALCIUM-10.1 PHOSPHATE-3.3 MAGNESIUM-2.2
[**2167-2-21**] 12:50PM WBC-5.9 RBC-4.82 HGB-15.1 HCT-41.3 MCV-86
MCH-31.4 MCHC-36.7* RDW-12.8
[**2167-2-21**] 12:50PM NEUTS-84.9* LYMPHS-10.0* MONOS-3.8 EOS-0.6
BASOS-0.7
[**2167-2-21**] 12:50PM PLT COUNT-218
CT head noncontrast [**2-21**]:
IMPRESSION:
1. Two new posterior cranial fossa/cerebellar lesions, with
surrounding edema and mild mass effect on the fourth ventricle,
concerning for metastatic disease.
2. A new 1.1 cm mass lesion in the third ventricle, with mild
hydrocephalus, concerning for additional site of metastatic
disease. An MRI with contrast is recommended for further
evaluation.
CT head with contrast [**2-22**]:
1. Right cerebellar and third ventricle lesions are new from
[**2166-8-18**],
concerning for metastatic disease. If clinically feasible, MRI
is more
sensitive to detect small lesions and leptomeningeal disease.
2. The lateral ventricles are slightly enlarged compared to
[**2166-8-18**],
raising the possibility of mild hydrocephalus due to third
ventricle lesion.
MRI with and without contrast [**2-23**]:
Supra- and infra-tentorial as well as intraventricular
metastatic
disease, notably involving the left insular cortex, right
cerebellar
hemisphere, and third ventricle.
While the right cerebellar lesion is associated with significant
mass effect and distortion of the fourth ventricle, there is
currently no CSF obstruction or hydrocephalus. The third
ventricle lesion is located below the foramen of [**Last Name (un) 2044**] and
likewise does not cause hydrocephalus.
MRI C/T spine [**2-24**]
1. Compression fracture, with mild loss of height of the
Thoracic T5
vertebral body with marrow edema pattern. No retropulsion of the
fragments,
no canal or compression on the cord. While this has the
appearance of a
benign compression fracture, given the history, an associated
pathologic
lesion within the T5 body cannot be completely excluded.
Correlation with
radionuclide studies and CT is recommended. No enhancing lesions
in the cord.
2. Multilevel mild degenerative changes in the cervical spine
without
significant canal or foraminal stenosis.
3. A 3.3 x 3.5 cm nodular lesion in the lower neck/upper
mediastinum, new
since the prior CT chest of [**2166-11-27**]. This needs further
evaluation with CT chest, including the lower neck. There is
moderate amount of pleural
effusion/pleural thickening noted on the left side.
MRI [**Doctor Last Name **] [**2-26**] FINDINGS: Since the prior study, the patient has
undergone biopsy of the
right cerebellar hemispheric lesion. Expected postoperative
change are seen
with relatively extensive intralesional hemorrhage and a
circumscribed tissue
defect. The previously reported extensive vasogenic edema as
well as mass
effect on the fourth ventricle is largely unchanged.
The previously reported additional metastatic lesions within the
left insular cortex and third ventricle demonstrate no short
interval change. However, with less motion artefact and better
image quality further lesions measuringapproximately 3 mm are
identified in the posterior aspect of the left temporal [**Month/Day (4) 3630**] as
well as the left cerebellar hemisphere.
There is no evidence of acute infarction. Flow voids of the
major
intracranial vessels are preserved.
IMPRESSION:
1. Status post biopsy of right cerebellar mass with expteced
intralesional
hemorrhage.
2. No short-term interval change with regard to the left insular
cortex and third ventricle metastatic lesions.
3. Identification of additional small lesions within the left
posterior
temporal cortex as well as the left posterior medial cerebellar
hemisphere.
[**2-27**] CT FINDINGS: Patient is status post a right-sided
ventriculostomy catheter with tip terminating in the frontal
[**Doctor Last Name 534**] of the right ventricle. No associated intraparencymal or
intraventricular hemorrhage identified. Ventricles demonstrate
stable mild dilatation, unchanged from the prior CT.
The patient is status post a right suboccipital craniotomy with
partial
resection of a known right cerebellar mass. Again there is a
small amount of air and expected post-surgical hematoma at the
site of the recent surgical intervention in the posterior
cranial fossa with an increasingly hypodense appearance
consistent with evolution of blood products. A 2.8 x 2.3 cm
rounded hyperdense mass most suggestive of residual tumor,
better identified on the prior MRI, and is located just superior
to the resection site and unchanged. Known left insular cortical
mass is not well seen, and better evaluated on the MRI.
Surrounding vasogenic edema in the cerebellar
hemispheres persists but with minimally improved mass effect on
the patent
fourth ventricle. The known 1.1 x 1.0 cm hyperdense mass in the
third
ventricle is unchanged. No new parenchymal hematoma or infarct
present. The mastoid air cells, middle ear cavities and
visualized paranasal sinuses are clear.
IMPRESSION:
1. Status post partial resection of the right cerebellar mass
with a stable distribution of surrounding vasogenic edema though
with a slight decreased mass effect on the widely patent fourth
ventricle. Continued evolution of blood products within
post-surgical hematoma. Residual tumor as described above.
2. Interval placement of a right-sided ventriculostomy catheter
with tip in the right frontal [**Doctor Last Name 534**]. No intraparenchymal or
intraventricular hemorrhage identified. Stable mild dilatation
of bilateral lateral ventricles.
[**2-27**] CT ABD
FINDINGS: There is a new left paratracheal mass measuring 3.8 x
3.4 x 2.2 cm causing mild deviaiton of the trachea and left
carotid artery concerning for a lymphadenopathy due to
metastasis. There is no , axillary, mediastinal or hilar
lymphadenopathy evident. The central vessels are unremarkable.
Heart size is normal and without pericardial effusion. A small-
to moderate-sized hiatal hernia is evident. There is a small
left pleural effusion with thickened rind evident at the level
of the upper [**Month/Day (4) 3630**], indicating chronicity. Pleural blebs are
identified within the right lung apex. No significant
emphysematous changes are identified. Changes consistent with
left upper lobectomy and mediastinal lymph node dissection are
evident. Nonspecific ground-glass opacities with minimal
associated architectural distortion identified in the left lung
apex are increased compared to prior study and likely represent
post-radiation changes. Minimal dependent atelectasis in
dependent portions of both lungs.
The liver is homogenous in attenuation without discrete masses
or lesions. There is no intrahepatic biliary ductal dilatation.
The gallbladder, pancreas and spleen are normal. The bilateral
adrenal glands have normal limb thickness and are without convex
margin to suggest mass. The bilateral kidneys are normal in size
and excrete contrast symmetrically. The stomach, small and large
bowel are unremarkable. There is no retroperitoneal, mesenteric
or portacaval lymphadenopathy identified. Multiple small foci of
air are noted within the abdomen as well as a layering posterior
to the left rectus sheath muscle, likely due to recent insertion
of a right-sided ventriculoperitoneal shunt with tip ending
lateral to the liver. No free fluid identified within the
abdomen. The rectum, bladder, uterus and adnexa are
unremarkable. No pelvic sidewall or inguinal lymphadenopathy
identified. The aorta is of normal caliber throughout. The main
portal vein and its major tributaries are unremarkable.
No suspicious lytic or blastic lesions evident.
IMPRESSION:
1. New 3.8 cm left paratracheal mass concerning for metastasis.
2. Expected post-surgical changes in the left upper [**Month/Day (4) 3630**]
consistent with
lobectomy and mediastinal biopsy. Increased ground-glass
opacities with
associated architectural distortion evident within the left
upper [**Last Name (LF) 3630**], [**First Name3 (LF) **] be related to radiation changes, though
malignancy is not excluded.
3. Small left pleural effusion, likely chronic.
4. Interval placement of a right-sided ventriculoperitoneal
shunt with tip at the level of the liver and few intraperitoneal
gas bubbles.
5. Small hiatal hernia.
[**2-27**] CT CHEST
FINDINGS: There is a new left paratracheal mass measuring 3.8 x
3.4 x 2.2 cm causing mild deviaiton of the trachea and left
carotid artery concerning for a lymphadenopathy due to
metastasis. There is no , axillary, mediastinal or hilar
lymphadenopathy evident. The central vessels are unremarkable.
Heart size is normal and without pericardial effusion. A small-
to moderate-sized hiatal hernia is evident. There is a small
left pleural effusion with thickened rind evident at the level
of the upper [**Month/Day (4) 3630**], indicating chronicity.
Pleural blebs are identified within the right lung apex. No
significant
emphysematous changes are identified. Changes consistent with
left upper
lobectomy and mediastinal lymph node dissection are evident.
Nonspecific
ground-glass opacities with minimal associated architectural
distortion
identified in the left lung apex are increased compared to prior
study and
likely represent post-radiation changes. Minimal dependent
atelectasis in
dependent portions of both lungs.
The liver is homogenous in attenuation without discrete masses
or lesions. There is no intrahepatic biliary ductal dilatation.
The gallbladder, pancreas and spleen are normal. The bilateral
adrenal glands have normal limb thickness and are without convex
margin to suggest mass. The bilateral kidneys are normal in size
and excrete contrast symmetrically. The stomach, small and large
bowel are unremarkable. There is no retroperitoneal, mesenteric
or portacaval lymphadenopathy identified. Multiple small foci of
air are noted within the abdomen as well as a layering posterior
to the left rectus sheath muscle, likely due to recent insertion
of a right-sided ventriculoperitoneal shunt with tip ending
lateral to the liver. No free fluid identified within the
abdomen. The rectum, bladder, uterus and adnexa are
unremarkable. No pelvic sidewall or inguinal lymphadenopathy
identified.
The aorta is of normal caliber throughout. The main portal vein
and its major tributaries are unremarkable.
No suspicious lytic or blastic lesions evident.
IMPRESSION:
1. New 3.8 cm left paratracheal mass concerning for metastasis.
2. Expected post-surgical changes in the left upper [**Month/Day (4) 3630**]
consistent with
lobectomy and mediastinal biopsy. Increased ground-glass
opacities with
associated architectural distortion evident within the left
upper [**Last Name (LF) 3630**], [**First Name3 (LF) **] be related to radiation changes, though
malignancy is not excluded.
3. Small left pleural effusion, likely chronic.
4. Interval placement of a right-sided ventriculoperitoneal
shunt with tip at the level of the liver and few intraperitoneal
gas bubbles.
5. Small hiatal hernia.
[**2167-3-2**] CTA/V head
IMPRESSION: The venous sinuses are patent without filling
defect. The
non-contrast head CT findings are unchanged compared to [**2167-2-27**].
[**2167-3-6**] MRI:
1. Post operative changes in the right posterior fossa.
Peripheral enhancement
along the resection cavity which likely represents post
operative change or residual tumor.
2. Stable metastatic lesions within the left insular cortex,
third ventricle, left temporal and left cerebellar hemisphere.
3. No acute infarct.
4. Right frontal approach ventriculostomy catheter with tip in
frontal [**Doctor Last Name 534**] of right lateral ventricle.
Brief Hospital Course:
Neuro:
Ms. [**Known lastname **] presented to the ED on [**2167-2-21**] following 2 weeks of
headaches, nausea/vomiting, and vertigo. CT head demonstrated a
large mass in the R cerebellum and a smaller lesion in the third
ventricle. Neurosurgery was consulted in the ED and declined
acute intervention. She was started on Decadron 4mg Q6 and
admitted to the neuro-ICU for monitoring. She did well overnight
without any evidence of hydrocephalus or increasing ICP, and her
symptoms began to improve. She was transferred to the neurology
floor on [**2167-2-22**].
MRI with and without contrast was performed which demonstrated
three lesions, largest in R cerebellar hemisphere as well as two
additional masses in third ventricle and left insula.
Neuro-oncology was consulted and recommended resection of
cerebellar lesion and whole brain radiation.
Her primary oncologists Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 11309**] were also
contact[**Name (NI) **].
Neurosurgery recommended suboccipital craniectomy followed by
VPS placement.
On [**2167-2-24**]: she had increased nausea and headaches. She was taken
to the OR and underwent resection of her cerebellar mass. She
tolerated the procedure well. Post operatively she returned to
the ICU for SBP control and neurochecks. Her exam remained
stable and post operative head CT showed no hemorrhage. On [**2-25**]
she was transferred to the floor. On [**2-26**] she had a routine head
CT for preoperative planning and this showed no change from
previous scans. She was kept NPO after midnight for VPS
placement on [**2-27**].
On [**2167-2-27**]: she was taken to the operating room for VP shunt
placement. She tolerated the procedure well. Post-operatively
she returned to the floor.
Postop MRI demonstrated residual cerebellar tumor and so on [**3-4**]
she returned to the OR for craniotomy for excision of residual
tumor.
On [**3-5**], patient was doing well, having some hallunications, but
knows that they are hallunications. Her decadron was tappered
and she was transferred to the floor. Her exam remains stable;
SQH was started as well.
CV:
She was maintained on telemetry monitoring throughout her
admission.
ENDO:
She was maintained on finger sticks QID and insulin sliding
scale while being treated with steroids.
FEN:
She was maintained on IVF upon admission due to poor PO intake.
She was advanced to a regular diet as her nausea improved. She
was maintained on a bowel regimen as well as a PPI for
prophylaxis.
ID:
She developed no signs of infection during her admission.
Prophylaxis:
She was maintained on SQ heparin for DVT prophylaxis and a PPI
for GI prophylaxis.
Dispo:
Patient was evaluated for PT and OT and discharged to [**Hospital1 **] in [**Location (un) 86**].
Medications on Admission:
Vicodin prn
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
2. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for Heart burn.
5. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Ondansetron 4 mg IV Q8H:PRN Nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Cerebellar lesion
Hydrocephalus
Intraventricular hemorrhage
Thoracic compression fx
steroid psychosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair 72 hours from the time of your surgery,
we recommend you use a mild shampoo and do not scrub the area.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen
. If you have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**6-30**] days (from your date of
surgery) for removal of your sutures . This appointment can be
made with the Nurse Practitioner. Please make this appointment
by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP.
[**Name Initial (NameIs) **] [**Name11 (NameIs) **] have a follow-up with Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 11309**] on [**2167-3-12**] at 2PM
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2167-3-16**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2167-3-12**] 2:00
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2167-3-6**]
|
[
"3051"
] |
Admission Date: [**2111-6-10**] Discharge Date: [**2111-6-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
confusion/aphasic
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81y/o F with h/o HTN, AF, MR who was last seen today by family
at 5:30pm conversant and ambulating around house. Patient then
found 2 hours later by family unable to speak, sitting on bed w/
declining mental status. They called 911 and was then
transferred to [**Hospital1 18**] ED. Here, in ED, patient noted to have
NIHSS=10 as the patient was globally aphasic, with a left sided
gaze preference, and did not cross midline on oculocephalic
testing. Also w/ hypertension. CODE stroke was called. She was
moving UE equally and antigravity and there was a decreased
response to stim in her right extremity. A STAT head CT showed a
massive subarachnoid hemorrhage with intraventricular extension
in b/l lateral ventricles, third and fourth ventricles with no
apparent sign of hydrocephalus except for ex vacuo. There was no
midline shift or mass effect at this point. Prior to the head
CT, the patient was intubated by the ED due to her sats in 70's
in the setting of decreasing alertness and depressed mental
status. NGT placed, given nimodipine, dilantin, started nipride
then shut off, then started labetalol then shut off, finally
started on versed and propofol. Neurosurgery consulted and
recommended drain placement and ICP monitoring/mannitol
administration. Given recommendations and assessment (severe
brain trauma) from neurology and neursurgical service, family
declined aggressive measures and moved for DNR/DNI, comfort
measures only. At this point Neurosurgery and neurology signed
off. Patient was admitted to MICU for extubation while family
arrived and patient given last rites.
Past Medical History:
PMHx: AF on Coumadin, HTN, MR, R Knee Arthritis (H/O childhood
inflammatory jt disease), pHTN (?: ECHO '[**02**] - "NML LVEF"). Has
never had mammogram or colonoscopy.
Social History:
Lives with son. [**Name (NI) **] ETOH/Tob.
Family History:
No known cancer. Father died of Cirrhosis/ESLD.
Physical Exam:
P: 62, BP: 106/41, R: 17, Sats 97% on CMV Vt 500 x 18, FiO2 100%
x Peep 5
GEN: intubated, not responsive to voice,
HEENT: NC/AT, Pupils reactive from 3mm to 2mm, ETT in place.
CV: Irreg, irreg rhythm, 2/6 sem at LLSB, no r/g
PULM: mechanical breath sounds, o/w CTA b/l, no w/r/r
ABD: bowel sounds present, flat, soft, non distended
Ext: no c/c, +edema in both lower ext 1+ pitting,
Skin: b/l onychomycosis of nails, chronic venous stasis changes
of skin in both lower extremities.
Vasc: 2+ dp/pt b/l
Neuro: absent corneal reflexes, pupils reactive 3mm to 2mm b/l,
left gaze deviation, decorticate posturing to pain, upgoing
babinski b/l.
Pertinent Results:
[**2111-6-10**] 10:34PM TYPE-ART O2-100 PO2-449* PCO2-29* PH-7.45
TOTAL CO2-21 BASE XS--1 AADO2-246 REQ O2-48 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2111-6-10**] 10:34PM GLUCOSE-191* LACTATE-2.1* K+-3.5
[**2111-6-10**] 09:00PM GLUCOSE-173* UREA N-33* CREAT-1.1 SODIUM-144
POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-21* ANION GAP-18
[**2111-6-10**] 09:00PM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-1.3*
[**2111-6-10**] 09:00PM WBC-14.0* RBC-3.99* HGB-11.8* HCT-35.4*
MCV-89 MCH-29.6 MCHC-33.3 RDW-14.2
[**2111-6-10**] 09:00PM NEUTS-93* BANDS-0 LYMPHS-3* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2111-6-10**] 09:00PM PLT SMR-LOW PLT COUNT-148*
[**2111-6-10**] 09:00PM PT-12.6 PTT-20.3* INR(PT)-1.1
[**2111-6-10**] 08:06PM GLUCOSE-163* UREA N-33* CREAT-1.2* SODIUM-139
POTASSIUM-8.1* CHLORIDE-103 TOTAL CO2-19* ANION GAP-25*
[**2111-6-10**] 08:01PM CK(CPK)-92
[**2111-6-10**] 08:01PM cTropnT-<0.01
[**2111-6-10**] 08:01PM CK-MB-NotDone
[**2111-6-10**] 08:01PM PHOSPHATE-3.4 MAGNESIUM-1.6
[**2111-6-10**] 08:01PM WBC-11.1* RBC-4.76# HGB-13.9# HCT-41.9#
MCV-88# MCH-29.3 MCHC-33.3 RDW-14.3
[**2111-6-10**] 08:01PM NEUTS-79.7* LYMPHS-16.5* MONOS-3.1 EOS-0.4
BASOS-0.4
[**2111-6-10**] 08:01PM PLT COUNT-187 LPLT-1+
[**2111-6-10**] 08:01PM PT-12.7 PTT-22.7 INR(PT)-1.1
[**2111-6-10**] 08:01PM FIBRINOGE-371
=
=
=
=
=
=
=
=
=
=
================================================================
CHEST (PORTABLE AP) [**2111-6-10**] 8:34 PM
TECHNIQUE: Single AP portable supine chest.
FINDINGS: An endotracheal tube is in place with tip terminating
3.6 cm from the carina. There is stable cardiomegaly. The aorta
is unfolded and prominently calcified. There is diffuse hazy
opacity over the lung fields bilaterally, suggestive of layering
bilateral pleural effusions. In addition, there is slight
prominence of the pulmonary vasculature and scattered peripheral
septal lines consistent with mild congestive heart failure. No
focal areas of pulmonary parenchymal consolidation or air
bronchograms are identified. No pneumothorax. The osseous
structures demonstrate osteopenia.
IMPRESSION:
1) Status post endotracheal intubation. Endotracheal tube in
satisfactory position.
2) Cardiomegaly, layering bilateral pleural effusions, and mild
congestive heart failure. No definite evidence of pneumonia,
although followup chest x- ray is recommended after treatment to
assess resolution.
=
=
=
=
=
=
=
=
=
=
================================================================
CT HEAD W/O CONTRAST [**2111-6-10**] 7:55 PM
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is massive subarachnoid hemorrhage, with
extension into the lateral ventricles. Hemorrhage fills the
third ventricle and the fourth ventricle, as well as the basilar
cisterns. There is brain edema with loss of [**Doctor Last Name 352**]/white
differentiation, predominantly in the inferior aspect of the
cerebral hemispheres. There is hydrocephalus involving the third
and lateral ventricles, as well as herniation. Region of
hypodensity within the left posterior frontal and parietal lobe
extending into the left occipital lobe is residua of prior
infarction. There is no shift of the normally midline
structures.
Slight osseous irregularity is visible along the left inferior
frontal/superior temporal region. Dense calcification of the
supraclinoid carotid arteries is visible. The paranasal sinuses
and orbits are grossly unremarkable. There is also dense
calcification of the vertebral arteries bilaterally.
IMPRESSION: Massive subarachnoid hemorrhage, likely from
ruptured aneurysm. Hydrocephalus, brain edema, and herniation.
Findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12870**] at the time of
the exam at 6:25 p.m., [**2111-6-10**].
Brief Hospital Course:
81y/o F with HTN, Afib, and MR p/w massive SAH.
1. SAH:
CT head findings were discussed with family by neurology and
neurosurgery service. They recommended drain placement and
administration of manitol and blood pressure medication for ICP
control. They conveyed to family that patient was brain dead.
Given the findings, explanation from the services and the
procedures to be done, the family declined any further
aggressive measures and wished to make their family member
DNR/[**Name2 (NI) 835**] and to proceed to extubation with morphine for comfort
once other family members arrived and last rites given. Patient
was then transferred to MICU intubated, kept on mechanical
ventilation until last rites given and family members arrived.
[**Name2 (NI) **] was then extubated, fentanyl and versed were stopped and
patient was then started on morphine for comfort. On day 2 of
admission patients neurological status improved, morphine drip
was stopped. Stroke team and neurosurgery team discussed the
improved neurological status of patient with family and
readdressed the option of drain placement. Family declined and
expressed their wishes of continuing patient with comfort
measures only. By day 3 of admission patients respiratory status
began to decline with several episodes of apnea and her
oxygenation began to decline as well with sats in 60's. She
became more unresponsive. Patient went into respiratory arrest
and by 2pm on [**2111-6-12**] Mrs. [**Known lastname 8271**] passed away.
2. FEN: NPO
3. CODE: DNR/DNI, comfort measures only.
Medications on Admission:
lipitor, lisinopril
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Massive sub arachnoid hemorrage
Hydrocephalus
Brain Edema
Herniation
Discharge Condition:
none, patient expired on [**2111-6-12**]
Discharge Instructions:
None
Followup Instructions:
None
|
[
"42731",
"4019"
] |
Admission Date: [**2170-12-15**] Discharge Date: [**2170-12-24**]
Date of Birth: [**2112-10-22**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
[**2170-12-20**]: PICC line placement
History of Present Illness:
58yo F well-known to Hepatobiliary / Transplant / West 1
surgical service from recent admission [**Date range (1) 106084**] for
obstructive jaundice ultimately leading to a new diagnosis of
cholangiocarcinoma with metastatic disease to her sigmoid colon.
She was treated with biliary stenting, currently with two bare
metal stents within CBD / L hepatic duct (placed endoscopically)
and within R hepatic duct (placed percutaneously), as well as
colonic stent. She was discharged two days ago to begin
outpatient chemotherapy. Overnight she experienced a fever to
102, presented to an OSH ED, was noted to be hypotensive and
bolused 3L of IVF, then transferred here for resumption of care.
In the ED here, she was persistently hypotensive and
tachycardic,
and bolused ~5 add'l liters of IVF, with marginal response
90s/50s.
ROS: Pt denies abdominal pain except for low-grade pain along
RUQ
which she has had since last admission. Denies nausea, emesis,
diarrhea, constipation. Denies chest pain, shortness of breath,
or cough. Denies dysuria or frequency.
Past Medical History:
PMH: Cholangiocarcinoma, Hypothyroidism, R Kidney stones
PSH: Knee arthroscopy, ?laparoscopy for ? ovarian cyst,
Tonsillectmy and adenoidectomy, Colonoscopy many years ago
Social History:
Lives alone, sister who lives out of state and a brother.
Reports some friends near her home. Negative ETOH/tobacco
Family History:
Mother had lung cancer (+tob). father is alive. No significant
history of colon, liver, gallbladder, pancreas cancer.
Physical Exam:
102.1, 149, 115/57, 24, 94 on NRB
A&Ox3, slightly dyspneic
coarse BS BL, no rales
RRR except tachy. no murmurs.
soft, slightly distended. non-tender to palpation. no masses.
WWP, no C/C/E.
Foley in place (scant med-yellow urine), PIV x2.
Pertinent Results:
[**11-30**]: Colon, distal sigmoid, "mass at 20 cm"; biopsy
(A):Comment: The tumor is present within the lamina propria, and
is without a recognizable precursor lesion. The malignant cells
are immunoreactive for cytokeratin 7 and are non-reactive for
cytokeratin 20 and CDX-2. The immunophenotype and the lack of a
precursor lesion are not characteristic of a primary colonic
carcinoma. Given the imaging findings metastatic
pancreaticobiliary carcinoma is likely though other primary
sites, including gastric and gynecologic, could be considered
[**11-26**] ERCP: ADENOCARCINOMA.
Labs on Admission: [**2170-12-15**]
WBC-41.9*# RBC-3.15* Hgb-9.4*# Hct-27.6* MCV-88 MCH-29.9
MCHC-34.2 RDW-14.0 Plt Ct-376
PT-17.2* PTT-29.6 INR(PT)-1.6*
Glucose-115* UreaN-11 Creat-0.8 Na-138 K-3.4 Cl-103 HCO3-24
AnGap-14
ALT-58* AST-52* AlkPhos-479* TotBili-1.1 Lipase-38
Albumin-2.2* Calcium-6.1* Phos-2.7 Mg-1.0*
On Discharge: [**2170-12-24**]
WBC-16.9* RBC-2.76* Hgb-8.3* Hct-24.2* MCV-88 MCH-30.2 MCHC-34.4
RDW-14.5 Plt Ct-595*
Glucose-86 UreaN-7 Creat-0.6 Na-138 K-3.8 Cl-103 HCO3-28
AnGap-11
ALT-13 AST-12 AlkPhos-185* TotBili-0.6
Calcium-8.2* Phos-3.5 Mg-2.0
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**12-15**] with concerns for
septic shock. She is a 58 yo female with cholangiocarcinoma,
likely metastatic to the colon (with a colonic mass s/p stent
placement) and s/p multiple biliary stents, currently with two
bare metal stents within CBD / L hepatic duct (placed
endoscopically) and within R hepatic duct (placed
percutaneously) on [**12-11**]. She was transferred from an OSH with
temperature of 102.
The patient was admitted to the ICU, given multiple fluid
boluses, and found to have 2/2 blood cultures growing Gram
Negative Rods, later E Coli sensitive to zosyn. She was placed
on pressors until her blood pressure stabilized. She was
started on cipro, vanco, flagyl, and zosyn presumptively; the
vanc and cipro discontinued following results of the blood
cultures. She was continued on the zosyn for the bacteremia and
flagyl for presumptive C. difficile colitis.
She underwent a CT scan of the abd to search for a presumed GI
source of her bacteremia. It revealed persistent and unchanged
hepatic lesions compatible with metastatic disease, colitis of
the right ascending colon and the distal transverse /splenic
flexure (thickened colonic wall), a small amount of ascites and
free pelvic fluid, and a RML infiltrate.
On [**12-17**] she was awoke tachycardic, tachypneic, hypertensive and
with rigors w/fever 101 presumed to be still septic, that
resolved w/zopenex nebulizer and demerol. CXR revealed
increasing b/l opacities concerning for pulmonary edema. ABG
7.38/32/62/20. She underwent a CTA of that chest that revealed
bilateral multifocal consolidations, worsening pleural
effusions, now moderate on the left and large on the right,
Anasarca, ascites, persistent hepatic lesion compatible with
metastatic cholangiocarcinoma, lucency in vertebral body of L1,
worrisome for metastasis.
The likely source of her bacteremia is either pneumonia or
colitis. She was treated empirically for both with zosyn and
flagyl; follow up blood cultures on [**12-17**] were without growth.
Following normalization of her hemodynamics and control of her
pneumonia, the patient was aggressively diuresed for b/l pleural
effusions (thought secondary to fluid resuscitation vs
parapneumonic vs malignant, though no tap performed). Her
effusions improved over time, and on [**12-23**] she was without any
oxygen requirement at rest and ambulating.
The patient also complained of loose stool; she was tested for C
dif that was negative x5, though was treated empirically with
flagyl. The diarrhea has decreased in frequency over her
hospitalization.
The patient diet was steadily advanced; she underwent a
nutrition consult who recommended a regular diet with
supplements. By the time of discharge she was tolerating a
regular diet, though remained with some residual nausea treated
well with zofran PRN.
She developed a superficial thrombophlebitis of her right upper
extremity that resolved with heat packs.
She had a PICC line placed on [**12-15**] in the RUE for antibiotic
delivery.
At the time of dictation the patient is without pain, on room
air both at rest and while ambulating, has documented negative
blood cultures ([**12-17**]), is tolerating a regular diet, urinating
well and without other complaints. The patient does remain with
a leukocytosis today of 16.9 down from a high of 41.9 on [**12-15**],
though she appears clinically stable. She is being discharged
on Ceftrixaone x 1 week and flagyl for 14 days since documented
negative blood cultures. Switched to Ceftrixaone prior to
discharge.
Finally, the patient does have metastatic cholangiocarcinoma to
the sigmoid colon, and so further symptoms are likely to occur
in the future. The patient is scheduled to begin outpatient
chemotherapy at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital.
Medications on Admission:
cipro 500' (x2wk), actigall 300'', protonix 40', levothyroxine
25', senna 8.6'', phenergan 5 q6:prn, dilaudid [**5-6**] q3:prn,
colace 100'', ambien 5'prn
Discharge Medications:
1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous every eight (8) hours as needed for line flush:
after flushing picc with normal saline 10ml.
Disp:*50 doses* Refills:*1*
2. Saline Flush 0.9 % Syringe Sig: One (1) Injection every
eight (8) hours for 1 weeks.
Disp:*50 * Refills:*1*
3. Picc Line Supplies
supply 1 week of tubing, dressing kits, pump
4. CeftriaXONE 1 gram Recon Soln Sig: One (1) unit Intravenous
Q24H (every 24 hours) for 7 days.
Disp:*7 unit* Refills:*0*
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
10. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Phenergan 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Septic shock with E coli bacteremia
Pneumonia
Cholangiocarcinoma
Discharge Condition:
Stable/Fair
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever greater
than 101, chills, nausea, vomiting, diarrhea, increased
abdominal apin, yellowing of skin or eyes, inability to take
adequete food and fluids.
Drink enough fluids to keep urine light yellow
Continue Ceftriaxone once daily through [**2170-12-31**] using Right
PICC
No Heavy lifting
No Driving if taking narcotic pain medication
Continue warm packs to right arm PRN comfort at PICC insertion
site
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2171-1-9**]
3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2170-12-24**]
|
[
"78552",
"486",
"99592",
"2449",
"2859"
] |
Admission Date: [**2125-1-31**] Discharge Date: [**2125-2-10**]
Date of Birth: [**2069-12-22**] Sex: M
Service: SURGERY
Allergies:
Skelaxin / Flexeril
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Trauma: Fall
R posterior rib fxs [**3-26**]
R lateral rib fxs [**6-25**]
pulmonary contusion
Major Surgical or Invasive Procedure:
s/p VATS & rib plating [**2125-2-5**]
thoracic epidural [**2125-2-1**], d/c [**2-4**]
History of Present Illness:
55 year old male who complains of chest pain. This patient was 5
feet up on a ladder sawing off a 200 pound tree branch which
swung from exporting rope striking him in the right chest. It
knocked him off the ladder. There was a documented LOC. He went
to [**Hospital6 3105**] where imaging showed multiple rib
fractures on the right, 7 through 9 with a suspected flail
segment, a pulmonary contusion, and a pleural effusion on the
right. There was no pneumothorax. Because of all of these
findings, he was sent to [**Hospital1 **] for further
evaluation and treatment. He has had CT scans read by attending
radiologist of his brain, cervical spine, and torso. The
injuries above are the only injuries that were found.
Past Medical History:
PMH: sleep apnea, hypothyroidism, depression, ADHD
PSH: tonsillectomy, perianal surgery for wart removal
Social History:
former smoker (quit 5 yrs ago), no illicit drugs
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission
Temp: 98.7 HR: 96 BP: 123/103 Resp: 19 O(2)Sat: 97-100% on
3 L Normal
Constitutional: Comfortable boarded and collared with a GCS
of 15.
On the triage sheet, there was an O2 sat of 93%, but all of
the O2 sats I saw, and I watched him for several minutes now
have all been 97% and above.
HEENT: Extraocular muscles intact, with both pupils being 3
mm and briskly constricting to light
There is no C-spine tenderness. Given his awake mental
status, his negative C-spine CT scan, we cleared his
cervical spine.
Chest: He has tenderness in the right chest wall. Breath
sounds are bilaterally symmetrical
Cardiovascular: Normal first and second heart sounds
without murmur
Abdominal: Soft, Nontender and specifically no right upper
quadrant tenderness
Extr/Back: All 4 extremities move normally without pain or
long bone findings.
His back is negative.
Neuro: Speech fluent with no lateralizing or localizing
motor findings
Psych: Normal mood, Normal mentation
Pertinent Results:
[**2125-2-8**] 06:00AM BLOOD WBC-4.2 RBC-3.32* Hgb-10.4* Hct-29.2*
MCV-88 MCH-31.5 MCHC-35.8* RDW-15.1 Plt Ct-187
[**2125-2-7**] 02:11AM BLOOD WBC-5.8 RBC-3.05* Hgb-9.8* Hct-26.8*
MCV-88 MCH-32.1* MCHC-36.5* RDW-14.3 Plt Ct-159
[**2125-2-8**] 06:00AM BLOOD Plt Ct-187
[**2125-2-7**] 02:11AM BLOOD Plt Ct-159
[**2125-2-8**] 06:00AM BLOOD Glucose-104* UreaN-15 Creat-1.0 Na-138
K-3.7 Cl-101 HCO3-30 AnGap-11
[**2125-2-7**] 03:19PM BLOOD Glucose-114* UreaN-16 Creat-0.9 Na-136
K-3.3 Cl-97 HCO3-36* AnGap-6*
[**2125-2-4**] 02:53PM BLOOD CK(CPK)-239
[**2125-2-4**] 10:45PM BLOOD CK-MB-7 cTropnT-<0.01
[**2125-2-4**] 02:53PM BLOOD CK-MB-5 cTropnT-<0.01
[**2125-2-4**] 04:29AM BLOOD CK-MB-5 cTropnT-<0.01
[**2125-2-8**] 06:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4
[**2125-2-5**] 03:00PM BLOOD Glucose-132* Lactate-0.7 Na-133 K-4.1
[**2125-2-6**] 01:46AM BLOOD freeCa-1.13
[**2125-1-31**]: chest x-ray:
IMPRESSION: Elevated right hemidiaphragm with tiny right pleural
effusion,
atelectasis and several displaced right rib fractures, but no
pneumothorax.
Please refer to CT for further details.
[**2125-2-1**]: chest x-ray:
IMPRESSION:
1) Fractures are in closer approximation with no pneumothorax.
2) Increased right basilar atelectasis with small right pleural
effusion.
Right hemidiaphragm is stably elevated.
[**2125-2-2**]: right shoulder x-ray:
No acute bony injury. Mild degenerative changes of the AC joint.
[**2125-2-4**]: CTA chest:
IMPRESSION: Flail chest with contiguous segmental fractures of
the right
8th-10th ribs and subsequent development of a large hemothorax
since four
days prior, now with compressive atelectasis without evidence of
pneumothorax.
No evidence of pulmonary embolism.
[**2125-2-4**]: chest x-ray:
Right chest tube remains in place with its tip at the apex.
There is
persistent elevation of the right hemidiaphragm with patchy
opacity at the
right base which either reflects loculated pleural fluid within
the horizontal fissure or could represent an evolving pneumonia.
Clinical correlation is advised. The left lung remains grossly
clear. No pneumothorax is seen. No evidence of pulmonary edema.
Overall cardiac and mediastinal contours are stable
[**2125-2-4**]: chest x-ray:
1. Interval placement of a right internal jugular central line
which has its tip in the distal SVC at the cavoatrial junction.
Right chest tube remains unchanged in position. Endotracheal
tube and nasogastric tube also unchanged; however, the
nasogastric tube has its side port near the gastroesophageal
junction.
2. Cardiac and mediastinal contours are stable. Left lung
demonstrates
slightly improved aeration at the left base with residual patchy
atelectasis.
There is also patchy atelectasis at the right base with an
associated layering effusion. No large pneumothorax is seen;
however, the ability to detect a pneumothorax on a supine
radiograph is diminished. Several right-sided anterolateral rib
fractures are again identified.
[**2125-2-7**]: chest x-ray:
IMPRESSION: Enlarging moderate to large right pneumothorax
sufficient to
shift mediastinum contralaterally, but not to displace the right
hemidiaphragm
[**2125-2-8**]: chest x-ray:
IMPRESSION: Increasing size in right pneumothorax.
Time Taken Not Noted Log-In Date/Time: [**2125-2-4**] 8:38 pm
SPUTUM
**FINAL REPORT [**2125-2-6**]**
GRAM STAIN (Final [**2125-2-4**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2125-2-6**]):
SPARSE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. HEAVY
GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
Brief Hospital Course:
55 year old gentleman admitted to the acute care service after
falling off a ladder while cutting a branch. He sustained loss
of consciousness as a result of the fall. He was taken to an
outside hospital where on imaging he was found to have multiple
rib fractures on the right, 7 through 9 with a likely flail
segment, a pulmonary contusion, and a pleural effusion on the
right. He was transferred here for further management. He was
admitted to the intensive care unit for observation. During this
time, he had an epidural catheter placed for management of his
rib pain. This was discontinued in 48 hours and he was
transitioned to PCA. His vital signs and respiratory status
remained stable and he was transferred to the surgical floor on
HD #3.
While on the floor, he had a late presentation right-sided
hemothorax which required emergent chest tube placement and
transfer back to the ICU. A CTA of the chest was done which
showed a flail chest with contiguous segmental fractures of the
right
8th-10th ribs and subsequent development of a large hemothorax
with compressive atelectasis without evidence of pneumothorax.
His epidural catheter was replaced and he required neosynephrine
for blood pressure support. He was intubation for increased
respiratory distress. He was bronched and started on
vancomycin, cefepime, and ciprofloxacin for hospital acquired
pneumonia. The thoracic service was consulted on HD #5 for
possible rib plating to help facilitate his pulmonary status.
He was taken to the operating room on HD #6 where he underwent a
right thoracotomy and evacuation of hemothorax. At this time,he
also had an internal rib fixation of ribs #7, 8, and 9.
His operative course was stable with a EBL of 100cc. He did
require additional PRBC during the procedure. He was bronched at
the completion of the procedure and transferred back to the
intensive care unit. He was extubated on POD #1. His hemodynamic
status was labile after the procedure requiring additional
fluid, albumin, and lasix. On POD #2, his pneumothorax was
enlarged, the chest repositioned, and it was placed to wall
suction with improvement of the pnemothorax. He was introduced
to clear liquids with advancment to a regular diet.
He was transferred to the surgical floor on POD #2. He was
started on cefepime for a sputum culture which grew H.Flu. His
vital signs and pulmonary status were closely monitored. A
chest x-ray showed a decrease in the size of the pneumothorax
and the chest tube was discontinued on POD # 3. Post chest-tube
removal x-ray showed a large right pneumothorax which is
unchanged from prior films. He was breathing comfortably with an
oxygen saturation of 97% on room air. His cefepime was switched
to cefepoxidime for completion of a 10 day course. During his
hospital stay, he ws evaluted by occupational therapy because
of his +LOC during the accident. They recommended follow-up with
cognitive neurology to re-evaluate him.
His vital signs are stable and he is afebrile. He is tolerating
a regular diet. His white blood cell count is normalized and
his hematorcrit is stable. He is preparing for discharge home
with follow up with the Thoracic service and with cognitive
neurology.
Medications on Admission:
citalopram 20, adderall 40'', levothyroxine 250, atarax 25-50
daily
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stool.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain: may cause drowsiness, avoid driving
while on this medication.
Disp:*40 Tablet(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*20 Tablet(s)* Refills:*0*
9. amphetamine-dextroamphetamine 5 mg Tablet Sig: Four (4)
Tablet PO BID (2 times a day).
10. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO every
twelve (12) hours for 6 days.
Disp:*24 Tablet(s)* Refills:*0*
11. ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for pain: please take with food.
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: fall
R posterior rib fxs [**3-26**]
R lateral rib fxs [**6-25**]
pulmonary contusion
flail chest
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 you fell off a ladder
while cutting a tree branch. You sustained rib fractures and a
bruise to your lungs. You were taken to the operating room for a
stabilization of your rib fractures. You also had a collection
of fluid in your lungs for which a chest tube was placed. The
chest tube has been removed and your respiratory status is
slowly getting better. You are preparing for discharge home
with the following instructions:
Because you had rib fractures, please follow:
* Your injury caused right sided [**3-26**] rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 95463**],MD
Specialty: Internal Medicine
When: Wednesday [**2-14**] at 11:30am
Location: [**Location (un) **] FAMILY MEDICINE, P.C.
Address: [**Location (un) 86867**], STE G06, [**Hospital1 **],[**Numeric Identifier 26407**]
Phone: [**Telephone/Fax (1) 45479**]
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Specialty: Cognitive Neurology
Location: [**Hospital1 18**] - COGNITIVE NEUROLOGY UNIT
Address: [**Location (un) **], KS 257, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1690**]
We are working on a follow up appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in the Neurology department within a month to follow
up on your head injury. You will be called at home with the
appointment. If you have not heard within 2 business days or
have questions, please call the number listed above.
Department: THORACIC SURGERY/CHEST DISEASE
When: TUESDAY [**2125-3-6**] at 3:30 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
Please arrive to this appointment at 2pm to have a chest xray
done. You will see the doctor at 3:30pm.
Completed by:[**2125-2-10**]
|
[
"51881",
"32723",
"2449",
"311"
] |
Admission Date: [**2158-6-5**] Discharge Date: [**2158-6-15**]
Date of Birth: [**2089-5-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Intermucosal adenocarcinoma of the
gastroesophageal junction.
Major Surgical or Invasive Procedure:
TransHiatal Esophagecty, jejunostomy, pyloroplasty
History of Present Illness:
The patient is a 68 year-old
gentleman with a 25 year history of GERD. He was recently
diagnosed with intermucosal adenocarcinoma of his
gastroesophageal junction, in the setting of a Barrett's
esophagus. The patient's preoperative work-up was negative
for any metastatic disease and therefore, he was deemed to be
suitable for a transhiatal esophagectomy.
Past Medical History:
GERD, recent dysphagia. Biopsy proven intramucosal AdenoCA and
[**Last Name (un) 865**] on EGD
PMH: HTN, Gout, SVT, BPH, basal cell CA
PSH: R ORIF, R IH, vasectomy
Family History:
non-contributory
Physical Exam:
general: well appearing male in NAD s/p esophagectomy and
feeding J-tube.
HEENT: left neck incision well approx, no redness, no drainage.
Staples d/c'd. JP Drain d/c'd.
Chest: CTA bilat
Cor: RRR S1, S2
Abd: soft, NT, +BS. J-tube site benign. Abd incision intact, no
redness, no drainage. Every other staple d/c'd.
extrem: no C/C/E
neuro: intact.
Pertinent Results:
CXR:
[**2158-6-9**]: In comparison with study of earlier in the day, there
has
apparently been thorcentesis with removal of pleural fluid and a
more sharp
appearance of the right costophrenic angle. No evidence of
pneumothorax. No
change in the appearance of the mediastinum or left chest.
Brief Hospital Course:
Pt was admitted and taken to the OR for
Esophagogastroduodenoscopy,Transhiatal esophagectomy with
bilateral plasty and placement of a feeding jejunostomy tube.
Or course was uneventful. An epidural was placed for pain
control. An NGT, JP and chest tube were placed at the time of
surgery. Pt was admitted to SICU post op intubated for vent
support and hemodynamic monitoring and volume resusitation. Pt
was extubated on POD#1.
POD#2 trophic tube feeds started.Left chest tube placed to water
seal. NGT d/c'd.
POD#3 developed afib- unsuccessful rate control w/ lopressor.
Responded to amiodarone bolus and drip.
POD#4 CXR w/ progressive right effusion- tapped for 900cc old
bloody fluid.
POD#5 PICC line for amiodarone until taking po's. Tube feeds
slowly increased to goal. Epidural d/c'd and pain well
controlled w/ roxicet. Bowel regimen effective.
POD#6 c/o right upper quad pain- w/u neg for biliary disease.
POD#7 given trial of grape juice orally and no evidence of juice
in anastomotic JP drain.
POD#8 Diet advanced to clears and [**Last Name (un) 1815**] well. Did c/o
intermittant fullness and cramping. Tube feeds held and given
laxative w/ good result and tube feeds were resumed.
POD#9 diet advancedto fulls. po meds were intiated and tube
feeds were advanced to goal.
POD#10 Pt abulating indep w/ RA sats 98%. d/c'd to home w/ vna
services for tube feed assistance.
d/c'd to home and will return for barium swallow before
advancing diet.
Medications on Admission:
atenolol, allopurinol, doxazocin, mvi, glucosamine, polaramine
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (un) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*420 ML(s)* Refills:*0*
2. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (un) **]: One Hundred (100) mls
PO BID (2 times a day) as needed for constipation.
Disp:*420 mls* Refills:*2*
3. Lactulose 10 gram/15 mL Syrup [**Last Name (un) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*400 ML(s)* Refills:*1*
4. Doxazosin 1 mg Tablet [**Last Name (un) **]: Two (2) Tablet PO HS (at bedtime).
5. Allopurinol 100 mg Tablet [**Last Name (un) **]: Three (3) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
8. tube feeding
replete with fiber continuous at 90cc/hr
flush w/ 50cc water every 8hrs and before and after feeds and
medication.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
GERD, recent dysphagia. Biopsy proven intramucosal AdenoCA and
[**Last Name (un) 865**] on EGD
PMH: HTN, Gout, SVT, BPH, basal cell CA
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you develop chest pain,
shortness of breath, nausea, vomiting, diarrhea, inability to
tolerate tube feeds or oral intake.
Continue on your tube feeds as directed and take full liquids by
mouth. No caffiene and no carbonation.
Flush your feeding tube with 50cc water before and after
medications and before and after feeding connect and disconnect.
if you feeding tube sutures break, tape your tube securely in
place and call the office [**Telephone/Fax (1) 170**] to have the sutures
replaced.
If you feeding tube falls out, save the tube and call the office
immediately. The tube needs to be replaced immediately because
the tract closes very quickly. You will need to come into the
office to have the feeding tube replaced. Bring your old tube
w/ you when you come in.
Followup Instructions:
You have a follow up appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] NP/ Dr.
[**Last Name (STitle) **] on wednesday [**6-21**] on the [**Hospital Ward Name **] [**Hospital Ward Name 121**] building
[**Hospital1 **] one in the chest disease center at 1:30pm.
You have a barium swallow on [**6-21**] at 11am on the [**Hospital Ward Name **] [**Hospital Ward Name 23**] clinical center [**Location (un) **] radiology. Stop your
tube feedings at midnight the night before.
Completed by:[**2158-6-15**]
|
[
"5119",
"42731",
"53081",
"4019",
"42789"
] |
Admission Date: [**2186-8-24**] Discharge Date: [**2186-8-31**]
Date of Birth: [**2115-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
ICD/BiV pacer placement in L chest
History of Present Illness:
70 M with CHF EF 10%, s/p ICD biv placement through L subclavian
vein approach on [**8-24**] complicated by L hemothorax. Chest tube
placed in OR-no evidence for active bleeding. Procedure today
was complicated by hitting subclavian artery became hypotensive
to 90s, Hct 30 to OR out of concern for subclavian artery stick.
Inserted chest tube for L hemothorax and pleural effusion Hct
16. 400 cc out, stopped draining overnight to [**8-25**]. Intubated
for 24 hrs, then extubated successfully. Aggressive diuresis
once BP stabilizes. Went into AFIB, cardioverted in AM, chest
tube pulled today.
.
SBP 150s by arterial line
s/p 2L of fluid
s/p 3 URBC
.
ROS: Pt denies fever or chills. No night sweats or recent weight
loss or gain. Denied headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias. No
rash.
Past Medical History:
New biv icd- concerto [**Company **]
CHF-ischemic cardiomyopathy EF %[**10-24**] (below)
CAD s/p CABG
AFIB
s/p R arm surgery w rodding for congenital abnormality
L CEA
Multiple right ankle fractures
arthritis
DM
Hyperlipidemia
Social History:
He has been happily married for 47 years. He has three
adult children. He is retired. Prior to retiring he worked as an
auto mechanic. He does not smoke or drink. He lives with his
wife.
Family History:
He has a mother who died of complications of
heart disease and diabetes. He has two brothers both of whom
have heart disease and diabetes
Physical Exam:
Vitals: 97.2 / 77 / 14 / 105-143/48-64 / 98%-100% RA
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, sclera anicteric.
MMM, OP without lesions
Neck: supple, no JVD or carotid bruits appreciated
Pulm: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G appreciated
Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted.
Ext: No edema b/t, 2+ radial, DP and PT pulses b/l.
Lymphatics: No cervical, supraclavicular, axillary, or inguinal
LAD.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert & Oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength, and tone throughout.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor, dysdiadochokinesia noted. F->N and H->S WNL bilaterally.
-DTRs: 2+ biceps, patellar and 1+ ankle jerks bilaterally.
Downgoing Babinskis bilaterally
Pertinent Results:
EKG: BiV paced
.
[**2186-8-26**] CXR: [**Location (un) 1131**] pending
.
[**2186-8-25**] CXR: There is no pneumothorax. Mild cardiomegaly is
stable. No pulmonary edema or
appreciable pleural effusion is present. Endotracheal tube was
removed
between 9:20 and 10:35 a.m. Transvenous right atrial and
ventricular pacer
leads are unchanged in their positions. The tip of the
ventricular lead
projects over the mid portion of the right ventricle, and
probably along the
anterior wall. The tip of the left pleural tube has also
repositioned more
inferiorly, now at the level of the left hilus.
.
TTE [**8-24**]:
EF 10-20%, [**1-9**]+ AR, 1+ MR
[**Name13 (STitle) 650**] global left ventricular hypokinesis. Overall left
ventricular systolic function is severely depressed. LVEF< 20%.
The right ventricular cavity is dilated. There is focal
hypokinesis of the apical free wall of the right ventricle.
Wires are visualized in the RA/RV/coronary sinus. There is a
moderate left pleural effusion visualized with small
loculations. The effusion mostly disappeared after chest tube
drainage.
.
[**2186-8-24**] 11:23PM TYPE-ART TEMP-35.3 PO2-205* PCO2-38 PH-7.40
TOTAL CO2-24 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2186-8-24**] 11:23PM O2 SAT-99
[**2186-8-24**] 09:57PM TYPE-ART TEMP-35.1 PO2-350* PCO2-33* PH-7.41
TOTAL CO2-22 BASE XS--2 -ASSIST/CON INTUBATED-INTUBATED
[**2186-8-24**] 09:57PM GLUCOSE-147* LACTATE-0.8 NA+-138 K+-4.0
CL--109
[**2186-8-24**] 09:57PM O2 SAT-98
[**2186-8-24**] 09:57PM freeCa-1.16
[**2186-8-24**] 09:28PM GLUCOSE-153* UREA N-48* CREAT-1.1 SODIUM-139
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-20* ANION GAP-13
[**2186-8-24**] 09:28PM CALCIUM-8.0* PHOSPHATE-3.8 MAGNESIUM-2.1
[**2186-8-24**] 09:28PM WBC-11.2* RBC-2.80* HGB-8.1* HCT-23.5* MCV-84
MCH-28.9 MCHC-34.5 RDW-16.3*
[**2186-8-24**] 09:28PM PLT COUNT-159
[**2186-8-24**] 09:28PM PT-15.5* PTT-33.3 INR(PT)-1.4*
[**2186-8-24**] 09:28PM FIBRINOGE-228
[**2186-8-24**] 08:27PM TYPE-ART PO2-305* PCO2-32* PH-7.42 TOTAL
CO2-21 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED
[**2186-8-24**] 08:27PM GLUCOSE-157* NA+-137 K+-3.8
[**2186-8-24**] 08:27PM HGB-6.8* calcHCT-20
[**2186-8-24**] 08:27PM freeCa-1.02*
[**2186-8-24**] 08:02PM TYPE-ART PO2-348* PCO2-39 PH-7.33* TOTAL
CO2-21 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED
[**2186-8-24**] 08:03PM PLEURAL HCT-16*
[**2186-8-24**] 08:02PM TYPE-ART PO2-348* PCO2-39 PH-7.33* TOTAL
CO2-21 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED
[**2186-8-24**] 08:02PM GLUCOSE-161* NA+-137 K+-4.4
[**2186-8-24**] 08:02PM O2 SAT-99
[**2186-8-24**] 08:02PM freeCa-1.02*
[**2186-8-24**] 06:44PM GLUCOSE-186* UREA N-51* CREAT-1.2 SODIUM-137
POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
[**2186-8-24**] 06:44PM WBC-13.4* RBC-3.47* HGB-9.8* HCT-29.3* MCV-85
MCH-28.2 MCHC-33.4 RDW-16.2*
[**2186-8-24**] 06:44PM PLT COUNT-183
Brief Hospital Course:
70 M with CHF EF 10%, s/p BiV/ICD placement through L subclavian
vein approach on [**8-24**] complicated by L hemothorax, now with L
chest hematoma.
.
# L chest hemothorax:
Patient has Class II-III CHF EF 10-20% and had a BiV/ICD pacer
placed through the left subclavian vein. Patient developed L
hemothorax and had a chest tube placed for one day for
evacuation (chest tube pulled on [**8-26**]). He was also intubated
and extubated after 1 day for airway protection. CXR showed
good lead placement. His hematocrit dropped as low as 15 with
SBP 90s, and he received 5 URBC to keep Hct above 30.
Throughout, he was asymptomatic, with no chest pain, no
shortness of breath. He was placed on ASA 325, plavix 75,
carvedilol 6.25 [**Hospital1 **], Lisinopril 2.5 QD, Digoxin 0.125 QD, lasix
20 QD. He was given Vancomycin for 48 hrs s/p ICD placement.
He was transferred to CCU stepdown, where he was placed on
heparin for AFIB, and developed a 7x7 cm hematoma in his L
chest. Pressure dressing was applied, and hematoma gradually
diminished over the next 2 days. His pacemaker was checked
inhouse by electrophysiology. He was discharged on coumadin 1.5
QD, to followup for Hematocrit and INR with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] as
his cardiologist, and Device Clinic.
.
# AFIB:
Patient was in AFIB and was cardioverted on [**8-26**] to NSR. He
remained in NSR, and was placed on heparin and coumadin for
anticoagulation. He is s/p BiV/ICD placement on [**8-24**], and is
paced at 75. For rate control, patient is on carvedilol 6.25
[**Hospital1 **], digoxin 0.125 QD. He was given 1 dose of ibutilide, then
was started on amiodarone 600 x1, then 400 x 10 days, then 200
QD thereafter.
.
# DM2:
Metformin and glyburide were held inhouse for hypoglycemic
episodes, and patient was on insulin ss. These meds were
reinstated upon discharge.
Medications on Admission:
Medications:
Carvedilol 6.25mg daily
Lasix 20mg daily
Magnesium Oxide 400mg twice daily
Lisinopril 25mg daily
Digoxin 0.125mg daily
Plavix 75mg daily
Potassium 40meq daily
Zoloft 50mg daily
Simvastatin 40mg daily
Aspirin 325mg daily
Glyburide 5 mg twice daily *Instructed patient to hold the
morning of the procedure
Metformin 500mg daily *Instructed patient to hold the morning of
the procedure
Captopril 12.5mg twice daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please start taking after Amiodarone 400 QD x 9 days.
Disp:*30 Tablet(s)* Refills:*2*
15. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO once a day: You
will need to have your INR checked by a doctor when you are
taking this medication.
Disp:*45 Tablet(s)* Refills:*2*
16. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
18. Hematocrit and INR check Sig: One (1) check Q3 days:
Please fax to:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] (cardiology) and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiology).
Disp:*30 checks* Refills:*2*
19. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
Primary diagnosis: ICD/BiV pacer placement complicated by L
hematoma in L chest
Secondary diagnosis: AFIB cardioverted to NSR, CHF EF 10%
Discharge Condition:
VSS, good, moderate hematoma (5x5 cm) over L chest, ambulating
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all appointments with your physicians as written
below.
3. Please come to the emergency room if you experience chest
pain, fatigue, dizziness.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2186-9-4**] 11:30 AM. You will have your hematocrit and
INR checked. Please bring your prescription for hematocrit and
INR check with you to this appointment.
.
2. Please make an appointment to see Dr. [**Last Name (STitle) 7047**] ([**Telephone/Fax (1) 3183**])
within the next week. Dial this phone number, then press 0.
Dr. [**Last Name (STitle) 7047**] is aware that you will be contacting him. Please
bring your 'Hematocrit and INR check' prescription to this
appointment.
.
3. If you cannot get an appointment with Dr. [**Last Name (STitle) 7047**], please
call [**Company 191**] outpatient clinic at [**Telephone/Fax (1) 250**], and state that you
need a blood test performed (you need a hematocrit and INR
check). Please bring your 'hematocrit and INR check'
prescription to your appointment.
.
3. If you get your hematocrit and INR checked by VNA nursing at
home, please have the results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**].
.
4. **Changes in medication:
a) DO NOT TAKE WARFARIN (COUMADIN) tonight (Thurs, [**8-31**]).
b) Take Warfarin 1.5 mg by mouth once a day starting on Friday.
c) Carvedilol 12.5 [**Hospital1 **] was changed to 6.25 [**Hospital1 **].
Completed by:[**2186-9-1**]
|
[
"4280",
"42731",
"V4581",
"25000",
"2724",
"2859"
] |
Admission Date: [**2110-5-11**] Discharge Date: [**2110-6-25**]
Date of Birth: [**2047-9-19**] Sex: M
Service: MEDICAL ICU
HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old
male with a history of moderately differentiated squamous
cell lung cancer at the left upper lobe diagnosed in [**2107**].
He presented to [**Hospital1 **] [**Hospital1 **] on [**2110-4-23**] with
excessive fatigue and shortness of breath two weeks after
completing his chemotherapy and radiation therapy. The
patient at that time initially had deferred surgery. At the
time of admission to [**Hospital1 **] [**Hospital1 **] the patient denied any
fevers or chills, cough or sputum production, but noted
increasing weight loss. While at [**Hospital **] [**Hospital3 2063**]
the patient was found to have a small PE and was placed on
intravenous heparin. He underwent multiple bronchoscopy
procedures, which resulted in his being intubated afterwards.
He also was found to have a large abscess and multiple
secretions, which precluded extubation. He had low
platelets, which was thought to be secondary to his overall
medical condition. He was placed on multiple intravenous
antibiotics with minimal change in status. He was also noted
to have episodes of rapid atrial fibrillation, which were
controlled with AV nodal blockers. On [**2110-5-11**] the
patient was transferred to the [**Hospital1 188**] for a left pneumonectomy of the necrotic left lung.
He was transferred on a ventilator and continued on
intravenous heparin. He also developed hyperglycemia and was
controlled with NPH.
On [**2110-5-14**] the patient underwent surgery and had a left
extra pleural intrapericardial pneumonectomy, a pedicled
thoracic latissimus dorsi muscle flap, a pedicled omental
flap, a G tube placed, open tracheostomy tube placed, right
thoracoscopy tube placed and he also underwent a flexible
bronchoscopy with tracheal bronchial tree aspiration. Mr.
[**Known lastname **] postoperative course was complicated by
cardiovascularly the patient required pressors for a short
period of time. Pulmonary, the patient required continued
ventilation on AC, but later was switched over to pressure
support after a long period of trials. His renal issues were
stable. His ID issues, the patient was found to hve gram
negative rods on his sputum culture and he underwent multiple
antibiotic regimens. The organisms were found to be
sensitive to Bactrim and he received a fourteen day course
for that. Gastrointestinal, the patient received tube feeds
through his peg tube. Heme/onc wise the patient required
transfusions immediately postoperative. Endocrine wise, the
patient required an insulin sliding scale for his episodes of
hyperglycemia and neurologically the patient was
intermittently agitated, but was being sedated with Haldol,
Ativan and/or Morphine.
The main issue during Mr. [**Known lastname **] hospital stay was
difficulty weaning from his ventilator support. After
numerous trials of gradually decreasing his pressure support
and PEEP on his ventilator the patient still required
increasing amounts of ventilatory support. On chest x-ray he
was found to have a loculated pleural effusion on his right
side, which may have contributed to his weaning difficulties.
Overall, the patient remained in stable condition until the
afternoon of [**2110-6-24**] when the patient acutely
decompensated. The patient was noted to have decreased urine
output and a drop in his systolic blood pressure into the 70s
and 80s. He was unresponsive to fluid boluses. The patient
was started on neo-synephrine and Levophed drips to support
his blood pressure and he received several liters of normal
saline boluses.
At about 8:00 p.m. on [**6-25**] the patient began complaining of
abdominal and chest pain and found to have right upper
quadrant tenderness on examination. His [**Known lastname **] count was
found to be elevated at 23 and his hematocrit had fallen to
24.2. The patient was cultured and a left subclavian line
and left arterial line was placed and Ativan drip was added
for sedation and comfort. The patient also received 2 units
of packed red blood cells. He then received an emergent
abdominal CT scan with contrast, which showed bilateral
pleural effusions, a rightward shift in his mediastinum,
large pericardial effusion, slight thickening of the cecal
wall, dilated colon with fluid and small pockets of free air
in the peritoneum, large amount of ascites and anasarca and a
suggestion of a calculus cholecystitis given the appearance
of the gallbladder on CT scan. The patient was started on
broad spectrum antibiotics including Flagyl, Triazene and
Ampicillin. He had an emergent cardiac echocardiogram
performed which initially showed a small circumferential
pericardial effusion, but later on review revealed tamponade
physiology of both the right and left ventricles and a large
loculated anterior pericardial effusion with right atrial and
right ventricular compression.
The patient because of his falling blood pressure was started
on vasopressin and hydrocortisone and morphine drip was added
for sedation. The colorectal surgery attending who consulted
on the case felt that exploratory laparotomy would not
reverse his current situation and throughout the day of [**6-25**] the patient's condition continued to deteriorate. The
patient required wide open pressors. Both of his brothers
[**Name (NI) **] and [**Name (NI) 32342**] were contact[**Name (NI) **] regarding his condition and
decided to withdraw life support and provide comfort
measures, which was done. The patient expired at
approximately 3:23 p.m. on [**2110-6-25**].
DISCHARGE STATUS: The patient expired.
DISCHARGE DIAGNOSES:
1. Cardiac arrest.
2. Septic shock.
3. Respiratory failure.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**]
Dictated By:[**Last Name (NamePattern1) 1336**]
MEDQUIST36
D: [**2110-6-25**] 15:53
T: [**2110-6-30**] 08:53
JOB#: [**Job Number **]
|
[
"0389",
"2875"
] |
Admission Date: [**2195-10-2**] Discharge Date: [**2195-10-14**]
Date of Birth: [**2124-8-21**] Sex: F
Service: SURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
cholangiocarcinoma and renal cell carcinoma
Major Surgical or Invasive Procedure:
R trisegmentectomy (Dr [**Last Name (STitle) **]and L partial nephrectomy (Dr
[**Last Name (STitle) 82578**]
History of Present Illness:
71 female with cholangiocarcinoma scheduled for surgery now with
a single episode this AM of blood in the toilet bowl mixed with
[**Known lastname **] BM, also colored a bit of the surrounding water. No blood
on tissue. Isolated episode, BM after that was normal. Ate
beets with her dinner.
Per Dr[**Name (NI) 1369**] note:
Briefly, she was evaluated for abdominal pain in [**2195-5-15**]. She
had prior outside CT scans on [**2195-4-8**] that demonstrated a
6 cm focus of decreased density within the liver and a 2.6 cm
exophytic mass coming off the posterior
cortex of the left kidney. On [**4-17**] an outside MRI
demonstrated a 7 x 4.5 x 7.5 cm mass thought to possibly
represent an atypical area of focal nodular hyperplasia. She was
also noted to have a fatty liver. The exophytic mass off
the left kidney measured 2.8 x 1.8 x 2.7 cm concerning for renal
cell carcinoma. On [**6-5**] a MRI demonstrated a mass measuring
7.7 x 6.1 x 6.9 cm within segment 4 of the liver but extending
into the anterior segments of segment 5. There was an obstructed
dilated bile duct raising the possibility
of a peripheral cholangiocarcinoma. There was also a second
discrete progressively enhancing lesion within the peripheral
aspect of segment 5 and it was thought to either represent
metastases versus FNH. There is also a subtle third lesion in
the dome at the junctions of segment VII and VIII. She also had
a 2.2 x 2.4 x 2.6 cm exophytic lesion of the lower inner pole
lesion of the left kidney. There was a 1 cm left adrenal nodule
not characterized at the time of this workup. A biopsy of the
lesion on [**6-18**] demonstrated metastatic moderately
differentiated adenocarcinoma positive for CK7, cytokeratin
cocktail, P504S/AMACR and carbonic anhydrase 9. The tumor was
negative for mammoglobin, GCDF, TTF-1 and PAX-2. The immuno
phenotype was nonspecific. The tumor was compatible with renal
artery but failure to stain with PAX-2 was unusual and
additional sites were considered. Chest CT
demonstrated no evidence of metastases. CT colonoscopy
demonstrated only a 6.5 mm polyp in the mid transverse colon.
She was referred for consideration of resection. She was felt to
require a right hepatic trisegmentectomy and underwent right
portal vein embolization and this had adequate hypertrophy of
the left lateral segment.
The surgery will be performed in conjunction with Dr [**Last Name (STitle) 82578**]
Past Medical History:
Hypertension, Hypothyroidism, Hyperlipidemia, Anxiety with
Panic/Agoraphobia, Atrophic, Vaginitis, Breast Cysts, Bone
Spurs, Sciatica, Chronic Bronchitis/COPD, Right Oophorectomy for
endometriosis, Bilateral cataract surgery, Cervical Polyp
portal vein embolization [**2195-9-3**]
Social History:
married, has 4 children, homemaker. Smoked 2
packs per week from age 11-35. No alcohol
Family History:
father died of colon cancer and had alcoholism,
Sister has breast cancer and diabetes, Mother had a CVA,
maternal
grandmother died of Lung cancer
Physical Exam:
Gen: A&O, NAD
Cards: RRR
Pulm: CTA b/l
Abdomen: Abd soft, nondistended, mild TTP consistent with
DRE small amt soft [**Known lastname **] stool, guiaic negative, no gross blood,
no palpable masses
No peripheral edema
Pertinent Results:
On Admission [**2195-10-1**]
WBC-7.8 RBC-4.31 Hgb-11.2* Hct-35.7* MCV-83 MCH-26.1* MCHC-31.5
RDW-14.4 Plt Ct-300
BLOOD PT-11.5 PTT-21.2* INR(PT)-1.0
UreaN-20 Creat-0.9 Na-141 K-4.4 Cl-101 HCO3-27 AnGap-17
ALT-32 AST-35 AlkPhos-105 TotBili-0.4
On Discharge [**2195-10-14**]
WBC-14.4* RBC-2.87* Hgb-8.1* Hct-25.5* MCV-89 MCH-28.2 MCHC-31.7
RDW-17.1* Plt Ct-249
PT-33.1* PTT-85.4* INR(PT)-3.3*
Glucose-94 UreaN-10 Creat-0.8 Na-136 K-3.7 Cl-104 HCO3-25
AnGap-11
ALT-51* AST-37 AlkPhos-169* TotBili-0.6 Albumin-2.6*
Brief Hospital Course:
[**Known firstname **] [**Known lastname 174**] was admitted to the transplant surgery service on
[**2195-10-2**] for right trisegment hepatectomy for cholangiocarcinoma
and left partial nephrectomy for renal cell carcinoma. The
hepatic portion of the surgery was performed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and the partial nephrectomy was completed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of urology. There were no complications during the
surgical procedures. The patient remained intubated and was
transferred to the SICU from the PACU. The patient was weaned
off of pressors and extubated on POD 1. She remained stable
throughout the day and night and was transferred to the floor on
POD2.
Neuro:
Post-operatively the patient was delirious secondary to pain
medication. After the IV pain medications were discontinued on
POD 2, the patient became much more responsive and remained
lucid (AAOx3, appropriate) throughout the remainder of her
hospital course.
Cards:
Patient was hypertensive with systolic blood pressures in the
180s on the floor (POD 2). Her home valsartan dose was
increased from 160 qd to 320 qd and she responded with good
effect. She was normotensive for the remainder of her hospital
course.
Pulmonary:
Her course on the floor was complicated by a pleural effusion on
the R. This was drained by thoracentesis on [**2195-10-8**] and was
found to be concerning for exudative effusion secondary to
infection and therefore the patient was started on Unasyn. A
repeat CXR on [**10-9**] showed residual fluid. A CT chest and
abdomen was obtained to rule out residual effusion. A repeat
thoracentesis was performed on [**10-12**] and the WBC increased to
7625 with 50% polys. The antibiotics were changed to Levaquin
and Flagyl which she will be continued on for two post discharge
date ([**2195-10-28**])
Renal:
Following the surgeries, the patient was fluid positive almost
10kg. Her UOP was adequate throughout her postoperative course,
and her creatinine remained stable (0.8-1.3). She began
mobilizing fluid and had increasing UOP starting on
postoperative day 2. In order to assist in diuresis, severel
one time doses of lasix were administered on days ([**Date range (1) 11879**]).
By the time of discharge, the patient was 5kg above her admit
weight. Monthly creatinine values are recommended to be obtained
per Dr [**Last Name (STitle) 82578**].
GI:
The patient began taking sips on POD1, was advanced to clears on
POD2, and tolerating a regular diet by POD5 without any nausea
or vomiting. She had return of bowel function by discharge
without any diarrhea.
Endocrine:
Patients finger sticks were all within an acceptable range
100-140s during her postoperative recovery on an insulin sliding
scale.
Musculoskeletal:
Patient was difficult to mobilize following surgery secondary to
pain and fatigue. She worked with physical therapy and was able
to ambulate in the hallways with assistance however, it was
believed that she would benefit from a short stay in a rehab
facility but then was cleared by PT for home with home PT
Heme: CT of abdomen obtained on [**10-9**] to evaluate pleural
effusion and possible bile leak returned an incisdental finding
of "Status post left partial nephrectomy with thrombus in the
left renal vein." She was initiated on heparin and started on
Coumadin when appropriate. Dr [**Last Name (STitle) 82578**] recommended a 3 month
coumadin course. She will be followed by VNA for PT/INR with
results to [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] RN for dosage changes initially.
Medications on Admission:
ALPRAZOLAM 0.5 mg Tablet - 1 Tablet(s) by mouth once a day
CLOBETASOL - 0.05 % Cream - apply to affected areas twice a week
CONJUGATED ESTROGENS - 0.625 mg/gram Cream - apply twice a wekk
LEVOTHYROXINE - 50 mcg Tablet - 1 Tablet(s) by mouth once a day
ROSUVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
SERTRALINE - 100 mg Tablet - 1 Tablet(s) by mouth once a day
VALSARTAN-HYDROCHLOROTHIAZIDE - 160 mg-12.5 mg Tabletonce a day
ACETAMINOPHEN 650 mg Tablet Sustained Release - 2 Tabletprn
CALCIUM CARBONATE-VIT D3-MIN 600 mg-400 unit Tablet once a day
CYANOCOBALAMIN - 500 mcg Tablet - 1 Tablet(s) by mouth once a
day
FOLIC ACID - 0.4 mg Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain or Temp above 101F.
3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
4. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
5. Alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Valsartan-Hydrochlorothiazide 160-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
8. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): As needed for soft formed stool daily. Hold for
loose stool.
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
12. Coumadin 1 mg Tablet Sig: As Directed Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
13. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
15. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
16. Conjugated Estrogens 0.625 mg/g Cream Sig: One (1)
application Vaginal 2 times/week.
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc
Discharge Diagnosis:
Hepatocellular carcinoma of the R liver lobe and L renal cell
carcinoma
Left renal vein thrombus
Discharge Condition:
Good/Stable
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for:
- fever > 101.4
- increasing abdominal pain
- signs of infection at the incision including redness, warmth,
increasing pain to palpation, and swelling
- nausea/vomiting/diarrhea
- blood in your stools or bloody vomit
- pain with urination associated with a fever
- difficulty breathing associated with a cough and sputum
production
- any other symptoms which concern you
-Recommend Creatinine monthly on labwork
-3 month CT Scan followup
Chest x ray prior to appointment with Dr [**Last Name (STitle) **] on [**2195-10-21**]
Take coumadin based upon instructions from Dr [**Last Name (STitle) 4727**] office
Followup Instructions:
Dr. [**Last Name (STitle) 82578**] ([**Telephone/Fax (1) 4537**]) will be coming to Dr [**Last Name (STitle) 4727**] office to
see you when you are at your follow up visit on [**10-21**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2195-10-21**]
1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2195-10-15**]
|
[
"2762",
"5119",
"4019",
"2449",
"2724",
"V5861"
] |
Admission Date: [**2132-1-31**] Discharge Date: [**2132-2-3**]
Date of Birth: [**2102-3-11**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Dyspnea/Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Otherwise healthy 29F, no sig PMH, history of smoking, developed
dyspnea and cough 3 days ago, and went to [**Hospital3 4107**], where
she was diagnosed with anxiety and a RML pneumonia on CXR and
discharged on azithromycin. Pt states that her coughing has
gotten worse over the past 3 days, and so she returned to the
[**Hospital1 **] ER, where she was found to be dyspneic with an O2 sat in
the low 80s. Pt had "low-grade" temp to 100F, with chills and
body aches. Pt had no n/v/d, no sputum production. Pt did feel a
subjective wheezing sensation. Pt was placed on BiPap, with
improvement in O2 sat to high 90s. A CXR revealed worsening
Right middle lobe infiltrate from prior study, with a
questionable LLL infiltrate as well. ABG revealed PaO2 63. Pt
received Azithro, ceftriazone, nebs, magnesium, solumedrol for
wheezing and ?asthma exacerbation, as well as a heparin bolus
and gtt. Given pt's hypoxia, pt was given a CTPE to r/o PE in
addition to pneumonia. This was read by [**Hospital1 39933**] radiologists as
showing b/l PEs, in addition to b/l multifocal pneumonia. Pt was
transferred to [**Hospital1 **] for further management.
.
In the ED, initial VS were: 98.9 ??????F (37.2 ??????C), Pulse: 94, RR:
25, BP: 126/74, O2Sat: 91, O2Flow: 5. PT was given Tamiflu for
concern for influenza, and the CT study was sent to radiology
for a 2nd read. She was taken off bipap here and subsequently
she satted 88% on 4L NC with RR 40s. She was switched to
non-rebreather with RR high 30s, and then placed on BIPAP with
RR 20s, FiO2 60, with O2 Sat high 90s. ABG was performed on
BiPap with PaO2 86. Pt had a persistent air leak on bipap mask,
and required multiple mask revisions. An informal bedside echo
in the ED revealed no RV strain, and her EKG revealed no R heart
strain. A Trop and BNP are pending (sent for prognosis of PE).
PT has a Flu swab, blood cx at [**Hospital3 4107**] none here.
Access:20 g and 18g
IVF: 1L at OSH, nothing here
Vitals: afebrile, HR 103, BP 120-130/82, RR 25 on BIPAP satting
95%.
.
On arrival to the MICU, pt is comfortable, satting 90% on 4L
NC. She was conversational but breathing quickly, and complained
of continuing dry cough and anxiety. PT also complained of a
wheezing sensation, but otherwise stated that she felt "well."
Past Medical History:
Anxiety, treated w/ gabapentin
Uterine hemmhorage 1 yr ago s/p D&C, no anemia since
weekly "migraine" headaches
Social History:
- Tobacco: 1 ppy for 3 yrs
- Alcohol: denies current use
- Illicits: denies
recently got a hamster as a pet
Family History:
No family history of lung disease, blood clots, pneumonia.
Physical Exam:
Admission Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: scattered inspiratory and expiratory wheezes and coarse
crackles r>l, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge Exam:
Vitals: Tm 98.1, BP 115/76, HR 70, RR 18, O2 95% RA
General: young woman lying in bed sleeping comfortably in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: scattered inspiratory wheezes, good air movement, cannot
appreciate rales or rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sleepy but oriented x3
Pertinent Results:
LABS:
On admission:
[**2132-1-31**] 11:22PM BLOOD WBC-8.8 RBC-3.98* Hgb-12.2 Hct-35.1*
MCV-88 MCH-30.7 MCHC-34.8 RDW-14.2 Plt Ct-243
[**2132-1-31**] 11:22PM BLOOD Neuts-95.1* Lymphs-3.8* Monos-0.3*
Eos-0.4 Baso-0.3
[**2132-1-31**] 11:22PM BLOOD PT-13.7* PTT-150* INR(PT)-1.3*
[**2132-1-31**] 11:22PM BLOOD Glucose-181* UreaN-13 Creat-0.7 Na-138
K-4.1 Cl-108 HCO3-23 AnGap-11
[**2132-2-1**] 03:41AM BLOOD AlkPhos-33*
[**2132-1-31**] 11:22PM BLOOD Calcium-8.2* Phos-2.7 Mg-2.0
[**2132-1-31**] 11:29PM BLOOD D-Dimer-756*
[**2132-1-31**] 11:55PM BLOOD Type-ART Rates-/23 FiO2-60 pO2-86
pCO2-33* pH-7.40 calTCO2-21 Base XS--2 Intubat-NOT INTUBA
Vent-SPONTANEOU
On discharge:
[**2132-2-3**] 07:20AM BLOOD WBC-7.0 RBC-3.88* Hgb-12.0 Hct-35.8*
MCV-92 MCH-30.9 MCHC-33.5 RDW-13.8 Plt Ct-398
[**2132-2-3**] 07:20AM BLOOD Glucose-96 UreaN-14 Creat-0.7 Na-141
K-3.8 Cl-108 HCO3-25 AnGap-12
[**2132-2-3**] 07:20AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9
MICRO:
Time Taken Not Noted Log-In Date/Time: [**2132-2-1**] 2:50 am
URINE 0013H.
**FINAL REPORT [**2132-2-1**]**
Legionella Urinary Antigen (Final [**2132-2-1**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2132-2-1**] 6:45 am Influenza A/B by DFA
Source: Nasopharyngeal swab SPECIMEN IDENTIFIED AND
AUTHORIZED BY
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 110200**] ON [**2132-2-1**] @0830.
**FINAL REPORT [**2132-2-1**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2132-2-1**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2132-2-1**]):
Negative for Influenza B.
[**2132-2-1**] 6:17 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2132-2-1**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2132-2-3**]):
SPARSE GROWTH Commensal Respiratory Flora.
FUNGAL CULTURE (Preliminary):
YEAST.
IMAGING:
CT CHEST ([**2132-1-31**]):
1. Multifocal ground-glass opacities, worse in the upper zones,
most
compatible with multifocal pneumonia. Hemorrhage can have a
similar
appearance. Please correlate with symptoms.
2. The examination is suboptimal for assessment of pulmonary
emboli to the
subsegmental levels, No large PE is detected. If there remains a
high clinical concern for small emboli, a repeat CTA could be
considered.
CXR ([**2132-2-1**]):
IMPRESSION: AP chest compared to [**1-31**]. Many small foci of
consolidation and ground-glass opacification, most prominent
around both hila have not changed since [**1-31**] consistent with
a multifocal, probably non-bacterial pneumonia. Heart size is
normal. Pleural effusions are small if any. No pneumothorax.
Normal cardiomediastinal and hilar silhouettes.
Brief Hospital Course:
29 yo F smoker with no other significant PMHx presents with dry
cough and worsening dyspnea over 3 days, transferred to [**Hospital1 18**] on
BiPap for hypoxia with chest CT showing multifocal pneumonia.
Admitted initially to the MICU for hypoxia, weaned down the
nasal cannula and transferred to the medicine floor the
following morning.
ACTIVE ISSUES BY PROBLEM:
# Multifocal pneumonia: CTA chest from [**Hospital1 **] showed multifocal
pneumonia and possible pulmonary embolisms, so patient arrived
on heparin gtt. Upon re-read of CTA by [**Hospital1 18**] attending
radiologist, no pulmonary embolism was seen, so she was taken
off the heparin gtt. She was weaned off BiPAP shortly after
admission to the MICU, stabilized 4-6 L NC. Given diffuse
wheezing on exam, prednisone 40mg was started as well as
ceftriaxone and levofloxacin for treatment of severe CAP
(started on [**1-31**]). She recieved scheduled ipratropium and
albuterol. Influenza and urine legionella were sent and found
to be negative. Sputum was sent and only showed yeast (normal
respiratory flora). Once stabilized on nasal cannula, she was
transferred to the medicine floor. On HD#3, she comfortable on
room air, and tachypnea and wheezing was greatly improved. She
tolerated activity (including stairs) with sats of 95% room air,
so it was felt that she could be discharged to home. She was
discharged with prescriptions for prednisone 40 mg (5 day course
through [**2-4**]), levofloxacin 750mg qday (5 day course, through
[**2132-2-4**]), and cefpodoxime 200 mg every 12 hours for 10 more days
(14 day course, through [**2132-2-13**]). She was also given a Rx for
albuterol inhaler, given her continued mild wheezing. She
should follow up with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39752**] in the next 1-2 weeks.
# Smoking - Pt encouraged regarding smoking cessation,
verbalized understanding of the importance of quitting,
especially now given the severity of her pneumonia.
CHRONIC, INACTIVE ISSUES:
# Anxiety - continued on gabapentin TID. Given occasional ativan
1 mg to help her sleep at night, but not sent home with rx.
TRANSITION OF CARE ISSUES:
- PNA: discharged with prednisone 40 mg (5 day course through
[**2-4**]), levofloxacin 750mg qday (5 day course, through [**2132-2-4**]),
and cefpodoxime 200 mg every 12 hours for 10 more days (14 day
course, through [**2132-2-13**]). Should follow up with PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] CODE this admission
Medications on Admission:
Gabapentin 600mg TID
Ibuprofen 400mg q8h prn pain
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
2. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
3. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 days: Course to be completed [**2132-2-4**].
Disp:*1 Tablet(s)* Refills:*0*
4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days: Course to be completed [**2132-2-4**].
Disp:*1 Tablet(s)* Refills:*0*
5. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 10 days: Course to be completed [**2132-2-13**].
Disp:*20 Tablet(s)* Refills:*0*
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Community acquired pneumonia
Secondary diagnoses:
Anxiety
Tobacco abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 931**],
You were admitted to the hospital for shortness of breath, and
you were found to have a severe pneumonia. You were given
intravenous antibiotics, nebulizers, and steroids, and you
slowly improved. You will need to continue these antibiotics
for a few more days (see below for end dates).
Changes to your medications:
START levofloxacin 750mg daily for 1 more days (through [**2132-2-4**])
START cefpodoxime 200 mg every 12 hours for 10 days (through
[**2132-2-13**])
START prednisone 40 mg daily for 1 more dose ([**2132-2-4**])
START albuterol inhaler 1-2 puffs every 4 hours as needed for
wheezing or shortness of breath
It was a pleasure to take care of you at [**Hospital1 **]!
Followup Instructions:
Please make an appointment to see your primary doctor, Dr.
[**Last Name (STitle) 39752**], within the next 1-2 weeks to follow up on your
hospitalization.
|
[
"486",
"3051"
] |
Admission Date: [**2116-1-22**] Discharge Date: [**2116-1-24**]
Date of Birth: [**2037-5-8**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
traumatic SAH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo female found in conscious state in outside driveway face
down by grandson. She was ambulatory at the scene, with multiple
abrasions, epistaxis, lacerated upper lip.Pt's family reports
they believe she slipped and fell on ice. Pt was speaking when
found, stating she was in pain. Pt brought to OSH with a head CT
showing small SAH in the superficial convexity on the left and
minimal intraparenchymal hemorrhages. Also showed deep white
matter ischemic disease and volume loss with fx of the nasal
bone
and anterior aspect of the nasal septum with fluid in the nasal
cavity ethmoid sinuses, and the right maxillary sinus.
Past Medical History:
HTN, CVA, ?dementia per family
Social History:
Lives with children
Family History:
NC
Physical Exam:
T: BP: 114/54,71,16,98%
Gen: WD/WN, agitated,restless, hard cervical collar intact, MAE,
yelling at family.
HEENT: Pupils: [**5-14**],brisk EOM's: UTA -pt uncoooperative
NC, no [**Last Name (un) 2043**] step off appreciated, No hemotympanum, negative
battles sign. + facial, nasal, chin abrasions, sutures noted to
tip of nose, distal nare, and chin (placed at outside hospital).
Neck: Cervical collar intact.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake,alert, un-cooperative with exam, agitated
Orientation: Oriented to self with family recognition.
Language: Speech fluent, agitated.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4to3 mm
bilaterally.
III, IV, VI: UTA due to orbital/periorbital edema and pt
uncooperative
V, VII: UTA-uncooperative
VIII: Hearing intact to voice.
IX, X: UTA-uncooperative.
[**Doctor First Name 81**]: UTA-uncooperative.
XII: UTA-uncooperative.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-15**] throughout. UTA pronator drift.
Pertinent Results:
[**2116-1-22**] 04:48AM GLUCOSE-153* UREA N-25* CREAT-1.1 SODIUM-141
POTASSIUM-3.2* CHLORIDE-100 TOTAL CO2-30 ANION GAP-14
[**2116-1-22**] 04:48AM CALCIUM-9.7 PHOSPHATE-2.7 MAGNESIUM-1.5*
[**2116-1-22**] 04:48AM PHENYTOIN-12.2
[**2116-1-22**] 04:48AM WBC-10.2 RBC-4.21 HGB-12.9 HCT-37.4 MCV-89
MCH-30.7 MCHC-34.6 RDW-13.9
[**2116-1-22**] 04:48AM NEUTS-76.5* LYMPHS-17.0* MONOS-6.1 EOS-0.2
BASOS-0.2
[**2116-1-22**] 04:48AM PLT COUNT-274
[**2116-1-22**] 04:48AM PT-15.0* PTT-26.4 INR(PT)-1.3*
[**2116-1-21**] 11:20PM GLUCOSE-130* UREA N-29* CREAT-1.1 SODIUM-140
POTASSIUM-3.1* CHLORIDE-99 TOTAL CO2-28 ANION GAP-16
[**2116-1-21**] 11:20PM estGFR-Using this
[**2116-1-21**] 11:20PM PHENYTOIN-<0.6*
[**2116-1-21**] 11:20PM WBC-9.6 RBC-4.16* HGB-13.1 HCT-36.4 MCV-88
MCH-31.4 MCHC-35.9* RDW-14.1
[**2116-1-21**] 11:20PM NEUTS-77.5* LYMPHS-17.7* MONOS-4.5 EOS-0.2
BASOS-0.1
[**2116-1-21**] 11:20PM PLT COUNT-235
[**2116-1-21**] 11:20PM PT-14.5* PTT-25.7 INR(PT)-1.3*
*****************
CT C-SPINE W/O CONTRAST [**2116-1-21**] 9:55 PM
CT C-SPINE W/O CONTRAST
Reason: S/P FALL ONTO FACE, FACIAL ABRASIONS. ? FX.
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman tx from LGH, s/p fall onto face and found to
have facial abrasions and L SAH at outside hospital.
REASON FOR THIS EXAMINATION:
please eval for Cspine fracture
CONTRAINDICATIONS for IV CONTRAST: None.
CT CERVICAL SPINE WITHOUT CONTRAST
INDICATION: 78-year-old woman transferred from outside hospital
status post fall on to face and presenting with facial abrasions
and subarachnoid hemorrhage.
COMPARISON: Not available.
CT CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: There is no
acute fracture or abnormal alignment. The odontoid process is
midline. Atlanto-axial and atlanto-occipital relationships are
maintained. There is no prevertebral soft tissue swelling.
Degenerative changes are noted at C5-6 level with intervertebral
disc space narrowing, subchondral sclerosis, and cyst formation.
Incidentally noted are carotid artery calcifications. There is a
2-cm cystic lesion in the left thyroid lobe. Imaged lung apices
are unremarkable.
There is mucosal thickening in the maxillary and ethmoid
sinuses. There is fluid in the middle ear cavities bilaterally.
IMPRESSION:
1. No acute fracture or abnormal alignment in the cervical
spine.
2. Incidentally noted likely thyroid colloid cyst.
CT HEAD W/O CONTRAST [**2116-1-21**] 9:55 PM
CT HEAD W/O CONTRAST
Reason: S/P FALL ONTO FACE, FACIAL ABRASION.
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman tx from LGH, s/p fall onto face and found to
have facial abrasions and L SAH at outside hospital.
REASON FOR THIS EXAMINATION:
Please eval for SAH.
CONTRAINDICATIONS for IV CONTRAST: None.
HEAD CT WITHOUT CONTRAST
INDICATION: 78-year-old woman transferred from outside hospital
status post fall on the face, with facial abrasions, and
subarachnoid hemorrhage.
COMPARISON: Not available.
FINDINGS: There are a few small foci of subarachnoid hemorrhage
layering within sulci near the vertex on the left, as well as a
small focus in the right interhemispheric fissure. There is no
edema, mass effect, shift of normally midline structures or
hydrocephalus. Hypodensities in the basal ganglia bilaterally
likely represent chronic lacunar infarctions. Periventricular
white matter hypodensities are consistent with chronic
microvascular ischemia.
Bone windows demonstrated bilateral fractures of the nasal bone
and fracture of the nasal septum. There is a radiopaque foreign
body in the soft tissues of the nose on the right. Bilateral
preseptal hematomas are present. The globes appear intact. There
is fluid in the middle ear cavities bilaterally. Mucosal
thickening is present, involving frontal, ethmoid, and maxillary
sinuses bilaterally.
IMPRESSION:
1. Small amount of subarachnoid hemorrhage near the vertex.
2. Bilateral nasal bone and nasal septum fracture.
3. Radiopaque foreign body in the soft tissues of the nose.
CT HEAD W/O CONTRAST [**2116-1-22**] 5:37 AM
CT HEAD W/O CONTRAST
Reason: r/o extension of sah, please do at 6am
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with sah
REASON FOR THIS EXAMINATION:
r/o extension of sah, please do at 6am
CONTRAINDICATIONS for IV CONTRAST: None.
CT HEAD WITHOUT CONTRAST
INDICATION: 78-year-old woman with subarachnoid hemorrhage.
COMPARISON: [**2116-1-21**], 22:02.
CT HEAD WITHOUT INTRAVENOUS CONTRAST: Again seen are small foci
of subarachnoid hemorrhage in the sulci near the vertex on the
left as well as a small focus in the interhemispheric fissure
and parietal lobe. There are no new foci of hemorrhage, edema,
shift of normally midline structures or hydrocephalus. The
appearance of the rest of the study is unchanged.
IMPRESSION: No significant change in small subarachnoid
hemorrhage.
Brief Hospital Course:
Ms [**Known lastname 105673**] was admitted to Neurosurgery ICU on [**2116-1-22**] for
small traumatic subarachnoid hematoma. Neurologically she is at
her baseline with mental status, and no focal neuro deficits
found on admission. Her [**Date Range **] was on hold and she received
platelet transfusion for h/o [**Date Range **] usage. Repeat head CT showed
stable small SAH. C-spine CT showed no cervical fracture. She is
recommended to wear soft c-collar due to complain of tenderness
at posterior neck. Neurologically she is stable at her baseline
and was transferred to regular floor on HD#3. She tolerated
regular diet. She has baseline bladder incontinence wearing
diaper-pants.
PT/OT are consulted and recommended patient to be discharged
home with 24hr supervision from family member.
Plastic services was also consulted regarding foreign body in
nose and nasal fracture. Foreign body was removed and she is
recommended to follow up with plastic services in outpatient
clinic.
Medications on Admission:
Lopressor 50MG qd, Lisinopril ?, HCTZ 25mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 325mg QD,
Rivastigmine, Xelon, OsCal
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QAM (once a day (in the morning)).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take along with narcotic pain medications.
Disp:*60 Capsule(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*20 500unit/g* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO three times a day for 7 days.
Disp:*42 Tablet, Chewable(s)* Refills:*0*
12. wheerchair
wheelchair x one
Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic subarachnoid hemorrhage
Traumatic nasal bone fracture
Discharge Condition:
Neurologically at baseline.
Discharge Instructions:
24hour supervision from the family is required after your
discharge.
?????? Please wear soft cervical collar at all the times until your
follow up with Dr [**Last Name (STitle) **]
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Take your pain medicine as prescribed; increase your intake of
fluids and fiber as pain medicine (narcotics) can cause
constipation
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any new change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
Followup Instructions:
- PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
- Please follow up with Plastic services clinic for your nasal
bone fracture within 1 week of discharge with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Call [**Telephone/Fax (1) 5343**] for appointment.
Completed by:[**2116-1-24**]
|
[
"4019"
] |
Admission Date: [**2135-11-11**] Discharge Date: [**2135-11-11**]
Date of Birth: [**2071-5-11**] Sex: M
Service: MEDICINE
Allergies:
Oxacillin / Ciprofloxacin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
aspirated an apple
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
64M with no prior hx of neurological disorders or GI dismotility
disorders who presents with a history of choking on an apple the
evening of admission. The patient reports that he felt that the
apple went down the wrong way. He became short of breath and
started wheezing.
He reports that at least once a week he has difficulty
swallowing. The food gets stuck in the back of his throat as he
tries to swallow. He also reports frequent burping. He has never
been evaluated by a gastroenterologist.
In the ED the patient's vitals were T 98.2, HR 99-108, BP
135/81, RR 14, O2sat 95RA. His physical exam was noteworthy for
end expiratory wheezes.
.
Past Medical History:
DM
HTN
Hyperlipidemia
A fib
Social History:
lives with wife
works as French teacher
denies tob, EtOH, ivdu
Family History:
noncontributory
Physical Exam:
Upon arrival to the [**Hospital Unit Name 153**]:
t98.8 bp137/80 hr82 (afib) RR22 o2sat 94% 2LNC
GEN: morbidly obese caucasian male in NAD
HEENT: MMM, OP clear
HEART: irreg, irreg; II/VI holosystic murmur LUSB
LUNGS: CTAb/l, no rrw
ABD: protuberant, +bs, unable to assess organomegaly
EXT: cold, faint dp
Pertinent Results:
Upon presentation:
[**2135-11-11**] 12:05AM GLUCOSE-476* UREA N-25* CREAT-1.5* SODIUM-136
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-23 ANION GAP-19
[**2135-11-11**] 12:05AM WBC-9.1 RBC-4.95 HGB-16.2 HCT-46.2 MCV-93
MCH-32.7* MCHC-35.1* RDW-15.0
[**2135-11-11**] 12:05AM NEUTS-82.2* LYMPHS-10.7* MONOS-5.7 EOS-0.7
BASOS-0.7
[**2135-11-11**] 12:05AM PLT COUNT-143*
[**2135-11-11**] 12:05AM PT-22.0* PTT-27.5 INR(PT)-2.2*
[**2135-11-11**]: Neck xray: Carotid calcifications are seen. No
prevertebral soft tissue swelling is noted. Lung apices are
clear. No radiopaque foreign body identified. Degenerative
changes at several facet joints noted.
.
[**2135-11-11**]: CXR: No evidence of opaque foriegn body, aspiration or
atelectasis
[**2135-11-11**]: Flexible Bronchoscopy: few thin secretions medial
airway with 2 areas of erythema and mild bleeding above left
lower lobe
Brief Hospital Course:
A: 64M with no known neuro/gi disorders who presents after
questionable aspiration on an apple
P:
1. Aspiration: The patient presented after aspiration of a small
apple piece. His breathing was not significantly challenged.
There was no evidence of a radio-opaque foreign body on imaging.
He was observed overnight in the ICU. The next day, he coughed
out a piece of apple. A follow-up bronchoscopy revealed
inflammed airways but no evidence of retained foreign matter.
Upon discharge, he was breathing at his baseline. No antibiotics
were indicated. He was discharged to follow-up with his primary
physician and to discuss referral to a gastroenterologist if he
has recurrent swallowing difficulties.
.
2.Cardiovascular history: The patient has a history of
hypertension and congestive heart failure. His home
antihypertensives (ACE inhibitor and beta-blocker) were
continued during this hospitalization and no changes were made
at discharge. His diuretic regimen continued as well. His
aspirin was held prior to undergoing the bronchoscopy.
Regarding his history of atrial fibrillation, his coumadin was
held overnight prior to the bronchoscopy. He will resume his
anticoagulation program with the [**Company 191**] anticoagulation service.
He received his home dose of niacin for his hyperlipidemia.
.
3. Anxiety: There were no acute issues and the patient received
his home dose of Xanax and ativan as needed.
.
4. Chronic kidney disease: This is likely due to hypertension
and diabetes. There were no acute issues and his creatinine was
at his baseline upon presentation.
.
5. Diabetes: While in the hospital, his blood sugars were
managed with insulin 70:30 and regular insulin sliding scale.
Upon discharge, he will resume his former outpatient regimen of
insulin 70:30, metformin, and Byetta.
.
6. Prophylaxis: He received a PPI and was ambulatory during this
admission.
.
7. Access: peripheral ivs.
.
8. Dispo: to home with instructions to follow-up with his
primary physician.
Medications on Admission:
Insulin 70:30 40 units [**Hospital1 **]
Byetta
Xanax 0.125 mg po qhs prn
Ativan 0.25 mg po qhs prn
Metformin 500 mg po qd
Coumadin 3.75 mg po qd x 4 days, 2.75 mg po qd x 3days
Aspirin 81 mg po qd
Aldactone
Lasix 80 mg po bid
Magnesium tablet
Potassium chloride
Lopressor 50 mg po bid
Lisinopril 5 mg po qd
Lipitor 10 mg po qd
Niacin
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO twice a day.
5. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Forty (40) units Subcutaneous twice a day: before breakfast
and before dinner.
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):
take as directed by the [**Hospital3 **].
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QEVENING ().
11. Niacin 500 mg Capsule, Sustained Release Sig: Three (3)
Capsule, Sustained Release PO BID (2 times a day).
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO twice a day: use as
directed by your primary doctor.
13. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
14. Byetta 5 mcg/0.02 mL Pen Injector Sig: One (1) unit
Subcutaneous asdir: as directed by your primary doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Foreign body aspiration
.
Secondary:
Obesity
Hypertension
Atrial fibrillation
Hyperlipidemia
Discharge Condition:
good. stable vital signs. tolerating oral medication and
nutrition. ambulating unassisted.
Discharge Instructions:
You have been evaluated and treated for a food aspiration. Your
vital signs remained stable. You were monitored in the ICU as a
precaution. You were able to cough out the remaining food
particle. The bronchoscopy revealed indirect evidence of the
aspiration but no evidence of the food particle itself.
.
If you continue to have trouble swallowing, please contact your
primary doctor and discuss referral to a gastroenterologist for
further evaluation.
.
If you develop and worsening cough, chest pain or shortness of
breath please seek medical care.
.
Please make and attend the follow-up appointment as recommended
below.
.
You will resume your home medications as previously prescribed.
.
In keeping with your history of heart disease you should adhere
to the following recommendations:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2.5 L per day
Followup Instructions:
Please call your primary medical doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 250**] to schedule a follow-up appointment to be seen
within the next 1-2 weeks.
.
Please contact the [**Hospital3 **] [**Name (NI) **] Clinic
to arrange your next blood draw.
|
[
"4280",
"40391",
"5859",
"42731",
"2724",
"V5861"
] |
Admission Date: [**2133-8-28**] Discharge Date: [**2133-9-3**]
Date of Birth: [**2069-1-21**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 64 year-old [**Location 43876**] male with no significant past medical history who
now presents with seven hours of constant crushing substernal
chest pain. The patient reports having less severe
substernal chest pain one day prior to admission while at
work, nonradiating in nature with no associated symptoms, and
relieved by ten minutes of rest. He denies any prior history
of such pain and attributed it to indigestion. Then around
8:00 a.m. on the day of admission the patient developed
substernal crushing chest pain while at work associated with
shortness of breath and nausea. Because the pain failed to
resolve he electively went to [**Hospital3 417**] Hospital and was
found to have ST elevations in 2, 3, AVF, V2-V6 with large Q
waves in the precordial leads. He was immediately started on
aspirin, nitroglycerin, morphine, Integrilin and Lopressor
and transferred to [**Hospital1 69**] for
emergent cardiac catheterization.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Brother died of an myocardial infarction at
the age of 35. Cousin died of myocardial infarction in his
60s. Father with prostate cancer. No history of diabetes or
strokes in the family.
SOCIAL HISTORY: Three and a half pack year tobacco history.
The patient quit three years ago. The patient drinks about
two to three beers per day. He denies any recreational drug
use.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: Temperature 97.9. Blood pressure
105/62. Pulse 78. Respirations 12. Sating 99% on room air.
In general, he is a well developed, well nourished [**Location 43876**] male who appeared fatigued, but was in no acute
distress. Pupils are equal, round and reactive to light.
Extraocular movements intact. Oropharynx was clear with
mucous membranes are moist. His neck was supple with no
appreciable JVD, carotid bruits, thyromegaly or
lymphadenopathy. Lungs are clear to auscultation
bilaterally. Cardiac examination revealed regular rate and
rhythm with no murmurs, rubs or gallops. His point of
maximal impulse was not displaced and there was no heave
present. His adomen was soft, nontender, nondistended with
normal bowel sounds and no hepatosplenomegaly. Extremities
were without any clubbing, cyanosis or edema or calf
tenderness. He had 2+ distal pulses throughout.
Neurological examination was nonfocal and symmetric.
LABORATORIES ON ADMISSION: Significant for a hematocrit of
37.5, white count 4.2, creatinine 0.6, INR 1.2, CKs peaked at
[**2122**], MBs peaked at 484 with a peak index of 24.3 and
troponins were greater then 50. AST 233, with the rest of
his liver function tests normal. Triglycerides 87, HDL 82,
LDL 190.
Cardiac catheterization left ventricular ejection fraction
less then 45%, large area of anteroapical and inferoapical
akinesis with hypokinesis at basal segments, left anterior
descending coronary artery with 40% proximal and 100% mid
stenosis, left circumflex with 80% proximal lesion, 80%
stenosis in upper branch of large obtuse marginal one, right
coronary artery with 60% origin and 80% distal region just
before posterior descending coronary artery.
HOSPITAL COURSE: A balloon was placed in the patient's mid
left anterior descending coronary artery without
complications during his cardiac catheterization. He was
started on an Integrilin drip along with aspirin, low dose
Metoprolol and Lipitor. He was started on an intravenous
heparin drip six hours after his femoral sheath was taken
out. Because the patient continued to have chest pain even
after his cardiac catheterization he was placed on a
nitroglycerin drip for symptomatic relief. A repeat
electrocardiogram showed no new changes. The patient's blood
pressure and heart rate remained stable off all pressors. He
was monitored closely on tele watching for any conduction
abnormalities after his large anterior myocardial infarction.
His electrolytes were checked on a regular basis and were
repleted as needed. His sats remained excellent on 2 liters
of nasal cannula. He was placed on a cardiac/diabetic diet
and given adequate post catheterization intravenous fluid
hydration. His hematocrit remained stable post
catheterization and his groin site showed no signs or
symptoms of a hematoma. He remained afebrile throughout his
hospital stay with no leukocytosis. His creatinine remained
stable throughout his hospital stay with no signs of dye
induced nephropathy.
On hospital day number two the patient developed acute mental
status changes consistent with delirium. A head CT was
obtained, which was negative for any infarction or bleed.
Sed rate, TSH, vitamin B-12, folate, RPR and serum tox
screens were all negative. Psychiatry was consulted and the
patient's increased agitation/delirium was felt to be a
result of alcohol withdraw. He was placed on a CIWA scale
with prn Valium. Neurology was also consulted and a head MRI
was obtained, which came back negative for any acute process.
The patient's mental status returned to baseline within the
course of the next three days with the help of prn Valium.
DISCHARGE DIAGNOSES:
1. Severe three vessel coronary artery disease status post
large anterolateral and inferior myocardial infarction.
2. Depressed left ventricular systolic function with an EF
of less then 45% and several wall motion abnormalities.
3. Delirium secondary to alcohol withdraw.
4. Hypercholesterolemia.
DISCHARGE MEDICATIONS: Aspirin 325 q.d., Lipitor 10 mg q.d.,
Atenolol 25 mg q.d., Lisinopril 10 mg q.d., folic acid q.d.,
Thiamine q.d., multivitamin q.d., Protonix 40 mg q.d.
DI[**Last Name (STitle) 408**]E STATUS: The patient was discharged to home in
stable condition. He is to see Dr. [**Last Name (Prefixes) **]
(cardiothoracic surgeon) on Thursday [**9-10**] at 10:30 a.m.
in his office to further discuss imminent coronary artery
bypass graft, which will be performed within the next two
weeks. The patient is to continue on his cardiac medications
(aspirin, statin, beta blocker and ace inhibitor). He has
been advised to avoid all alcohol at least until his cardiac
surgery.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D.
Dictated By:[**Last Name (NamePattern4) 1198**]
MEDQUIST36
D: [**2133-10-22**] 16:27
T: [**2133-10-27**] 10:24
JOB#: [**Job Number 10064**]
|
[
"41071",
"41401",
"4240",
"4019",
"V1582"
] |
Admission Date: [**2163-6-6**] Discharge Date: [**2163-6-23**]
Date of Birth: [**2091-12-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Levaquin / Latex / Doxycycline / Peanut
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Hypoxia.
Major Surgical or Invasive Procedure:
Rigid bronch x 2.
History of Present Illness:
71 yo man with severe COPD on oxygen at baseline, new dx of
NSCLC and recnet GIB who was transferred here on [**6-6**] for
treatment of SC lung CA via photodynamic therapy, now with GIB.
.
Briefly, his OSH course began in late [**Month (only) 958**] when he was admitted
for COPD exacerbation. He was dc'd on [**5-13**] but returned on [**5-17**]
with increased SOB, secretions, hypoxia and rapid afib. During
his hospital course he was found to have RLL PNA and tx with
levaquin, zosyn, tobramycin nebulizers and high dose steriods.
He had a bronch on [**5-20**] with b/l mucoid impacation and
endobronchial lesion. On [**5-28**] he had repeat bronch showing RUL
endobronchial lesion and biopsy demonstrating NSCLC. His course
we c/b by BRBPR on [**5-30**] requiring 11 units PRBCs. [**Last Name (un) **] on [**5-31**]
shoued large sigmoid polyp that was not removed, diffuse
diverticulosis, multiple small polyps and no active bleed. He
was transferred to [**Hospital1 **] on [**6-6**] for futher management of RUL
carcinoma.
Here he underwent the first 2 portions of photodynamic therapy
([**6-8**] and [**6-10**]) and was awaiting debridement when he developed
BRBPR and tachycardia on the morning of [**6-11**]. [**Name8 (MD) **] RN notes, he
had a large amt of BRBPR in the morning. He began to get
anxious, respiratory rate increased and he became hypertensive
to 170/110 with HR in the 140s. Audible wheezes were noted on
exam, so he was given 20 mg IV lasix for presumed flash
pulmonary edema. He was give IV lopressor 5 mg IV for HR. His
hct and plts were checked and stable. He put out 500 cc to the
lasix, RR rate improved and sats were 95% on 4L prior to txfr.
HR improved to 83.
.
On arrival to the MICU: HR was in the 80s, SBP in the 130s. He
denies abdominal pain, nausea, vomiting, chest pain,
palpitations, lightheadedness, fevers or chills. Has a cough
that has been present for 11 yrs. Also c/o 40 lb wt loss in the
past 5 weeks.
Past Medical History:
severe COPD (O2 dependent at home)
chronic multidrug-resistant pseudomonas colonization
bilateral lower lobe bronchiectasis
common variable immune deficiency tx IVIG q2wks
thrombocytopenia
s/p LGI bleed [**2163-5-30**], s/p colonoscopy [**5-31**] as above
herpes labialis
asthma
h/o rapid a fib (on coumadin-currently held)
h/o prior episode of SVT
Social History:
Quit smoking 8 yrs ago. Prior to that had 100 pack year history.
Quit drinking 17 yrs ago. Denies drug use. Lives in RI with his
wife.
Family History:
Mother with COPD, no family h/o CAD.
Physical Exam:
VS: Tc: 97.3 BP: 139/69 HR: 87 RR 18 O2 sat 94% on
GEN: chronically ill appearing, elderly, NAD
HEENT: NC, pupils equal and round, no conjuctival injection,
anicteric, dry MM. Has two erythematous scabbing lesions on his
lip.
Neck: supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, difficult to hear over breath sounds
PULM: coarse breath sounds b/l, with exp wheezes and rhonchi.
Possible crackles at the bases b/l.
ABD: soft, NT, ND, + BS, no hepatomegally
EXT: warm, dry, +2 distal pulses BL,
NEURO: alert & oriented, CN II-XII grossly intact.
PSYCH: appropriate affect
Pertinent Results:
OSH pathology:
[**5-31**] [**Last Name (un) **]: tubulovillous adenoma
[**5-28**] bronch RUL brush cytology: malignant cells, NSCLC, likely
squamous cell carcinoma
[**5-28**] RUL washing cytology: suspicious for malignancy, severely
atypical squamous cells c/w high grade dysplasia/squamous cell
carcinoma
[**5-28**] path RUL biopsy: makedly atypical squamous epithelium c/w
high grade dysplasia or SCC in situ
[**5-28**] bronch cxL few pseudomonas resistant to gent, cefepime,
tobramycin, fortaz, levaquin, cipro, zosyn and amikacin.
Intermiediate to primaxin.
.
CXR: hyperinflated lungs, haziness in LLL (my read)
.
CT chest [**6-6**]:
1. Negative examination for endotracheal or endobronchial
lesions in the central bronchi.
2. Moderate emphysema.
3. Extensive severe, purulent bronchiectasis in both lungs.
4. One bronchiectatic segment with nodular peribronchial
inflammation and nodularity, could represent a bronchogenic
carcinoma or nodular inflammation.
5. Atherosclerotic calcification of the coronary arteries and
major neck vessels.
6.Large likely simple renal cysts arising from the kidney for
which a
dedicated ultrasound examination is recommended.
7.Liver lesions too small to characterize on this examination.
CHEST (PORTABLE AP) [**2163-6-22**]
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: There is no change in
appearance of underlying pattern of emphysema with bilateral
lower lung ring shadows consistent with bronchiectasis. There is
no evidence of pleural effusion or infectious consolidation.
[**2163-6-22**] WBC-12.6* RBC-3.58* Hgb-10.4* Hct-32.2* Plt Ct-634*
[**2163-6-7**] WBC-5.5 RBC-3.68* Hgb-10.9* Hct-31.2* Plt Ct-79*
[**2163-6-20**] Glucose-239* UreaN-25* Creat-1.2 Na-138 K-4.2 Cl-98
HCO3-33*
[**2163-6-7**] Glucose-134* UreaN-29* Creat-0.8 Na-143 K-3.6 Cl-104
HCO3-31
Brief Hospital Course:
A/P: 71M PMH CVID, COPD, bronchietasis, new dx of NSCLC
undergoing phototherapy and recent LGIB who was transferred to
[**Hospital1 **] for photodynamic therapy for his lung cancer and management
of rectal bleeding.
.
1 Non small cell lung cancer: He has known COPD and
bronchiectasis but was transferred to [**Hospital1 **] with a new RUL mass c/w
NSCLC for which he received photodynamic therapy. He requires 3L
NC O2 at baseline. His oxygenation need increased slightly
around the time of treatment but improved to baseline by
discharge. He went to OR [**6-13**], [**6-14**] for debridement. His
prednisone was changed from 40 mg to 20 mg [**6-7**] and from 20 mg
to 10 mg on [**6-11**] but increased again to 20 mg [**6-13**], then to 15mg
at time of discharge. This should be slowly tappered. He was
continued on his azythromycin and inhaled tobramycin
prophylaxis. He was also continued on fluticasone inhaled and
nasal spray, as well as xopenex nebulizers. He will need follow
up with interventional pulmonary after discharge and he will
need photodynamic precautions (no UV light exposure, speacial
glasses) for 6 weeks from [**2163-6-13**].
.
2 Gastrointestinal Bleeding: He was transferred with bright red
blood per rectum. He had continuing melena and bright red blood
here despite holding coumadin and aspirin, with intermittent
decrease in hematocrit requiring blood transfussions. He had a
recent colonoscopy at the outside hospital prior to transfer
which showed a polyp and diverticuli. It was noted to be a poor
prep so the colonoscopy was repeated here [**6-17**] and showed: bright
red blood, diverticulosis.
.
3 Pancytopenia: New thrombocytopenia diagnosed during his OSH
admission. Etiology unclear. [**Name2 (NI) **] report he is HIT Ab negative.
This improved during his course suggesting improving
consumption from bleeding possibly. He also had leukopenia
during his course but this improved by time of discharge and was
thought possibly related to his CVID.
.
4 Renal insufficiency: Unclear baseline creatinine but this
improved to creatinine of 0.8 by discharge.
.
5 Atrial fibrilation: He remained in NSR and rate controlled on
short-acting diltiazem 60mg qid. His home regimen is 240mg
long-acting in the morning, 180mg long-acting at night. His
coumadin and aspirin were held given his gastrointestinal
bleeding.
.
6 CVID: He had no active issues regarding his immune deficiency.
He normally receives IvIg every 2 weeks and was due for this on
[**6-15**]. He was dosed per his infusion center at [**Hospital **] hospital
in [**Location (un) **]: [**Telephone/Fax (1) 78393**]: 30 gm, tylenol 1000mg, benedryl 25mg
po. pre medication. He ws also due for vitamin b12 1000 mcg sq
(q month) so this was given in house.
.
7 Hyperglycemia: He was noted to have elevated blood sugar on
prednisone so was given a diabetic diet and covered with sliding
scale insulin for control of his sugars.
Medications on Admission:
inhaled tobramycin 300 [**Hospital1 **]
zithromax 250 MWF
prednisone 10 daily
accolate 20 [**Hospital1 **]
xopenex 1.25 q4
atrovent nebs
flovent nasal [**Hospital1 **]
digoxin 0.125 daily
coumadin (stopped [**5-24**])
cardizem 240'/180'
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for headache.
7. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO MON/WED/FRI
().
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
10. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q4H () as needed.
11. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
3 ML Inhalation Q4H (every 4 hours).
12. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
15. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QAM.
16. Mucinex 600 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO every twelve (12) hours.
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous once a day as needed for line flush.
18. Saline Nebs
Saline nebs 5ml q6hrs
19. Accolate 20 mg Tablet Sig: One (1) Tablet PO twice a day.
20. Cardizem CD 180 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO QPM.
21. Insulin Sliding Scale
Fingerstick blood sugars AC, HS Regular Insulin
Regular insulin: 120-160 2 units: 161-200 4 units; 201-240
6 units, 241-280 8 units, 281-320 10 units, 321-360 12 units
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
squamous cell carcinoma of carina, RUL
chronic obstructive pulmonary disease requiring home O2
atrial fibrilation
lower gastrointestinal bleed
common variable immune deficiency
chronic multidrug-resistant pseudomonas colonization
Discharge Condition:
deconditioned, on supplemental oxygen.
Discharge Instructions:
Call Dr.[**Name (NI) 14680**] office [**Telephone/Fax (1) 10084**] if you have any increased
shortness of breath, chest pain, fever>101, worsening cough or
sputum production.
Continue photosensitive precautions for 5 weeks. Protect
yourself from sunlight with protective eye wear and clothing as
directed.
Indirect sunlight allowed. No direct sunlight for 5 weeks.
Followup Instructions:
Please follow-up with your primary care doctor and your
pulmonologist.
Please also follow-up with Dr. [**Last Name (STitle) **] in interventional
pulmonology.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2163-6-28**]
|
[
"2875",
"496",
"42731"
] |
Admission Date: [**2176-3-18**] Discharge Date: [**2176-3-22**]
Service: NEUROLOGY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Right facial droop, mutism, and right sided weakness.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 89 year old female with history of chronic renal
failure and hypertension who was in her usual state of health
until she was witnessed to have sudden onset of right facial
droop, mutism, and right sided weakness between 4-5pm on the day
of admission. She was with three other friends at her place of
residence at the time and was talking when she had this abrupt
cessation of speech.
EMS was called and patient was found to be hypertensive about
230s/130s with finger stick blood glucose of 90. She was not
responding to commands but was alert en route. She was
transferred to the [**Hospital1 18**]. Vitals wer BP 290/140, T 98, HR 71, RR
24, Oxygen 100%/2 liters. On initial presentation, there were no
available family members and so history was difficult to
corroborate. According to the on-call PCP coverage, patient was
seen as recently as [**3-8**] and her BP was 160/100 and she was
started on Clonidin patch 0.2 weekly at that time.
Code Stroke was called. Noncontrast head CT showed a dense left
MCA sign. CT Angiogram with decreased contrast in M1/M2
bifurcation on the left. Multiple dosese of Labetalol 10 mg IV
and then Labetalol drip were started for blood pressure control.
Patient was not a candidate for thrombolytics given her
hypertension.
She was transferred to the NeuroICU. On exam, she had right
facial droop, right arm weakness, aphasia and right neglect.
Past Medical History:
1. Hypertension
2. Glaucoma
Social History:
Unknown habits. Resident at nursing home.
Family History:
Negative for stroke.
Physical Exam:
Vitals: Afebrile, BP240/130, RR16, Oxygen 98%/RA
Gen: No acute distress.
HEENT: Supple neck. No carotid bruits.
Pulmonary: Clear to auscultation.
Cardiovascular: Regular rate and rhythm.
MENTAL STATUS: Opens eyes and alerts to voice. No verbal output.
No response to commands. No naming or repetition.
CRANIAL NERVES: Does not respond to threats from right. Unable
to appreciate fundi. Pupils are surgical and symetric at 2mm.
Gaze towards left at at rest. Cannot track objects in space.
Cannot move her eyes to the right. No nystagmus. Right facial
droop. Positive gag. Tongue midline.
MOTOR: Right arm decreased tone. No withdrawal of right upper or
lower extremity to noxious. Withdraws left arm and leg briskly.
COORDINATION: Cannot be tested due to mental status.
REFLEXES: Present, with right side>left. Right toe is upgoing.
SENSATION: Question response to pain anywhere in her body,
barely grimaces.
GAIT: Deferred.
Pertinent Results:
Labs on admit:
[**2176-3-18**] 05:40PM WBC-8.1 RBC-5.39 HGB-15.3 HCT-45.4 MCV-84
MCH-28.3 MCHC-33.7 RDW-13.9
[**2176-3-18**] 05:40PM NEUTS-72.9* LYMPHS-21.5 MONOS-4.8 EOS-0.5
BASOS-0.2
[**2176-3-18**] 05:40PM PLT COUNT-194
[**2176-3-18**] 05:40PM PT-13.4 PTT-24.8 INR(PT)-1.1
[**2176-3-18**] 05:40PM GLUCOSE-116* UREA N-30* CREAT-1.5* SODIUM-142
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-33* ANION GAP-14
[**2176-3-18**] 05:40PM CALCIUM-9.9 PHOSPHATE-3.3 MAGNESIUM-2.3
[**2176-3-18**] 05:40PM CK(CPK)-116
[**2176-3-18**] 05:40PM CK-MB-6
[**2176-3-18**] 05:40PM cTropnT-0.04*
[**2176-3-18**] 07:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2176-3-18**] 07:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2176-3-18**] 07:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
-----
Labs on Transfer to Floor:
[**2176-3-20**] 03:15AM BLOOD WBC-9.4 RBC-3.93* Hgb-11.1* Hct-32.6*
MCV-83 MCH-28.1 MCHC-34.0 RDW-14.1 Plt Ct-134*
[**2176-3-20**] 03:15AM BLOOD Plt Ct-134*
[**2176-3-20**] 03:15AM BLOOD PT-13.9* PTT-30.3 INR(PT)-1.2
[**2176-3-20**] 03:15AM BLOOD Glucose-117* UreaN-23* Creat-1.1 Na-141
K-3.8 Cl-107 HCO3-26 AnGap-12
[**2176-3-20**] 03:15AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.0
[**2176-3-19**] 02:36AM BLOOD Triglyc-49 HDL-58 CHOL/HD-2.6 LDLcalc-82
-----
CTA head [**2176-3-18**]: Bilateral vertebral arteries and bilateral
carotids are normal in caliber with no evidence of stenosis.
Distal to the left middle cerebral artery bifurcation at the
M1/M2 segment, there is an abrupt change of caliber in the
middle cerebral artery. There is no intracranial mass effect,
hemorrhage, or shift of normally midline structures. There is no
major vascular territorial infarction. The density values of the
brain parenchyma are within normal limits. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. Insular ribbon is intact
bilaterally and there are no focal areas of hypoattenuation
within the basal ganglia. The surrounding soft tissue and
osseous structures reveal a a density in the posterior left
orbit possibily indicating a collapsed lens. There is a small
polyp within the left posterior maxillary sinus. The surrounding
skull and facial bones are intact.
IMPRESSION:
1) Abrupt transition with narrowing and change of caliber in the
left middle cerebral artery, at the M1/M2 segment.
2) No evidence of acute infarction. No intracranial pathology.
3) Small denisty within the left posterior orbit. Differential
diagnosis includes collapsed lens, Druysen.
-----
CXR [**2176-3-18**]: The heart is slightly enlarged. The aorta is
calcified. There is a left pleural effusion. Interstitial
markings are somewhat coarse, but there is no evidence of CHF.
An NG tube is seen with its tip coursing below the diaphragm,
though off the edge of the film. The osseous structures
demonstrate a marked scoliosis of the thoracic spine convex to
the right.
IMPRESSION:
Left pleural effusion. No pneumonia or definite CHF.
-----
CT head [**2176-3-19**]: There is extensive hypodensity/edema within
the left frontal, parietal and temporal lobes in the
distribution of the left middle cerebral artery that has an
appearance consistent with a large left middle cerebral artery
infarction. There is no evidence of hemorrhage. The sulci within
the affected region are slightly effaced. There is no evidence
of hydrocephalus or shift of normally midline structures.
Bone windows show no evidence of bone destruction or bone
erosion.
IMPRESSION: Large evolving infarction in the distribution of the
left middle cerebral artery with increased edema/hypodensity
when compared to the previous day. No evidence of hemorrhage or
herniation at this time.
-----
Brief Hospital Course:
Patient is a [**Age over 90 **] year old female with past medical history of
hypertension and glaucoma who was in her usual state of health
until [**2176-3-18**]. At that time, she acute onset of global aphasia
and right sided weakness. Found to have large left MCA infarct.
Not a candidate for tPA given profound intractable hypertension.
She was transferred to the NeuroICU. Blood pressure controlled
with Clonidine patch and Labetalol. Started on aspirin 325 mg po
qd. Repeat head CT showed evolution of infarct.
Family was contact[**Name (NI) **]. [**Name2 (NI) 227**] prognosis, family opted to make
patient comfort measures only. She was seen by the palliative
care team. Goals of care clarified with family. Ativan,
Morphine, Scopoloamine and Tylenol ordered on as needed basis to
treat patient's symptoms to keep her comfortable. Small doses of
Seroquel were used to prevent patient from climbing out of bed
and injuring herself and to avoid use of physical restraints.
Per discussion with family, will allow to eat soft diet via hand
feeding as long as not overtly aspirating. Her son [**Name (NI) **] [**Name (NI) 22799**]
is Health Care Proxy ([**Telephone/Fax (1) 60147**].
Medications on Admission:
1. Atenolol
2. Acular eye drops
3. Clonidine
4. ASA
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: [**12-24**] Suppositorys Rectal
Q4-6H (every 4 to 6 hours) as needed for fever, pain.
2. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72 HOURS () as needed for prn secretions.
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for pain/discomfort.
4. Morphine Concentrate 20 mg/mL Solution Sig: One (1) 0.25 mL-1
ml PO Q2H (every 2 hours) as needed for discomfort/pain: titrate
to comfort.
5. Quetiapine Fumarate 25 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours) as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
Courtyard - [**Location (un) 1468**]
Discharge Diagnosis:
1. Left MCA infarction with global aphasia, right hemiparesis
2. Hypertension
3. Glaucoma
Discharge Condition:
Guarded. Goal of care is comfort.
Discharge Instructions:
Patient has suffered a large left middle cerebral artery
infarction. The family has elected to pursue palliative care.
Patient is to be discharged to a skilled nursing for comfort
care.
Followup Instructions:
None
|
[
"40391"
] |
Admission Date: [**2113-11-7**] Discharge Date: [**2113-11-9**]
Date of Birth: [**2070-1-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Seizure
EtOH withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr. [**Known lastname **] is a 43 yo M w/PMHx sx for alcohol abuse (>5
drinks/day) with withdrawal seizures who presented initially to
the ED on [**11-7**] with tonic-clonic seizures at home witnessed by
his girlfriend, who per the MICU note, "states that he was
watching TV and started to shake all over and foam at mouth".
The episode lasted 10 minutes, followed by a 10 minute postictal
state w/o bowel or bladder incontinence, then had a second
episode. Patient was unresponsive during his seizure. She denied
head trauma or LOC at the time. He does not remember seizing,
but does remmeber that after the episode he did not
incontinence.
.
Per girlfriend, patient had his last drink 3 days ago. The
patient states that he had his last drink 8 days PTA because he
decided to stop drinking.
.
In the ED, vitals were 97.1, HR 134, BP 143/63, R 18, 99% RA. He
was given a total of 50mg IV valium, 1L NS, and a banana bag,
and subsequently admitted to the MICU for closer monitoring due
to concern for sedation.
.
In the MICU, patient received standing valium for alcohol
withdrawal with no recurrence of his seizures. A CT head was
performed, and was negative for bleed. He was noted to have a
transaminitis, likely alcoholic hepatitis, and also had an
elevated amylase and lipase, without symptoms, for which he was
given IVF. He was also started on a low dose BB w/ BP 130s/80s.
.
Past Medical History:
PMH:
LE muscle pain/aches
Hepatitis C
ETOH abuse
Tobacco abuse
H/o alcohol withdrawal seizures
Psoriasis
? seizures
Social History:
SH: Lives with GF. Smokes [**11-22**] ppd x > 20 yrs. Drinks vodka, [**11-22**]
shots at a time, all day and night per girlfriend. Denies
illicit drug use. Unemployed
Family History:
FH: non-contributory
Physical Exam:
PE
VS: 96.2 BP 143/106 HR 80 RR 18 O2sat 98% RA
Gen: Sleepy, well appearing. NAD
HEENT: MMM. No scleral icterus. Neck supple.
Hrt: RRR. No MRG
Lungs: Expiratory wheezing.
Abd: S/NT/ND. No hepatomegaly. No massess.
Ext: WWP. Psoriasis plaques noted bilaterlly.
Neuro: CN intact. 5/5 strength. Sensation to LT intact. No
asterixis.
Pertinent Results:
[**2113-11-7**] 06:15PM URINE HOURS-RANDOM
[**2113-11-7**] 06:15PM URINE HOURS-RANDOM
[**2113-11-7**] 06:15PM URINE GR HOLD-HOLD
[**2113-11-7**] 06:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2113-11-7**] 06:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2113-11-7**] 06:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2113-11-7**] 06:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2113-11-7**] 03:40PM GLUCOSE-123* UREA N-7 CREAT-0.7 SODIUM-133
POTASSIUM-3.7 CHLORIDE-92* TOTAL CO2-22 ANION GAP-23*
[**2113-11-7**] 03:40PM estGFR-Using this
[**2113-11-7**] 03:40PM ALT(SGPT)-45* AST(SGOT)-64* ALK PHOS-103 TOT
BILI-1.0
[**2113-11-7**] 03:40PM LIPASE-129*
[**2113-11-7**] 03:40PM CALCIUM-10.0 PHOSPHATE-2.8 MAGNESIUM-1.7
[**2113-11-7**] 03:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2113-11-7**] 03:40PM WBC-5.8 RBC-4.25* HGB-14.9 HCT-42.8 MCV-101*
MCH-35.0* MCHC-34.8 RDW-14.7
[**2113-11-7**] 03:40PM NEUTS-76.0* LYMPHS-17.4* MONOS-5.5 EOS-0.6
BASOS-0.5
[**2113-11-7**] 03:40PM PLT SMR-VERY LOW PLT COUNT-73*#
.
Studies:
CT head negative for bleed or fracture
CXR: negative
Brief Hospital Course:
A/P: 43 y.o. man with ETOH abuse who presented with witnessed
tonic-clonic seizures in the setting of alcohol withdrawal
.
# Seizures: Likely alcohol related given tachycardia,
hypertension, agitation, and given history of heavy alcohol use
with history of alcohol withdrawal seizures. pt currently
asymptomatic, had been getting valium standing and per ciwa,
though no longer requiring valium. no seizures while in
hospital. Pt is s/p an uneventful micu course [**12-23**] concern for
respiratory depression [**12-23**] high dose benzos
.
# ETOH abuse/withdrawal:
-standing valium d/ced today, ciwa continued pt pt not
requiring: stable for d/c, will taper as valium clears
-Appreciate SW consult
-MVI/thiamine/folate
.
#. Wheezing. Likely has COPD given extensive tobacco hx.
-Continue albuterol/ipratropium nebs for now.
.
# Transaminitis: Most likely [**12-23**] hepatitis C and alcoholic
hepatitis
-Viral serologies pending
-Monitor LFTs for now
.
# Thrombocytopenia - likely [**12-23**] chronic liver dz. No evidence of
active bleeding. Avoid heparin SC
.
# LE cramps: continue amitriptyline and gabapentin
.
#.Psoriasis: triamcinolone cream.
Medications on Admission:
Amitriptyline 50mg QHS
Gabapentin 600ng QHS
Triamcinolone cream
Discharge Medications:
Amytriptylline 50 mg qhs
Gabapentin 600 mg qhs
cont Triamciniolone cream as well
Discharge Disposition:
Home
Discharge Diagnosis:
EtOh Withdrawal
Discharge Condition:
Good
Discharge Instructions:
You came into the hospital after having a seizure most likely
related to alcohol withdrawal. You had a short stay in the ICU
in order to have close monitoring surrounding the seizure. You
have gotten medication to prevent further problems during your
withdrawal from alcohol. At this point it is safe for you to go
home.
Please follow up as directed.
Please call your physician or return to the hospital for further
seizures or other medical concerns/problems.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 29932**]/Dr. [**Last Name (STitle) **] on
Friday [**12-15**] at 330. The office is located on the [**Location (un) **] of
[**Hospital Ward Name 23**]. If you need to change the appointment please call [**Telephone/Fax (1) 14384**].
In order to change your primary care provider as above you must
call your insurance company, mass health and notify them of the
change. Please give them Dr. [**Last Name (STitle) **] name.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
"496"
] |
Admission Date: [**2145-9-13**] Discharge Date: [**2145-9-29**]
Date of Birth: [**2075-8-10**] Sex: M
Service: MED
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
wheezing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
70 year old man with severe COPD, CHF, and dementia secondary to
chronic alcohol use was admitted [**2145-9-13**] for acute respiratory
distress and hypoxia requiring intubation in teh ED and transfer
to the MICU.
At his extended care facility in [**Hospital1 789**], NH, the patient was
noted to be agitated and wheezing. At baseline he is prescribed
continuous 02 but is reportedly noncompliant as per his
neuropsychiatric baseline of agitation and behavioral outbursts.
On the day of admission, he was increasingly agitated and his
nurse noted that his RA sats dropped to 73% from low 90s. Also,
he had a temperature of 99.0, drop in blood pressure 120/78 ->
100/60, tachycardia 132-150, wheezing, and respiratory distress
without improvement after nebulizer therapy and oxygen
supplementation by face mask.
In ED patient was found to be agitated with saturation of 87% on
non-rebreather mask in respiratory distress and ABG 7.39/37/57.
He was intubated with etomidate and succinate. Copious, thick
yellow secretions were found post-intubation. His temperature
spiked to 101.8 and he was started on vancomycin and
levofloxacin, given 40mg IV lasix with 1L IV normal saline with
resulting urine output of 540ml. Also, he received nebs,
solumedrol 125 x1, haldol, and ativan.
In the MICU, the patient was was extubated on [**9-14**] and tolerated
a switch to CPAP well with preserved oxygenation, maintaining 02
sats 90-94%. Chest x ray post extubation showed worsening
bilateral lower lobe infiltrates which improved over time. By
[**9-16**], the patient was oxygenating well at 95-100% on a
non-rebreather mask. However, it was difficult to assess the
patient's true oxygen requirement since he frequently exhibits
agitated behavior and would remove the mask. In the MICU, the
patient became severely agitated and delirious. Psychiatry
consult was obtained while the patient was in the MICU and all
psych meds except haldol were discontinued per psych
recommendations. Ativan was discontinued because it worsened the
delirium. The patient's mental status and behavior became less
acutely agitated over time.
The patient transferred to the medicine floor today in
restraints with a security guard sitter in stable condition
breathing spontaneously on ventimask oxygen supplementation.
Past Medical History:
Pneumonia
Chronic Obstructive Pulmonary Disease: on chronic predisone 5mg
tid, s/p previous intubation in the setting of percocet OD.
Congestive Heart Failure: with preseved EF 70% and chronic
bilateral lower extremity edema
Hyptertension
H/O alcohol abuse
Organic personality disorder with negative head CT in [**4-25**].
Dementia attributed to alcohol abuse w/agitation,
hallucinations.
Chronic low back pain, treated with percocet.
Gastroesophageal Reflux Disease
h/o c. diff, VRE
Urinary Incontinence
Social History:
Transferred to [**Location (un) 3844**] resident facility in [**2145-5-22**], for
verbally abusive behavior at previous facility. History of
percocet overdose and severe alcohol abuse. Further history
unknown. PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] of [**Hospital3 4262**] Group, gets other care
at [**Hospital3 1443**]. Previous psychiatric admissions at
[**Hospital3 1443**].
Family History:
Unknown.
Physical Exam:
EXAMINATION: Temperature 97.9, heart rate 100, blood pressure
144/68, respiratory rate 19, oxygen saturation 90% ventimask
FiO2 0.5, 12L
air. In general, the patient is alert and oriented to self and
hospital, in four point soft restraints with a security guard
sitter, speaking loudly with verbal repetition and using
profanity
HEENT: PERRL, EOMI, anicteric, moist mucous membranes,
oropharynx crowded.
NECK: Supple, thick, no LAD
CARDIOVASCULAR: RRR, normal S1 and S2, no murmurs, rubs or
gallops.
LUNGS: +wheezing
ABDOMEN: obese, soft, nontender, nondistended, NABS
EXTREMITIES: no edema, erythema or warmth, +toenail
onychomycosis
NEURO: A&O x 2. Sensation intact. Moves all extemities well.
MSEx: speech sparse, mood labile with anger, thoughts
perseverative, uncooperative with exam
Skin: no rash
Pertinent Results:
[**2145-9-17**] 03:21AM BLOOD WBC-14.4* RBC-4.80 Hgb-12.7*# Hct-38.6*
MCV-80* MCH-26.4* MCHC-32.9 RDW-18.5* Plt Ct-323
[**2145-9-14**] 04:50AM BLOOD Neuts-90.0* Lymphs-6.9* Monos-2.5 Eos-0.5
Baso-0.1
[**2145-9-17**] 03:21AM BLOOD Glucose-66* UreaN-24* Creat-0.7 Na-142
K-4.1 Cl-100 HCO3-30* AnGap-16
[**2145-9-14**] 04:50AM BLOOD ALT-8 AST-10
[**2145-9-17**] 03:21AM BLOOD Calcium-9.8 Phos-5.2* Mg-2.1
[**2145-9-13**] 09:47PM BLOOD Valproa-58
[**2145-9-15**] 04:00AM BLOOD Glucose-127* Na-134* K-3.0* Cl-97*
[**2145-9-13**] 05:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2145-9-13**] 05:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2145-9-13**] 05:40AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2145-9-14**] 6:20 pm **FINAL REPORT [**2145-9-15**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2145-9-15**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2145-9-14**] 11:50 am SPUTUM Site: ENDOTRACHEAL **FINAL REPORT
[**2145-9-16**]**
GRAM STAIN >25 PMNs and >10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS c/w
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2145-9-16**]):
No predominance of these respiratory pathogens: S.
pneumoniae, H.
influenzae, and M. catarrhalis.
GRAM STAIN (Final [**2145-9-13**]):
>25 PMNs and <10 epithelial cells/100X field. NO
MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2145-9-15**]): SPARSE GROWTH
OROPHARYNGEAL FLORA.
BETA STREPTOCOCCI, NOT GROUP A.
[**2145-9-14**] 9:52 am urine/serology**FINAL REPORT [**2145-9-15**]**
Legionella Urinary Antigen (Final [**2145-9-15**]): NEGATIVE
[**2145-9-13**] 5:40 am URINE CULTURE (Final [**2145-9-14**]): NO GROWTH.
Blood Cx x4 pending
ECG Study Date of [**2145-9-17**] 12:49:06 PM Sinus tachycardia.
Probable left atrial abnormality. Compared to the previous
tracing of [**2145-9-15**] the rate is slightly faster. Otherwise, no
significant diagnostic change.
CHEST (PORTABLE AP) [**2145-9-15**] 12:24 AM IMPRESSION:
1. Triangular opacity adjacent to right heart border, concerning
for a collapsed right middle lobe. In a patient recently
intubated, this could be due to mucus plugging. However, follow
up films are suggested to document resolution. If this fails to
resolve, CT or bronchoscopy would be recommended.
2. Improving aeration at the lung bases, likely due to a
resolving aspiration pneumonia.
Brief Hospital Course:
Brief Hospital Course by System
70 year old man with history of severe COPD, CHF, and dementia
due to prior alcohol abuse presented with respiratory distress,
was intubated and treated for pneumonia in the MICU, and
transferred to the medicine floor in stable condition.
1) PNEUMONIA: Admitted from Provident NH, where he was found to
have desaturated to 73%, wheezing and in resp distress.
Susequently intubated and sedated on propofol. Initially started
on Vancomycin, levofloxacin, nebs and solumedrol. LLL infiltrate
on CXR. HD #2, Pt placed on PSV, did well and susequently
extubated. Pt placed on shovel mask post extubation but agitated
and wouldn't cooperate. He received IV vancomycin and
levofloxacin for his first 2 days of admission and the
vancomycin was discontinued on [**9-15**] since cultures were negative
for s. aureus. Sputum was legionella negative and consistent
with normal flora. For several days Pt remained dependednt on
NRB for sat's >95%. [**2145-9-13**], Pt transfered to general medical
service. Pt slowly improved saturation wise so that eventually
weaned off O2 and with refusal of NC was saturating consistently
inthe low 90's. Pt finished 10 day total course of
levofloxacin. Pt afebrile and respiratory wise stable on medical
service.
2) COPD: Pt with lonstanding COPD and chronic oxygen dependance.
On admission started on Prednisone 60, Salmeterol, Fluticasone,
Montelukast, albuterol and atrovent with impression of COPD
exacerbation in light of likely bacteria PNA. Prednisone tapered
from 60mg qd, to 40mg qd, to 20mg qd and finally to home dose of
15mg qd; however might be adequate to taper even further to 10qd
given psychiatric comobidities. Pt tolerating current COPD
regimen and would continue so as an outpatient. As PNA and COPD
exacerbation resolved so did Pt's respiratory status.
3) CHF: Cardiac enzymes negative for MI on presentation with an
unremarkable ECG. Pt has history of diastolic dysfuntcion with
preerved EF; LVEF 70% per echo. Pt started on metoprolol 12.5 mg
[**Hospital1 **] as well as 325 mg ASA without difficulty. Not started on
ACEi, but would consider it in the outpatient setting.
Continued on lasix PRN for gradual diuresis during hospital
stay.
4) PSYCH/personality disorder: Pt with a complex and significant
psychiatric history including personality disorder, EtOH induced
dementia . It is not uncommon for Pt to uncooperative and
noncomplinat with treatment as resident of nursing home. Patient
had been extraordinarily agitated and delirious at times in the
MICU, considered worse than his baseline of dementia and
irritability from organic personality disorder due to prior
severe alcohol abuse. Pt seen and followed by psychiatry who
recommendations initially recommended d/c home seroquell. He was
started on an alternating Haldol/Ativan regimen, witrh combined
ativan/haldol PRN. Placed in restraints and with 1:1 sitter.
The following day, Ativan was d/c'd as well and was placed on
Haldol only. Haldol increased as tolerated and as necessary. He
was recieveing 15-20 mg q2-4 hrs prn. Per report seemed to have
improved somewhat on these high doses of haldol. Pt transferred
to medical service recieving 60mg PO TID with 15-20 mg IV q2-4hr
prn. ECGs were frequently checked given risk for QTc elongation;
and it was found that the high doses of Haldol were elongating
the QTc (480 on [**9-20**]). Because of this Haldol was decreased
almost daily and seroquell added and slowly titrated up from 50
mg qhs. Pt's agitation still consistent, but slowly improved as
seroquell increased. Pt over the last few days of
hospitalization were able to be off restraints for several hours
at a time. Pt eventually titrated up to home regimen of 100 mg
qAM, 100 mg qNoon, 150 mg qPM.
5) PPX: Pneumoboots, SC heparin, PPI while hospitalized.
Medications on Admission:
prednisone 15mg
lasix 40 mg [**Hospital1 **]
protonix 40 qd
percocet [**1-22**] q4 prn
combivent
atrovent
albuterol
Buspar 20 tid
seroquell 100/100/250 am/noon/pm
neurontin 400 qid
trileptal 300 tid
seroquel 50 prn
KCL 40 qd
depakote 1000/2250/2250
thiamine
folate
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
3. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Salmeterol Xinafoate 50 mcg/DOSE Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-22**]
Drops Ophthalmic PRN (as needed).
11. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID
(4 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
14. Quetiapine Fumarate 25 mg Tablet Sig: Three (3) Tablet PO
QAM (once a day (in the morning)).
15. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
16. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
[**Hospital1 **] (2 times a day) as needed.
17. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day.
18. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
19. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
20. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
22. Quetiapine Fumarate 100 mg Tablet Sig: 1.5 Tablets PO QHS
(once a day (at bedtime)).
23. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO
qNoon.
24. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
Discharge Disposition:
Extended Care
Facility:
Provident Skilled Nursing Center - [**Location (un) 583**]
Discharge Diagnosis:
pneumonia
COPD exacerbation
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please call PCP or return to ED if fever >101, severe chest
pain, acute shortness of breath, persitsent nause or vomitting,
inability to tolerate food or liquid.
Followup Instructions:
follow up with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5762**] at [**Telephone/Fax (1) 608**], in one to two
weeks
|
[
"486",
"51881",
"4280"
] |
Admission Date: [**2152-2-28**] Discharge Date: [**2152-3-5**]
Service: MEDICINE
Allergies:
Anesthesia IV Set-Clamp / Flagyl
Attending:[**First Name3 (LF) 34537**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] F with a history of hypertension, atrial fibrillation on
Coumadin, polycythemia [**Doctor First Name **], prior LGIB managed conservatively,
who presents with one day of BRBPR. She recently had a fever
last week and was treated with a 5-day course of Bactrim
beginning Friday for presumed UTI (culture from [**2152-2-24**] gre
pan-sensitive E. coli). She held Coumadin on Friday and Saturday
but resumed yesterday, with plan to re-check INR today. She
awoke this morning at 5:00 AM with an episode of BRBPR. She had
no associated pain, nausea, or vomiting. She had a second
episode at 9:00 AM, and a third at noon; she then came into the
ED.
.
Upon arrival to the ED vitals were: T 99.2, HR 67, BP 129/40, RR
18, O2 sat 99% on RA. She was noted to be guaiac-positive on
exam with BRB on the glove during exam. She had another episode
of bleeding in the ED of 400 cc of blood mixed with stool. Her
Hct was noted to be 28 from recent baseline of 34 and her INR
was elevated at 4.7. She was seen by the GI consult team in the
ED and received 40 mg IV Protonix, 5 mg of PO vitamin K, and 1
unit of FFP. Vitals prior to transfer to the MICU were: BP
134/39, HR 69, RR 19, O2 sat 97% on RA.
.
On arrival to the MICU, patient is comfortable. She is awake and
alert, denies any pain. Daughter [**Name (NI) **] is with her.
Past Medical History:
HTN
Paroxysmal afib
Osteoarthritis
Hearing loss
s/p Appy
3 C sections
Diverticulitis
Mitral regurgitation- ECHO '[**42**] w/ EF 65%, 3+ MR, 2+TR, LVH
Depression
Osteoporosis
s/p right knee replacement
Social History:
Social history is significant for the absence of current or past
tobacco use. There is no history of alcohol abuse. Pt lives in
duplex with her dtr living upstairs and her son next door.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION:
GEN: Awake, alert, mildly hard of hearing
HEENT: Pink conjunctiva, PERRL, clear OP, moist MM
NECK: Supple, no JVD
PULM: CTA bilaterally
CARD: RRR, + 2/6 systolic murmur at apex
ABD: Soft, NT/ND, + slightly hyperactive bowel sounds, no
rebound/guarding
EXT: palpable DP pulses, bony protrusion (non-tender) over
dorsum of right foot, trace pedal edema
PSYCH: Appropriate, cooperative
Pertinent Results:
Labs on Admission:
[**2152-3-1**] 04:02AM BLOOD WBC-7.5 RBC-3.13*# Hgb-10.4* Hct-29.9*
MCV-96 MCH-33.4* MCHC-34.9 RDW-19.0* Plt Ct-236
[**2152-2-29**] 07:59PM BLOOD Hct-34.1*
[**2152-2-29**] 01:49PM BLOOD Hct-28.8*
[**2152-2-29**] 12:34PM BLOOD Hct-29.7*
[**2152-2-29**] 04:44AM BLOOD WBC-6.9 RBC-2.47* Hgb-8.7* Hct-24.7*
MCV-100* MCH-35.4* MCHC-35.4* RDW-18.3* Plt Ct-242
[**2152-2-28**] 11:36PM BLOOD Hct-22.1*
[**2152-2-28**] 04:00PM BLOOD WBC-7.5 RBC-2.67* Hgb-9.6* Hct-28.2*
MCV-106* MCH-36.2* MCHC-34.2 RDW-14.6 Plt Ct-271
[**2152-3-1**] 04:02AM BLOOD PT-17.0* PTT-30.0 INR(PT)-1.5*
[**2152-2-29**] 04:44AM BLOOD PT-26.8* PTT-35.3* INR(PT)-2.6*
[**2152-2-28**] 04:00PM BLOOD PT-44.0* PTT-42.5* INR(PT)-4.7*
[**2152-3-1**] 04:02AM BLOOD Glucose-80 UreaN-33* Creat-1.5* Na-141
K-4.9 Cl-108 HCO3-25 AnGap-13
.
Labs on Discharge:
[**2152-3-5**] 07:10AM BLOOD WBC-11.3* RBC-2.84* Hgb-9.4* Hct-28.9*
MCV-102* MCH-33.2* MCHC-32.6 RDW-18.0* Plt Ct-301
[**2152-3-5**] 07:10AM BLOOD Glucose-94 UreaN-40* Creat-1.4* Na-141
K-4.4 Cl-112* HCO3-21* AnGap-12
.
CXR: FINDINGS: No focal consolidation is seen. No pneumothorax
is seen. Prominent hila and elevation of the left hilum are
unchanged compared to prior. Heart size is within normal limits
and unchanged. Calcification of the mitral annulus is again
seen. Left atrial enlargement is noted on lateral view. The
aorta is calcified. There is no evidence for pulmonary edema.
Blunting of the left costophrenic angle is unchanged and likely
represents scarring. IMPRESSION: No radiographic evidence for
acute pulmonary abnormality.
Brief Hospital Course:
[**Age over 90 **] F with history of prior diverticulitis 12 years ago and GI
bleed two years ago managed conservatively (no scope) who
presented with BRBPR and falling Hct in the setting of
suprtherapeutic INR to 4.7.
.
1. GI BLEED: Given painless GIB, likely LGIB in setting of
supratherapeutic INR from interaction of TMP/SMX with coumadin.
Patient was treated conservatively with reversal of
supratherapeutic INR with FFP and vitamin K, and transfusion
with PRBC. Total transfusion requirement was 3 units PRBC and 3
units FFP. Patient was evaluated by Gastroenterology during
admission, with further diagnostic/therapeutic procedures
including colonoscopy deferred. HCT remained stable following
transfusion. She continued to have small volume guaiac positive
stools, but believed to represent old blood in right colon.
Coumadin held at discharge.
.
2. ATRIAL FIBRILLATION: Patient with known PAF on coumadin, with
supratherapeutic INR on admission that was reversed as above.
Coumadin was held during hospital course and at discharge.
Decision will be made as outpatient visit regarding the
initiation of aspirin therapy.
.
3. ACUTE-ON-CHRONIC RENAL FAILURE: Believed to be pre-renal
etiology in the setting of bleeding and poor appetite.
.
4. POLYCYTHEMIA [**Doctor First Name **]: Dr. [**Last Name (STitle) **] made aware, and hydroxyurea held
during presentation given bleed and anemia. Will be re-started
as outpatient.
6. HYPERTENSION: Antihypertensives held on initial presentation,
and discharged home off these medications as she remained
orthostatic.
.
Transitions of Care:
--Coumadin, hydroxyurea, and anti-hypertensives held at
discharge.
Medications on Admission:
- PERI-COLACE 8.6 mg-50 mg Tab by mouth twice a day
- sulfamethoxazole-trimethoprim 800 mg-160 mg Tab PO BID
- Acetaminophen Extra Strength 500 mg Tab as needed
- hydroxyurea 500 mg Cap by mouth once a day except on Sundays
and Thursdays
- Lisinopril 40 mg PO twice a day
- Amiodarone 100 mg PO daily
- Warfarin 2.5 mg PO daily (held Friday and Saturday)
- Amlodipine 5 mg by mouth twice a day
- Multiple Vitamins 1 tab by mouth daily
- Ranitidine 75 mg PO daily
- Calcium citrate + vitamin D
- Vitamin C 1000 mg PO daily
- Acidophilus PO daily (recently stopped)
Discharge Medications:
1. PERI-COLACE 8.6-50 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
2. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
3. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO daily
except on Sunday and Thursday.
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. calcium citrate-vitamin D3 Oral
7. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Lower Gastrointestinal Bleeding
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 36698**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with rectal
bleeding. This bleeding was likely due to a condition of the
bowel called diverticulosis. You were given several blood
transfusions in order to maintain your blood counts. These blood
counts remained stable prior to your discharge from the
hospital.
.
Please STOP the following medications:
COUMADIN
LISINOPRIL
AMLODIPINE
.
Please discuss re-starting your blood pressure medications with
Dr. [**Last Name (STitle) 713**] when you see her in follow-up. You should also
discuss the use of Aspirin (in place of coumadin) at your
follow-up appointment.
.
If you experience any further epsisodes of bleeding, abdominal
pain, dizziness or weakness, please call your primary care
doctor or return to the emergency room.
.
Followup Instructions:
We would like you to call Dr.[**Name (NI) 1602**] office in order to
schedule an appointment for the next 2-3 days. We were unable to
set this up over the weekend.
.
Department: GERONTOLOGY
When: THURSDAY [**2152-3-23**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2152-4-25**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"5849",
"5990",
"42731",
"V5861",
"311",
"4240",
"40390",
"5859"
] |
Admission Date: [**2144-8-3**] Discharge Date: [**2144-8-27**]
Date of Birth: [**2144-8-3**] Sex: F
Service: Neonatology
HISTORY: Baby Girl [**Known lastname 8360**] #1 was the 1750 gram product of a
33-0/7 week twin gestation born to a 39-year-old G1 P0 now 2
mom. Prenatal screens: O+, antibody negative, GBS unknown
hepatitis surface antigen negative, RPR nonreactive woman.
Antepartum remarkable for IUI conception found at 18 weeks to
have resulted in a mono-mono twinning admitted at 30 weeks
and treated with betamethasone following serial ultrasounds,
no complications noted. Delivery by cesarean section with
spinal anesthesia. Apgars at 8 and 9.
PHYSICAL EXAM ON ADMISSION: Remarkable for pink-crying
infant in mild respiratory distress. Vital signs stable.
Soft anterior fontanel, normal facies, intact palate,
mild-to-moderate retractions. Fair air entry, coarse breath
sounds, no murmur, gallop. Present femoral pulses, soft,
flat, and nontender abdomen without hepatosplenomegaly.
Normal external genitalia. Stable hips. Fair tone,
activity. Left leg pale and mildly delayed capillary refill
and present pulses.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Female First Name (un) **]
was briefly in CPAP with increased work of breathing noted.
Chest x-ray suggested respiratory distress syndrome. Infant
intubated electively. Received one dose of Surfactant and
extubated. She has remained on room air throughout the
remainder of her hospital course and has not required
methylxanthine therapy.
Cardiovascular: No issues.
Fluid and electrolytes: Birth weight is 1760 grams, 50th
percentile. Length 41.5 cm, 25th percentile. Head
circumference 30.5 cm, 50th percentile.
Infant was initially started on 80 cc/kg/day of D10W.
Enteral feedings were initiated on day of life #1. Achieved
full enteral feedings by day of life #5, and is currently
with maxed enteral caloric density of breast milk 28 calorie
with ProMod at 150 cc/kg/day. She is currently adlib feeding
breast milk concentrated to 24 calories with Enfamil powder
or breast feeding. Her discharge weight is 2205 grams.
GI: Peak bilirubin was on day of life four 11.2/0.3. She
received phototherapy with good response and the issue has
been resolved.
Hematology: Hematocrit on admission was 43.9. The infant
has had no other concerns. Infant has received no blood
transfusions during this hospital course.
Infectious disease: Complete blood count and blood cultures
were obtained on admission. Complete blood count was benign.
Antibiotics were given for a total of 48 hours at which time
blood cultures remained negative, and antibiotics were
discontinued. No further sepsis risk factors.
Neurology: Has been appropriate for gestational age.
Sensory: Audiology hearing screening was performed with
automated auditory brain stem responses and the infant passed
both ears.
Psychosocial: A social worker has been involved with this
family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], telephone
number is [**Telephone/Fax (1) 51451**].
CARE RECOMMENDATIONS: Feeds at discharge: Continue adlib
feeding breast milk or breast milk 24 calorie with Enfamil
powder.
MEDICATIONS: Fer-In-[**Male First Name (un) **] supplementation of 4 mg/kg/day.
Poly-Vi-[**Male First Name (un) **] supplementation of 1 mL po q day.
State Newborn Screens have been sent per protocol. Car seat
position screening has been performed and the infant passed.
Immunizations received: She received her hepatitis B vaccine
on [**2144-8-26**].
DISCHARGE DIAGNOSES:
1. Former 30-3/7 week twin.
2. Mild respiratory distress syndrome.
3. Mild hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 38444**]
MEDQUIST36
D: [**2144-8-26**] 11:10
T: [**2144-8-26**] 11:16
JOB#: [**Job Number 51452**]
|
[
"7742",
"V053",
"V290"
] |
Admission Date: [**2144-12-5**] Discharge Date: [**2144-12-23**]
Date of Birth: [**2093-10-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
altered mental status; malaise
Major Surgical or Invasive Procedure:
1. Endo-trachael intubation from [**2144-12-7**] to [**2144-12-15**] for airway
protection secondary to supraglottic, upper pharyngeal swelling
2. Hemodialysis for ARF [**2-24**] ATN started on [**12-10**]
3. Left internal jugular central venous catheter placement.
4. Right triple lumen tunneled catheter placement.
History of Present Illness:
51 yo F w/o significant PMH presented to ED on [**2144-12-4**] c/o
malaise and change in mental status x 2d. Pt had been in USOH
until approx 4 days previous when began having URI sxs
consisting of non-productive cough and sore throat. One day
prior to admission she felt worse w/ increased fatigue and
states she slept all day. On the day of admission, her mental
status had significantly worsened as noted by her husband and he
brought her in to [**Name (NI) **].
In the ED, the patient was confused and disoriented. She was
febrile to 101.6, tachycardic and tachypneic, and had episode of
rigors. Pt resuscitated with 2 L of NS, CXR obtained and was
negative, Head CT neg for bleed, UA neg for infection. No
history of trauma.
Past Medical History:
Social History:
+ tobacco >30pack/yr hx
+ social EtOH
denies drugs
Lives with husband of 26yrs in [**Location (un) 686**] with two children.
Works in [**Location (un) 86**] school system.
Family History:
Mother: + DM, HTN
Father: EtOH abuse
Sibs and offspring: no health probs
Physical Exam:
At the time of discharge to medicine [**Hospital1 **] svc:
General: Obese AA female in NAD, no complaints of chest pain,
shortness of breath, leg pain, or abdominal pain
HEENT: NCAT, PERRL, EOMI, injected sclera bilaterally, MMM, oral
pharynx clear without significant posterior pharyngeal swelling
NECK: thick neck, no visible JVP, no palpable LAD
PULM: CTA bilaterally, equal breath sounds, no wheeze, no
stridor
CV: RRR, nl S1, S2, no M/R/G
ABD: soft +BS, non-tender, non-distended
GU: Foley in place
EXT: significant [**2-25**]+ bilateral UE/LE edema, middle finger of
right hand black ischemic, contracted, duskiness of toes on
bilateral feet, significant weakness 3/5 strength of UE and LE
[**2-24**] deconditioning
NEURO: CN II-XII intact, alert and oriented x 4
Pertinent Results:
[**2144-12-16**] 02:33AM BLOOD WBC-25.2* RBC-3.01* Hgb-8.9* Hct-25.6*
MCV-85 MCH-29.5 MCHC-34.7 RDW-16.6* Plt Ct-265
[**2144-12-15**] 05:20PM BLOOD Hct-27.3*
[**2144-12-16**] 02:33AM BLOOD Plt Ct-265
[**2144-12-16**] 02:33AM BLOOD PT-13.3 PTT-54.2* INR(PT)-1.1
[**2144-12-13**] 04:13AM BLOOD Fibrino-303
[**2144-12-16**] 02:33AM BLOOD Glucose-112* UreaN-103* Creat-6.8*#
Na-139 K-4.2 Cl-102 HCO3-21* AnGap-20
[**2144-12-16**] 02:33AM BLOOD Calcium-8.9 Phos-9.0*
[**2144-12-15**] 04:42AM BLOOD Calcium-9.0 Phos-8.9* Mg-2.0
[**2144-12-11**] 09:50AM BLOOD calTIBC-166* Ferritn-588* TRF-128*
[**2144-12-5**] 09:32PM URINE HOURS-RANDOM UREA N-388 CREAT-91
SODIUM-17 POTASSIUM-52 CHLORIDE-19
[**2144-12-5**] 09:32PM URINE OSMOLAL-329
[**2144-12-5**] 04:05PM GLUCOSE-222* UREA N-30* CREAT-1.8* SODIUM-140
POTASSIUM-4.1 CHLORIDE-115* TOTAL CO2-18* ANION GAP-11
[**2144-12-5**] 04:05PM HCT-39.9
[**2144-12-5**] 09:47AM GLUCOSE-243* UREA N-25* CREAT-1.5* SODIUM-143
POTASSIUM-5.1 CHLORIDE-118* TOTAL CO2-18* ANION GAP-12
CT HEAD W/O CONTRAST [**2144-12-4**] 10:29 PM
IMPRESSION: No acute hemorrhage or mass effect.
ECHO Study Date of [**2144-12-9**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and
free wall motion are normal. The 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 mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
No vegetation seen (cannot definitively exclude).
CT NECK W/O CONTRAST (EG: PAROTIDS) [**2144-12-8**] 10:10 AM
IMPRESSION: 1. Limited examination, with no evidence of abscess
on the current study.
RENAL U.S. [**2144-12-9**] 6:39 PM
IMPRESSION
1. Prior seen right kidney upper pole lesion clearly identified
on the
current study. This likely represents an artifact due to the
heterogeneous echotexture of the renal cortex.
2. Heterogeneous renal echotexture, likely due to medical renal
disease.
3. Normal arterial and venous waveforms.
Brief Hospital Course:
[**Date range (1) 40897**]: The patient was initially admitted to the MICU
service for her altered mental status and potential sepsis. Her
initial labs showed an elevated wbc w/ bandemia,
thrombocytopenia. In addition she had a significant metabolic
acidosis with a lactate of 5.6. She also had elevated Cr,
elevated LFTs, markedly elevated CK 5516. A code sepsis was
called and the pt was treated with ceftriaxone and Vanc for
presumed sepsis of unknown source. U/A, CXR, and head CT wnl. A
discussion regarding the utility/need for a lumbar puncture was
discussed, but as the patient did not have any signs of
meningismus it was not performed. Blood cultures were drawn. On
admission the patient's skin on her legs from knees to feet was
mottled as well as from elbows to fingers bilaterally. Petechia
were noted on both thighs and upper arms. Radial, DP/PT pulses
however were 2+ and palpable bilaterally. Her mental status
briefly improved but then began to wax and wan again. On [**12-6**]
she began complaining of a sore throat. A speculum exam was
performed to r/o a retained tampon and was negative. On [**12-7**]
blood ctx from [**12-4**] came back positive for strep pneumo. ID was
consulted and advised continuation of ceftriaxone and
discontinuation of vanc. The patient's mental status worsened
and she had progressive respiratory distress, odynophagia,
hypoxemia. Her speech was noted to be hoarse (breath w/ harsh
soft noises), but no drooling or stridor. Oral exam revealed
bleeding mucosa, palate fullness, inability to visualize
posterior pharynx, mild tongue angioedema, blood tinged
secretions noted in oral cavity, unable to expectorate. Elective
intubation was performed by anesthesia at the bedside for airway
protection and the patient was started on solumedrol for
probable supraglottitis.
[**12-7**] to [**12-15**]: The patient remained intubated for airway
protection. Since admission the Renal team was following the
patient. Her kidney function continued to worsen with her
creatine peaking at 6.3. She was oliguric throughout her
admission. Renal failure was thought to be secondary to ATN and
possibly post-streptococcal glomerular nephritis. A left IJ HD
line was placed and the patient was started on HD. In addition,
she developed purpura fulminans with full ischemia and necrosis
of her right middle finger and ischemia of her toes. Vascular
surgery was consulted and recommended anticoagulation with
heparin and eventual elective removal of the digit. On [**12-15**]
after HD to remove excess fluid, the patient was taken to the OR
where she was extubated under controlled conditions without
difficulty. The patient also had anemia. Hemolysis labs were
sent and Heme/Onc was consulted. There was no evidence of
hemolysis.
[**12-16**]: The patient passed her speech and swallow eval and was
able to tolerate PO. PT and OT were both consulted regarding
deconditioning and strength exercises for the patient.
[**12-16**] to [**2144-12-23**] by problem:
1. Strep pneumo sepsis: the patient was transferred to the
Medicine service afte extubation, and continued ceftriaxone to
complete a 14 day course of IV antibiotics in the hospital.
After completing antibiotics, she had no signs or symptoms of
infection for the remainder of her hospital stay. At d/c, she
is afebrile with no signs of infection.
2. Acute renal failure: she continued to be oliguric throughout
her admission, with creatinine peaking at 9.4. However, her
urinary output showed progressive improvement throughout the
last week of hospitalization. On the day of DC, the pt produced
nearly 30cc/hour of urine. During her admission, she was
followed by the Renal service and received hemodialysis and
ultrafiltration based on electrolyte abnormalities and fluid
overload. She will require continued dialysis after d/c,
initially every other day, for acute renal failure likely [**2-24**]
ATN and post-Strep glomerulonephritis. Her renal function is
expected to show continued improvement. She must be followed
closely by a Renal physician to determine the schedule of her
dialysis as her renal function improves.
3. Purpura fulminans with dry gangrene of the digits: her
sepsis was complicated by dry gangrene of the right 3rd/5th
digits and bilateral toes. She was evaluated by Vascular and
Plastic Surgery during her admission. She was intially treated
with heparin gtt for dry gangrene, which was d/c when
antibiotics were finished and pt had obviously cleared her
sepsis. Plastic surgery recommends daily dressings to the
effected digits with gauze and bacitracin, and close monitoring
for signs of infection. The patient must follow-up with Plastic
Surgery clinic in 2 weeks to be assessed for surgical
debridement. At DC, there is no redness, drainage, or other
signs of infection of the digits.
4. Anemia: the patient has been anemic throughout her
admission. Lab studies were consistent with anemia of
inflammation; she has no iron or B12/folate deficiency. Her HCT
trended down throughout her admission to 27, where it plateaued
and remained stable for the final 3 days of her stay. She was
continuously guaiac negative and showed no signs of GI bleed.
At DC, HCT is stable and there are no symptoms of anemia. She
will require close monitoring of HCT.
5. Hyperphosphatemia: serum phosphorous levels started to
increase after she developed acute renal failure. Phosphorous
climbed to a peak of 9 despite treatment with AlOH, PhosLo, and
Renagel. However, with conistent use of these medications,
serum phosphorous decreased to 5 on the day of DC. She will
require continued treatment with AlOH, PhosLo, and Renagel.
6. Respiratory failure: after extubation, she had no further
respiratory distress, maintaining O2 saturation greater than 93%
on room air.
Medications on Admission:
tylenol
ibuprofen
theraflu
Discharge Medications:
1. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
2. Acetaminophen 160 mg/5 mL Elixir Sig: Six [**Age over 90 1230**]y (650)
mg PO Q4-6H (every 4 to 6 hours) as needed for fever or pain.
3. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)) as needed.
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
7. Calcium Acetate 667 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
12. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
13. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Sixty
(60) ML PO QID (4 times a day) as needed for increasing phos.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
1. Pneumococcal sepsis
2. Acute renal failure with hemodialysis
3. Post-streptococcal glomerulonephritis
4. Anemia
5. Septic emboli with ischemia of digits
Discharge Condition:
Stable to go to rehab. No signs or symptoms of infection.
Renal function recovering slowly, but still recovering
hemodialysis every other day, and requiring close monitoring by
Renal team. Ischemic digits on R hand and bilateral feet with
dry gangrene, awaiting surgical debridement of necrotic tissue
in 2 weeks.
Discharge Instructions:
Please take all medications regularly as prescribed. Please
follow-up closely with all of your doctors as detailed below.
Present to the ED for evaluation if you have fever, shaking
chills, dizziness, bleeding, confusion, or other concerning
symptoms. You will need hemodialysis often until your kidneys
recover, likely every other day.
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], your new Primary Care
Physician, [**Name10 (NameIs) **] [**Name11 (NameIs) 191**] clinic on [**2144-12-29**] (call [**Telephone/Fax (1) 250**] for
appointment)
Follow-up with Plastic Surgery Clinic in [**2145-1-12**] at 9:30 AM
([**Telephone/Fax (1) 274**])
Follow-up with [**Hospital 2793**] clinic in 1 week (call [**Telephone/Fax (1) 60**] for
appointment)
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"5845",
"2875",
"2762",
"99592",
"2859",
"3051"
] |
Admission Date: [**2148-12-12**] Discharge Date: [**2148-12-19**]
Date of Birth: [**2079-6-19**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Code stroke: right sided weakness, right facial droop, slurred
speech, left eye deviation, right field cut
Major Surgical or Invasive Procedure:
TPA - incomplete
PEG placement
History of Present Illness:
HPI: The pt is a 69 year-old R-handed male with minimal PMH who
presents with new onset R sided weakness, slurred speech, left
eye deviation, and right sided field cut. Per wife at 8:30 pm
patient developed 'tunnel vision' which then progressed into a
headache. Patient who has had a history of migraine head aches
with what sounds like fortification auras did not think much of
it. He took a Xanax to help him fall asleep which he did so
around 10 pm. He then woke up at 11pm and he told wife that he
still has headache. However, no neurologic symptoms were noted
at this time. However, when he woke up at again at 1am and his
speech was garbbed and his wife called ambulance and to come to
[**Hospital1 **] and code stroke was activated. In the ED, he presented
with
with eye deviation left eye deviation and right hemiparesis and
aphasia. His CT showed left MCA sign and his CTA shows left ICA
occlusion( can not rule out carotid dissection) and MCA
occlusion. his CTP shows increased mean transit time and reduced
cerebral volume and decread CBF. He was given tPA at 323am, but
tPA was held due to severe vomiting and headache( also noticed
trace
blood in the emesis). His exam then worsened at 430am and he had
hemiplegia and worsening aphasia. His score is 18. A repeat CT
of head and did not show any hematoma.
On general review of systems, the wife denies any recent
illness,
fevers, chills, chest pain, SOB. No recent trauma
Past Medical History:
1. Patient had a history of what he believed to be angina
however had a negative Thallium stress test.
2. The patient has a history of left knee pain and has
undergone arthroscopy several times.
3. HTN
4. Prostate Cancer, s/p radiation seeding
Social History:
About 2 EtOH drinks per night no tobacco, or illicit drug use
Family History:
father with cardiac problems
Physical Exam:
Physical Exam (Initial EXAM):
General: Awake, cooperative,
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND,
Extremities: warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 2 (stating [**2108**]). Language
was
dysarthric.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. No reaction to threat on Right
side. III, IV, VI: eyes deviated to the left
V: Facial sensation intact to light touch.
VII: Right sided facial droop
VIII: Hearing intact to voice
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Was able to lift the
right
side against gravity but with significant drift. left side was
full
-Sensory: stated a decrease to pinprick on the right upper and
lower extremity
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, [**Doctor First Name **] intact
-Gait: not tested
Pertinent Results:
MRI:
FINDINGS: Diffusion imaging demonstrates an extensive left MCA
territory
infarct without associated hemorrhage. There is subtle FLAIR
abnormality at
this time indicating the acute nature of the infarct. T2
sequences
demonstrate lack of the normal flow void in the left MCA,
particularly the M1
and M2 segments.
There is no other area of infarct. There is no edema, mass or
mass effect.
Ventricles and sulci are normal in size and configuration. Other
intracranial
flow voids are unremarkable.
IMPRESSION: Extensive acute left MCA infarct . No hemorrhage.
NCHCT:
1. No hemorrhage.
2. Hyperdense appearance of the Left ICA and Left MCA,
concerning
for
thrombosis.
CTA:
1. There is thrombosis of the left cervical ICA extending to the
terminal
portion of ICA,. thrombus in the left MCA, M1 and M2 segments,
with narrowing
of the distal branches.
2. Few section of the cervical portion of R ICA have a fillind
defect,
question thrombus/ dissection.
3.Posterior circualtion is patent.
3 D recons pending. CTP pending.
CTP: MTT is increased in the entire L MCA territory, with mild
decrease in the cerebral blood volume and cerebral blood flow.
TTE [**2148-12-12**]
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No pathologic valvular abnormality seen.
Compared with the report of the prior study (images unavailable
for review) of [**2139-8-5**], mild symmetric LVH is seen on the
current study
[**2148-12-12**] 04:24PM CK(CPK)-237
[**2148-12-12**] 04:24PM CK-MB-6 cTropnT-<0.01
[**2148-12-12**] 08:09AM GLUCOSE-148* UREA N-21* CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2148-12-12**] 08:09AM ALT(SGPT)-23 AST(SGOT)-29 LD(LDH)-208
CK(CPK)-119 ALK PHOS-29* TOT BILI-0.6
[**2148-12-12**] 08:09AM CK-MB-3 cTropnT-<0.01
[**2148-12-12**] 08:09AM ALBUMIN-3.8 CALCIUM-8.0* PHOSPHATE-2.7
MAGNESIUM-1.9 CHOLEST-165
[**2148-12-12**] 08:09AM %HbA1c-5.8 eAG-120
[**2148-12-12**] 08:09AM TRIGLYCER-44 HDL CHOL-62 CHOL/HDL-2.7
LDL(CALC)-94
[**2148-12-12**] 08:09AM WBC-8.2 RBC-4.73 HGB-14.8 HCT-40.8 MCV-86
MCH-31.3 MCHC-36.3* RDW-13.8
[**2148-12-12**] 08:09AM PLT COUNT-226
[**2148-12-12**] 08:09AM PT-12.8 PTT-22.0 INR(PT)-1.1
[**2148-12-12**] 04:19AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2148-12-12**] 02:48AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2148-12-12**] 02:21AM LACTATE-1.7
[**2148-12-12**] 02:00AM GLUCOSE-152* UREA N-24* CREAT-1.0 SODIUM-141
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16
[**2148-12-12**] 02:00AM LIPASE-33
[**2148-12-12**] 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2148-12-12**] 02:00AM WBC-6.6 RBC-4.84 HGB-15.3 HCT-41.6 MCV-86
MCH-31.6 MCHC-36.7* RDW-13.9
[**2148-12-12**] 02:00AM PT-12.3 PTT-21.4* INR(PT)-1.0
[**2148-12-12**] 02:00AM PLT COUNT-238
[**2148-12-12**] 02:00AM FIBRINOGE-267
[**2148-12-19**] 06:25AM BLOOD WBC-8.2 RBC-4.90 Hgb-15.0 Hct-43.1 MCV-88
MCH-30.7 MCHC-34.9 RDW-13.3 Plt Ct-285
[**2148-12-18**] 05:40AM BLOOD WBC-9.5 RBC-4.99 Hgb-15.2 Hct-43.2 MCV-87
MCH-30.4 MCHC-35.1* RDW-13.2 Plt Ct-269
[**2148-12-17**] 05:47AM BLOOD WBC-7.5 RBC-5.65 Hgb-17.0 Hct-48.8 MCV-86
MCH-30.1 MCHC-34.8 RDW-13.1 Plt Ct-281
[**2148-12-16**] 07:35AM BLOOD WBC-6.2 RBC-5.13 Hgb-15.3 Hct-43.5 MCV-85
MCH-29.9 MCHC-35.3* RDW-13.2 Plt Ct-259
[**2148-12-15**] 07:45AM BLOOD WBC-6.8 RBC-5.20 Hgb-16.3 Hct-45.4 MCV-87
MCH-31.4 MCHC-35.9* RDW-13.5 Plt Ct-243
[**2148-12-14**] 08:05AM BLOOD WBC-7.8 RBC-5.43 Hgb-16.2 Hct-46.9 MCV-86
MCH-29.8 MCHC-34.4 RDW-13.4 Plt Ct-246
[**2148-12-13**] 12:49AM BLOOD WBC-10.0 RBC-5.01 Hgb-15.4 Hct-43.6
MCV-87 MCH-30.6 MCHC-35.2* RDW-13.6 Plt Ct-265
[**2148-12-12**] 08:09AM BLOOD WBC-8.2 RBC-4.73 Hgb-14.8 Hct-40.8 MCV-86
MCH-31.3 MCHC-36.3* RDW-13.8 Plt Ct-226
[**2148-12-12**] 02:00AM BLOOD WBC-6.6 RBC-4.84 Hgb-15.3 Hct-41.6 MCV-86
MCH-31.6 MCHC-36.7* RDW-13.9 Plt Ct-238
[**2148-12-15**] 07:45AM BLOOD PT-12.6 PTT-25.5 INR(PT)-1.1
[**2148-12-14**] 08:05AM BLOOD PT-12.4 PTT-24.4 INR(PT)-1.0
[**2148-12-12**] 08:09AM BLOOD PT-12.8 PTT-22.0 INR(PT)-1.1
[**2148-12-12**] 02:00AM BLOOD PT-12.3 PTT-21.4* INR(PT)-1.0
[**2148-12-12**] 02:00AM BLOOD Fibrino-267
[**2148-12-14**] 08:05AM BLOOD ESR-7
[**2148-12-13**] 09:15PM BLOOD ACA IgG-PND ACA IgM-PND
[**2148-12-19**] 06:25AM BLOOD Glucose-148* UreaN-27* Creat-0.8 Na-139
K-4.0 Cl-104 HCO3-28 AnGap-11
[**2148-12-18**] 05:40AM BLOOD Glucose-116* UreaN-29* Creat-0.9 Na-142
K-4.2 Cl-107 HCO3-28 AnGap-11
[**2148-12-17**] 05:47AM BLOOD Glucose-118* UreaN-25* Creat-0.9 Na-139
K-4.2 Cl-100 HCO3-31 AnGap-12
[**2148-12-16**] 07:35AM BLOOD Glucose-152* UreaN-25* Creat-0.8 Na-136
K-4.2 Cl-100 HCO3-27 AnGap-13
[**2148-12-15**] 07:45AM BLOOD Glucose-135* UreaN-29* Creat-0.8 Na-142
K-3.3 Cl-103 HCO3-28 AnGap-14
[**2148-12-14**] 08:05AM BLOOD Glucose-129* UreaN-25* Creat-0.8 Na-142
K-3.9 Cl-104 HCO3-31 AnGap-11
[**2148-12-13**] 12:49AM BLOOD Glucose-122* UreaN-18 Creat-0.8 Na-138
K-3.5 Cl-104 HCO3-29 AnGap-9
[**2148-12-12**] 08:09AM BLOOD Glucose-148* UreaN-21* Creat-0.8 Na-140
K-3.9 Cl-107 HCO3-24 AnGap-13
[**2148-12-12**] 02:00AM BLOOD Glucose-152* UreaN-24* Creat-1.0 Na-141
K-3.9 Cl-104 HCO3-25 AnGap-16
[**2148-12-16**] 07:35AM BLOOD ALT-20 AST-44* AlkPhos-32*
[**2148-12-14**] 08:05AM BLOOD ALT-20 AST-27 AlkPhos-34* TotBili-0.8
[**2148-12-13**] 12:49AM BLOOD CK(CPK)-264
[**2148-12-12**] 04:24PM BLOOD CK(CPK)-237
[**2148-12-12**] 08:09AM BLOOD ALT-23 AST-29 LD(LDH)-208 CK(CPK)-119
AlkPhos-29* TotBili-0.6
[**2148-12-13**] 12:49AM BLOOD CK-MB-3 cTropnT-<0.01
[**2148-12-12**] 04:24PM BLOOD CK-MB-6 cTropnT-<0.01
[**2148-12-12**] 08:09AM BLOOD CK-MB-3 cTropnT-<0.01
[**2148-12-14**] 08:05AM BLOOD Albumin-4.1 Calcium-9.2 Phos-2.5* Mg-2.3
[**2148-12-12**] 08:09AM BLOOD Albumin-3.8 Calcium-8.0* Phos-2.7 Mg-1.9
Cholest-165
[**2148-12-14**] 08:05AM BLOOD VitB12-507
[**2148-12-12**] 08:09AM BLOOD %HbA1c-5.8 eAG-120
[**2148-12-14**] 08:05AM BLOOD Homocys-8.6
[**2148-12-12**] 08:09AM BLOOD Triglyc-44 HDL-62 CHOL/HD-2.7 LDLcalc-94
[**2148-12-14**] 08:05AM BLOOD CRP-54.3*
[**2148-12-14**] 08:05AM BLOOD TSH-0.76
[**2148-12-12**] 02:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2148-12-12**] 02:21AM BLOOD Lactate-1.7
Brief Hospital Course:
Initial Assessment / Hospital Course:
The pt is a 69 year-old R-handed male with minimal PMH who
presents with new onset R sided weakness, slurred speech, left
eye deviation, and right sided field cut. Patient presented
about 3 hours and 52 mintues following the onset of symptoms. In
the ED, he presented with with eye deviation left eye deviation
and right hemiparesis and aphasia. His CT showed left MCA sign
and his CTA shows left ICA occlusion( can not rule out carotid
dissection) and MCA occlusion. His CTP shows increased mean
transit time and reduced cerebral volume and decread CBF. He was
given tPA at 323am, but tPA was held due to severe vomiting and
headache (also notice trace blood in the emesis). His exam then
worsened at 430am and he had hemiplegia and worsening aphasia.
His score was 18. Head CT was repeated and did not show
hematoma.
Mr. [**Known lastname **] was admitted to the neurology ICU for monitoring after
tPA, and was then transferred to the neuromedicine stroke team
on the floor, attending Dr. [**First Name (STitle) **]. He had an MRI/MRA which
showed an acute L-ICA thrombotic occlusion with a large left
hemispheric infarct. The etiology of ICA occlusion could be
either atherosclerotic or
due to a dissection. He was started on Aspirin 325mg. His TTE
was negative. His HbA1c was 5.8. His homocysteine was 8.6. TG
was 42. LDL was 94, HDL was 62, cholesterol was 175. He was
started on simvastatin 10mg. Fibrinogen was 267. ESR was 7.
Toxicology was negative.
Mr [**Known lastname **] was evaluated by speech and swallow, and was unable to
consistently initiate oral transit with a high risk of
aspiration. He had a video swallow which also showed significant
aspiration. He initially had an NGT placed, and then had a PEG
placed by surgery on [**2148-12-17**]. He has been tolerating G-tube
feeds.
Mr. [**Known lastname **] has a severe global aphasia, although it does appear
at times he is comprehending information, responding with
occasionally appropriate yes/no head responses. Speech pathology
worked with Mr. [**Known lastname **] with AAC picture boards and a Lightwriter
were, but neither were successful at this time. He also was
unable to type at this type.
Mr. [**Known lastname **] did seem to have complaints of leg pain, though it was
difficult to assess given his severe global aphasia. There was
no warmth or erythema or tenderness to palpation, although he
was noted by sursing to have a slight asymmetry in his calf
size, with the left side larger (circumference 1.5" greater).
Therefore, lower extremity ultrasound was obtained, which was
negative for DVT.
Also, 2d after Foley was removed, he exhibited urinary frequency
and seemed to c/o lower abdominal discomfort. A UA was
unremarkable overnight 1/5-6/[**2148**]. A bladder scan was + for
retention (800cc) [**2148-12-19**] (day of discharge). He was
straight-cathed at that time, and may require repeat Foley
catheterization or straight catheterization for urination
initially.
Medications on Admission:
Citracell OTC
Terazosin 10 mg daily
HCTZ 12.5 mg daily
Aspirin 81 mg
Naproxen daily
MVI daily
vitamin D
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG
PO BID (2 times a day).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for stroke.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day) as needed for DVT ppx.
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Principle diagnosis:
- Stroke (Left ICA/MCA-territory ischemic infarction)
Secondary diagnoses:
1. Patient had a history of what he believed to be angina
however had a negative Thallium stress test.
2. The patient has a history of left knee pain and has
undergone arthroscopy several times.
3. HTN
4. Prostate Cancer, s/p radiation seeding
Discharge Condition:
alert, awake.
Global aphasia.
Right facial droop.
Right sided hemiplegia.
Discharge Instructions:
You were admitted to our Neurology service at [**Hospital1 18**] and found to
have a large stroke on the left side of your brain. It was the
result of clot formation in the blood vessels to your brain
(Middle Cerebral Atery and Internal Carotid Artery). The stroke
has caused you to have weakness on your right side and to be
unable to communicate verbally or fully understand language. You
were started on Aspirin 325mg to reduce the odds of another
stroke in the future. You were unable to swallow without
aspirating food into your lungs, so you had a PEG placed so that
you could continue to receive food. If your swallowing ability
recovers, this could be taken out in the future. You are being
transferred to an inpatient facility for acute Rehabilitation.
Followup Instructions:
Neurology: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2149-1-27**] 1:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2148-12-19**]
|
[
"4019"
] |
Admission Date: [**2145-3-9**] Discharge Date: [**2145-3-13**]
Date of Birth: [**2070-8-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Exertional chest pain and shortness of breath
Major Surgical or Invasive Procedure:
[**2145-3-9**] Aortic Valve Replacement(21 St. [**Male First Name (un) 923**] Epic Porcine Valve)
and Single Vessel Coronary Artery Bypass Grafting utilizing the
left internal mammary artery to LAD.
History of Present Illness:
Mr. [**Known lastname 70228**] is a 74 year old male with history of known
aortic stenosis and coronary artery disease. Serial
echocardiograms have shown progression of aortic valve
gradients. Most recent ECHO from [**2144-10-29**] revealed EF 70%
with mean aortic gradient of 50mmHg. Over the last several
months, he admits to worsening exertional chest discomfort and
dyspnea on exertion. He has no history of syncope. Recent
cardiac catheterization from [**2145-1-29**] showed a right
dominant system and three vessel coronary artery disease. He
underwent routine preoperative evaluation and was eventually
cleared for surgery.
Past Medical History:
Coronary Artery Disease
Aortic Valve Stenosis
Hypertension
Elevated Cholesterol
Chronic Renal Insufficiency
Type II Diabetes Mellitus
History of Gout
History of Kidney Stones - prior Lithotripsy
Polypectomy
Tonsillectomy
Hemrrhoidectomy
Social History:
Quit tobacco over 50 years ago. Admits to occasional ETOH. He is
married. He is a retired construction worker.
Family History:
Brother died of MI in his early 50's.
Physical Exam:
Vitals: 120/64, 68, 16
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI. + rhinophyma
Neck: Supple, no JVD. Some soft tissue fullness in
supraclavicular area
Lungs: CTA bilaterally
Heart: Regular rate and rhythm. 3/6 systolic ejectiom murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally. Transmitted murmur in carotid region.
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2145-3-9**] Intraop TEE:
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are complex (>4mm) atheroma in the ascending
aorta. There are focal calcifications in the aortic arch. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. There
is severe aortic valve stenosis (area <0.8cm2). Mild to moderate
([**12-30**]+) aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. There is no pericardial effusion.
POST-BYPASS:
Preserved biventricular systolic function and it is normal.
Preserved ascending aortic contour. Mild to Moderate mitral
regurgitation.
A bioprosthesis is seen in the native aortic valve position,
stable and functioning well with a mean gradient of 10mm of Hg.
CHEST (PA & LAT) [**2145-3-13**]
There is slightly better aeration of the lungs since the prior
study. There is a small left pleural effusion and there is very
minimal left lower lobe atelectasis. The right lung is clear.
Cardiomediastinal silhouette is unremarkable. Status post median
sternotomy.
IMPRESSION:
Improved aeration of the left lung. Small left pleural effusion,
minimal left lower lobe atelectasis.
[**2145-3-9**] WBC-12.0* RBC-3.02*# Hgb-9.7*# Hct-27.6*# Plt Ct-143*
[**2145-3-12**] WBC-14.5* RBC-3.81* Hgb-12.2* Hct-35.4* Plt Ct-129*
[**2145-3-9**] UreaN-25* Creat-1.1 Cl-114* HCO3-25
[**2145-3-12**] Glucose-117* UreaN-19 Creat-1.1 Na-136 K-4.1 Cl-100
HCO3-31
Brief Hospital Course:
Mr. [**Known lastname 70228**] was admitted and underwent aortic valve
replacement and coronary artery bypass grafting surgery. For
surgical details, please see separate dictated operative note.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. He maintained stable
hemodynamics. Postoperatively he was taken to the cardiac
surgical intensive care unit for monitoring. On postoperative
day one, he was transferred to the step down unit for
monitoring. Mr. [**Known lastname **] was gently diuresed towards his
preoperative weight. He was restarted on his preoperative
medications. Tolerated a regular diet and had good pain control
with PO pain medications. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. He continued to make steady progress and was
discharged to home on POD #4. He will follow-up with Dr. [**Last Name (Prefixes) **] as an outpatient.
Medications on Admission:
Allopurinol 100 [**Hospital1 **], Norvasc 5 qd, Lipitor 80 qd, Zetia 10 qd,
Tricor 145 qd, Lasix 20 qd, Gabapentin 300 qd, Glipizide 2.5
am/1.25 pm, Imdur 60 qd, Lopressor 50 [**Hospital1 **], KCL, Diovan 160 qd,
ASpirin 325 qd
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5
days: then 20 mg daily previous home dose.
Disp:*5 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 5 days.
Disp:*5 Tablet Sustained Release(s)* Refills:*0*
11. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO Qam: 0.5 mg QPM.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Coronary Artery Disease, Aortic Valve Stenosis - s/p AVR/CABG
Hypertension
Elevated Cholesterol
Chronic Renal Insufficiency
Type II Diabetes Mellitus
Lung Nodule
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
1)Dr. [**Last Name (STitle) 1290**] in [**4-3**] weeks, call for appt
2)Dr. [**Last Name (STitle) 7047**] in [**1-31**] weeks, call for appt
3)CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-3-3**] 11:30 AM
[**Hospital Ward Name 23**] [**Location (un) **]. Nothing to eat or drink for 3 hours prior to
scan. Arrive by 11:00 AM. For lung nodule follow up.
Completed by:[**2145-3-13**]
|
[
"4241",
"41401",
"2720",
"40390",
"5859",
"25000"
] |
Admission Date: [**2161-6-5**] Discharge Date: [**2161-6-10**]
Date of Birth: [**2088-11-10**] Sex: M
Service: SURGERY
Allergies:
Procardia / Benadryl
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
RLE pain x1 day and difficulty ambulating bilaterally
Major Surgical or Invasive Procedure:
Right leg 3-compartment fasciotomy ([**2161-6-6**])
Wound vac placement ([**2161-6-8**])
History of Present Illness:
72M presenting with 1-2 day h/o sudden onset of pain in RLE that
has progressed over past day to point where he has had
difficulty ambulating. Patient states initially he felt like he
'pulled a muscle' in his hamstring. Pain also in calf. He was
having difficulty moving legs and had numbness of his right foot
causing difficulty ambulating and causing him to fall. Also
states difficulty
moving left leg, feels like he has to pull his leg forward.
Patient also claims he syncopized today.
Past Medical History:
PMH:
-coronary artery disease
-EF 20%
-complete heart block, pacer dependent
-diabetes mellitus type 2
-obstructive sleep apnea on CPAP
-history of syncope
-hypertension
-benign prostatic hypertrophy
-peripheral vascular disease
-hiatal hernia
-Meniere's disease
-psoriasis
-cervical and lumbar spinal stenosis
-GERD
-right eye blindness
PSH:
-CABGx3 '[**44**] (LGSV)
-pacemaker and ICD '[**54**]
-laminectomy of the cervical and lumbar spine
Social History:
Lives alone, widowed, Tobacco - quit cigars 30 yrs ago, No eTOH,
no illicits
Family History:
No family history of cardiac disease
Physical Exam:
PE:
97.5 96 138/96 96RA
A&Ox3
Obese male in no acute distress
Regular rate/rhythm
CTA b/l
Abd obese, +bs, non-distended, non-tender, unable to palpate
abdominal aorta.
RLE minimal lower leg. Motor diminished in LE
Able to move toes b/l but diminished in Rt
VAC dressing in place. Fasciotomy site is c/d/i
B/l popliteal aneurysms.
Pulses:
F [**Doctor Last Name **] PT DP
R 2+ 3+ 1+ Trip
L 2+ 3+ 1+ 1+
Pertinent Results:
[**2161-6-10**] 05:59AM BLOOD
WBC-11.3* RBC-3.11* Hgb-9.1* Hct-27.4* MCV-88 MCH-29.3 MCHC-33.3
RDW-13.8 Plt Ct-388
[**2161-6-10**] 05:59AM BLOOD
PT-17.4* PTT-56.5* INR(PT)-1.6*
[**2161-6-10**] 05:59AM BLOOD
Glucose-59* UreaN-12 Creat-0.8 Na-141 K-4.1 Cl-106 HCO3-24
AnGap-15
[**2161-6-7**] 09:09PM BLOOD
CK(CPK)-5571*
[**2161-6-9**] 03:51AM BLOOD
CK(CPK)-2291*
[**2161-6-10**] 05:59AM BLOOD
Calcium-8.8 Phos-3.7 Mg-2.2
[**2161-6-6**] 1:10 am MRSA SCREEN NASAL.
MRSA SCREEN (Final [**2161-6-8**]): No MRSA isolated.
HISTORY: 72-year-old male with mottled right foot, concern for
vascular
disease.
FINDINGS:
CT OF ABDOMEN AND PELVIS: Imaged lung parenchyma reveals 5-mm
pulmonary
nodule in the lingula and a calcified 2-mm nodule in right
middle lobe that are stable since [**2157**]. Previously described
nodule in the anterior right middle lobe appears to be of
ground- glass density on today's study and is unchanged in size.
There is no pericardial or pleural effusion.
Gallstones in otherwise unremarkable gallbladder. A 9-mm nodule
with
indeterminate features in the left adrenal gland seems to be
present in [**2159**] study, but it is difficult to compare due to
different techniques. The liver, spleen, right adrenal gland,
and kidneys are unremarkable. The pancreas is atrophic without
focal lesions. Bowel loops are normal in caliber. There are no
pathologically enlarged mesenteric or retroperitoneal lymph
nodes.
CT OF THE PELVIS: Urinary bladder appears unremarkable. Prostate
gland is
enlarged and heterogenous, with gross calcifications, measuring
up to 72 mm in laterolateral diameter. Seminal vesicles are
unremarkable. There are no pathologically enlarged pelvic lymph
nodes. There is no free fluid or free air in pelvic cavity.
CT ANGIOGRAM: Abdominal aorta is normal in size without evidence
of
dissection. Atherosclerotic changes with calcifications and
mural plaques,
some of them ulcerated, are noted along the arterial tree. A
focal ectasia of proximal celiac artery is identified, although
the origin is not narrowed. The origins of the superior
mesenteric, single renals and inferior mesenteric arteries are
patent.
On the right side, the common and external iliac arteries are
patent. There is a tight stenosis (60%) with post-stenotic
dilatation of the right internal iliac artery (3A:135). The
common, deep and superficial femoral arteries are unremarkable.
There is a 41 x 32 mm mostly thrombosed aneurysm of the
popliteal artery that extends for approximately 60 mm. There is
no opacification of AT. PT is patent, giving off branches to the
plantar arch. The DP opacifies from the collaterals coming from
the plantar arch. Peroneal artery has a narrowed origin, and
presents with multilevel disease.
On the left side, the origin of the common iliac artery is
narrowed, and then becomes aneurysmal, measuring up to 20 mm and
with large irregular areas of contrast pooling about the
periphery and separated from the vessel lumen by curvilinear
density, an appearance that may represent extensive ulcerated
plaque but could also represent chronic focal dissection. The
internal iliac artery presents a focal 12- mm aneurysm. The
external iliac artery and femoral arteries are unremarkable.
There is a 42 x 41 x 42-mm mostly thrombosed aneurysm in the
popliteal artery. There is no opacification of AT. The flow in
PT and peroneal arteries is delayed compared to the
contralateral side (could be due to proximal disease). The
peroneal artery has a narrowed origin, opacifies well only until
the mid- calf, and then shows faint opacification, but could be
due to a very slow flow. The patent PT gives off dorsalis pedis.
DP is filled by collaterals from the plantar arch.
OSSEOUS STRUCTURES: Bilateral spondylolysis and grade 1
anterolisthesis are noted at L5- S1. Degenerative changes in
spine.
IMPRESSION:
1. Bilateral mostly thrombosed popliteal artery aneurysm,
measuring up to 42 mm.
2. Aneurysm of the left common iliac artery that presents with
complicated
probable ulcerated plaques vs focal dissection with multiple
areas of saccular foci of contrast, measuring up to 20 mm.
3. Focal aneurysm of the left internal iliac artery.
4. No opacification of anterior tibialis arteries bilaterally.
5. Delayed flow in the left PT and peroneal arteries.
6. Narrowing at the origin of the left common iliac, the right
internal iliac and both peroneal arteries.
7. Gallstones.
8. Left adrenal gland nodule, indeterminate but possibly
previously present.
9. Stable lingular and right middle lobe nodules stable since
[**2157**] consistent with benignity. Ground- glass opacity in right
middle lobe is stable. Continued attention may be paid at next
follow up.
Brief Hospital Course:
Admitted through ED. Currently coming in with 1-2 day h/o
sudden onset of pain in RLE that has progressed over pastday to
point where he has had difficulty ambulating. Patientstates
initially he felt like he 'pulled a muscle' in his
hamstring. Pain also in calf. He was having difficulty moving
legs and had numbness of his right foot causing difficulty
ambulating and causing him to fall. Also states difficulty
moving left leg. feels like he has to pull his leg forward.
Diagnosis of Compartment syndrome. He agreed to have an elective
surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preperations were
made.
Pt started on IV heparin drip. Moniter of PTT. To be DC'd on
Lovenox untill surgery.
Bicarb drip started.
He underwent a:
Right leg 3-compartment fasciotomy.
VAC dressing placed.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, he was extubated and transferred to the CVICU
for further stabilization and monitoring.
His CK's were followed:
[**Numeric Identifier 35553**]*, [**Numeric Identifier **]*, [**Numeric Identifier 97371**]*, 9357*, 7560*, 5571*, 2291*. All in a
downtrend. On Dc his leg has less pan, improved movement and
sensation.
It was noticed that he had significant hematuria in the post op
period. A urology consult was obtained. Pt currently in being
worked up. Has out patient cystoscopy planned on the 14th. Most
labs are outptient. He currently has a CBI. This has been in
place since urology has seen the patient. Can remove at rehab.
If so clamp CBI. Hand irrigate if needed. If clears can pull
foley. If cannot urinate replace.
Pt also had an acute episode on chronic systolic dysfuntion.
Recieved lasix IV. responded appropriatly. Cardiology on board.
managed care. Resolved with lasix.
He was then transferred to the VICU for further recovery. While
in the VICU he recieved monitered care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabalized from the acute setting of post operative care,
he was transfered to floor status.
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged to a rehabilitation
facility in stable condition.
Medications on Admission:
Aspirin 81, Lipitor 40', Diovan 40', Coreg 12.5", Flomax 0.4',
Actos 15', Advair 250/50', Gemfibrozil 600", Omeprazole 20",
Ranitidine 150', Glyburide 10", Nasonex 1", Albuterol, Metformin
500 QID, Lasix 20'
Discharge Medications:
1. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) puffs Inhalation [**Hospital1 **] (2 times a day) as needed for
shortness of breath or wheezing.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. CPAP 13
50 cc EERS, 2 liters oxygen
For severe mixed sleep disordered breathing
6. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation PRN as needed for shortness of breath
or wheezing.
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal twice a day.
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
17. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
19. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a
day: STOP THE MORNING DOSE THE DAY OF YOUR SURGERY WITH DR
[**Last Name (STitle) 1111**].
20. Metformin 500 mg Tablet Sig: One (1) Tablet PO qid: 8 AM,
NOON, 4 PM AND [**2152**].
21. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Bilateral popliteal aneurysms
Right lower extremity distal ischemia
Anemia secondary to blood loss requiring PRBC's.
hematuria
Acute CHF on chronic CHF systolic dysfunction
Discharge Condition:
Good
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from your incision site, chest pain, shortness of
breath, or anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
YOU ARE ON LOVENOX. THE DAY BEFORE YOUR SCHEDULED SURGERY YOU
MUST STOP THE MORNING DOSE.
Followup Instructions:
1. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Name (STitle) **] on [**2161-6-15**] at 4:00 p.m.
for your outpatient cystoscopy. Call the office at [**Telephone/Fax (1) 921**]
to confirm your appointment.
2. Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2161-6-15**] 4:00
3. Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2161-7-2**] 2:00
4. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2161-7-15**] 10:10
5. You are scheduled for b/l popiteal stents. Call Dr [**Last Name (STitle) **]
office to get the exact date. His number is [**Telephone/Fax (1) 3121**]. It
should be scheduled [**7-1**]. This is not affirmed as of yet.
Completed by:[**2161-6-10**]
|
[
"2851",
"4280",
"41401",
"V4581",
"25000",
"32723",
"4019",
"53081",
"V1582"
] |
Unit No: [**Numeric Identifier 72923**]
Admission Date: [**2195-7-5**]
Discharge Date: [**2195-7-21**]
Date of Birth: [**2195-7-5**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 72924**] was the
2.630 kg product of a 36 and [**6-15**] week gestation, born to a 32
year-old, G1, P0 now 1 mother. Prenatal [**Name2 (NI) **]: Blood type A
positive, antibody negative, RPR nonreactive, Rubella immune,
hepatitis surface antigen negative, GBS negative. This
pregnancy was complicated by mild PIH over the prior weeks to
delivery. The patient presented with spontaneous rupture of
membranes overnight, progressing to spontaneous vaginal
delivery. No intrapartum fever was noted. Mother did not
receive intrapartum antibiotics. Variable decelerations were
noted during labor.
At delivery, tight nuchal cord and knot in cord were noted.
Infant emerged with moderate tone and respiratory effort,
requiring stimulation and blow-by oxygen by labor and
delivery. Heart rate was reportedly greater than 100
throughout and Apgars were 7 and 8. NICU was called at
approximately 5 minutes of life. At that time, infant was
found to have diminished tone with moderate grunting.
Aeration was adequate. Infant was left in labor and delivery.
At approximately 30 minutes of life, symptoms had improved
but grunting persisted one hour and infant was brought to the
Neonatal Intensive Care Unit.
PHYSICAL EXAMINATION ON DISCHARGE: General: Infant was in
room air, open crib. Skin was warm and dry. Color pink, well
perfused. Left chest tube site healing. No drainage or
erythema. Anterior fontanel open, level, sutures opposed.
Eyes clear. Chest with clear and equal breath sounds, easy
respirations. Regular rate and rhythm, no murmur, normal S1
and S2. Pulses 2+. Abdomen soft, no masses. Positive bowel
sounds. Cord on and drying. Genitourinary: Normal male.
Testes descended. Extremities: Moving all extremities.
Intact suck, grasp, Moro and symmetric tone.
HOSPITAL COURSE:
1. Respiratory: Infant admitted to the NICU with moderate
grunting, was noted within the first 12 hours of age. Did
have a left sided pneumothorax, treated with an oxygen
[**Doctor Last Name **] wash with progressive grunting, flaring and
retracting and increasing 02 needs. Decision was made to
place a left chest tube. The chest tube remained in for a
total of 5 days at which time it was discontinued. The
pneumothorax had resolved and chest had been stable. The
infant was requiring nasal 02. He was transitioned to
room air on [**2195-7-18**]. He had occasional episodes
where he required some brief periods of oxygen during
feeding but has been stable out of oxygen since [**98**] p.m.
on [**7-18**].
2. Cardiovascular: Infant has an intermittent audible
murmur, has otherwise been cardiovascularly stable
without issue.
3. Fluids, electrolytes and nutrition: Infant was started
on 60 cc/kg per day. Enteral feedings were started on
day of life #4. He advanced to full enteral feedings by
day of life number 6. He is currently ad lib feeding,
breast milk 20 calorie and breast feeding, taking in good
amount. His discharge weight is 2995 grams.
4. Gastrointestinal: Peak bilirubin was 14.8 over 0.5. He
was treated with phototherapy. His rebound bilirubin was
less than 9 and he has been stable since that time.
5. Hematology: Hematocrit on admission was 49. Infant has
not required any blood transfusions.
6. Infectious disease: CBC and blood culture were obtained
on admission. CBC was benign. He was treated for pneumonia
with a total of 14 days of antibiotics.
Lumbar puncture was within normal limits. Gentamycin levels
were all within normal limits. Antibiotics were discontinued
on [**7-19**].
7. Neuro: The infant has been appropriate for gestational
age. The time which the infant had an indwelling chest
tube, he was receiving some Fentanyl and morphine sulfate
for pain control and has not had any further issues.
8. Sensory: Hearing screen was performed with automated
auditory brain stem responses and passed both ears.
9. Psychosocial: This family has been invested and involved
in the infant's care.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**Name6 (MD) 72925**] [**Name8 (MD) 17470**], MD, [**Telephone/Fax (1) 70900**].
CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk
20 calorie.
Medications: Continue Tri-Vi-[**Male First Name (un) **] with 1 ml p.o. daily and
ferrous sulfate supplementation of 0.2 ml p.o. daily (25
mg/ml).
Iron and vitamin D supplementation: Iron supplementation is
recommended for preterm and low birth weight infants until 12
months corrected age. All infants fed predominantly breast
milk should receive Vitamin D supplementation at 200 i.u.
(may be provided as a multi-vitamin preparation) daily until
12 months corrected age.
Car seat position screening was performed for a 90 minute
screen and the infant passed.
State newborn screen was sent on [**7-8**] and has been within
normal limits.
The infant received hepatitis B vaccine on [**2194-7-18**].
DISCHARGE DIAGNOSES:
1. 36 and [**6-15**] week infant with delayed transition.
2. Left pneumothorax.
3. Pneumonia.
4. Rule out sepsis with antibiotics.
5. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2195-7-20**] 22:43:15
T: [**2195-7-21**] 04:55:11
Job#: [**Job Number 72926**]
|
[
"7742",
"V053"
] |
Admission Date: [**2144-2-27**] Discharge Date: [**2144-3-6**]
Date of Birth: [**2076-4-27**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
less interactive and independent after a fall at home
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 year old man with history of bilateral frontal strokes and
hypertension who presents with left intracranial hemorrhage. Two
days ago, his son was helping him dress while standing. patient
then started to fall backwards, hitting his head without loss of
consciousness. The next day, patient began to have decreased
verbal output but appeared understand his son. [**Name (NI) **] complained of
headache and started having increasing general weakness to the
point that he could not even stand with assistance (he normally
walks with a walker). His swallowing requires thickened food but
it now appeared to be unable to hold
this food. Son took him to [**Hospital **] hospital around 11 am where
NCHCT showed 1 x 1 x 1 cm left frontal hemorrahge. His sbp was
running 157-186. He was then given 1 gm dilatin and caused him
to be more sedated. Patient was then transferred for further
management
ALL: ?statin
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. Type 2 diabetes mellitus.
4. Coronary artery disease with a myocardial infarction 20
years ago. The patient is status post coronary artery bypass
graft in [**2140-2-11**], for five-vessel disease.
5. History of gastrointestinal bleed.
6. Bifrontal stroke s/p right CEA when Left ICA was totally
occluded [**2141**]
7. Chronic renal insufficiency 1.8-2
Social History:
The patient lives with son and was a part time at a court house
as a security guard. He quit smoking in [**2124**] and use to drink
heavy etoh but quit months ago. no ivdu
Family History:
no seizure or stroke
Physical Exam:
PE: 98 59 137/59 20 100% room air
Gen: sleeping
Neck: no carotid bruit
CV: RRR
Chest: CTA
Abd: soft, nontender
ext: no edema
Neuro:
sleeping but easily opens eyes to voice and stay awake for exam
decreased verbal output with maximum of 2 words for spontaneous
speech. intact comprehension and repetition.
Pupil 3 to 2 mm bilaterally. unable to see fundi. visual fields
grossly full to finger counting. no facial assymetry. tongue
midline and palate elevates symmetrically.
Motor: increased tone throughout. raises arms antigravity
without drift. strong left grasp but weak right grasp. right
leg externally rotates but both legs move symmetrically at 2/5
spontaneously and to stimuli
Sensory: localizes pain in four extremities. has more brisk
withdrawal on left than right arm.
Reflex: brisk DTRs with [**Name2 (NI) 11849**] toes bilaterally
Coordination/Gait: unable to test 2nd to cooperation
Pertinent Results:
Admission Labs:
[**2144-2-27**] 07:22PM BLOOD WBC-7.9 RBC-3.66* Hgb-9.8* Hct-29.1*
MCV-79*# MCH-26.8*# MCHC-33.8 RDW-17.6* Plt Ct-351
[**2144-2-27**] 07:22PM BLOOD Neuts-65.9 Lymphs-24.8 Monos-2.6 Eos-5.6*
Baso-1.1
[**2144-2-27**] 07:22PM BLOOD PT-13.7* PTT-26.3 INR(PT)-1.2
[**2144-2-27**] 07:22PM BLOOD Glucose-142* UreaN-43* Creat-1.8* Na-142
K-4.5 Cl-107 HCO3-24 AnGap-16
[**2144-2-27**] 07:22PM BLOOD Calcium-10.2 Mg-2.0
Other lab results:
[**2144-2-27**] 07:22PM BLOOD CK(CPK)-35*
[**2144-2-28**] 04:00AM BLOOD ALT-12 AST-12 CK(CPK)-44
[**2144-2-29**] 03:48AM BLOOD CK(CPK)-43
[**2144-2-28**] 04:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2144-2-29**] 03:48AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2144-2-29**] 03:48AM BLOOD VitB12-622 Folate-GREATER THAN 20
[**2144-2-28**] 04:00AM BLOOD calTIBC-333 Ferritn-532* TRF-256
[**2144-2-29**] 03:48AM BLOOD TSH-1.4
[**2144-2-29**] 03:48AM BLOOD Phenyto-2.8*
[**2144-3-3**] 04:55AM BLOOD Phenyto-11.8
[**2144-2-28**] 10:00AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2144-2-28**] 10:00AM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
[**2144-2-28**] 10:00AM URINE RBC-0-2 WBC-21-50* Bacteri-MANY
Yeast-NONE Epi-0
MIcro:
BLOOD CULTURE [**2-28**] negative
URINE CULTURE (Final [**2144-3-3**]):
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing E. coli and Klebsiella species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S =>32 R
CEFAZOLIN------------- 16 I =>64 R
CEFEPIME-------------- <=1 S R
CEFTAZIDIME----------- <=1 S R
CEFTRIAXONE----------- <=1 S R
CEFUROXIME------------ 4 S R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S =>16 R
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN----------<=0.25 S =>8 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 32 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S 8 I
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
ECG: no st-t changes
NCHCT [**2-27**]: left frontal hemorrhage 1 x 1 x 1.2 cm anterior to
left lateral ventricle and located parasagitally. (scan at OSH
at noon shows 1x1x1 cm bleed)
MR brain [**2-27**]:
Area of hemorrhage in the left corona radiata unchanged in size
since the prior CT obtained on the same day. There is
questionable rim enhancement in postcontrast studies around the
area is not certain if these are related to the patient's
motion. There is evidence of multiple prior infarctions.
Echo [**2-28**]:
1.The left atrium is normal in size. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mild depressed. Resting regional wall
motion abnormalities include basal septal hypokinesis,
inferobasal akinesis, with inferior and basal septal
hypokinesis.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic root is moderately dilated. The ascending aorta is
moderately dilated.
5.The aortic valve leaflets (3) are mildly thickened.
6.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
7.The estimated pulmonary artery systolic pressure is normal.
8.There is no pericardial effusion.
Brief Hospital Course:
1. Parasagittal hemorrhage. 67 year old man with history of
bilateral ischemic strokes, vascular risk factors, and
hypertension who presented with worsening weakness, dysphagia,
and speech 2 days after a fall. The patient was admitted to the
neurology service. Head CT was done and showed small left
parasagittal hemorrhage. MR of the brain was done but did not
visualize the area of the hemorrhage because the bleeding was
located above where the cuts were taken. The differential
diagnoses included hypertensive bleed, bleeding secondary to
AVM, aneurysm, mass, or amyloid. The patient's blood pressure
control was optimized with goal to keep SBP between 120-140. He
was also started on insulin sliding scale for glycemic cont tol.
The patient underwent CT Angio on [**3-4**] which was negative for
aneurysm. The patient was loaded with dilantin on [**2-28**] for
seizure prophylaxis. Dilantin was tapered and discontinued prior
to discharge. His symptoms improved prior to the discharge. He
became more alert, demonstrated improved spontaneous movement
and was able to speak in full sentences although his voice
remained soft. The patient was evaluated by PT and OT and felt
to be a candidate for rehab.
2. UTI. The patient had urinalysis on admission that was c/w
UTI. He was initially started empirically on Levofloxacin which
on [**3-2**] was changed to Zosyn after his urine culture grew
resistant E coli and sensitive Klebsiella. He spiked fevers up
to 100.7. On [**3-3**] CXR showed new LLL infiltrated and Clindamycin
was added to cover aspiration pneumonia. The patient has been
afebrile since [**3-4**]. He should complete 7 days course of
antibiotics.
3. Parkinsonism. Sinemet was resumed on [**3-4**].
4. Apnoea. Initially, the patient had episodes of central and
obstructive apnea with >20 sec frequent apneic pauses. Per
family he has a history of not breathing followed by loud
snoring at home. It was thought that he would benefit from being
initiated on CPAP given obstructive component of apnea. The
patient went to ICU but did well in the ICU and did not require
CPAP.
5. Chronic renal insufficiency. Baseline Cr 1.4-1.8. Patient
received Mucomyst and hydration with bicarb IV fluids for renal
protection pre- and post- contract administration for CT Angio
on [**3-4**]. His medications were renally dosed. His renal function,
urine output will need to be monitored closely given risk of
nephrotoxicity. On the day of discharge, his creatinine was
stable at 1.4.
5. Anemia. Patient received one unit pRBC for HCT 28 given h/o
CAD on [**2-28**]. His HCT has been stable close to 30. Fe studies
(pre-transfusion) were checked and showed normal serum iron,
high ferritin and normal TIBC. He was not restarted on Fe
supplements.
6. Hypernatremia - hypovolemic hypernatremia due to NPO and
being on IV NS. This was corrected slowly with free water
boluses.
7. Hypertension. The patient's goal SBP 120-140 in the acute
period after the hemorrhage and then can be lowered to goal SBP
<130. He was restarted on an ACE inhibitor. HCTZ was added to
his medications for BP control. His SBP was in 130-150 range on
these medications. His medications will need to be adjusted to
achieve goal BP gradually.
8. Nutrition. The patient initially failed speech and swallow
eval. He received several days of NG tube feedings. He underwent
video swallowing study on [**3-5**] and did well. He was resumed on a
cardiac/diabetic/low sodium diet prior to discharge and
tolerated it well. He requires assistance with feeding at all
times and should be maintained on aspiration precautions.
Medications on Admission:
Meds:
isordil 60 mg po qd
lisinopril 2.5 mg po qd
gemfibrozil 600 mg po bid
insulin NPH 10 units qam
regular insulin sliding scale
glyburide 7.2 mg o qam and 5 mg po qhs
sinemet 25/100 po tid
asa 81 mg po qd
atenolol 12.5 mg po qhs
folate
thiamine
effexor 75 mg po qd
feso4
prevacid 30 mg po bid
colace
actos 30 mg po qd
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **]Nursing Home
Discharge Diagnosis:
1. Intracranial bleed, parasagital
2. Parkinsonism
3. Urinary tract infection
4. Hypertension
5. History of alcohol dependence
6. Diabetes
7. Hypernatremia
8. Pneumonia, aspiration
Discharge Condition:
Improved, slightly bradykinetic, able to move all four
extremities, eat with assistance and supervision, and answer
simple questions.
Discharge Instructions:
Please keep all follow- up appointments.
Please take all medications as prescribed.
Please do not take aspirin or other blood thinners/anti-platelet
agents for 3 weeks after discharge.
Please return to care if you develop new weakness, numbness,
difficulty speaking, or other concerning sympomts.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 656**] ([**Telephone/Fax (1) 102424**]) in [**1-12**] weeks
after discharge. Please follow up with your neurologist in [**1-12**]
months.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2144-3-6**]
|
[
"5070",
"5990",
"2760",
"412",
"V4581",
"2859",
"4019",
"25000"
] |
Admission Date: [**2122-10-19**] Discharge Date: [**2122-10-21**]
Date of Birth: [**2068-2-26**] Sex: M
Service: MEDICINE
Allergies:
Toradol / Celebrex
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
ICD pocket infection
Major Surgical or Invasive Procedure:
ICD generator and lead extraction
History of Present Illness:
54 y old male w/ hx of CHF w/ EF of 30% s/p biV ICD/pacer in
[**9-18**], and NYHA functional class II-III, CAD s/p MI in '[**15**] with
BMS to OM1, CABG and MV repair [**9-19**] (LIMA to LAD, SVG to OM,
SVG to PDA, 30 mm [**Doctor Last Name **] Physio-Ring), L shoulder replacement,
Left TKA, cervical spine fusion with hardware tx'd from [**Hospital 3856**] for pacer pocket infection.
Approximately 3 weeks ago the skin over the pacer started to
turn dark red/purple and became exquisitely tender. The patient
denied any fever, chills, nausea, headache, or general malaise.
He has not had any recent rash, skin breakdown or insect bite.
He did notice increase in cough but no increased rhinorrhea,
sputum production, or sinus pressure.
Last Friday, the patient went to his PCP and was prescribed
Keflex for presumed soft tissue infection overlying the
ICD/Pacer. He had normal WBC and no fever at that time. The
symptoms of redness and swelling did not improve so was taken
for pacer generator revision on [**10-19**] at [**Hospital **] hospital. They
discovered a large pus pocket, placed a drain and transferred
the patient to [**Hospital1 18**] for emergent pocket washout and lead
removal.
ABG on arrival was 7.23/72/209/30/1 with a lactate of 1.0. Was
taken directly to OR where pacer pocket and lead extraction
which was uncomplicated although one pacer in the LV had to be
abandoned.
Past Medical History:
# Congestive Heart Failure w/ EF of 30% s/p single Chamber
pacer [**12-19**], with upgrade to biV in [**9-18**]
# Coronary Artery Disease
- s/p Myocardial Infarction [**2115**] with thrombectomy and BMS to
OM1
- s/p CABG and MV repair [**9-19**] (LIMA to LAD, SVG to OM, SVG to
PDA, 30 mm [**Doctor Last Name **] Physio-Ring)
# Hypertension
# Hyperlipidemia
- Most recent panel: Total chol 225, LDL 116, HDL 35, Trig 372
(from over 500)
# Cervical disc herniation s/p fusion with hardware
# s/p lumbar disc surgery x 2
# s/p Cholecystectomy
# s/p Left shoulder surgery
# s/p Left total knee replacement
# s/p pericarditis [**2115**]
# Osteoarthritis
# GERD
Social History:
Tobacco: 70pack/yr hx, one PPD currently
ETOH: denies
Family History:
Father w/ CABG at 57. Brother w/ Myocardial Infarction at 42.
Physical Exam:
(on admission)
VS: T 97.3 ,BP 144/70, HR 70
Vent settings: AC 650/12, FiO2 50%, PEEP 5
Gen: Middle aged male intubated and sedated, with occacional
coughing
HEENT: Sclera anicteric. PERRL, tracking intact. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple
CV: RR with mild systolic murmur best heard at LUSB, normal S1,
S2. No S4, no S3.
Chest: L upper chest with large dressing c/d/i. well healed
midline scare over sternum. No obvious chest wall deformities.
Bilateral crackles anteriorly.
Abd: Obese, soft, NTND, No HSM or tenderness.
Ext: No c/c/e. R groin with access.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2122-10-20**] 12:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2122-10-20**] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2122-10-19**] 11:27PM TYPE-ART TEMP-38.7 RATES-18/ TIDAL VOL-690
O2-40 PO2-106* PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED VENT-CONTROLLED
[**2122-10-19**] 08:01PM TYPE-ART PO2-108* PCO2-46* PH-7.37 TOTAL
CO2-28 BASE XS-0
[**2122-10-19**] 08:01PM O2 SAT-97
[**2122-10-19**] 06:12PM GLUCOSE-93 UREA N-15 CREAT-0.7 SODIUM-139
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
[**2122-10-19**] 06:12PM CALCIUM-8.2* PHOSPHATE-3.4 MAGNESIUM-2.2
[**2122-10-19**] 06:12PM NEUTS-71.6* LYMPHS-23.8 MONOS-3.7 EOS-0.9
BASOS-0.1
[**2122-10-19**] 06:12PM PLT COUNT-235#
[**2122-10-19**] 03:12PM GLUCOSE-79 LACTATE-1.0 NA+-142 K+-4.3 CL--102
[**2122-10-19**] 03:12PM freeCa-1.15
.
CXR ([**2122-10-20**]): FINDINGS: In comparison with the study of
[**2121-9-26**], the pacemaker device has been removed. A prosthetic
mitral valve is again seen. There is continued enlargement of
the cardiac silhouette with relatively mild vascular congestion.
No evidence of acute pneumonia.
Endotracheal tube tip lies about 4 cm above the carina and the
nasogastric
tube extends to at least the upper stomach. Metallic fixation
device
involving the lower cervical spine is again seen.
.
CXR ([**2122-10-20**]): FINDINGS: In comparison with the study of [**10-19**],
there is little change in the appearance of the heart and lungs.
The endotracheal and nasogastric tubes have been removed.
IMPRESSION: No acute pneumonia.
Brief Hospital Course:
54 y old male w/ hx of CAD s/p MI in '[**15**] with BMS to OM1, CABG
and MV repair [**9-19**], CHF w/ EF of 30% s/p Dual Chamber ICD [**9-18**]
w/ epicardial lead, Left TKA, L shoulder replacement, cervical
spine fusion with hardware tx'd from [**Hospital3 1280**] for pacer pocket
infection on [**10-19**]
At [**Hospital1 18**], was taken to the OR urgently and he had the atrial and
RV leads explanted along with the generator. A ventricular lead
was pulled back, cut and allowed to self-retract. In the OR, the
patient was hypotensive on neosynephrine for much of the case.
The episode of hypotension and fever to 101.5 was concerning for
sepsis and the patient was started on Vanco/Zosyn.
Intraoperative TEE did not show any evidence of endocarditis.
.
In the CCU at [**Hospital1 18**] pt was intially febrile to 101 when arriving
with sbp's in low 90's although appearing quite well with good
mentation, UOP and perfusion. Pt's ABG quickly normalized and
pt was extubated on the day after admission. Sbp's responded to
gentle fluid boluses and maintenance IVFs during the night of
the admission and was never on pressors in the CCU. Pt has
since continued to be afebrile and HD stable with sbps in the
120s and without an elevation in white count. Pt was re-started
on BB prior to d/c.
.
On the day of transfer the following plan was discussed:
# ID/ICD pocket infection s/p ICD lead extraction with abandoned
pacer in LV remaining
- Cont vancomycin and zosyn for empiric abx therapy since we
have no cultures to follow. Cultures from [**Hospital1 **] also NGTD
including cultures from pacer pocket; it is possible the
infection was treated with keflex prior to drainage if the
infection was g-staph
- ID recommended cont. current abx for now and for at least 4
weeks to be followed by oral supressive therapy
- cough productive of clear sputum positive with 4+ G- rods and
1+ G+ cocci; If truly has a pulm infecton as sputum suggests it
is covered with vanc/zosyn although CXR without obvious
infiltrates
- PICC line placed prior to transfer
- f/u culture of pacer tips, blood cultures, and sputum cultures
- daily wet to dry dressing changes
.
# Pump/CHF w/ EF of 30% s/p Dual Chamber ICD [**9-18**] now s/p ICD
lead extraction
- appears euvolemic to mildly overloaded
- cont. titrate up on BB, [**Last Name (un) **] as tolerated
- pt to go home with life-vest: This will need to be set up via
case management at [**Hospital1 **] and with the patient's
cardiologist.
- pt will likely need a new ICD implanted at some point in the
future
.
# Rhythm
- monitor on tele
- pt should go home with life-vest
.
# Ischemia/Coronary Artery Disease, s/p MI in '[**15**] with
thrombectomy and BMS to OM1, s/p CABG and MV repair [**9-19**]
- cont ASA 81, atorvastatin 80 mg
- cont. titrate up on BB, [**Last Name (un) **] as tolerated
.
# Pulm
- cough productive of clear sputum possitive with 4+ G- rods and
1+ G+ cocci; If truly has a pulm infecton as sputum suggests it
is covered with vanc/zosyn although CXR without obvious
infiltrates
- f/u sputum cultures
.
# Hypertension
- cont. titrate up on BB, [**Last Name (un) **] as tolerated
.
# Hyperlipidemia
- cont atorvastatin
.
# Code Status: Full code
.
# Dispo: transfer to [**Hospital1 **]. will need VNA when going home
from [**Hospital1 **] to assist with medications and IV antiobiotics.
Patient will also need teaching with IV antiobiotic dosing prior
to discharge from [**Hospital1 **]. He has a right PICC placed at
[**Hospital1 18**], with a CXR performed showing good placement (in SVC) and
no pneumothorax.
.
# Communication: Wife, [**Name (NI) **] [**Name (NI) 17111**] [**Telephone/Fax (1) 17112**]
Medications on Admission:
HOME MEDICATIONS (per wife and pt):
Aspirin 325 mg po DAILY
Protonix 40 mg [**Hospital1 **]
Prilosec 20mg po bid
Carvedilol 25 mg po BID
valsartan 160mg po bid
Spironolactone 25mg po bid
lasix 40mg po bid
hydral 25 mg po bid
norvasc (amlodopine) 10mg po bid
Atorvastatin 40 mg po DAILY
keflex
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H () as needed for pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Docusate Sodium 50 mg Capsule Sig: [**12-16**] Capsules PO twice a
day as needed for constipation.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Vancomycin 1000 mg IV Q 12H
day 1 [**10-19**]
14. Piperacillin-Tazobactam Na 4.5 gm IV Q8H
day 1 [**10-19**]
Discharge Disposition:
Extended Care
Discharge Diagnosis:
ICD pocket infection
Discharge Condition:
Stable
Discharge Instructions:
You were admitted and treated for ICD pocket infection.
.
If you develop fever greater than 101F chest pain, shortness of
breath, or if you at any time become concerned about your health
please contact your PCP, [**Name10 (NameIs) **] or [**Hospital1 18**] at [**Telephone/Fax (1) **] or
present to the nearest ED.
.
Please take your medications as prescribed.
.
Please make sure to have appointments with electrophysiology and
infectious disease prior to discharge from [**Hospital1 **] for this
serious infection of your ICD pocket.
Followup Instructions:
Please make sure [**Hospital1 **] has scheduled appointments with the
following prior to dicharge or schedule follow-ups to be seen
within 1-2 weeks with the following:
- electrophysiology
- infectious disease
- your cardiologist
- your PCP
|
[
"0389",
"4019",
"2724",
"4280"
] |
Admission Date: [**2121-1-27**] Discharge Date: [**2121-2-1**]
Date of Birth: [**2055-3-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Colon tumor
Major Surgical or Invasive Procedure:
s/p Right colectomy, primary anastamosis
History of Present Illness:
Mr. [**Known lastname 8271**] is a 65yo male with a 50yo h/o of cigarette smoking
and h/o CAD, HTN, obesity who underwent a colonoscopy and was
found to have a sessile 50 mm polyp in the hepatic flexure which
could not be removed by colonoscopy and therefore the area was
marked with a tattoo and the patient was referred for surgery.
He was a heavily built man and he had co-morbid conditions of
chronic obstructive pulmonary disease and prior cardiac disease.
His Plavix was stopped 5 days prior to surgery.
Past Medical History:
CAD s/p stent '[**15**], s/p brachytherapy stent, restenosis '[**15**], HTN,
DM, obesity, smoker(50yrs), h/o ETOH abuse-sober 20years
Social History:
Single. Lives alone. Retired engineer from Mass Maritime-[**State 1727**].
Supportive family & friends. H/O ETOH abuse-sober 20 years.
Currently smokes 1-2 packs per day for past 50years. Denies
illicit drug use.
Family History:
Non-contributory
Physical Exam:
PRE-OP
Vitals:T-97.5,HR-76,BP-125/54,RR-20,O2 sat-95% RA
Well-appearing, NAD
Cardiac-RRR, no m/r/g
Lungs-CTAB
ABD obese, soft, NT
Extrem:WWP, no c/c/e
Pertinent Results:
[**2121-1-31**] 06:10AM BLOOD WBC-8.0 RBC-4.73 Hgb-14.5 Hct-42.6 MCV-90
MCH-30.6 MCHC-34.0 RDW-13.7 Plt Ct-120*
[**2121-1-27**] 03:05PM BLOOD WBC-16.0*# RBC-5.10 Hgb-16.0 Hct-46.9
MCV-92 MCH-31.4 MCHC-34.1 RDW-14.8 Plt Ct-169
[**2121-1-31**] 06:10AM BLOOD Plt Ct-120*
[**2121-1-28**] 03:13AM BLOOD PT-15.2* PTT-29.2 INR(PT)-1.3*
[**2121-1-27**] 03:05PM BLOOD PT-17.1* PTT-30.3 INR(PT)-1.5*
[**2121-1-31**] 06:10AM BLOOD Glucose-121* UreaN-15 Creat-0.7 Na-142
K-3.6 Cl-104 HCO3-31 AnGap-11
[**2121-1-27**] 03:05PM BLOOD Glucose-124* UreaN-16 Creat-0.9 Na-142
K-4.9 Cl-108 HCO3-27 AnGap-12
[**2121-1-28**] 03:13AM BLOOD ALT-24 AST-32 LD(LDH)-233 CK(CPK)-466*
AlkPhos-44 Amylase-25 TotBili-1.0
[**2121-1-27**] 03:05PM BLOOD ALT-26 AST-34 LD(LDH)-254* CK(CPK)-234*
AlkPhos-49 Amylase-30 TotBili-1.0
[**2121-1-30**] 11:05AM BLOOD proBNP-1164*
[**2121-1-31**] 06:10AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.0
[**2121-1-27**] 03:05PM BLOOD Albumin-3.9 Calcium-8.4 Phos-2.4* Mg-1.8
.
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2121-1-27**] 5:54 PM:
[**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION
65 year old man with h/o CAD and COPD, s/p hypoxic event
peri-operatively, with increased A-a gradient
IMPRESSION:
1. No evidence of pulmonary embolism in central or segmental
branches. Limited evaluation of the subsegmental branches due to
bolus timing.
2. Bilateral lower lobe airspace consolidation likely
representing atelectasis.
3. Small perihepatic fluid.
4. ETT at the thoracic inlet. Advancement is recommended.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2121-1-27**] 2:25 PM
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with
REASON FOR THIS EXAMINATION:
DESATS IN OR
SINGLE PORTABLE SEMI-UPRIGHT CHEST: Compared to [**2120-6-20**]. A large
portion of the right lung has been excluded from field of view.
Patient is intubated with the tip of the endotracheal tube 8 cm
above the carina at the superior margin of the clavicles. There
has been clearing of the previous left lower lobe consolidation
with some residual opacity in the medial basilar aspect of the
left lower lobe, likely atelectasis. No pneumothorax.
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2121-1-30**] 11:31 AM
REASON FOR THIS EXAMINATION:
Rule out pneumonia, effusions, and changes lung anatomy
IMPRESSION: Persistent low lung volumes with atelectasis at both
bases and small right pleural effusion. Findings discussed with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13289**], nurse practitioner, at the time of dictation.
.
[**2121-1-27**] Pathology Tissue: right colectomy. [**2121-1-27**]
[**Last Name (LF) **],[**First Name3 (LF) **] M. Not Finalized
Brief Hospital Course:
Mr. [**Known lastname 13290**] operative course was complicated by difficult
intubation, decreased oxygen saturations, bradycardia, and
hypotension. He was stabilized with successful intubation, and
IV hydration. His surgery was completed, and he ws transferred
to ICU for further management.
.
POD1-He was extubated in the ICU in the morning, & monitored
closely. He was weaned to 4L of nasal cannula with sats>95%. He
appeared stable, and was transferred to [**Hospital Ward Name **].
.
RESP:He had audible bibasilar crackles post-op. He was diuresed
with IV Lasix, and responded with decreased demand in oxygen via
nasal cannula. He required more time to wean from oxygen. His
sats are currently 92% on RA. Pulmonary Team was consulted who
recommended PFT's on outpatient basis and sleep studies to rule
out sleep apnea. Recommendations also included daily diuresis,
BNP>1200, Spiriva/albuterol/atrovent and aggressive IS
use/CPT/and frequent ambulation. He was taught proper use of
MDI's. Smoker cessation was offered. Patient made it clear he
had no intention of quitting. His [**Last Name (LF) 802**], [**Name (NI) **], will make a
follow-up appointment for PFT's on outpatient basis.
.
ABD:His abdomen is large, soft, NT/ND with active bowel sounds.
His abdominal incision is OTA with staples with a small amount
of erythema along the incision line. He was started on IV
cephazolin, and switched to PO Augmentin due to reports of GI
upset with PO Keflex in the past. He will have the staples
removed at the follow-up appointment with Dr. [**Last Name (STitle) **].
.
NUT:He was NPO post-op. His diet was advanced as his bowel
function resumed. He has been tolerating a regular diet without
complaints of nausea and/or vomiting.
.
ELIM:He had a foley catheter inserted intra-op. The catheter was
removed, and he was able to urinate without difficulty. He
reports passing flatus, but has not had a bowel movement since
surgery.
.
PAIN:His pain was managed with an IV PCA post-op. He was
advanced to oral Percocet once tolerating oral fluids. He
reports her pain 0-2/10 at rest, and increases to [**5-31**] with
activity which is well tolerated. He will be discharged with a 2
week supply of percocet, and colace to prevent constipation.
.
He reports not having a current PCP, [**Name10 (NameIs) **] does not have interest
inestablishing a relationship with a family physician. [**Name10 (NameIs) **] was
encouraged to follow-up with Pulmonology, and to consider
finding a PCP. [**Name10 (NameIs) **] will be discharged home with VNA services for
assessment of respiratory status.
Medications on Admission:
Glyburide/metformin 2.5/500", Avandia 4', Lantus 45Uqhs, Cozaar
50', atenolol 100', Lipitor 10', Plavix 75', testosterone patch.
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Glyburide-Metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Lantus 100 unit/mL Solution Sig: 45 units Subcutaneous at
bedtime.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*1 Cap(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheeze/SOB.
Disp:*1 * Refills:*1*
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
polyp at hepatic flexure
Post-op hypotension
Post-op hypoxemia
.
Secondary:
Smoker
Obese
CAD
HTN
DM2
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow-up appointment with
Dr. [**Last Name (STitle) **].
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
1. Please make a follow-up appointment with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) **] in [**1-22**] weeks.
2. Make an appointment with Dr. [**First Name8 (NamePattern2) 13291**] [**Last Name (NamePattern1) 4507**] [**Telephone/Fax (1) 13292**] for
Pulmonary Function Tests in [**2-24**] weeks.
3. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2041**]
Date/Time:[**2121-2-20**] 10:20
4. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2121-7-2**] 11:00
|
[
"5180",
"9971",
"25000",
"4019",
"4280",
"496",
"41401",
"V4582",
"42789",
"32723",
"3051"
] |
Admission Date: [**2197-5-28**] Discharge Date: [**2197-6-1**]
Date of Birth: [**2120-2-10**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 77 yo M with multiple medical conditions including
Stage IV NSCLC (adenocarcioma) s/p chemoradiation, CAD and PVD
on [**Hospital **] transferred from [**Hospital6 **] ED for BRBPR.
.
Patient began having BRBPR last night. He presented to [**Hospital1 112**] ED
and was found to have a Hct of 20 (baseline in high 20s/low
30s). He received 1U PRBC there. Given that he receives most of
his medical care here, including treatment for his NSCLC, he was
transferred to [**Hospital1 18**] to further management.
.
In the ED, initial vs were: T- 100.3, P- 84, BP-151/64, RR-18,
SaO2- 100% on RA. Patient complained of abdominal pain, mainly
in the suprapubic region. CT scan was negative but did show
significant fecal load. He received 3L NS in the ED. In
addition, he received IV PPI. His temp went up to 103.0 so he
was given tylenol and cultured. UA was positive so he was
started on Cipro. He was also given a dose of flagyl for
abdominal pain and fever. He complained briefly of chest pain so
troponins were sent- came back at 0.04.
.
On the floor, patient was fatigued but arousable. Vital signs:
T- 99.0, HR- 103, BP- 124/65, RR- 19, SaO2- 98% on 2L. He did
not complain of any abdominal tenderness.
Past Medical History:
1. Stage IV non-small cell lung cancer. Histology:
adenocarcinoma. Status post 5 doses of chemotherapy with
carboplatin AUC of 2 and paclitaxel 50 mg/m2 weekly with
radiation, for 6 weeks. Week 2 was held for evaluation of chest
pain. Completed daily fractionated radiation to 5040 cGy in
5/[**2194**].
.
Other PAST MEDICAL HISTORY:
- HTN
- Peripheral [**Year (4 digits) 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**].
- S/p bilateral shoulder displacement.
- CAD s/p MI '[**85**]
- Hypercholesterolemia,
- GI bleed '[**87**]
- Gout
- Osteoarthritis
- Herniated L4-5 disc
- L5-S1 stenosis
Social History:
The patient started smoking at age 15 and continues smoking now.
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.
.
Family History:
Sister that died from a throat cancer apparently. There is no
other history of cancer in the family. There is history of
coronary disease in the family.
Physical Exam:
Physical Exam:
Vitals: T- 99.0, HR- 103, BP- 124/65, RR- 19, SaO2- 98% on 2L
General: Fatigued but arousable. 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: Tachycardic. Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. TTP to suprapubic
region.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2197-5-28**] 09:10PM URINE HOURS-RANDOM
[**2197-5-28**] 09:10PM URINE GR HOLD-HOLD
[**2197-5-28**] 09:10PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.025
[**2197-5-28**] 09:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2197-5-28**] 09:10PM URINE RBC-[**1-27**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0
[**2197-5-28**] 07:30PM LACTATE-2.3*
[**2197-5-28**] 06:25PM cTropnT-0.04*
[**2197-5-28**] 06:25PM WBC-3.7* RBC-3.46* HGB-9.0* HCT-27.3* MCV-79*
MCH-26.0* MCHC-32.8 RDW-16.7*
[**2197-5-28**] 06:25PM NEUTS-90.3* BANDS-0 LYMPHS-7.4* MONOS-1.2*
EOS-0.9 BASOS-0.1
[**2197-5-28**] 06:25PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-2+
TEARDROP-OCCASIONAL ACANTHOCY-OCCASIONAL
[**2197-5-28**] 06:25PM PLT SMR-NORMAL PLT COUNT-203#
[**2197-5-28**] 06:25PM RET AUT-0.3*
[**2197-5-28**] 03:06PM COMMENTS-GREEN TOP
[**2197-5-28**] 03:06PM LACTATE-1.7
[**2197-5-28**] 03:06PM HGB-10.4* calcHCT-31
[**2197-5-28**] 03:00PM GLUCOSE-112* UREA N-22* CREAT-1.2 SODIUM-134
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13
[**2197-5-28**] 03:00PM estGFR-Using this
[**2197-5-28**] 03:00PM ALT(SGPT)-31 AST(SGOT)-43* LD(LDH)-346* ALK
PHOS-113 TOT BILI-1.5 DIR BILI-0.3 INDIR BIL-1.2
[**2197-5-28**] 03:00PM ALBUMIN-3.2*
[**2197-5-28**] 03:00PM HAPTOGLOB-366*
Brief Hospital Course:
Pt was initially evaluated in the [**Hospital1 756**] ED for BRBPR but was
transfered to the [**Hospital1 18**] ED where he recieves oncologic care. GI
bleed resolved and HCT stabilized. Pt was evaluated by GI in the
ED who did not feel intervention was needed at that time and
recommended close Hct monitoring and tagged scan/angio if
patient re-bleeds. He received one unit of PRBC in the ED.
Patient found to have UTI on UA, which corresponded with his
suprapubic pain. He was started on cipro in ED. He was febrile
to 103 in ED.
.
Pt was transferred to the [**Hospital Ward Name 332**] ICU on [**2197-5-28**]. His HCT remained
stable from 27.3--> 26.1. He was kept NPO overnight, was given
pantoprazole 20 mg iv q24. C. diff cultures were sent and he was
started on flagyl while those cultures were pending. His plavix
and home anti-hypertensives were held. He showed no evidence of
further GI bleed and he remained hemodynamically stable. He did
have a mild bump in troponin due to demand ischemia.
.
For his UTI, we continued the ciprofloxacin started in the ED.
He was also given morphine prn for his described [**7-4**] suprapubic
pain. His blood cultures returned [**12-27**] gram negative rods.
.
On the floor, the pt continued on IV antibiotics for bacteremia
with cipro-sensitive E.Coli. GI recommended outpatient
follow-up for likely ischemic colitis. His ASA and plavix were
held, and he should follow-up with his primary care physician,
[**Name10 (NameIs) 44284**], or [**Name10 (NameIs) 1106**] surgeon about restarting them. He was
transfused for a falling Hct, which bumped appropriately and
remained stable thereafter. He complained of bony pain and was
seen by palliative care for pain management, with tweaking of
his pain medication regimen.. He is FULL code.
Medications on Admission:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Oxycodone 5 mg Tablet Sig: 3-5 Tablets PO Q2H (every 2 hours)
as needed for pain.
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
every eight (8) hours as needed for constipation.
17. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: One
(1) tsp PO every 4-6 hours as needed for cough.
18. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
19. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
21. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1)
tablet Sustained Release 12 hr PO twice a day.
22. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for nausea/anxiety.
.
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release(s)* Refills:*0*
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Metoprolol Succinate 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. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: Please apply to shoulder 12 hours on and 12
hours off.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheeze.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Morphine 15 mg Tablet Sig: 2-3 Tablets PO Q2H (every 2
hours) as needed for pain.
Disp:*1080 Tablet(s)* Refills:*0*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
18. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
19. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
every eight (8) hours as needed for constipation.
20. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: One
(1) tsp PO every 4-6 hours as needed for cough.
21. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for nausea, anxiety.
22. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
23. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Ten (10)
mL PO once a day.
Disp:*300 mL* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Multicultural Home Care
Discharge Diagnosis:
Primary Diagnoses: Ischemic Colitis, Urinary Tract Infection,
Bacteremia
Secondary Diagnoses: Stage IV Non-Small Cell Lung Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after passing bright red blood
through your rectum. At the time you were also found to have an
infection of your blood stream and urine. You were treated with
bowel rest and antibiotics. During your hospitalization you
also complained of your chronic bone pain due to your cancer.
Your pain medications were changed to give you better pain
control.
.
The following changes were made to your medications:
Aspirin and Plavix were STOPPED. You should see your primary
care doctor [**First Name (Titles) **] [**Last Name (Titles) 1106**] surgeon within the next week or two to
consider restarting these medications.
.
OxyContin and Oxycodone were STOPPED.
.
You were STARTED on MSContin for long-acting pain relief and
Morphine IR for short-term pain relief. You were STARTED on a
Lidoderm Patch that you can place over your shoulder/back where
you are having severe pain. You were STARTED on Megace
(Megestrol) to increase your appetite.
.
Your metoprolol dose was INCREASED.
.
You should STOP taking lisinopril. You should discuss
restarting lisinopril with your primary care doctor or
cardiologist.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD
Phone:[**0-0-**]
Date/Time:[**2197-6-22**] 10:30
|
[
"5990",
"3051",
"2720",
"412",
"41401",
"4019"
] |
Admission Date: [**2187-11-7**] Discharge Date: [**2187-11-15**]
Date of Birth: [**2117-1-25**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Severe coronary artery disease.
HISTORY OF PRESENT ILLNESS: This is a 70-year-old man, who
was transferred from outside hospital. He has been
experiencing chest pain at rest with left arm pain while
eating breakfast. He has no shortness of breath. No nausea,
vomiting, no lightheadedness, no history of coronary artery
disease, no hypertension, and no shortness of breath, no
tobacco use. He is an active person, who participates in
both golf and tennis.
One day prior to admission, he had an exercise tolerance test
that was discontinued after three minutes because of EKG
changes.
PAST MEDICAL HISTORY:
1. Type 2 diabetes.
2. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. Appendectomy.
2. Bilateral knee arthroscopies.
ALLERGIES: He has no known drug allergies.
MEDICATIONS:
1. Glucophage.
2. Lipitor.
3. Viagra.
SOCIAL HISTORY: He lives in [**Location 47**] with his wife. [**Name (NI) **] is
currently retired and also has a summer house in [**Last Name (Titles) 54050**]. He has no tobacco use and he drinks 2-4
drinks per week.
REVIEW OF SYSTEMS: He has no history of any sort of strokes.
PHYSICAL EXAMINATION: He is afebrile. Vital signs stable.
He is in general, a well-developed and well-nourished man
lying in bed in no apparent distress. Head and neck: There
is no JVD, no lymphadenopathy, and no bruits. His oropharynx
is clear. Cardiovascular: Regular, rate, and rhythm, no
murmurs. Lungs are clear to auscultation bilaterally.
Abdomen is soft, nontender, nondistended. Extremities: No
cyanosis, clubbing, or edema. Saphenous vein has no
varicosities. His pulses are 3+ throughout the spine.
LABORATORY VALUES ON ADMISSION: Were within normal limits.
EKG: Was normal sinus rhythm, no ischemic changes.
An echocardiogram showed mild inferior hypokinesis and
ejection fraction of greater than 55%.
The catheterization performed on the day of admission showed
a 90% occlusion of the left main coronary artery and a 60%
occlusion of diagonal #1, 95% occlusion of diagonal #2. He
was also shown to be right dominant.
[**Last Name (STitle) 2708**]was admitted to [**Hospital1 69**]
in preparation for a CABG procedure. On [**11-8**], patient was
preoped for this procedure. An ultrasound of the carotid
arteries was unremarkable and chest x-ray and EKG were within
normal limits. He was consented, and made NPO after
midnight, and was taken to the operating room on [**2187-11-9**].
Please refer to the previously dictated operative note by Dr.
[**Last Name (Prefixes) **] of [**11-9**].
In brief, the left internal mammary artery was anastomosed to
the left anterior descending artery and two saphenous vein
grafts were connected to the diagonal and oblique arteries.
The patient tolerated the procedure well, and transferred
postoperatively to the Intensive Care Unit.
Over the next day, the patient was weaned off his various
drips including Neo-Synephrine, propofol, and insulin. On
postoperative day two, he was transferred to the floor in
good condition. He was tolerating a regular diet, and was
alert and oriented times three.
On the floor, his major issues were physical therapy, and by
the day of discharge, he was up walking about the floor and
ambulating up stairs. Activity level ............. His
diet, he is tolerating a full regular diet. He did have some
constipation, which resolved with some Colace and at the time
of discharge, he is having regular bowel movements, and
finally, there was some tweaking of his cardiac medications
increasing his Lopressor to maintain a regular heart rate.
Therefore, on [**2187-11-15**], postoperative day six, patient is
being discharged home in good condition.
DISCHARGE DIAGNOSES:
1. Hypercholesterolemia.
2. Diabetes mellitus type 2.
3. Coronary artery disease.
4. Unstable angina.
5. Status post coronary artery bypass graft.
6. Status post coronary angiography.
7. Constipation.
8. Tachycardia.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg once a day for seven days.
2. Potassium chloride 20 mg twice a day for seven days.
3. Aspirin 325 mg once a day.
4. Percocet 1-2 tablets p.o. q.4h. as needed for pain.
5. Lipitor 40 mg once a day.
6. Glucophage 500 mg p.o. twice a day.
7. Pioglitazone 30 mg p.o. once a day.
8. Metoprolol 100 mg p.o. twice a day.
9. Colace 100 mg p.o. twice a day.
10. Benadryl 25 mg as needed for help with sleep.
FO[**Last Name (STitle) **]P INSTRUCTIONS: He has a follow-up appointment with
his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8049**] in about 10 days, and he
has a follow-up appointment with Dr. [**Last Name (Prefixes) **] in four
weeks.
FRANK [**Last Name (Prefixes) 413**], M.D.
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2187-11-14**] 22:27
T: [**2187-11-15**] 06:07
JOB#: [**Job Number 54051**]
|
[
"41401",
"25000",
"2720"
] |
Admission Date: [**2161-10-20**] Discharge Date: [**2161-10-25**]
Date of Birth: [**2078-12-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue and lightheadedness
Major Surgical or Invasive Procedure:
[**2161-10-20**] Aortic Valve Replacement (21 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic-tissue)
History of Present Illness:
82 year old female with known aortic stenosis which has been
followed by serial echocardiograms over the past 10 years. Her
most recent echocardiogram revealed an increased mean systolic
gradient from 72 mm Hg to 93 mmHg with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.3cm2. Ms.
[**Known lastname 32245**] is fairly adament that she does not experience any
symptoms related to her disease however, when pressed, over the
last couple of months she reports mild intermittent
lightheadedness and increasing fatigue. At one point she did
experience some chest pain with walking however this is not a
frequent occurrence. Overall she is very active, climbing a
couple of flights of stairs with laundry and or groceries daily.
She denies any palpitations or syncope. Given the severity of
her disease, she now presents for surgical consultation.
Past Medical History:
Aortic Stenosis s/p Aortic valve replacement
Past medical history:
- Moderate MR
- Non sustained VT, NSVT, multifocal VEA on Holter [**2157-12-22**]
- Peripheral vascular disease
- Mild Carotid Artery Disease
- Anemia - [**2152**] found incidentally, GI workup was negative
except
for the "beginning of Barrett's Esophagus. Received 11 units of
PRBC. No recent bleeding or further work. She avoids Aspirin.
- History of hematochezia. W/U negative and this resolved. FeSO4
started.
- Irritable Bowel Syndrome
- Dyslipidemia
- Hypertension
- Vulvodynia
- Rheumatic fever at age 7
- Vertigo
Past Surgical History:
- s/p Tonsillectomy
- s/p Vocal Chord Nodule Excision (benign)
- Cataract surgery OD. Awaiting surgery for OS.
- D+C
- Cystoscopy
- H/O Varicose vein sclerosing therapy. (Posteriorly in thighs
Social History:
Race: Caucasian
Last Dental Exam: 3 weeks ago
Lives alone. Widow and lost her husband in [**2160-11-12**] with
dementia. She lives in [**Hospital1 3494**] MA. She has three supportive
children.
Contact: Phone #
Occupation: Retired
Cigarettes: Smoked no [X] yes [] Hx:
Other Tobacco use:
ETOH: < 1 drink/week [X] [**1-19**] drinks/week [] >8 drinks/week []
Illicit drug use: Never
Family History:
No premature coronary artery disease. Father with valvular heart
disease and RHD. Died at 62.
Physical Exam:
Pulse: 60 Resp: 16 O2 sat: 99%
B/P Right: 148/75 Left: 149/69
Height: 5"3" Weight: 150 lbs
General: WDWN in NAD. Appears younger then stated age.
Skin: Warm, Dry and intact. Faint inframammary
erythematous/scaly
rash c/w fungal infection.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, NlS1-S2, IV/VI harsh systolic ejection murmur.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema- trace left, none
on right
Varicosities: Multiple distal lspider varicosities. Dilated
veins
posteriorly and laterally. GSV appears suitable on standing.
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit Transmitted R>L
Pertinent Results:
[**2161-10-20**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. The
mitral valve leaflets are myxomatous. Mild to moderate ([**12-14**]+)
mitral regurgitation is seen. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results at time of
surgery.
POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Biventricular function is unchanged. There is a
well-seated bioprosthetic valve in the aortic position. There is
a mean gradient of 12 mmHg at a cardiac output of 3.2 L/min. No
aortic regurgitation is seen. No paravalvular leak is seen.
Mitral regurgitation is mild (1+). The aorta is intact
post-decannulation.
Brief Hospital Course:
The patient was brought to the operating room on [**10-18**] where the
patient underwent Aortic valve replacement 21-mm St. [**Hospital 923**]
Medical Biocor tissue valve.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. Pt went into afib post op. Amio
was started. pt in afib longer then 24 hrs. Coumadin was
iniated, Now on a amio taper with coumadin ofr new onset afib.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility.
By the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to rehab in good
condition with appropriate follow up instructions.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 0.5
(One half) Tablet(s) by mouth once a day
PREGABALIN [LYRICA] - (Prescribed by Other Provider) - 100 mg
Capsule - 1 (One) Capsule(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth once a day
Medications - OTC
FERROUS SULFATE - (OTC) - 325 mg (65 mg iron) Tablet - 1 (One)
Tablet(s) by mouth every other day
FOLIC ACID -
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. pregabalin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): TAPE 400 [**Hospital1 **] X 7 DAYS, THEN 200 [**Hospital1 **] X 7 DAYS, THEN 200
QD UNTILL F/U WITH PCP.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: INR
GOAL IS 2=3, FOR AFIB. PLEASE FOLLOW INR.
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 7 days: HOLD FOR K
OF GREATER THEN 4.5.
16. INSULIN
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 2 Units 2 Units 2 Units 0 Units
160-199 mg/dL 4 Units 4 Units 4 Units 2 Units
200-239 mg/dL 6 Units 6 Units 6 Units 4 Units
240-280 mg/dL 8 Units 8 Units 8 Units 6 Units
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic valve replacement
Past medical history:
- Moderate MR
- Non sustained VT, NSVT, multifocal VEA on Holter [**2157-12-22**]
- Peripheral vascular disease
- Mild Carotid Artery Disease
- Anemia - [**2152**] found incidentally, GI workup was negative
except
for the "beginning of Barrett's Esophagus. Received 11 units of
PRBC. No recent bleeding or further work. She avoids Aspirin.
- History of hematochezia. W/U negative and this resolved. FeSO4
started.
- Irritable Bowel Syndrome
- Dyslipidemia
- Hypertension
- Vulvodynia
- Rheumatic fever at age 7
- Vertigo
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2161-11-25**] at 1pm in the
[**Hospital **] Medical Office Building, [**Last Name (NamePattern1) **]., [**Hospital Unit Name **].
Cardiologist: Dr. [**Last Name (STitle) **] on [**2161-11-13**] at 1;30pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name (STitle) 15316**] [**Name (STitle) 12646**] ([**Telephone/Fax (1) 4615**]) in [**3-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2161-10-25**]
|
[
"9971",
"4019",
"42731"
] |
Admission Date: [**2114-8-1**] Discharge Date: [**2114-8-7**]
Date of Birth: [**2068-6-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1491**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD with banding
History of Present Illness:
46 yo F s/p liver transplant '[**05**] for acute Hep A who is
undergoing liver/kidney transplant eval at [**Hospital1 18**] had colonoscopy
and EGD on [**7-31**] which was notable for grade 3 varices which were
banded and an unremarkable colonoscopy. However, she developed
abd pain after the colonoscopy. She went home, noted severe abd
pain and presented to [**Hospital3 **] hospital. Presented with mildly
increased distension of abdomen - KUB and CT showed no free air,
but did show increased air in colon which could have resulted
from [**Last Name (un) **]. [**Hospital3 **] spoke with Dr. [**Last Name (STitle) 497**] who recommended
paracentesis, but they did not feel comfortable doing this.
Therefore, Dr. [**Last Name (STitle) 497**] requested she receive a dose of ceftriaxone
and be transferred to [**Hospital1 18**].
.
In the ED at [**Hospital1 18**], the patient had a diagnostic and therapeutic
paracentesis which drained 2.7L of amber liquid. Peritoneal
fluid was negative for SBP with 31 WBC, culture pending. She
also received phenergan, morphine, and 1000cc NS.
.
The patient was admitted to medicine for further evaluation of
abdominal pain. Upon arrival to the floor, the patient had 3
episodes of coffee ground emesis (approx 350cc total) with a 6
point drop in Hct. Liver fellow was contact[**Name (NI) **] who recommended IV
protonix, octreotide, and transfer to MICU for emergent EGD and
monitoring. In the MICU an EGD was performed which showed grade
III varices which were banded. Following this procedure and
multiple blood transfusion, her Hct has stabilized at 34. Given
persistent complaints of tense abdomen and pain, have made
multiple attempts to repeat paracentesis - hindered by dilated
loops of bowel. As her HCT remains stable she was transfered
back to medicine for further care.
Past Medical History:
-liver transplant '[**05**] for acute hep A (obtained after eating
chinese food) now complicated by cirrhosis documented by bx
[**10-26**].
-h/o variceal bleeding s/p banding
-osteopenia
-h/o scarlet fever
Social History:
no etoh, drugs, or tobacco. Lives with parents. From [**Location (un) 86**].
Family History:
noncontributory
Physical Exam:
PE: 98.7 151/80 116 18 94% RA
Gen: appears uncomfortable, lying still
HEENT: anicteric, MM slightly dry.
Neck: supple, no JVD
CV: tachy, possible +S4/split S1
Back: no CVA tenderness
Abd: +BS, tense, diffuse tenderness to palpation; previous
transplant scars; +caput; no obvious rebound, + ventral hernia
easily reducable.
Ext: no LE edema
Skin: +spider [**Last Name (LF) 61458**], [**First Name3 (LF) **] erythema
Neuro: somnolent but interactive. A&Ox3. MAEW. strenght [**4-26**]
throughout. sensation in tact to LT.
Pertinent Results:
[**2114-8-1**] 09:20PM HCT-33.1*
[**2114-8-1**] 08:43PM URINE HOURS-RANDOM UREA N-470 CREAT-89
SODIUM-<10
[**2114-8-1**] 08:43PM URINE OSMOLAL-349
[**2114-8-1**] 08:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2114-8-1**] 08:43PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-8-1**] 08:43PM URINE RBC-[**2-24**]* WBC-[**2-24**] BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2114-8-1**] 08:43PM URINE HYALINE-<1
[**2114-8-1**] 04:00PM GLUCOSE-153* UREA N-47* CREAT-2.3* SODIUM-135
POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-20* ANION GAP-19
[**2114-8-1**] 04:00PM CALCIUM-8.2* PHOSPHATE-6.1* MAGNESIUM-1.7
[**2114-8-1**] 04:00PM WBC-18.6* RBC-3.74* HGB-9.5* HCT-30.0*
MCV-80* MCH-25.5* MCHC-31.8 RDW-20.3*
[**2114-8-1**] 04:00PM PLT COUNT-113*
[**2114-8-1**] 04:00PM PT-13.8* PTT-27.5 INR(PT)-1.3
[**2114-8-1**] 01:04PM HCT-30.6*
[**2114-8-1**] 01:04PM PT-13.5* PTT-27.8 INR(PT)-1.2
[**2114-8-1**] 05:45AM ASCITES WBC-31* RBC-9800* POLYS-45* LYMPHS-5*
MONOS-0 MESOTHELI-10* MACROPHAG-40*
[**2114-8-1**] 03:40AM GLUCOSE-123* UREA N-37* CREAT-2.2* SODIUM-138
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17
[**2114-8-1**] 03:40AM ALT(SGPT)-34 AST(SGOT)-27 ALK PHOS-200* TOT
BILI-0.8
[**2114-8-1**] 03:40AM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-5.7*
MAGNESIUM-1.8
[**2114-8-1**] 03:40AM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-5.7*
MAGNESIUM-1.8
[**2114-8-1**] 03:40AM WBC-12.6*# RBC-4.48# HGB-11.0*# HCT-36.1#
MCV-81* MCH-24.6* MCHC-30.5* RDW-20.9*
[**2114-8-1**] 03:40AM NEUTS-88.2* LYMPHS-6.3* MONOS-4.0 EOS-1.3
BASOS-0.2
[**2114-8-1**] 03:40AM HYPOCHROM-3+ ANISOCYT-2+ MICROCYT-3+
[**2114-8-1**] 03:40AM PLT COUNT-150
[**2114-7-31**] 08:20AM CYCLSPRN-80*
Brief Hospital Course:
46 y/o female w/ h/o liver transplant for Hep A c/b cirrhosis,
and grade 3 esophageal varices, originally admitted with diffuse
abdominal pain after colonscopy, now with coffee ground emesis x
3 s/p EGD with banding of varices and persisting ascites.
.
1) UPPER GI BLEED: pt w/ coffee ground emesis on [**8-1**] had grade
3 varices on EGD [**8-1**], banded. She received a total of 3 U PRBC
during MICU course. She is now hemodynamically stable and her
HCT has remained stable since transfusions. Patient recieved
Octreotide for total of 5 days Patient continued on Protonix 40
mg po BID. Patient given sucralfate. Nadolol was held.
.
2) ABDOMINAL PAIN - There was concern for perforation given
recent colonoscopy; however, X-ray and Abd CT @ OSH did not show
evidence of free air, and repeat upright CXR @ [**Hospital1 18**] shows no
free air. Also considered was SBP from bacterial translocation
from colonoscopy. Pt received ceftriaxone at OSH, but pt only
had 31 WBC by paracentesis. Abdominal pain improved since
initial paracentesis in ED; now ascites redeveloped and pain has
returned. Ceftriaxone/Rifaximin was given immunosuppression and
elevated WBC. She recieved morphine prn for pain.
.
A second paracentesis was attempted; however only 10 cc of fluid
was removed. She was then taken to have U/S-guided paracentesis,
but found to have significantly dilated loops of bowel which
hindered further attempts. On repeat US guided paracentesis for
[**8-6**] for symptomatic relieve was successful. Her abdominal pain
resolved prior to discharge.
.
3) RENAL FAILURE - likely [**1-24**] to nephrotoxity from cyclosporin;
appears to have resolved as pt's creatinine at baseline of 2.2.
She was given 25 grams of Albumin after her paracentesis. Her
medications were renally dosed
.
4) CIRRHOSIS - Cirrhosis of transplanted liver is thought to be
[**1-24**] to prior noncompliance with immunosuppressive meds. Patient
being evaluated for a re-transplant by Dr. [**Last Name (STitle) 28609**] at [**Hospital1 18**]. pt
intially w/ varices and now w/ asterixis. possibly
enephalopathic due to increased urea load w/ GIB. Her
encephalopathy resolved. Decreased cyclosporin to 50 qd and
started sirolimus 4 mg qd on [**8-3**].
She continued Lactulose and rifamixin for encephalopathy ppx.
Diuretics were held given GIB and renal dysfunction. She
continued prednisone. Her cyclosporin and sirolimus levels were
checked.
.
5) DIARRHEA - likely related to Lactulose, resolved prior to
discharge
.
Medications on Admission:
1. levaquin 250 po qd
2. Lactulose prn
3.Lasix 40mg po qd
4. Aldactone 50mg po qd
5. Rifaximib
6. Iron sulfate
7. Protonix 40mg po qd
8. Neoral 100mg po qd
9. Morphine SR 60mg po prn
10. Prednisone 10 mg po qd
11. Calcium supplements
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO tid-qid:
Tritrate to 3 bowel movement a day.
Disp:*q/s ml * Refills:*2*
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sirolimus 2 mg Tablet Sig: One (1) Tablet PO once a day: Do
not take on [**8-8**] and [**8-9**]. Restart on [**8-10**] (Friday).
Disp:*30 Tablet(s)* Refills:*2*
4. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
7. Pantoprazole Sodium 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*
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
9. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
SBP, Upper GI bleed
Discharge Condition:
stable
Discharge Instructions:
Please call primary care provider or come to emergency room if
have increased abdominal pain, vomiting of blood,
lightheadedness or any other concerning symptoms.
** Do not take Rapamune for next 2 days ([**8-8**] and [**8-9**], then
restart om [**8-10**] Friday at 2mg daily.
Followup Instructions:
1.Dr. [**Last Name (STitle) 497**] on Monday, transplant coordinator will call
2.Transplant coordinatro will call with appointment
Completed by:[**2114-8-13**]
|
[
"5849"
] |
Admission Date: [**2114-3-21**] Discharge Date: [**2114-3-22**]
Date of Birth: [**2048-9-5**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
right subdural hematoma
Major Surgical or Invasive Procedure:
right craniotomy and evacuation of subdural hematoma
History of Present Illness:
65 yM fell on Saturday; presented to OSH today with severe
headache and projectile emesis, became unresponsive and
developed
decorticate posturing and fixed pupils, and a head CT revealed a
large R-sided subdural hematoma with midline shift. The patient
was intubated for airway protection, and he was transferred to
[**Hospital1 18**] for further care.
Past Medical History:
MS
[**First Name (Titles) **]
[**Last Name (Titles) **]
Hypothyroidism
Social History:
non-contrib
Family History:
non-contrib
Physical Exam:
O: T: BP:212/80 HR:80
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: fixed @ 5cm bilat
Neck: in c-collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated and sedated, unresponsive, with
decorticate posturing
Pertinent Results:
[**2114-3-21**] 02:25PM TYPE-ART PO2-231* PCO2-32* PH-7.46* TOTAL
CO2-23 BASE XS-0
[**2114-3-21**] 12:38PM PHENYTOIN-9.1*
CT HEAD W/O CONTRAST [**2114-3-21**] 12:12 AM
IMPRESSION: Large acute on chronic right subdural hematoma
causing marked mass effect and midline shift causing entrapment
of the left lateral ventricle. Subfalcine herniation with
effacement of the basal cisterns without frank uncal herniation.
CT HEAD W/O CONTRAST [**2114-3-21**] 3:33 AM
IMPRESSION:
1. Status post evacuation of large right subdural hematoma with
interval improvement in the degree of mass effect and midline
shift. Effacement of the basal cisterns is unchanged. There
remains subfalcine herniation. The left lateral ventricle
remains enlarge.
MR HEAD W & W/O CONTRAST [**2114-3-21**] 5:19 PM
IMPRESSION:
1. Status post evacuation of large right subdural hematoma with
interval improvement of leftward subfalcine herniation.
2. Diffusion-weighted imaging abnormality indicating acute
ischemic changes involving the medial temporal lobes
bilaterally, right greater than left, mid brain, and pons.
Hemorrhages associated with the abnormalities in the mid brain.
These likely represent manifestations of prior herniation injury
or possibly contusions from prior trauma.
3. Periventricular white matter T2/FLAIR hyperintensity which
likely represents transependymal edema from hydrocephalus. More
focal areas of signal abnormality within the periventricular
white matter may also represent manifestation of transependymal
edema or preexisting white matter disease.
Brief Hospital Course:
Pt arrived in the ED @ [**Hospital1 18**] intubated and unresponsive, with
fixed/dilated pupils and decorticate posturing. After a head CT
that showed a large right-sided subdural hematoma with 2cm
midline shift, he was taken emergently to the OR for a right
craniotomy and evacuation of hematoma. Post-operatively, his
left pupil decreased to 3mm (but still unreactive), and his R
eye remained fixed and dilated @ 5mm; he was transferred
post-operatively to the SICU.
There was no change in examination over the first 24 hours. An
MRI was ordered to determine what brain tissue had infarcted,
and DWI positive lesions consistent with infarct were seen in
the temporal lobes, midbrain and pons. A stroke consult was
called on [**2114-3-22**] and the stroke team evaluated the patient and
informed the family of the poor prognosis.
Based on their discussions with neurology and neurosurgery, the
family decided to make the patient comfort measures only. This
was done around 1900 [**2114-3-22**] and the patient expired at 2045.
Medications on Admission:
lisinopril, aspirin, atenolol, amantadine, synthroid
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"2449",
"4019",
"V4581"
] |
Admission Date: [**2106-2-5**] Discharge Date: [**2106-2-12**]
Date of Birth: [**2061-7-7**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Sent from NWH with left sided hemorrhage
Major Surgical or Invasive Procedure:
Cerebral Angio
History of Present Illness:
The pt is a 44 year-old right handed woman with no signifcant
PMH and family history significant for stroke (father, paternal
uncle and sister @ 46 years) who was transferred from [**Location (un) 745**]
[**Hospital 3678**] Hospital with a left sided intraparenchymal hemorrhage.
The patient was in her USOH when she developed speech
difficulties at work at 5pm on [**2106-2-4**]. She was having
difficulting speaking cohorently and was noted by co-workers to
be repeating the same sentence. She was saying something about
how cold she was and how hungry she was. She also noted a
headache. The co-workers called her husband and the patient was
brought by EMS to NWH. There blood pressure was 109/55 and pulse
was 70. GCS was 14 losing a point for confusion and the patient
was noted to move all extremities. A CBC and coagulation panel
were unremarkable, but a CT can revealed a 9X4X3cm left temporal
hemorrhage. The patient was transferred here for further
management.
The patient is unable to augment the history as she is aphasic.
Past Medical History:
Had an ulcer at age 10
Social History:
Works at the [**Last Name (un) **] Laboratories in [**Location (un) 2624**].
Married. Has a son.
[**Name (NI) **] ETOH, TOBACCO, or Drugs.
Family History:
Father died of multiple strokes at age 63.
Paternal Uncle died of stroke.
Patient sister died of stroke (not clear if ischemic or
hemorrhagic) in [**Country **] at age 46.
Physical Exam:
Vitals: T:96.7 P:72 R:14 BP:111/58 SaO2:99%RA
General: Awake, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: The patient has fluent aphasia. When asked how
she was doing she said, "My father cares for me....(and trailed
off)" . When asked where she was, she said, "I went to school
and i...(trailed off)" No response when asked her age. When
asked to name items off of the NIHSS picture sheet, she called
the chair "Ashes". She was able to follow commands variably. Sh
closed her
eyes, showed her right hand and kept all four limbs aloft to
command. She intiailly woudn't show her teeth and she never
showed her tongue. Unable to read, name, or repeat.
-Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and brisk.
VFF difficult to assess, but the patient doesn't appear to blink
to threat from any angle. There is mild left ptosis. Funduscopic
exam wsa limited by patient inattention (will not hold still).
EOMI unable to assess. No facial droop, facial musculature
symmetric. Patient can hear the examiner.
-Motor: All four extremities are antigravity. She has no drift
in any of her limbs. Formal muscle testing was not feasible.
-Sensory: Intact to pain. She winces.
-Coordination: Not testable.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Gait: Not testable.
Pertinent Results:
[**2106-2-5**] 12:00AM BLOOD WBC-9.9 RBC-4.48 Hgb-14.1 Hct-39.8 MCV-89
MCH-31.5 MCHC-35.5* RDW-12.2 Plt Ct-367
[**2106-2-5**] 03:48AM BLOOD ESR-5
[**2106-2-5**] 12:00AM BLOOD PT-13.2 PTT-33.4 INR(PT)-1.1
[**2106-2-5**] 12:00AM BLOOD Glucose-132* UreaN-8 Creat-0.5 Na-140
K-4.0 Cl-105 HCO3-22 AnGap-17
[**2106-2-5**] 12:00AM BLOOD ALT-55* AST-38 LD(LDH)-167 CK(CPK)-54
AlkPhos-67 Amylase-90 TotBili-0.8
[**2106-2-5**] 12:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2106-2-5**] 03:48AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2106-2-5**] 03:48AM BLOOD %HbA1c-5.2
[**2106-2-5**] 03:48AM BLOOD Triglyc-33 HDL-88 CHOL/HD-2.2 LDLcalc-95
[**2106-2-5**] 03:48AM BLOOD TSH-0.65
[**2106-2-5**] 03:48AM BLOOD HCG-<5
[**2106-2-5**] 03:48AM BLOOD CRP-0.6
[**2106-2-5**] 03:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT HEAD W/O CONTRAST [**2106-2-4**] 11:47 PM
FINDINGS: There is a large approximately 4 x 2.7 cm (on axial
view) focus of hyperdensity of the left temporal lobe consistent
with intraparenchymal hemorrhage. There is a surrounding rim of
hypodensity indicating vasogenic edema. No definite underlying
mass is seen. There is no definite underlying aneurysm on this
non-contrast study. The septum pellucidum appears to be shifted
approximately 2 mm to the right which may be positional or
possibly due to slight mass effect. The ventricular system is
symmetric and normal in size. The paranasal sinuses and mastoid
air cells are clear.
IMPRESSION: Large intraparenchymal hemorrhage of the left
temporal lobe with surrounding vasogenic edema. Septum
pellucidum shifted approximately 2 mm to the right may be
positional or indicate slight mass effect.
MRA BRAIN W/O CONTRAST [**2106-2-5**] 2:15 AM
As seen on CT, there is a large area of intraparenchymal
hemorrhage in the left temple lobe with a fluid-fluid hematocrit
level seen within it. FLAIR images demonstrate surrounding edema
without shift of normally midline structures or hydrocephalus.
There is central high signal on DWI and low signal on ADC
consistent with acute hemorrhage. The intracranial flow voids
are preserved without any evidence of high-flow arteriovenous
malformation. There is no abnormal contrast enhancement or mass.
Minimal ethmoid air cell mucosal thickening versus fluid is
noted anteriorly. The mastoid air cells remain clear. The orbits
appear unremarkable.
MRA OF THE BRAIN: The distal internal carotid and vertebral
arteries are normal in caliber, as are their intracranial
branches. There is no evidence of occlusion, flow limiting
stenosis, or aneurysm. Note is made of an infundibulum at the
takeoff of the right MCA inferior temporal branch. There is no
evidence on this MRA study of arteriovenous malformation, or
other vascular abnormality.
IMPRESSION:
1. Large left temporal intraparenchymal hemorrhage. No
underlying etiology identified. In the absence of other
explanation, a catheter angiogram may be of value to exclude
abnormalities such as small arteriovenous malformations, which
are below the resolution of MRA.
EEG:
This is an abnormal portable EEG in the waking and sleeping
states due to persistent mixed theta and delta frequency
slowing, moderate in amplitude, noted in the left
fronto-temporal region, at times with periodic admixed slow
blunted sharp waves with phase reversal at T3. The findings are
consistent with an underlying area of cortical and subcortical
dysfunction with the periodic blunted slow sharp waves raising
concern for a potential focus of epileptogenesis. However, no
runs of more frequent or sustained discharges were noted. No
electrographic seizures were noted.
Conventional Cerebral Angiogram:
Notable for left temporal lobe arteriovenous malformation.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the ICU for closer monitoring. She had
an MRI/MRA which did not show an underlying mass or AVM. She had
screening labs which were normal. She was therefore taken to the
angio suite and found to have a left temporal lobe AVM. She was
monitored initially in the ICU, and when felt to be stable
neurologically, she was watched clinically on the floor by the
neurology service. She continued to have a fluent aphasia, with
impaired comprehension for commands but some intact repetition
for single words and recognition of phrases (and appropriate
answers) for questions regarding headache. On [**2-10**] she
underwent embolization of the AVM with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in the
angio suite. Most of the feeding vessels were embolized
successfully, though a very small feeding vessel remains. She
will follow up with Dr. [**Last Name (STitle) 3929**] next week for consideration of
cyberknife. She will see Dr. [**First Name (STitle) **] in four weeks, she will need
a repeat MRI/MRA of the brain just prior to her visit with Dr.
[**First Name (STitle) **]. She was discharged on Keppra given left temporal sharp
waves. This should be tapered to off in the months following her
treatment. She should follow up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] at the
stroke neurology center in [**4-25**] weeks.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain. Tablet(s)
2. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
3. Outpatient Occupational Therapy
Please evaluate and treat
4. Outpatient Speech/Swallowing Therapy
Please evaluate speech and treat
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): For seizure prevention.
Disp:*120 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Intracerebral hemorrhage
Arteriovenous malformation of the left temporal lobe
Discharge Condition:
Stable. Fluent Aphasia.
Discharge Instructions:
You were admitted for sudden difficulty speaking (fluent
aphasia) that was related to a left temporal lobe hemorrhage.
The was caused by an arteriovascular malformation. You underwent
embolization of the vessels, but will need further treatment
with cyberknife to completely seal the vessels.
You are being treated for a urinary tract infection (two days
remaining). You are on a medicine to prevent seizures. This may
eventually be tapered off under the guidance of your physicians
in a few months following further treatment.
Call your doctor or 911 immediately if you experience worsening
headache, worsening difficulty speaking or comprehending speech,
weakness, numbness, tingling, chest pain, shortness of breath,
or any other concerning symptoms.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 3929**] next week for planning for
radiotherapy/cyberknife. Office number: ([**Telephone/Fax (1) 8082**].
Follow up with neurosurgery, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in four weeks, on
the [**Hospital1 18**] [**Hospital Ward Name **] [**Hospital **] Medical Office Building [**Location (un) **],
Thursday, [**3-11**] at 1pm. You will need to have a repeat
MRI/MRA just prior to this visit.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"5990"
] |
Admission Date: [**2200-4-23**] Discharge Date: [**2200-4-30**]
Date of Birth: [**2126-6-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Shortness of breath, fatigue.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 73 y/o M with CMML who was admitted on [**2200-4-2**] at
[**Location (un) 5871**] for splenic rupture where he underwent emergent
splenectomy on [**4-2**], course complicated by intra-abdominal staph
infection. There is no discharge summary available but per the
patient the procedure was without complications, no pressor
requirement per operative report. Culture of hematoma revealed
coagulase negative staphylococcus with multiple resistances but
sensitive to vancomycin. He was started on vancomycin for this.
Per pt he also had diarrhea related to c. diff infection and
flagyl was started. He was discharged from the OSH to complete a
course of vancomycin and flagyl. Since discharge the patient
reports that he has generally remained somewhat tired and
occasionally has felt some soreness in his ankles. This morning
he reports feeling much more tired and noticed that,
intermittently, he has felt some shortness of breath. No
associated chest pain or diaphoresis. The patient was taken by
hospital to the oncology clinic. There he was afebrile and
hemodynamically stable; however, his O2 saturation was noted to
be 90 on room air. He was subsequently admitted to the hospital.
Currently the patient reports he doesn't feel short of breath
except with exertion. He believes his diarrhea has resolved.
Past Medical History:
myelodysplastic syndrome
diverticulosis
AML 12 years ago(treated with chemo and recovered)
HTN
Social History:
Married, two children, does not smoke, having stopped some time
ago. Social alcohol. Perhaps two glasses of wine per day. Coffee
none. He is retired, having worked at D.E.C.
Family History:
Notable for coronary disease and diabetes mellitus.
Physical Exam:
VS: T 98.9 P 80 BP 112/80 RR 20 O2 95 on 2L
Gen: Elderly Caucasian gentleman in NAD.
Head: NCAT.
Eyes: PERRL, EOMI, anicteric,
Mouth: Small black spot on L lateral tongue, otherwise MMM, no
other lesions
CV: RR, nl S1S2, 3/6 systolic murmur at LLSB
Lungs: Slightly diminished at R base, otherwise fair air
movement with no adventitial sounds heard.
Abdomen: Purpuric bruising at abdomen LUQ and LLQ. Non-tender,
non-distended, normoactive BS,
Extrem: no c/c/e
Pertinent Results:
WBC 38 (was 23.1 on [**4-1**]), monocytic predominance
Hct 39.6
Plt 54
Cr 3.3 (baseline 2.1 to 2.4)
K 3
CK/CK MB nl. Trop 0.07
Microbiology
urinalyisis: negative for LE, nitrates. Few bacteria.
from OSH
LUQ hematoma: coag negative staphylococcus PCN resistant but
vancomycin sensitive.
Brief Hospital Course:
This is a 73 year old man with CMML with recent admission to OSH
for emergent splenectomy after splenic rupture who is admitted
for hypoxemia and worsening bilateral ground glass opacities.
He was treated aggressively on the floor with antibiotics and
other etiologies (PE, MI, etc) were appropriately addressed. He
was fluid resusitated and continued on his CMML regimen.
Despite this, the patient became progressively hypotensive and
was transfered to the ICU for further care.
In the ICU the patient continued to deteriorate and developed
progressive hypotension and acidosis despite aggressive fluid
repletion, pressor support, and bicarbonate drip. He received >
8L NS, 8amps bicarb, pressor support w/ levophed and
vasopressin, and maximum ventilatory support. Despite these
measures, his lactate continued to trend upwards and he became
progressively more hypotensive on the PEEP settings required to
adequately oxygenate him. Furthermore, the patient developed
tumor lysis syndrome in the setting of his chemotherapy and
became anuric producing only 40cc of urine over 8hr. Renal
service was called emergently to consider dialysis but the
family elected to change his code status to DNR/DNI and focus
care on comfort as a priority, after discussion w/ his
oncologist Dr [**First Name (STitle) 1557**] and to defer more aggressive therapy.
Medications on Admission:
MED Danazol 200 mg PO BID Start: 4 pm
MED Folic Acid 1 mg PO DAILY
MED Pantoprazole 40 mg PO Q24H
MED Atenolol 25 mg PO DAILY Start: In am
Please hold for SBP less than 100, HR less than 55.
MED Prednisone 12.5 mg PO DAILY Start: In am
MED Metronidazole 500 mg PO TID
MED Hydroxyurea 1500 mg PO DAILY
MED Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
CMML, splenic rupture, hypotension
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2200-9-23**]
|
[
"5849",
"40391",
"4280",
"4019"
] |
Admission Date: [**2155-4-27**] Discharge Date: [**2155-5-2**]
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female, who presented with one-day history of severe
bilateral upper quadrant pain and epigastric pain with
radiation to the back and right shoulder. The patient
reports that she had an acute onset of pain with no known
precipitant. She was unable to tolerate PO the day before
presentation and reported nausea and vomiting times 3, the
day before. She was taken to an outside hospital and
reported significant pain during her travel with any sudden
movements. Her pain was controlled when lying still. She
received no relief with Maalox and Tums, but did improve when
admitted secondary to morphine at the outside hospital. She
denied pain with deep inspiration or pleuritic pain. No
dysuria or diarrhea. No melena, hematemesis, fever, chills,
or shortness of breath. No chest pain. No history of
gallstones or gallbladder disease. No history of
pancreatitis, dark urine, or weight loss.
PAST MEDICAL HISTORY: Significant for hypertension, coronary
artery disease, diabetes, and elevated cholesterol. She is
status post CABG.
MEDICATIONS: Medications on admission were:
1. Atenolol.
2. Glyburide.
3. Aspirin.
4. Lipitor.
5. Klonopin.
6. Meclozine.
7. Zetia.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives alone and no tobacco or
history of alcohol use.
PHYSICAL EXAMINATION: Vital Signs: Temperature 98.2, pulse
67, blood pressure 110/54, and saturations 95 percent on room
air. The patient was lying very still on bed, but was alert
and oriented. Cardiac exam: Regular rate and rhythm. No
murmurs, rubs, or gallops. Respiratory exam: Bibasilar
crackles. No pain or discomfort with deep inspiration.
Negative [**Doctor Last Name 515**] sign. Abdominal exam: She had positive
bowel sounds. No tenderness to percussion. Abdomen was soft
with mild epigastric tenderness. No rebound. No guarding.
She reported that her exam was different from when she
presented to outside hospital where she was much more
uncomfortable. Her rectal exam was negative for blood and
guaiac negative. Extremities: Warm and well perfused. No
peripheral edema.
LABORATORY DATA: At the outside hospital included, sodium of
145, potassium 3.8, chloride 106, bicarbonates 28, BUN 23,
creatinine 1.1, and glucose 139. Her white count was 20.7,
hematocrit 42.9, and platelets 291. Her magnesium was 1.8.
Albumin 3.5, alkaline phosphatase 205, ALT 134, AST 313,
lipase 22,460, and total bilirubin was 1.4. CT scan at the
outside hospital showed distention with edematous gallbladder
and common bile duct dilatation. No pseudocyst.
HOSPITAL COURSE: It was decided that the patient would be
admitted as her presentation was consistent with acute
cholecystitis and possible gallstone pancreatitis. She had
received levofloxacin and Flagyl at an outside hospital for
presumptive cholecystitis. She was admitted and aggressively
resuscitated with fluid. Ampicillin was given in the
emergency department. An ultrasound was obtained. She was
made nothing by mouth and ordered for IVP medication as
needed. She was monitored closely. She was initially
admitted to the Intensive Care Unit. The patient was started
on Lactated Ringers 200 cc per hour. Her ultrasound revealed
cholelithiasis with evidence of cholecystitis. Common bile
duct dilatation was present. It was thought that the patient
should receive an MRCP when she stabilized.
On hospital day number 1, her labs were checked, which
revealed an ALT of 214, AST of 494, amylase 1705, and lipase
of 4435, alkaline phosphatase is 178 and total bilirubin 2.1.
On hospital day number 2, her white count was down to 9.7,
her ALT was 113, AST 126, alkaline phosphatase 130, lipase
428, amylase 407, and total bilirubin 0.6. She was doing
well clinically on hospital day number 2 with her pain well
controlled. Her white blood count had normalized. She
continued to be monitored carefully. On hospital day number
2, she was transferred to the floor. On hospital day number
3, the patient reported some increase in pain that was
consistent with her presentation on admission. She continued
to be given IVP medication as needed, it consisted of a
hydromorphone 0.2-1 mg IV q.3-4h. p.r.n. Physical therapy
was ordered for her. Urine output remained good at this
time. A CT with IV contrast was obtained on hospital day
number 3. She was started on clears and was then advanced to
a low-fat diet on hospital day number 5. The CT scan, which
had been obtained showed significant improvement. Hence the
patient was improving clinically, it was decided on hospital
day number 6 that she would be ready for discharge.
On the day of discharge, her white count was 8.5. Her vital
signs were stable. She was afebrile. She was ambulating
regularly and tolerating a low-fat diet. Her amylase was
stable and it was decided that she would return to clinic
with Dr. [**Last Name (STitle) **] to schedule an appointment for surgery in
the future.
DISCHARGE DIAGNOSIS: Gallstones pancreatitis.
DISCHARGE INSTRUCTIONS: She was instructed to call the
clinic or come to the Emergency Department if she experienced
increased abdominal pain, nausea, vomiting, inability to take
p.o., fevers, chills, chest pain, or shortness of breath.
She was instructed to maintain a low-fat diet and to call Dr.[**Name (NI) 41561**] clinic to schedule a followup appointment and to
schedule a date for cholecystectomy.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Vicodin 5-500 mg 1 to 2 tablets p.o. q. 4-6h. She was
given 40.
2. Sucralfate 1 g 1 tablet p.o. q.i.d. She was given 120
tablets.
3. Pantoprazole 40 mg tablet delayed release one tablet p.o.
q. 24h. She was given 30 and she was instructed to
restart her home medications.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**]
Dictated By:[**Last Name (NamePattern1) 15009**]
MEDQUIST36
D: [**2155-6-21**] 17:36:14
T: [**2155-6-21**] 23:18:51
Job#: [**Job Number 41562**]
|
[
"25000",
"4019",
"V4581"
] |
Admission Date: [**2118-7-28**] Discharge Date: [**2118-8-11**]
Date of Birth: [**2040-2-5**] Sex: M
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Mr. [**Known lastname 78131**] is a 78M with stageIV NSCLC on palliative Tarceva
who presents from his nursing facility with fevers x2d as high
as 103.6F. Per paperwork from rehab, he was given levofloxacin
500mg.
.
Of note, he was recently admitted to the OMED service, having
presented with fevers and discharged on [**7-14**] on cefpodoxime and
azithromycin for suspected pneumonia.
.
In the ED, initial vs were T98 P 73 BP 86/51 RR 22 98% on . He
was given vancomycin, cefepime, flagyl, acetaminophen, zofran,
and started on peripheral dopamine. Awake and mentating, making
small amounts of dark urine. CT abdomen done for h/o 1day of
diarrhea, noncontrast showed ?of colitis. Got 5L of saline. BP
remains 70's systolic on 15mcg dopamine and levophed.
.
On the floor, he denies any complaints - though initially
reported some abdominal pain to the RN. Review of systems
otherwise negative, though unclear if patient's history is
reliable.
Past Medical History:
Past Medical History:
1. Hypertension
2. Atrial Fibrillation
3. COPD
4. h/o bilateral hernia repair
5. aspiration
.
Oncologic History: (Per OMR note [**2118-6-15**] by Dr. [**Last Name (STitle) **]
1. Stage IIB nonsmall cell lung cancer (adenocarcinoma) s/p
surgical resection and adjuvant chemotherapy.
2. FDG avid left lower [**Last Name (STitle) 3630**] lung nodule with non-malignant
biopsy in [**2117-2-13**].
3. Stage IV nonsmall cell lung cancer (bone and lung
recurrence)diagnosed in [**2118-4-15**].
TREATMENT:
1. Status post right thoracotomy with right lower lobectomy,
mediastinal lymph node sampling in [**2117-4-13**].
2. Status post 4 cycles of carboplatin 5AUC and pemetrexed
500mg/m2 every 21 days of a 3 week cycle today. Started in
[**2117-6-29**] and last dose was given [**2117-8-31**].
3. Status post 3000 cGy of radiotherapy to left hip lesion
completed in [**2118-5-10**].
4. Started erlotinib 150 mg/day in [**2118-5-24**].
5. h/o mets to sacral spine s/p radiation, on narcotics for pain
control
Social History:
70+ year h/o smoking. Currently at rehab facility.
Family History:
Unknown cause of death of mother or father. The patient does
have siblings that are alive. No recurrent cancers in the
family.
Physical Exam:
On [**Hospital Unit Name 153**] admission:
Vitals 96.3 102 101/58 21 100% on 4L
General Chronically ill appearing man, appears anxious
HEENT Sclera anicteric, dry MMM
Neck supple
Pulm Lungs with few bibasilar rales L>R
CV Tachycardiac regular S1 S1 no m/r/g
Abd Soft +bowel sounds tender to palpation throughout without
rigidity or guarding
Extrem Warm tr bilateral edema palpable distal pulses
Neuro Awake and interactive, oriented to hospital in [**Location (un) 86**],
does not know date
Derm No rash or jaundice
Lines/tubes/drains Foley with yellow urine, RIJ
Pertinent Results:
On admission [**2118-7-28**]:
WBC-10.9 RBC-3.71* Hgb-10.3* Hct-32.1* MCV-87 MCH-27.8 MCHC-32.2
RDW-17.1* Plt Ct-410
Neuts-55 Bands-27* Lymphs-6* Monos-10 Eos-0 Baso-0 Atyps-0
Metas-2* Myelos-0
PT-17.9* PTT-33.4 INR(PT)-1.6*
Glucose-143* UreaN-35* Creat-1.6* Na-130* K-4.1 Cl-94* HCO3-26
AnGap-14
ALT-17 AST-34 AlkPhos-60 TotBili-0.7
Albumin-2.6* Calcium-7.6* Phos-3.7 Mg-2.0
[**7-29**] FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA
[**7-28**] EKG: Probable sinus rhythm with low amplitude P waves
(visible in lead V1) versus ectopic atrial rhythm. Right
bundle-branch block. Left anterior fascicular block. Q-T
interval prolongation. Compared to the previous tracing of
[**2118-7-7**] P waves are less apparent. Q-T interval is more
prolonged.
[**7-28**] CXR: 1. Stable post-surgical changes in the right lung from
prior right lower lobectomy and upper [**Month/Year (2) 3630**] wedge resection due
to known non-small cell lung cancer.
2. Hazy opacity in the left lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] reflect atelectasis.
[**7-28**] CT Abd/pelvis:
1. Bibasilar lung consolidations, worse when compared to prior
exam.
Differential diagnosis includes infectious etiologies as well as
a slow
growing lesion such as bronchoalveolar carcinoma. Clinical
correlation is
recommended.
2. No evidence of small bowel obstruction. Colon appears
relatively
featureless with air-fluid levels and possibly pericolonic fat
stranding
versus third spacing. These findings may suggest a colitis.
3. Extensive vascular calcifications.
4. Large prostate.
5. S1 vertebral body fracture with buckling of the superior
cortex, worse
when compared to prior exam.
[**7-30**] Left LENI:
IMPRESSION: No left lower extremity DVT.
[**7-31**] KUB:
FINDINGS:
Small bowel loops containing air are seen without distension.
There is a
paucity of air in the left lower quadrant which might be due to
liquid stool within the descending colon. No free air is seen on
the right lateral decubitus film. The visualized osseous
structures are unremarkable. The right lung base is not well
seen with the dome of the diaghragm being pushed superiorly.
This correlates with the right lower [**Month/Year (2) 3630**] atelactasis on the
corresponding CT.
IMPRESSION: No distended loops of bowel seen.
Brief Hospital Course:
Mr. [**Known lastname 78131**] is a 78M with stage IV NSLC who presents with
fevers from his rehab facility.
.
* Hypotension: Patient presented with hypotension concerning for
sepsis. He was briefly on levophed and was taken off of
pressors when SBP 100s-110s. His hypotension was probably due
to hypovolemia from diuresis but severe hypotension in setting
of developing sepsis was also considered. Lactate down to 1.0
from 1.3 on admission with SVO2 73.
On the floors, his SBP's ranged in the 130's to 140's and he was
restarted on his home doses of LASIX WAS HELD FOR THE SEVERAL
DAYS PRIOR TO DISCHARGE BECAUSE HE WAS AUTODIURESING. HE NEEDS
TO BE RE-EVALUATED REGULARLY FOR WHETHER LASIX NEEDS TO BE
RESTARTED. HE WILL LIKELY NEED HIS LASIX RESTARTED AT SOME POINT
AT REHAB. His pressures remained stable throughout
hospitalization.
.
* Fever: Patient's fever likely caused by C diff as patient is
toxin positive, although aspiration pneumonia was also
considered a possibility given evidence of dysphagia on prior
video swallow. His underlying pulmonary malignancy predisposes
him to a post-obstructive pneumonia. However the absence of
cough or hypoxia made a pulmonary etiology less compelling.
Blood and urine cultures are negative. His C difficile colitis
was originally treated with PO vancomycin and IV flagyl. Prior
to discharge, as diarrhea began to resolve, he was switched to
PO flagyl alone, to be continued for a two week course (until
[**2118-8-12**]).
.
* L leg swelling and pain: Patient had lower extremity pain
edema greater on left than right after receiving fluid
resuscitation in the ICU. LENI showed no evidence of DVT. He
was diuresed with lasix until his fluid output was negative. He
was autodiuresing on discharge so his lasix was held. His fluid
status should be reassessed daily to determine if he needs to be
restarted on lasix.
* Hyponatremia: Patient's hyponatremia resolved after
intravenous fluids, which supports hypovolemia as cause on
admission. Review of OMR shows Na's running ~130. At last
discharge, thought to have a component of SIADH.
* Acute renal failure: Patient had creatinine elevated to 1.4
and FeNa was 0.1 on admission. Creatinine has improved to
0.7-0.8 (his baseline). His acute renal failure has resolved and
was likely pre-renal as it improved with IVF.
* Anemia: His hematocrit is down from admission but suspect
this was secondary to hemoconcentration. His anemia is
consistent with baseline.
* NSCLC: Advanced disease, on palliative chemotherapy. Social
work and palliative care were consulted throughout this
hospitalization and discussed goals of care with the family.
Erlotinib will be restarted on [**2118-8-19**] and should be taked every
other day. He will follow up with Dr. [**Last Name (STitle) **].
* Atrial fibrillation: His sotalol was restarted now that his
hypotension resolved.
# Nutrition ?????? Patient has aspiration risks and is unable to
swallow pills easily. He was evaluated by nutrition and kept on
a pureed diet with TID ensure. He also had an elevated INR
despite not being on anticoagulation which possibly could be due
to malnutrition. INR improved after administration of one dose
of vitamin K.
# Oral thrush: Patient failed nystatin swish and swallow. He was
loaded with 400mg fluconazole and should continue 200mg daily
until [**2118-8-25**].
#Pain control: Patient was maintained on methadone and diluadid
PRN during hospitalization. His methadone should be tapered and
pain reassessed daily while in rehab.
Medications on Admission:
At rehab:
Erlotinib 100mg daily
Simvastatin 10mg daily
Lasix 20mg daily
Sotalol 80mg [**Hospital1 **]
Nifedipine 30mg daily
Methadone 15mg tid
Folate
Lidoderm patch
[**Name (NI) **], [**Name (NI) 78132**], MOM, dulcolax, lactulose, senna, guiafenesin,
colace, tylenol all prn
Zofran prn
Neurontin 300mg q12h
Heparin 5000 units SQ TID
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: One (1)
injection Injection TID (3 times a day).
2. Metronidazole 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q8H (every
8 hours): continue util [**2118-8-12**].
3. Neurontin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO every twelve
(12) hours.
4. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2
times a day) as needed for constipation: once diarrhea subsides,
please start taking as standing dose [**Hospital1 **].
5. Methadone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
6. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: no more than 4g in 24 hours.
8. Sotalol 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off.
10. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
11. Nifedipine 30 mg Tablet Sustained Release [**Hospital1 **]: One (1)
Tablet Sustained Release PO DAILY (Daily).
12. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
13. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO
DAILY (Daily).
14. Oral Wound Care Products Gel in Packet [**Hospital1 **]: One (1) ML
Mucous membrane TID (3 times a day) as needed.
15. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for fungal rash-groin.
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
18. Dilaudid 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every four (4)
hours as needed for pain.
19. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO twice a day as
needed for constipation: Please start taking after diarrhea has
resolved.
20. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
[**Last Name (STitle) **]: One (1) dose PO once a day as needed for constipation:
Please use as needed after diarrhea has resolved.
21. Dulcolax 10 mg Suppository [**Last Name (STitle) **]: One (1) Rectal once a day
as needed for constipation: Please start using as needed after
diarrhea has resolved.
22. Zofran 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every eight (8)
hours as needed for nausea.
23. Ambien 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia.
24. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every
24 hours): continue until [**2118-8-25**].
25. Erlotinib 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QOD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 4444**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Clostridium difficil colitis
2. Dehydration
3. Hyponatremia
4. Hypotension
SECONDARY DIAGNOSIS:
1. Non Small Cell Lung Cancer
Discharge Condition:
Stable, afebrile [**2-16**] BM's per day.
Discharge Instructions:
You were admitted to the hospital on [**2118-7-28**] with fevers
secondary to clostridium dificile colitis (an infection in your
colon). You are being treated with an antibiotic called flagyl.
You need to continue this antibiotics until [**2118-8-12**].
You should STOP taking lasix (water pill). Your body has been
eliminating excess fluid well without the lasix. Your doctors
[**Name5 (PTitle) **] [**Name5 (PTitle) 4656**] your fluid status at rehab and decide whether or
not you need lasix in future.
You can continue to take methadone with dilaudid as needed for
breakthrough pain. Your doctors at rehab [**Name5 (PTitle) **] taper your
methadone as needed. Never drive while taking these medications
or perform any activities requiring a fast reaction time. Never
drink alcohol with these medications. Once your diarrhea stops,
you should start taking colace and senna daily to prevent
constipation, which is a common side effect of narcotics.
You also had thrush in your mouth. Continue to take fluconazole
200mg daily until [**2118-8-25**].
You should restart your erlotinib on [**2118-8-19**] and take it every
other day.
Use miconazole for the fungal rash in your groin. Apply it four
times a day.
Please return to the emergency room if you have worsening
diarrhea >10 BM per day, bloody/black stools, fever>100.4, chest
pain, shortness of breath, or any other symptoms concerning to
you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**12-17**] weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
Completed by:[**2118-8-11**]
|
[
"0389",
"78552",
"5849",
"2761",
"99592",
"2859",
"496",
"4019",
"42731"
] |
Admission Date: [**2111-6-12**] Discharge Date: [**2111-6-16**]
Date of Birth: [**2052-2-23**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
cc:[**CC Contact Info 45809**].
History was obtained from ED report and from medical record
.
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5700**] in [**Location (un) 583**], MA.
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Ms. [**Name14 (STitle) **] is a 59 yo female with a h/o HTN,
hypercholesterolemia, who presents after witnessed 45 second GTC
seizure. She has no known history of seizure activity. Per
history obtained by Neurology resident prior to intubation,
patient was visiting her mother here in the hospital and seized
while exiting the hospital. She reported feeling well earlier in
the day but that after visiting her mother, on the way out of
the [**Hospital Ward Name 517**] building, she felt nauseous, lightheaded and
vertiginous. She experienced visual changes and could only see
blue and red. She told someone who was outside that she didn't
feel well and that was the last thing she remembers. Per report,
patient sat down and then had witnessed generalized tonic clonic
seizure x45 seconds, with tongue biting but no urine or bowel
incontinence. She was then transported to ED.
.
On arrival to ED at 3 p.m., T 98.8, HR 105, BP 133/83, RR 24,
SpO2 99% on RA. She was reported to be alert and seated on the
bench without evidence of injury. She had a head CT which was
negative for intracranial process. Neuro was consulted and
recommended admission to medicine for toxic-metabolic and
infectious work-up. She subsequently had two witnessed
generalized tonic/clonic seizures in the ED, each lasting 20-30
seconds. Her mental status did not resolve following these
seizures, and nonsensical speech and agitation requiring
restraints were reported. She received a banana bag, Mag sulfate
2 grams IV, Keppra 500 mg IV, and Ativan 2 mg IV x 5, and Valium
10 mg IV. Patient was noted to be warm to touch and repeat temp
was 104 (rectal). Given extreme agitation, she was electively
intubated at that time for LP. She received vancomycin 1 gram
and ceftriaxone 2 grams IV. She received a total of 2 L IVF in
the ED.
Past Medical History:
1. Uterine fibroid of 3.1 cm to 3.5 cm found in [**Month (only) 1096**] of
[**2104**].
2. Rosacea in [**2105**]
3. ? h/o ETOH abuse and withdrawal; admitted in '[**06**] at [**Hospital1 18**]
with suspicion of EtOH withdrawal
4. HTN
5. Hypercholesterolemia
6. ? s/p CCY
Social History:
Husband died in [**Month (only) 404**]. Father w/prostate illness and mother
is currently hospitalized here at [**Hospital1 18**]. Understands and speaks
English but primary language is Romanian. Per Neurology note
"Denies current etoh use, last drank on her b-day this past
[**Month (only) 956**]." No tobacco or drug use.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
VS: T 101.2, HR 82, BP 100/60, SpO 97% on FiO2 100%
Gen: intubated, agitated
HEENT: PERRL 3->2 mm bilaterally, MMM, evidence of tongue
laceration
CV: regular rhythm, normal s1 and s2, no m/r/g
Resp: lung fields CTA
Abdomen: no scars, soft, non-distended, non-tender, no
hepatosplenomegaly, no palpable masses
Extrem: no edema, clubbing, or cyanosis
Neuro: non-purposeful movements in all 4 extremities, toes
upgoing bilaterally
Rectal: rectal vault empty, guiac-negative
Pertinent Results:
[**2111-6-12**] 11:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-23
GLUCOSE-94
[**2111-6-12**] 11:00PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-26*
POLYS-0 LYMPHS-0 MONOS-0
[**2111-6-12**] 11:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-31*
POLYS-0 LYMPHS-0 MONOS-100
[**2111-6-12**] 08:50PM URINE HOURS-RANDOM
[**2111-6-12**] 08:50PM URINE HOURS-RANDOM
[**2111-6-12**] 08:50PM URINE UHOLD-HOLD
[**2111-6-12**] 08:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2111-6-12**] 08:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2111-6-12**] 08:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2111-6-12**] 08:50PM URINE RBC-0-2 WBC-[**3-25**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2111-6-12**] 08:50PM URINE GRANULAR-0-2 HYALINE-[**6-30**]*
[**2111-6-12**] 08:50PM URINE MUCOUS-FEW
[**2111-6-12**] 05:04PM LACTATE-2.1*
[**2111-6-12**] 04:52PM GLUCOSE-140* UREA N-25* CREAT-2.2* SODIUM-136
POTASSIUM-2.8* CHLORIDE-98 TOTAL CO2-26 ANION GAP-15
[**2111-6-12**] 04:52PM LD(LDH)-175 DIR BILI-0.6*
[**2111-6-12**] 03:19PM GLUCOSE-161* LACTATE-9.3* NA+-138 K+-2.9*
CL--97* TCO2-18*
[**2111-6-12**] 03:10PM UREA N-27* CREAT-2.9*
[**2111-6-12**] 03:10PM estGFR-Using this
[**2111-6-12**] 03:10PM ALT(SGPT)-91* AST(SGOT)-112* ALK PHOS-150*
AMYLASE-85 TOT BILI-1.7*
[**2111-6-12**] 03:10PM ALBUMIN-4.5 CALCIUM-9.3 PHOSPHATE-5.3*
MAGNESIUM-1.6
[**2111-6-12**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2111-6-12**] 03:10PM WBC-12.8* RBC-4.46 HGB-15.2 HCT-43.7 MCV-98
MCH-34.1* MCHC-34.8 RDW-13.5
[**2111-6-12**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2111-6-12**] 03:10PM PT-12.9 PTT-27.4 INR(PT)-1.1
[**2111-6-12**] 03:10PM PLT COUNT-217
[**2111-6-12**] 03:10PM FIBRINOGE-260
.
CXR [**2111-6-12**]: ET tube tip is 2.9 cm top of the carina. Cardiac
size is top normal. NG tube tip is in the stomach. There is mild
fluid overload. The left lateral CP angle was not included on
the field. There are no ____ pleural effusions. Small
atelectasis in the left lower lobe in the retrocardiac area is
new. There is no pneumothorax.
.
RUQ u/s [**6-12**]: IMPRESSION:
1. Diffusely echogenic liver, consistent with fatty
infiltration. Other forms of liver disease, including
significant hepatic fibrosis or cirrhosis cannot be excluded.
2. No evidence of intra- or extra-hepatic biliary duct
dilatation.
Findings entered into the ED dashboard at the time of
interpretation.
.
[**6-12**] CT head: IMPRESSION:
1. No acute intracranial process.
2. Likely small arachnoid cyst in the left temporal region.
Brief Hospital Course:
Assessment: Ms. [**Known lastname 45810**] is a 59 yo female s/p CCY who presents
with seizure activity, fever, and ARF
.
1) Seizure activity: The initial concern given the constellation
of thrombocytopenia, ARF, neurologic event, and fever was for
TTP/HUS. Platelets were reduced by 50% on repeat CBC and
hematocrit dropped by 10 points; however, there was no evidence
of schistocytes on peripheral smear. Neurologic exam reported as
normal by neurology consult, and non-contrast head CT negative
for bleed or obvious seizure focus. Differential included EtOH
withdrawl, infection, vs. other toxic-metabolic process.
Admission labs were also notable for multiple electrolyte
derangements, including ARF, hypokalemia, hypomagnesemia.
Patient was normoglycemic throughout hospital course. Urine and
serum tox screens were negative. Prior discharge summary invoked
possible h/o alcohol abuse, and serum ethanol level were
negative at time of admission, supporting possible delirium
tremens, although patient denied EtOH use on both occasions
consistently. Benzo withdrawl was also considered as patient
reports taking Lorazapam but urine tox negative. CSF was
unremarkable with negative gram stain. Upon arrival to the ED,
the neurology team was consulted and recommended that the
patient be loaded with IV Keppra. She had two further episodes
of generalized tonic clonic activity in the ED and was
subsequently confused. She was treated in the ICU for close
monitoring. She was electively intubated at that time and lumbar
puncture performed. CSF gram stain and preliminary culture was
negative so the vancomycin and ceftriaxone were not continued.
CSF cytology and HSV PCR were sent and the patient continued on
IV acyclovir for empiric treatment of HSV encephalitis. She was
placed on a CIWA scale for possible EtOH withdrawal, but had
very low scores. She was also started on MVI, folic acid, and
thiamine. While in the ICU, the patient self-extubated and did
well off of the ventilator. She was called out to the medicine
floor. She displayed no seizure activity while there and
remained afebrile. MRI and EEG were both were unremarkable. LFTs
remained abnormal as well as thyroid function tests which are
both further areas of exploration for inciting event for new
seizures.
.
2) Acute Renal Failure: Upon admission, her creatinine was 2.9,
with no known h/o renal insufficiency. She was treated with IVFs
as this was felt to be due to possible rhabdomyolysis, and
creatinine now improved to 0.9.
.
3) Transaminitis: Upon admission, she had elevated LFTs, with
AST>ALT, suggestive of alcohol use. RUQ ultrasound notable only
for echogenic fatty liver. Patient does have a discharge summary
from [**Hospital1 18**] from [**2106**] which describes a suspicion of alcohol
withdrawl, although patient persistently denied. INR of 1.1
supports that synthetic hepatic function is preserved. Viral
hepatitis serologies were checked but were pending at time of
discharge. Also, ferritin was found to be persistently elevated
at >[**2103**], so hemochromatosis should also be excluded as an
outpatient. Her transaminases normalized prior to discharge.
.
4) Anemia: Hematocrit dropped 10 points at admission, then
stablized. Iron studies showed as above a very high ferritin and
also low B12. She was started on po B12 supplementation, but
will require close monitoring to determine if replacement is
adequate. Anti-intrinsic factor antibodies as well as H. pylori
serologies were sent; H. pylori antibody was equivocal and
anti-IF antibodies were pending at discharge.
.
5) FEN/GI: the patient had multiple electrolyte abnormalities at
admission. She required recurrent repletement of potassium,
which was maintained at >4, and magnesium, which was maintained
at >2, given her seizures.
.
6) Code status: Full code, confirmed with patient
Medications on Admission:
Lorazepam
Folic acid
Lipitor
Med for her bones
Liver med
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Cyanocobalamin 2,000 mcg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
7. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Mobic 15 mg Tablet Sig: One (1) Tablet PO once a day.
9. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
12. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO every four
(4) hours for 5 days: take while awake. to complete course on
[**6-21**]. thank you.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Generalized tonic clonic seizure
2) Hypertension
3) Abnormal thyroid tests
4) hypercholesterolemia
5) Transaminitis
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital after having several seizures.
You were initially treated in the intensive care unit for closer
monitoring. You were started on a new medication called Keppra
to prevent recurrence of seizures. You were also started on a
medication called acyclovir for the possibility of HSV
infection. An MRI of your brain was normal. It is very important
that you see your primary care provider and that you see a
neurologist after discharge for continued workup to determine
the cause of your seizures. In particular, you will need to have
further workup of your liver and thyroid function.
.
It is very important that you do NOT drive after discharge from
the hospital until you see your neurologist. Also, do not work
at heights, with open fires, take a bath while home alone, or
swimming in
unguarded pools. You should call to make an appointment with Dr.
[**First Name4 (NamePattern1) 2431**] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] in the neurology deparement at
[**Hospital1 18**].
.
If you experience additional seizure activity - uncontrolled
muscle movement, visual changes, lightheadedness, dizziness,
falls, loss of consciousness, or if you feel worse in any way
seek [**Hospital 5121**] medical attention or call 911.
Followup Instructions:
Call Dr. [**First Name4 (NamePattern1) 2431**] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] in the neurology
department to make an appointment at [**Telephone/Fax (1) 541**] within the
next 2 weeks.
.
Also, call Dr. [**First Name (STitle) 5700**], your PCP, [**Name10 (NameIs) **] discharge to make an
appointment as soon as possible.
|
[
"5849",
"51881",
"2720",
"2875",
"2859"
] |
Admission Date: [**2179-1-18**] Discharge Date: [**2179-1-22**]
Date of Birth: [**2118-12-6**] Sex: F
Service: MEDICINE
Allergies:
Trazodone / Risperdal / Indocin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
CC:[**CC Contact Info 109704**]
Major Surgical or Invasive Procedure:
Total Knee Replacement R
History of Present Illness:
Patient is a 60 yo F with mult med probs including obstructive
and restrictive lung dx (from asbestos), HTN, Diastolic HF, and
recent laminectomy presents s/p R knee total knee replacement
for respiratory monitoring. During patient's last surgery [**12-3**]
patient devoloped post operative pulmonary edema in the setting
of intraoperative IV fluids and underlying diastolic hf. She
was intubated for 6 days and agressively diuresed. This
admission patient feels well and just complains of some post op
pain in her right knee and her chronic back pain. She denies
cp/sob/n/v/d.
Intraop patient was given 1100 cc and had an output of 790 cc.
Pulse was in the 80's. She also rec'd 1 dose of vanco intraop.
.
HPI on transfer from ICU: 60 yo F c obesity, diabetes,
obstructive/restrictive combined lung disease, hypertension,
diastolic CHF, and s/p laminectomy with complicated post op
course involving intubation for CHF who was admitted to [**Hospital Unit Name 153**] for
respiratory monitoring following surgery. Pt. presented for
surgery with no complaints. Seemed to have tolerated surgery
well from anesthesia/ortho notes. Received 1 u pRBCs intraop.
In [**Name (NI) 153**] pt. required NC 4-5 L to maintain O2 sat. Beta blocker
dose uptitrated. Started on lovenox post op. On my exam, pt.
groggy but conversant. Reporting diffuse pain over knee.
Unable to further characterize. No CP, SOB, N/V, HA, abd pain.
Past Medical History:
CHF- Diastolic HF, echo: ef 65% with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 13385**], mod ra
dilatation,nl valves with tr MR and no AR
Hypertension
Hypercholesterolemia
Palpitations daily
COPD- O2 dependent (3 L) pft [**2178-12-8**] fev1 1.75 (84%), fvc 2.29
(90%), last hospitalization [**11-1**] in [**Hospital1 **] [**Location (un) **] requiring
intubation, steroids, iv abx
DM-last hbaic 5.5%
Recurrent UTI's
Melanoma- excised between toes of right foot
OSA- cannot tolerate cpap
Hiatal hernia- s/p repair in the 70's w/ recurrance
h/o Siezures- TLE, no meds
RA- recent dx
OA
interstitial lung dx due to asbestos
LBP w/ lle pain intermittent, fractured screw from prior
laminectomy
GERD
Bipolar disorder
MRSA
PSH: 1/04 L tkr, 6/03 L knee scope, '[**77**] periumbilical
herniorrhaphy
[**12-3**] laminectomy, [**10-29**] RLL bx
Social History:
Social Hx: smokes- 40-50 pack year hx ("quit" 1 wk ago), no
etoh. retired. formerly worked on pc boards. Lives alone,
housekeeper helps with adl's. can walk [**11-30**] blocks- limited by
knee.
Family History:
NC
Physical Exam:
PE: on admission to ICU
60 in, 220 lb, 3L nc 02 92-95% P 92 BP 117/54
7.45/41/99 on 3L
Gen: morbidly obese f in nad, speaking in full sentences, slow
speech
HEENT: PERRLA, EOMI, no oropharyngeal lesions, jvp elevated to
jaw
Lungs: ant clear with decreased air movement in apices, no
wheezes or rales appreciated
Heart: s1 s2 no m/r/g
Abdomen:obese, midline scar, soft nt +bs
Extremities: R leg in tracking device wrapped post op, LLE with
no edema or cyanosis, +pulse on left foot
Neuro: AOx3, able to follow commands
.
PE on transfer from ICU
VS - Tm 99.9, Tc 99.3, HR 96, BP 97/46 [97-126/46-66], RR 22,
93% NC 5
HEENT - dry MM, no elevation JVP, OP clear, no LAD
LUNGS - diffuse expiratory wheezing, bibasilar crackles, rhonchi
HEART - RRR, S1, S2, + [**1-4**] SM at LUSB
ABD - soft, NT, ND, BS+
EXT - wwp. R leg with elaborate brace and ACE bandage; thin
drainage tube extending out of brace draining blood. No ttp
over foot; yellow discoloration likely [**12-31**] betadine
Pertinent Results:
ADMIT LABS:
[**2179-1-18**] 05:20PM TYPE-ART TEMP-36.0 O2 FLOW-3 PO2-85 PCO2-59*
PH-7.30* TOTAL CO2-30 BASE XS-0 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
[**2179-1-18**] 05:20PM LACTATE-1.0
[**2179-1-18**] 05:20PM freeCa-1.20
[**2179-1-18**] 04:50PM GLUCOSE-97 UREA N-25* CREAT-0.9 SODIUM-138
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
[**2179-1-18**] 04:50PM PHOSPHATE-5.2* MAGNESIUM-1.8
[**2179-1-18**] 04:50PM WBC-10.7 RBC-3.01* HGB-9.3* HCT-27.0* MCV-90
MCH-30.9 MCHC-34.5 RDW-14.9
[**2179-1-18**] 04:50PM PLT COUNT-252
[**2179-1-18**] 04:50PM PT-12.2 PTT-22.9 INR(PT)-1.0
[**2179-1-18**] 12:13PM GLUCOSE-152* UREA N-24* CREAT-0.8 SODIUM-140
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
[**2179-1-18**] 12:13PM WBC-8.5 RBC-2.97* HGB-9.2* HCT-26.8* MCV-90
MCH-30.9 MCHC-34.3 RDW-14.0
[**2179-1-18**] 12:13PM PLT COUNT-245
[**2179-1-18**] 10:58AM GLUCOSE-134* LACTATE-2.4* NA+-138 K+-4.2
CL--103
[**2179-1-18**] 10:58AM TYPE-ART PO2-99 PCO2-41 PH-7.45 TOTAL CO2-29
BASE XS-3 INTUBATED-INTUBATED
[**2179-1-18**] 10:58AM HGB-9.4* calcHCT-28
[**2179-1-18**] 10:58AM freeCa-1.19
[**2179-1-18**] 09:11AM HGB-10.2* calcHCT-31
[**2179-1-18**] 08:46AM TYPE-ART PO2-118* PCO2-44 PH-7.43 TOTAL
CO2-30 BASE XS-4
[**2179-1-18**] 08:46AM GLUCOSE-149* LACTATE-1.5 NA+-135 K+-4.2
[**2179-1-18**] 08:46AM HGB-7.7* calcHCT-23
[**2179-1-18**] 08:46AM freeCa-1.24
.
DISCHARGE LABS
[**2179-1-22**] 07:30AM BLOOD WBC-7.5 RBC-3.01* Hgb-9.1* Hct-26.9*
MCV-89 MCH-30.3 MCHC-33.9 RDW-14.6 Plt Ct-236
[**2179-1-22**] 07:30AM BLOOD Plt Ct-236
[**2179-1-19**] 04:23AM BLOOD PT-12.3 PTT-21.2* INR(PT)-1.0
[**2179-1-19**] 04:23AM BLOOD Fibrino-436*
[**2179-1-22**] 07:30AM BLOOD Glucose-155* UreaN-16 Creat-0.8 Na-131*
K-3.8 Cl-96 HCO3-29 AnGap-10
[**2179-1-22**] 07:30AM BLOOD Calcium-9.2 Phos-1.8* Mg-1.6
[**2179-1-21**] 03:09PM BLOOD Type-ART pO2-65* pCO2-42 pH-7.46*
calHCO3-31* Base XS-5
[**2179-1-21**] 03:09PM BLOOD Lactate-1.3
[**2179-1-21**] 03:09PM BLOOD O2 Sat-95
.
STUDIES:
Right knee bone:
1. Bony fragments with prominent articular cartilage
degeneration.
2. Abundant trilineage hematopoiesis is noted. Iron stains are
negative.
.
cxr post op
Mild pulmonary edema, greater in the left lung and mediastinal
venous engorgement, it has worsened slightly since [**1-7**].
Asymmetric enlargement of the right pulmonary artery has been
present for many years. A CT angiogram of the chest on [**12-14**], [**2176**] showed this was due to a combination of enlarged lymph
nodes and pulmonary veins, with no pulmonary embolism. Heart
size is top normal. There is no appreciable pleural effusion or
indication of pneumothorax.
.
cxr: prior to d/c
FINDINGS: AP single view of the chest has been obtained with the
patient in semi-erect position and analysis performed in direct
comparison with a similar previous chest examination of [**1-19**], [**2178**]. The lung fields are now clear, and no evidence of
significant congestion or acute parenchymal infiltrates is
noted. The lateral pleural sinuses are free. No pneumothorax is
present.
In comparison with the next previous study, the suggested
pulmonary edema pattern has normalized.
Brief Hospital Course:
A/P: Patient is a 60 yo female who presents s/p R TKR for
respiratory monitoring. Patient has diastolic heart failure and
had a prolonged course s/p her last surgery [**12-3**] with chf
exacerbation.
.
Post Op - received vancomycin for 24 hrs post op. Treated
initially c hydromorphone PCA and then switched to oral
percocets. Walking with PT on discharge. Should be weaned off
percocets at rehab as tolerated.
.
Diastolic CHF- Her last echo [**1-3**] shows nl ef, but impaired
relaxation c/w diastolic hf. Her daily weights were monitored
and strict I/Os were kept. She required some additional
diuresis with IV lasix. On d/c she was well compensated with
good O2 sat on [**1-30**] L NC which is her baseline.
.
Rhythm- has episode of svt in [**2173**], and episode of avnrt in sicu
[**1-3**]. She was continued on her aspirin and monitored on
telemetry, her beta blocker was restarted for better rate
control. During her admission, she had an episode of
tachycardia, an EKG was done suggestive of atrial flutter
(reviewed by cardiology in house). Started pt. on coumadin on
discharge; this needs to be monitored with serial INR. Also
considered other etiologies of tachycardia including PE post op;
felt unlikely as no change in O2 saturation, no new pain in leg.
Likely related to recent albuterol inhaler use prior to episode
vs. pain.
.
Chronic LBP- control with percocets after she is off
hydromorphone pca for her knee
.
HTN- well controlled in the 100's systolic. She was continued
diltizem and lisinopril, her betablocker was reinitiated with
better control of her heart rate. She needs f/u with her outpt.
cardiologist re: her HTN and her atrial flutter.
.
DM- She was continued on her oral antiglycemic regiment and an
insulin sliding scale. On d/c she was kept on an oral regimen
only.
.
COPD- She has a combination of obstructive and restrictive with
a FEV of 1 of 1.75 and fev1/fvc ratio 1.75/2.29. She was
maintained on nebulizers and 3L NC to keep her oxygen saturation
above 92%.
.
GERD- continued outpt regimen of protonix [**Hospital1 **]
.
Bipolar dx- continued olanzapine qd, clonazepam, venlafaxine
Medications on Admission:
advair
albuterol nebs
asa 81
klonipin .5mg [**Hospital1 **] and prn
combivent nebs
diltiazem 240'
effexor 150'
lasix 40 mg [**Hospital1 **]
glipizide 2.5'
lipitor 20'
lisinopril 5'
metformin 850'''
Nabumetone 750''
percocet [**12-4**] daily
protonix [**Hospital1 **]
tramadol 50 mg prn
zyprexa 15''
sulfasalazine 500'''
Discharge Medications:
1. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-30**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Olanzapine 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
12. Sulfasalazine 500 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): to be stopped once INR [**1-1**]; also discuss
with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1022**] from orthopedics prior to stopping: [**Telephone/Fax (1) 109705**]
[**Numeric Identifier 109706**].
15. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
20. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
23. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
24. Outpatient Lab Work
Please check INR q 2-3 days at rehab. Received last dose
coumadin 5 mg on [**1-22**]. For questions, page orthopedic surgeon ,
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1022**] - [**Telephone/Fax (1) 109705**], [**Numeric Identifier **]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Primary
1. Total knee replacement
2. Restrictive, Obstructive lung disease
3. Congestive heart failure
Discharge Condition:
Good
Discharge Instructions:
You should take all your medications as directed. You should
follow up with your PCP and your cardiologist in [**1-1**] weeks
following your discharge. You have been started on coumadin, an
anticoagulation medication, for atrial flutter. You will need
to have your INR monitored when taking this medication. This
should be arranged through your PCP. [**Name10 (NameIs) **] should also see Dr.
[**First Name (STitle) 1022**] for follow up of your knee replacement.
Followup Instructions:
You should call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30197**], [**Telephone/Fax (1) 19980**] for follow
up in [**1-1**] weeks following discharge from the hospital. You
should call your cardiologist for an appointment in [**1-1**] weeks as
well. You should follow up with Dr. [**First Name (STitle) 1022**] (orthopedics) in 3
weeks as well. His phone number is: [**Telephone/Fax (1) 7807**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"4280",
"496",
"42731",
"2859",
"42789"
] |
Admission Date: [**2145-6-25**] Discharge Date: [**2145-7-13**]
Date of Birth: [**2090-12-8**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This patient is a 55-year-old
man status post cadaveric renal transplant on [**2145-4-21**],
complicated by wound hematoma and opening of the wound. The
patient has been managed on an outpatient basis with a VAC
dressing and has been discharged to rehabilitation prior to
this admission. The patient presented today to the Clinic
where an exposed renal graft was noted in the wound.
PHYSICAL EXAMINATION: Temperature 97.9 degrees Fahrenheit,
heart rate 83, blood pressure 182/86, respiratory rate 20 and
oxygen saturation 100 percent on room air. The patient was
awake and alert in no apparent distress. The patient's heart
was in regular rate and rhythm with no murmurs, rubs or
gallops. His lungs were clear to auscultation bilaterally.
His abdomen was noted to have a wound VAC dressing in place;
otherwise, it was soft, non-tender, non-distended,
normoactive bowel sounds. His extremities were warm. Distal
pulses were two plus and he had no peripheral edema in both
lower extremities and slight peripheral edema in his left
upper extremity at the site of where he had a prior fistula
for hemodialysis.
HOSPITAL COURSE: At this point the patient was admitted to
[**Hospital1 69**] and was continued on his
prior medications from a recent discharge medicine list and
his VAC was placed to continuous suction. The patient was
also followed by the Renal Transplant Service who also noted
his creatinine to reveal excellent graft function. The
patient was on vancomycin during this time one gram q. 48h.
to protect against potential wound pathogens. The plan at
this time was to have Plastic Surgery to see the patient to
evaluate a possible wound flap to cover the exposed graft.
On [**2145-6-29**], hospital day five, the patient continued to
progress well. Was voiding without complaint and the service
was waiting for Plastic Surgery evaluation at this time for
potential wound flap coverage. The patient's vital signs
were stable during this time. The patient was afebrile
throughout his hospital stay up until this point. The
patient was given nutritional supplements with meals, Boost
three times a day, and on [**2145-6-30**], the patient was
visited by the Plastic Surgery service. On [**2145-6-30**],
the patient was found in his room to be complaining of
feeling hot and generally "not well." Vital signs were taken
revealing a blood pressure of 204/109 with a heart rate of
144, breathing at 70 percent on room air. The patient
received 5 mg of intravenous push Lopressor. Blood pressure
at this point was 208/111, heart rate 137. Blood gases were
drawn. Electrolytes and blood cultures were sent and Foley
catheter was inserted. A second dose of intravenous
Lopressor was given and his blood pressure was 206/90 at this
point, heart rate of 137 and at this point 10 mg of
intravenous Lopressor was hung and 10 mg was pushed. The
patient continued to have labored breathing. Was alert and
oriented but sleepy and arousable. Chest x-ray revealed what
looked like a likely pneumonia. Electrocardiogram showed
sinus tachycardia. His blood gases at this point were pO2 of
82, pCO2 of 54 and a pH of 7.19. The patient at this point
was transferred to the Surgical Intensive Care Unit. A
central venous line was also placed at this point without
complications with the patient having insufficient peripheral
access for the purpose of ABG drawing, hemodynamic
monitoring. The patient at this point was on metoprolol on
hydralazine 25 mg q. 6h. The plan was for serial ABG's. The
patient was placed on nonrebreathable oxygen mask. On the
same day Plastic Surgery saw the patient and recommended that
patient would likely benefit from right gracilis flap to
protect and cover the open wound with kidney graft exposed.
The patient was then consulted to see Cardiology after this
bout of respiratory distress and sinus tachycardia who
recommended tighter blood pressure control and metoprolol was
thus restarted at a dose of 150 mg p.o. b.i.d. and aspirin
was continued 325 mg q. day. On SICU day two, the patient
was noted to be significantly improved and vital signs were
within normal limits. His blood pressure was 161/82 at this
point and he was saturating at 95 percent on room air with a
heart rate of 83. The patient at this point was on
vancomycin, Zosyn and Bactrim. This was the second day of
Zosyn. At this point the plan was for Plastic Surgery, after
seeing the patient on hospital day eight, [**2145-7-2**], to
bring the patient to the Operating Room on Monday for likely
gracilis flap, possible rectus flap and they would pre-op the
patient for surgery. The patient then was transferred back
to the floor later in the day after noted to be doing very
well. His vital signs were stable. The patient was
saturating well and his heart rate and blood pressure were
within normal limits. Blood pressure at this point was
115/68. He had no complaints of shortness of breath or chest
pain at this time. On the 17th day of [**Month (only) 30676**] hospital day
nine, the patient continued to progress well and the patient
was scheduled for stress echocardiogram as preoperative
evaluation after events that led to the patient being
transferred to the Surgical Intensive Care Unit.
Echocardiogram revealed moderate inferior wall hypokinesis
with an ejection fraction of approximately 27-28 percent and
it was determined at this point that the patient would likely
benefit from cardiac catheterization. The patient, however,
required two negative sets of blood cultures which were drawn
on the 16th and [**7-3**] which eventually came back
negative and the patient was brought to cardiac
catheterization on [**7-9**] revealing that the patient had
normal coronary arteries. No signs of stenosis. Ejection
fraction at this point was noted to be in the mid 30's,
approximately 35 percent. The patient continued to progress
well during his hospital stay, was afebrile and without
complaint and at this point was awaiting possible of Plastic
Surgery flap closure for his open wound. The patient was
also followed by Physical Therapy and Occupational Therapy
who suggested that the patient would likely benefit from a
stint in rehabilitation before being discharged to home and,
upon learning that the patient would not be able to be
scheduled for plastic surgery closure until the following
week, likely to occur on [**7-20**] or 4th of [**2144**], it was
determined that the patient could be discharged to
rehabilitation on the wound VAC.
The patient was stable on the day of discharge. The patient
was afebrile. The rest of his vital signs were within normal
limits.
DISCHARGE DIAGNOSES: Status post cadaveric renal transplant
[**2145-4-17**] with open wound and exposed kidney.
End-stage renal disease.
Diabetes mellitus type 2.
Hypertension.
Hepatitis C virus.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: The patient was to be discharged to
rehabilitation facility where patient would have wound VAC
changes every fourth day, to [**Name8 (MD) 138**] M.D. if patient had any
increasing fevers, chills, nausea, vomiting, decreased urine
output, excessive blood coming from site of wound VAC or if
there were any other questions.
DISCHARGE MEDICATIONS:
1. Bactrim one tab q. day.
2. Metoclopramide 10 mg p.o. q.i.d.
3. Protonix 40 mg p.o. q. day.
4. Percocet 5/325 one to two tablets p.o. q. 4-6h. as needed
pain.
5. Regular insulin sliding scale as directed per sliding
scale.
6. Colace 100 mg p.o. b.i.d.
7. Prednisone 10 mg p.o. q. day.
8. ____________ 450 mg p.o. q. day.
9. Epogen 20,000 units three times per week, Monday,
Wednesday and [**Name8 (MD) 2974**].
10. Nystatin 5 mL p.o. q.i.d.
11. Metoprolol 150 mg p.o. b.i.d.
12. Heparin 5000 units one injection three times a day.
13. Azathioprine 75 mg p.o. q. day.
14. Furosemide 40 mg p.o. q. day.
15. Clonidine 0.2 mg p.o. t.i.d.
16. Aspirin 325 mg p.o. q. day.
17. Cyclosporin 125 mg p.o. b.i.d.
18. Hydralazine 37.5 mg q.i.d.
DISPOSITION: Patient stable and to be discharged to
rehabilitation facility.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2145-7-13**] 12:49:02
T: [**2145-7-13**] 14:01:07
Job#: [**Job Number 19457**]
|
[
"41071",
"4280",
"40391"
] |
Admission Date: [**2185-3-9**] Discharge Date: [**2185-4-20**]
Date of Birth: [**2145-10-21**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Zithromax / Biaxin / Plaquenil / Amantadine /
Amoxicillin / Fish Product Derivatives / Hydromorphone / Ativan
/ Versed / Tegaderm / Zyrtec / Vicodin / Dilaudid / Midazolam /
Shellfish Derived / Fentanyl / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
[**2185-3-10**]
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Small bowel resection.
4. Temporary abdominal closure.
5. primary classical cesarean delivery
[**2185-3-11**]
Re-exploration, washout and temporary closure
[**2185-3-14**]
Re-exploration of the abdomen, end-ileostomy, abdominal fascial
closure.
History of Present Illness:
Patient is a 38 year old female with an extensive past medical
history significant for chronic abd pain and Sphincter of Oddi
stenosis. She is s/p major duodenal papilla sphincteroplasty
with open J tube and open G tube placement on [**2184-4-20**]. She
responded very well to this surgery in terms of management of
her chronic abdominal pain.
She is now 25 weeks pregnant. She presents [**2185-3-9**] with
exquisite epigastric abdominal pain that woke her from sleep at
4am. It started suddenly and has been unremitting and not
controlled with her home darvocet pain meds. She was seen
earlier this month with less intense abd pain and was monitored
clinically. Per pt, she saw Dr. [**Last Name (STitle) **] in clinic and he reduced
a hernia.
Pt denies fevers or chills, vomiting, or diarrhea. She has some
nausea and still has flatus. She also has abdominal wall pain
secondary to known neuromas from her previous surgeries that had
been treated by Dr. [**Last Name (STitle) 957**] with
injections.
Past Medical History:
Past Medical History:
- Sphincter of Oddi dysfunction with stricture of the main
pancreatic duct s/p major duodenal papilla sphincteroplasty with
open J tube and open G tube placement
- Pancreatic insufficiency and pancreatitis
- h/o Lyme disease
- Thyroiditis
- [**Last Name (un) 8061**] syndrome with vasculitis
- Chronic neuropathic pain and optic neuritis
PSH:
Age 4, tonsillectomy and an adenoidectomy.
[**2173**] - rhinoplasty.
[**2164**] - cystoscopy.
[**12/2169**] and [**4-/2173**] - pelviscopy (? hystero-salpingoscopy or
colposcopy)
[**2172**] to [**2175**] - three Hickman catheters for IV antibiotics for
Lyme disease.
[**2174**] - Laparoscopic cholecystectomy @ [**Hospital1 112**], [**2174**]
[**2177**] - Hernia repair
[**2-/2183**] - EGD
[**5-/2183**] - Lipoma and incisional hernia on the left side and a
lipoma on the right side 1.5 cm2.
[**4-/2184**] - Biliary and pancreatic sphincteroplasty, open G tube
and
J tube for sphincter of oddi stenosis
Social History:
lives with husband, does not work
denies tobacco, alcohol, or illicit drug use
Family History:
non-contributory
Physical Exam:
On day of admission:
T 97.9 P 84 BP 100/52 R 20 SaO2 99%RA
Gen: mild distress with obvious pain
Neck: supple
Heent: an-icteric
Lungs: clear
Heart: RRR
Abd: well healed horizontal incisions, very tender over
epigastric incision site. Small palpable nodule. No hernia
palpated although exam limited by tenderness.
soft, nondistended,
gravid, nontender uterus
Extrem: warm, well-perfused
Pertinent Results:
[**2185-3-9**] 04:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2185-3-9**] 03:13PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2185-3-9**] 09:00AM GLUCOSE-90 UREA N-6 CREAT-0.3* SODIUM-136
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-21* ANION GAP-15
[**2185-3-9**] 09:00AM ALT(SGPT)-12 AST(SGOT)-17 LD(LDH)-149 ALK
PHOS-52 AMYLASE-54 TOT BILI-0.2
[**2185-3-9**] 09:00AM LIPASE-20
[**2185-3-9**] 09:00AM CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-1.6 URIC
ACID-2.3*
[**2185-3-9**] 09:00AM HBsAg-NEGATIVE
[**2185-3-9**] 09:00AM WBC-7.9 RBC-3.57* HGB-11.5* HCT-34.6* MCV-97
MCH-32.2* MCHC-33.2 RDW-14.2
[**2185-3-9**] 09:00AM NEUTS-81.9* LYMPHS-13.0* MONOS-4.7 EOS-0.4
BASOS-0
[**2185-3-9**] 09:00AM PLT COUNT-182
[**2185-3-9**] 09:00AM PT-13.0 PTT-36.1* INR(PT)-1.1
.
[**2185-3-10**] Pathology:
SPECIMEN SUBMITTED: terminal illium, placenta:
DIAGNOSIS:
1. Terminal ileum (A - C):
Recent hemorrhage and mucosal necrosis consistent with ischemic
type injury. The changes extend to the margins of resection
focally.
2. [**Doctor Last Name 11468**] placenta (156 grams) D - G:
A. Umbilical cord with three vessels.
B. Fetal membranes: No evidence of chorioamnionitis.
C. A thrombus is noted in a vessel beneath the amniotic surface
of the placenta.
Clinical: Fetal demise/? bowel obstruction. Small bowel
volvulus/fetal demise. 38 year old IU FD at 25 weeks.
Hysterotomy for delivery.
Gross: The specimen is received fresh, in two parts, each
labeled with the patient's name "[**Known firstname 1154**] [**Known lastname 11469**]" and the medical
record number.
Part 1 is additionally labeled "terminal ileum", and consists of
an unoriented segment of small intestine measuring 44 cm in
length x 3.5 cm in diameter. The two stapled ends each measure
3.0 cm in length. The serosa of the entire specimen appears dark
red to black. The specimen is opened along the antimesenteric
side to reveal a dark red to black lumen filled with blood. The
attached mesentery measures 9.5 x 4.5 x 0.5 cm, pink to red in
color. The specimen is sectioned to reveal dark red to black cut
surfaces. The specimen is represented as follows: A=stapled
margins, B=representative sections of mucosa, C=section of
mucosa with adjacent mesentery.
Part 2 is additionally labeled "placenta", and consists of a
[**Doctor Last Name **] placenta. The umbilical cord has three vessels, is 8.0
cm in length and 1.0 cm in average diameter and has a normal
insertion. The umbilical cord has no twists and is otherwise
unremarkable. The fetal membranes have a 100% marginal
insertion, are normal in color and do not have attached granular
deposits of decidua. The point of rupture is not identified. The
trimmed disc weighs 156 grams and measures 18 x 17.5 x 1.3 cm.
The fetal identified shows patchy subchorionic fibrin and a
normal arborizing fetal vascular pattern without thrombosis. The
maternal surface is complete and does not have adherent blood
clot or decidual hemorrhage. On cut sections, the placenta is
unremarkable. The specimen is represented as follows: D=cross
sections of the vocal cord, E=sections of placental membrane,
F-G=sections of placental disc.
.
[**2185-3-9**] Abdominal MRI:
1. Pancreas divisum anatomy. The pancreas otherwise appears
normal.
2. Small amount of free fluid in the abdomen and pelvis.
3. Moderate amount of stool throughout the colon. The patient
may be
constipated, worsened by compressive effect of the gravid uterus
on the
sigmoid colon. No evidence of bowel obstruction.
4. No anterior abdominal wall hernia is identified.
Brief Hospital Course:
She was admitted to labor and delivery for evaluation and
management of abdominal pain. General sugery consult was
obtained. Initial workup included an MRI on HD#1 which did not
report any significant findings. Her pain persisted and on the
morning of hospital day 2 her clinical picture changed with the
development of oliguria, leukocytosis, change in hematocrit, and
change in abdominal exam. In addition, sadly
at this time an intrauterine fetal demise was diagnosed. The
decision was made to proceed to the operating room for
exploratory laparotomy by the general surgeons as well as
cesarean delivery for the intrauterine fetal demise.
Intraoperatively, the demised fetus was delivered by primary
classical cesarean section and found to be grossly normal.
Please see Dr.[**Name (NI) 11470**] (obstetrics) and Dr.[**Name (NI) 11471**] (surgery)
operative notes for full details.
[**3-10**]: exploratory laparotomy, c-section, resection 10cm TI,
abdomen remained open, continued on pressors, given prbc for low
hematocrit, remained intubated
[**3-11**]: returned to the operating room for a second look, bowel
looked better, abdomen still open to suction, remained
intubated, weaned off pressors; given 4units albumin, 1u prbc
[**3-12**]: remained intubated, on vasopressors
[**3-14**]: returned to the operating room for end-ileostomy, closure,
started cipro/vanc/flagyl, TPN
[**3-15**]: remained intubated, back on pressors, bladder pressures
okay, hct falling, kept paralzyed, started diflucan for
candidiasis, got 1 upRBC
[**3-16**] off pressors, cont TPN, remained intubated
[**3-17**] 1 u pRBC, autodiuresing, still on vent, no pressors, TPN
[**3-18**] febrile, TPN, autodiuresing, pan cultured, on CPAP
[**Date range (1) 11472**] extubated, autodiuresing, discontinued vancomycin,
ciprofloxacin and flagyl, started meropenem
[**3-21**] continued ICU care, episodes of emesis, NGT replaced
[**3-22**] bolused for high NGT output, pain control, transferred to
floor for continued monitoring, continued meropenem and
fluconazole
[**3-23**] foley catheter removed
[**3-24**] NGT clamping trials started, discontinued meropenem and
fluconazole
[**3-25**] NGT removed, diet advanced to clears
[**3-27**] diet advanced to fulls, seen by PT, ostomy care
[**3-28**] - [**3-30**] regular diet, increased loperamide for high ostomy
output; TPN cycled, TPN fat taken out, cycled, volume halved
[**3-31**] ostomy leaking
[**4-1**] hydrocort for benzoin reaction, started hydrocort
[**4-2**] -[**4-7**] continued cycled TPN, monitor ostomy output and
adjust medications as needed; Calorie counts performed x 3days
with results as follows: [**4-4**] cal counts = 880 cal, 24g fat,
18.5g prot, [**4-5**] cal counts = 1000cal, [**4-6**] cal counts = 1236
cal, 24.5g protein.
[**4-7**] no events
[**4-8**] started tincture of opium
[**Date range (1) 11473**] No events
[**4-13**] advanced to clears.
[**4-14**] TPN returned to 24 hour infusion from cycled. Continued on
clears and IV fluids. No events.
[**Date range (1) 11474**] continued clears and IVF; no major events
[**4-17**] decreased IVF, but still thirsty. No leakage from ostomy.
Complaint of migraine; started on fioricet prn with good effect.
[**4-19**] On clears/TPN. No events.
At the time of discharge on [**2185-4-20**], the patient was doing well,
afebrile with stable viral signs. The patient was tolerating a
clear/full diet, ambulating, voiding without assistance, and
pain was well controlled. The patient was dischaged home with
VNA for ostomy care and infusion services for TPN. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
Flonase
Prilosec 20mg [**Hospital1 **]
Sucralfate 1g QID
Creon 20 3 capsules TID
Metamucil 2 caplets [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Folic acid 400 mcg daily
Demerol prn
Darvocet N100 [**Hospital1 **]-TID
Zofran 8mg QD-TID PRN
Fioricet PRN migraine
[**Doctor First Name **] 180mg PRN
Vitamin B-6
Vitamin B-12
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Loperamide 2 mg Capsule Sig: [**12-10**] Capsules PO Q4H (every 4
hours) as needed for excessive ostomy output.
Disp:*120 Capsule(s)* Refills:*2*
4. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q4-8HOURS as needed for nausea.
Disp:*120 Tablet, Rapid Dissolve(s)* Refills:*2*
5. Psyllium Packet Sig: One (1) packet PO TID (3 times a
day).
6. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for migraine.
7. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**12-10**]
Tablets PO Q6H (every 6 hours) as needed.
Disp:*120 Tablet(s)* Refills:*2*
9. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO
Q6HOURS ().
Disp:*QS - 1 month mL* Refills:*0*
10. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
12. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Small bowel mesenteric volvulus around a fixed point of a
former jejunostomy tube
2. 25-week fetal demise.
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
.
TPN Instruction:
-Continue to cycle TPN for 12 hours overnight.
-Weekly Labwork: Your electrolytes will be checked weekly per
the VNA. Adjustments to your TPN formula will be made
accordingly [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) 553**] [**Last Name (NamePattern1) 11475**](Home Hyperal Service
Coordinator), [**Telephone/Fax (1) 11476**], FAX: [**Telephone/Fax (1) 11477**].
-Check you blood sugars 4 times per day, at the same time each
day.
-Treat with insulin injections as indicated.
Followup Instructions:
Please call the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] to arrange a
follow up appointment in [**1-11**] weeks at ([**Telephone/Fax (1) 6347**]
Please call the office of Dr. [**Last Name (STitle) **] (Obstetrics) to arrange a
follow up appointment in 2 weeks at ([**Telephone/Fax (1) 11478**]
Completed by:[**2185-4-20**]
|
[
"0389",
"2851",
"2762",
"99592",
"5849"
] |
Admission Date: [**2106-3-26**] Discharge Date: [**2106-4-12**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest tightness
Major Surgical or Invasive Procedure:
s/p cardiac catheterization
s/p CABGx2 [**3-29**]
LIMA-LAD, SVG-OM
History of Present Illness:
Mrs. [**Known lastname **] is an 80 yo woman with a known h/o CAD who has had
PCI to her RCA, presented to the ED with SOB and chest tightness
on [**3-26**].
Past Medical History:
CAD
s/p RCA PCI
PVD
s/p R popliteal PCI
HTN
anxiety
HOH
collagenous colitis
hypercholesterolemia
glaucoma
macular degeneration
s/p bilateral cataract surgery
Social History:
Mrs. [**Known lastname **] lives at home with her husband. She denies tobacco
or EtOH.
Pertinent Results:
[**2106-4-9**] 07:08AM BLOOD WBC-11.0 RBC-3.87* Hgb-11.8* Hct-35.2*
MCV-91 MCH-30.5 MCHC-33.6 RDW-15.1 Plt Ct-433
[**2106-4-9**] 07:08AM BLOOD Plt Ct-433
[**2106-4-9**] 07:08AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1
[**2106-4-9**] 07:08AM BLOOD Glucose-91 UreaN-23* Creat-1.0 Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
Brief Hospital Course:
Mrs. [**Known lastname **] presented to [**Hospital1 18**] on [**3-26**] with c/o chest tightness
and shortness of breath. Her cardiac catheterization showed a
normal ejection fraction and significant 2 vessel disease. She
was taken to the operating room on [**3-29**] with Dr. [**Last Name (STitle) **] on [**3-29**]
for CABGx2. She tolerated the procedure well and was
transferred to the ICU in stable condition. She was weaned and
extubated from mechanical ventilation without difficulty and
transferred to the regular floor on POD#2. On POD#2 she
required PRBC transfusion and had several episodes of atrial
fibrillation. She was started on amiodarone and began to
develop periods of bradycardia. On the morning of POD#5 she
developed HTN, SOB and rales. She was treated with diuretics
and IV nitroglycerine and the decision was made to transfer her
to the ICU for close monitoring. Her EKG was without ischemic
changes, and echocardiogram did not show any wall motion
abnormality or pericardial effusion. Her symptoms of heart
failure resolved with continued diuresis and she was transferred
back to the regular floor. Her beta blockers were discontinued
due to her bradycardia, however she continued to have episodes
of atrial fibrillation. On POD#10 an electrophysiology consult
was obtained due to continues episodes of rapid atrial
fibrillation and it was recommended to decrease her dose of
amiodarone and restart a low dose of atenolol. She was started
on Coumadin for anticoagulation, and by POD#14, her INR was 2.1
and she was cleared for discharge to home.
Medications on Admission:
lisinopril 2.5mg qd
atenolol 25 mg qd
zocor 10 mg qd
ativan prn
asprin 325 mg qd
imdur 60mg qd
trusopt eye gtts
occuvite
paxil 10mg qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Dorzolamide HCl 2 % Drops Sig: One (1) Drop Ophthalmic TID
(3 times a day).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a
day.
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO once a
day for 2 days: then check with Dr.[**Name (NI) 12389**] office for
continued dosing.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
s/p CABG
PVD
anxiety
HTN
collagenous colitis
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not swim or take a bath for 1 month
do not drive for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
do not lift anything heavier than 10 pounds for 1 month
Followup Instructions:
Follow up with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 457**] in [**1-17**] weeks
follwo up with Dr. [**Last Name (STitle) **] in [**3-19**] weeks
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD follow up in [**1-17**] weeks
Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2386**]
follow up with Dr. [**Last Name (STitle) **] in [**2-18**] weeks ([**Telephone/Fax (1) 12390**]
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2106-5-13**] 3:15
Provider: [**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2106-7-13**] 1:30
Completed by:[**2106-4-12**]
|
[
"41401",
"4280",
"42731",
"4019",
"2720",
"2724",
"412",
"V4582"
] |
Admission Date: [**2103-12-28**] Discharge Date:
Date of Birth: [**2064-2-21**] Sex: F
Service: MEDICINE SERVICE TO THE MICU ON [**First Name4 (NamePattern1) 640**] [**Last Name (NamePattern1) 31397**]
SERVICE AND THEN TRANSFERRED TO THE GENERAL MEDICINE SERVICE
WITH [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AS THE ATTENDING.
The patient was admitted on [**2103-12-28**], as a
transfer from [**Hospital3 3583**] for further management of
hypertension and respiratory failure.
HISTORY OF THE PRESENT ILLNESS: The patient, [**Known firstname 31398**]
[**Known lastname 17029**], is a 39-year-old woman who presented to [**Hospital3 6265**] Emergency Room on [**12-27**], in the afternoon
with a three-day history of back pain, which is chronic,
nausea, vomiting, and possibly diarrhea. The patient also
noted weakness and hand numbness, left greater than right.
The patient also has a rash over her right upper extremity,
shoulder, and axilla. Vital signs, on arrival to the
emergency room of the outside hospital, were the following:
temperature 104.2, blood pressure 83/50, heart rate 148,
respiratory rate 12. The patient was menstruating near the
end of her cycle and had a tampon in her vagina. The
patient's blood pressure decreased to 60 systolic and she was
started on fenethylline drip for hypotension. The tampon was
removed and the patient received 2-g IV oxacillin and 100 mg
IV gentamicin. While in the emergency room, the patient
apparently had a cyanotic episode and was intubated. The
patient was transferred to [**Hospital1 188**] Emergency Room via [**Location (un) **] on hospital day #2,
[**2103-12-28**]. In the [**Hospital1 188**] Emergency Room, the patient had a blood pressure of
90/palp on neosynephrine with a heart rate in the 140s.
Temperature was 37.9. She was ventilated. She received
Vancomycin 1-g IV, Ceftriaxone 2-g IV. She was also given
fentanyl and Ativan for sedation. A left femoral line was
inserted for central access and a right brachial artery line
was inserted for blood pressure monitoring. At that point,
the patient was transferred to the medical ICU.
PAST MEDICAL HISTORY:
1. L5 spinal surgery one year ago in [**2103-11-29**].
2. Splenectomy secondary to trauma.
MEDICATIONS: None.
ALLERGIES: The patient is allergic to ERYTHROMYCIN, CODEINE,
CORTISONE, AND SULFA; reactions are unknown to those
medications.
SOCIAL HISTORY: The patient's primary care physician is
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 31399**] in [**Location (un) 3320**], who is an OB-GYN physician. [**Name10 (NameIs) **]
patient lives in [**Location 3320**] with her sister and her own four
children. Her sister [**Name (NI) **] [**Name2 (NI) 31400**] phone # is:
[**0-0-**]. She is disabled and the patient is a former
nurses aid.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Physical examination on admission to
the medical ICU revealed the following: [**Known firstname 31398**] is an obese,
middle-aged woman, intubated, and sedated. Vital signs:
Temperature 99.1, blood pressure 84/52, on 340 mcg per minute
of neosynephrine. Heart rate was 100. She is on assist
control, tidal volume 800, respiratory rate 10, PEEP 5, FIO2
50%. HEENT: Conjunctivae are clear, no scleral icterus, no
mucosal ulcerations. NECK: Obese, neck veins not well
visualized. CHEST: Coarse breath sounds bilaterally with
occasional wheezes. CARDIOVASCULAR: Tachycardiac, regular,
no murmur appreciated. ABDOMEN: Examination was soft,
nontender, nondistended, bowel sounds present, midline
abdominal scar. EXTREMITIES: Warm with no edema. Back
examination revealed surgical scar over the lumbar spine.
NEUROLOGICAL: The patient is sedated and not responding to
painful stimuli. SKIN: Skin showed petechiae and pustules
over her left inner thigh and petechiae with erythema over
the right axilla and shoulder.
LABORATORY DATA: Laboratory data revealed the following:
ABG at the outside hospital on 100% nonrebreather 7.34, CO2
35, pO2 173. White count, at the outside hospital was 35.6,
hematocrit 43.5, platelet count 547,000. SMA 7 at the
outside hospital 131, 4.5, 96, 20, 32, 2.8, glucose 210,
anion gap 50. AST 125, ALT 124, alkaline phosphatase 91,
T-bilirubin 2.2, albumin 3.0, total protein 6.1, calcium 8.3.
Chest x-ray at the outside hospital showed right mainstem
intubation, low lung volume, no infiltrate. EKG at the
outside hospital showed sinus tachycardia with normal axis.
At [**Hospital1 69**] in the Emergency Room
the labs were as follows: white count 37.9, hematocrit 33.5,
platelet count 478,000, SMA 7 138, 4.1, 106, 19, 32.2,
glucose 161, anion gap 13. The PT was 20.8, PTT 39.0, INR
3.0. CK 604, troponin 0.9, alkaline phosphatase 68, lipase
3, phosphorus 4.3, magnesium 1.0. Urinalysis revealed
moderate blood, positive protein, trace ketones, 6 to 10
white cells, 6 to 10 epithelial cells, 0 to 2 granular casts,
6 to 10 hyaline casts.
MICROBIOLOGY DATA: Blood cultures and urine cultures are
pending. The ABG revealed pH of 7.22, carbon dioxide 33,
oxygen 364 with a bicarbonate 14.
IMPRESSION: This is a 39-year-old woman with hypertension,
fever, and multiorgan failure including DIC and renal failure
and metabolic acidosis. The patient is in septic shock
secondary to an unknown cause; likely causes include
toxic-shock syndrome, meningeal coxemia and gram-negative
sepsis. She has a history of back pain and spinal surgery,
also concerning, but no recent surgeries noted and no
inflammation or localizing signs on examination.
Other etiologies included [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**] Spotted fever,
although that is thought to be less likely.
The patient was given oxacillin and Clindamycin for toxic
shock, Ceftriaxone for meningeal coxemia and gram-negative
sepsis. The patient was given Doxycycline for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**]
Spotted fever. The patient was given aggressive volume
resuscitation and pressors to maintain blood pressure with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] greater than 60. The patient was intubated and placed
on a ventilator. The patient's renal function will be
followed as will her urine output as it appears that the
patient is in acute tubular necrosis. A DIC panel was
checked on admission as the patient had elevated coagulation
panel.
On hospital day #2, the patient pressor was switched to
Levophed and the neosynephrine was discontinued. The patient
was started on an activated protein C. Oxacillin,
Clindamycin, Ceftriaxone were all continued. During her
entire time, the patient was given supportive care on the
ventilator and with fluids.
On hospital day #3, pressors were weaned to off. Cultures of
the tampon came back positive for Staphylococcus aureus,
which was Penicillin resistant, but methicillin sensitive.
Sedation was decreased with the goal of a spontaneous
breathing trial prior to extubation.
On hospital day #4, all cultures, urine and blood, have been
negative to date. The Clindamycin, Oxacillin, Ceftriaxone
and activated protein C were continued and stool was sent for
C-difficile analysis. The patient is still in nonoliguric
renal failure, likely acute tubular necrosis secondary to
ischemia. The original blood samples on the tampon from
[**Hospital3 3583**] were transferred to [**Hospital1 190**] and then sent on to the CDC for toxic shock
syndrome toxin #I and for antibodies to toxin #1.
Hospital day #5, the patient had right upper lobe and left
lower lobe infiltrates on chest x-ray. PICC line was placed.
On hospital day #6, antibiotics were changed to oxacillin and
Ciprofloxacin. The Ciprofloxacin was added to treat a
ventilator-associated pneumonia, presumptively. The other
antibiotics were discontinued. The Propofol was weaned to
off.
On hospital day #7, the patient continued to wean off the
ventilator support. On hospital day #8, the patient was
extubated. A new rash was noted and thought secondary to
antibiotics or other medications. Consequently, the
antibiotic were discontinued. The patient maintained good
urine output and the creatinine started to come down. On
hospital day #9 the patient was eating well and her
saturation was maintained on minimal oxygen.
On hospital day #10 the patient complained of weakness in her
hands, which she complained for three to four days prior to
the outside hospital emergency room. She also said that she
felt like she was breathing hard and she complained of her
usual chronic back pain. However, the patient was deemed
stable enough to be transferred to the floor. On transfer to
the floor team, current issues included pulmonary bilateral
infiltrates, ARDS versus ventilator-associated pneumonia.
The saturation was 87% on room air and 97% on three liters.
The patient complained subjectively of dyspnea.
INFECTIOUS DISEASE: The patient has all cultures negative.
The tampon grew out Staphylococcus aureus and the patient had
clinical criteria for toxic shock syndrome. The toxic shock
syndrome toxin #1 test and antibody are pending from the CDC
at this point in time. The patient is off all antibiotics.
HEMATOLOGICAL: The patient DIC has resolved and the
activated protein C was discontinued on [**1-3**],
hospital day #7. The hematocrit is stable at 25 and the
patient will not be transfused until the hematocrit drops
below 22. The patient is in post ATN diuresis phase with
high urine output and slowly decreasing creatinine.
GASTROINTESTINAL: The patient complained of mild abdominal
pain and cramping.
CARDIOVASCULAR: The patient has been cardiovascularly
stable, off pressors, for five to six days.
FLUIDS: The patient is making significant amounts of urine
and keeping herself 3-4 liters negative per day.
MUSCULOSKELETAL: The patient continues to complain of her
chronic low back pain and weakness of her hands bilaterally.
NEUROLOGICAL: The patient has sensory deficit to her elbow
bilaterally and weakness of her hands.
SKIN: The rash that the patient had on admission is now
resolved.
On hospital day #11, which was [**1-7**], stool was sent
for C. difficile and Flagyl was started empirically for loose
stool, crampy abdominal pain, and persistently elevated white
count to 22. The patient continued to improve in all areas.
On hospital day #12, the patient was weaned off oxygen to
room air. The patient continued to regain some function and
feeling in her hands bilaterally. The left one is
persistently worse than her right. The patient's abdominal
pain and cramping persisted with minimal p.o. intake. The
patient's creatinine continued to drop.
On hospital day #13, the patient's reported resolving loose
stool and decreased abdominal cramping and the patient was
able to take some POs. The patient also reported continued
improvement in her neurological symptoms of her hands
bilaterally.
On hospital day #14, [**1-10**], the patient regained her
voice. It had been hoarse previous to this. The patient
tolerated a full breakfast for the first time and having form
stool of two to three per day. The patient continues to take
the Flagyl 500 mg p.o. t.i.d.
The neurological deficits continued to resolved slowly. MRI
of the cervical spine was obtained to rule out any central
pathology. The results of the toxic shock syndrome toxin and
antibody test returned on Thursday, [**1-10**], or Friday,
[**1-11**]. The patient was screened for rehabilitation
on [**1-9**]. On [**1-10**], after tolerating a good
breakfast, the patient was deemed stable for discharge if the
patient could each a good lunch without any abdominal
cramping or loose stool.
The patient will be discharged on [**1-10**], in the
afternoon or possibly [**1-11**], early in the morning to
[**Hospital 46**] Rehabilitation, who should receive a copy of this stat
dictation summary.
After the patient tolerates good p.o. intake, the patient
will be discharged on the following medications:
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o.q.d.
2. Tums 1000 mg p.o.t.i.d.
3. Vitamin D 400 IU p.o.q.d.
4. Nystatin power to affected areas b.i.d. as needed.
5. Flagyl 500 mg p.o.t.i.d. until [**2104-1-18**].
6. Tylenol 650 mg p.o. q.4 to 6h.p.r.n.
7. Colace 100 mg p.o.b.i.d.
8. Serax 15 mg p.o.q.h.s. as needed on a regular diet.
The patient is in stable condition on discharge with the
diagnoses of the following:
1. Toxic shock syndrome.
2. Low back pain, chronic.
3. Neuropathy of upper extremities.
4. Acute tubular necrosis.
5. Adult respiratory distress syndrome, now resolved.
FOLLOW-UP CARE: The patient will followup with her OB-GYN
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 31399**]. The patient will return to see the
[**Hospital 878**] Clinic here for followup.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-955
Dictated By:[**Last Name (NamePattern1) 31401**]
MEDQUIST36
D: [**2104-1-10**] 11:19
T: [**2104-1-10**] 11:20
JOB#: [**Job Number 31402**]
cc:[**Hospital1 31403**]
|
[
"51881",
"486",
"5845",
"2762",
"4019"
] |
Admission Date: [**2121-5-14**] Discharge Date: [**2121-5-17**]
Date of Birth: [**2048-12-27**] Sex: M
Service: [**Year (4 digits) 662**]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with DES to the RCA
History of Present Illness:
72yoM with h/o HTN, multiple basal/squamous cell skin ca
admitted for inferior STEMI. He was in his USOH until 0800 this
AM when he noticed L-sided chest pain. He thought it was
indigestion at the time and went about his normal day - cleaning
up a house he is renovating. He then went to his regularly
scheduled appt to have a skin cancer removed from his neck in
[**Location (un) **]. After the appt, he went to IHOP where he ate a large
meal. He then went home and was laying down in bed when his
L-sided chest pain acutely worsened to an 8 or [**8-16**] - radiating
across his R chest associated with diaphoresis and tingling in
both his hands. His friend called 911 and he was brought to
[**Hospital1 18**] ED.
.
In the ED, initial VS 96.6 72-82 179-200/105-106 22 97% on
4L. EKG showed NSR, rate 74, RAD and 3 mm STE in II, III, and
aVF with depressions in I, aVL, and V2. Initial Trop was < 0.01,
Cr 1.1, Hct 48.7. The patient was given ASA 325 mg, Plavix 600
mg, heparin bolus and gtt, integrillin gtt, SL nitro and
morphine. Code STEMI was called and he was taken directly to the
cath lab. Cath showed 80% proximal LAD stenosis w/ diffuse
disease, 70% stenosis in the diagonal, subtotal occlusion of the
distal RCA (prox to PDA and RLV) with thrombus - this was not
collateralized, and 50% stenosis in the mid-PDA. DES was placed
to the RCA. Metoprolol 5 mg IV was given for slow Vtach. There
are plans for repeat PCI to the LAD.
.
Currently the patient denies CP, endorses mild pain in his
groin. He denies ever experiencing CP before today. No history
of heart problems. [**Name (NI) **] recent illness.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, ? Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: as above
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Hypertension
-Squamous cell skin cancer
-Basal cell skin cancers
-Rheumatic fever as child
- hospitalized 1 year ago for 'respiratory problem' after
inhaling paint fumes, said that w/u was normal
Social History:
Renovates houses. Lives with a significant other. [**Name (NI) **] 2
biological daughters and 5 children from 2nd marriage.
- Tobacco history: none
- ETOH: none
- Illicit drugs: none
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death.
mother - died young of breast cancer
father - died age 69 of ulcers
brother - died of kidney disease
Physical Exam:
On admission to CCU:
VS: 96.8 71 156/92 15 98% on RA
GENERAL: NAD. Lying flat after cath. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP not elevated
CARDIAC: RR, quiet S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTA -
anteriorlly
ABDOMEN: Obese, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. 2+ pt/dp pulses, 2+
radial pulses
SKIN: L posterior head is bandaged w/ clean bandage
.
On discharge:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP not elevated
CARDIAC: RR, quiet S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB
ABDOMEN: Obese, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. 2+ pt/dp pulses, 2+
radial pulses, R groin bandage with some dried blood.
SKIN: L posterior head is bandaged w/ clean bandage
Pertinent Results:
Labs on admission:
.
[**2121-5-14**] 02:52PM BLOOD WBC-9.1 RBC-5.22 Hgb-16.7 Hct-48.7 MCV-93
MCH-32.0 MCHC-34.3 RDW-13.1 Plt Ct-296
[**2121-5-14**] 02:52PM BLOOD Neuts-64.7 Lymphs-23.7 Monos-6.5 Eos-1.7
Baso-3.4*
[**2121-5-14**] 02:52PM BLOOD PT-12.9 PTT-20.5* INR(PT)-1.1
[**2121-5-14**] 02:52PM BLOOD Glucose-222* UreaN-17 Creat-1.1 Na-142
K-3.5 Cl-102 HCO3-26 AnGap-18
[**2121-5-14**] 02:52PM BLOOD cTropnT-<0.01
.
[**5-14**] Cardiac cath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated 2 vessel coronary artery disease. The LMCA was free
of
angiographically significant disease. The LAD had an 80%
stenosis
proximally. The distal vessel was diffusely diseased with 70-80%
stenosis at its worst. There was a 70% stenosis in the diagonal.
There
was a subtotal occlusion of the distal RCA (proximal to the PDA
and RLV)
with thrombus. This was not collateralized. There was a 50%
stenosis in
the mid-PDA.
2. Limited resting hemodynamics demonstrated moderate to severe
systemic
arterial hypertension (range 160-210mmHg systolic).
3. The patient had slow VT during the procedure with drop in
blood
pressure to the 90s systolic.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Distal RCA occlusion with thrombus
3. Moderate to severe systemic arterial hypertension
4. Slow ventricular tachycardia.
.
On discharge:
[**2121-5-17**] 09:00AM BLOOD WBC-8.0 RBC-4.51* Hgb-14.2 Hct-42.1
MCV-94 MCH-31.5 MCHC-33.7 RDW-13.1 Plt Ct-225
[**2121-5-17**] 09:00AM BLOOD Neuts-74.9* Lymphs-18.2 Monos-4.0 Eos-1.7
Baso-1.1
[**2121-5-17**] 09:00AM BLOOD Glucose-166* UreaN-22* Creat-1.0 Na-138
K-3.8 Cl-105 HCO3-21* AnGap-16
[**2121-5-16**] 06:50AM BLOOD cTropnT-1.92*
[**2121-5-17**] 09:00AM BLOOD Calcium-8.6 Phos-1.9* Mg-2.3
[**2121-5-15**] 02:58AM BLOOD %HbA1c-6.6* eAG-143*
[**2121-5-15**] 04:33AM BLOOD Triglyc-231* HDL-40 CHOL/HD-4.9
LDLcalc-109
Brief Hospital Course:
72yoM with h/o HTN, multiple basal/squamous cell skin ca
admitted for inferior STEMI
.
# CAD w/ Inferior STEMI: The patient presented to the ED with
complaints of acute onset chest pain. EKG showed inferior ST
elevations. Code STEMI was called and he was taken urgently to
the cath lab. Trops peaked at 5.25. He was Plavix loaded and
started on a heparin and integrillin gtt. Aspirin 325 mg was
administered. Cath showed thrombus in the proximal RCA and this
was stented. Atorvastatin 80 mg qhs and metoprolol succinate 25
mg qday were started. On discharge, he was continued on ASA at
325 mg per day and Plavix 75 mg qday x 12 months. Cath also
showed an 80% LAD lesion - this was not stented and plans are
for this to be medically managed. He is to have a stress test
arranged by his PCP [**Name Initial (PRE) 176**] 2 weeks. A cardiology appt was
scheduled though the patient may request a referral to a
cardiologist close to home.
.
# PUMP: TTE showed normal EF, mild LVH, regional LV systolic
dysfunction - hypokinesis of the basal and mid-inferolateral
segments.
.
# RHYTHM: NSR at rate of 69. Had slow Vtach in cath lab for
which he received 5 mg IV metoprolol. He had rare PVCs in the
CCU, no further therapy was administered.
.
# HTN: He was hypertensive w/ SBPs in the 180s on admission -
initially captopril was used to control BP. His discharge
regimen was Toprol 25 mg qday and Losartan 50 mg qday.
.
# Squamous cell ca: Lesion removed on L occiput on [**5-14**], plans
for repeat dressing change on [**5-16**]. Outpatient f/u.
.
# DM: Blood sugars were elevated on admission. A1c was sent and
was 6.6%. The patient was counseled that he had a new diagnosis
of diabetes and was encouraged to improve his diet. A nutrition
consult was placed. He was encouraged to follow-up with his PCP
[**Last Name (NamePattern4) **]: this new diagnosis.
.
DVT prophylaxis was with subQ heparin
CODE: Full Code, confirmed
COMM: daughter [**Name (NI) 17**] [**Name (NI) 22916**] [**Telephone/Fax (1) 89602**]
Medications on Admission:
HCTZ 25 mg qday
ASA 81 mg qday
Losartan 50 mg qday
Fluorouracil 40 gm
Discharge Disposition:
Home
Discharge Diagnosis:
STEMI s/p DES to the RCA
Diabetes Mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 54184**],
It was a pleasure participating in your care. You were
admitted for a heart attack caused by a clot in one of your
coronary arteries. You had a cardiac catheterization and a drug
eluting stent was placed. You were started on plavix which you
will need to take for at least a year to prevent clotting of
this stent. You were also started on atorvastatin to reduce risk
of coronary artery disease.
During your cardiac cath an area of narrowing was seen in one
of your vessels. As this has not caused you any symptoms, we
will medically manage you at present and you should have a
stress test in about 2 wks. A test has been ordered and you need
to speak with your primary care doctor in order to schedule this
test. You will have follow up with a cardiologist to further
manage your problems - if you choose to see a cardiologist
closer to home, that's fine and you can cancel the appointment
we have made.
During this admission it was also found that you have
diabetes. This can significantly increase your risk of cardiac
diseases. You should exercise and eat healthily to try to
decrease this risk. You should also follow up with your PCP to
discuss whether you would benefit from starting on medication.
Please call or return to the hospital if you develop chest
pain, shortness of breath, leg swelling, or any other symptoms
that concern you.
-------------------
Please START the following medications:
- Plavix (Clopidogrel) 75mg daily
- Atorvastatin 80mg daily
- Metoprolol succinate 25mg daily
Please STOP the following medications:
- hydrochlorothiazide
Please CONTINUE Losartan 50 mg per day
The following medications have CHANGED:
- Aspirin should now be taken at 325mg daily (not 81mg)
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] F.
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**]-[**Location (un) **]/WESTW
Address: [**Street Address(2) 21600**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 17753**]
Appt: [**5-22**] at 9:30am
Name: [**Last Name (LF) 5858**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD
Location: [**Hospital1 **] CARDIOLOGY
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 4105**]
Appt: [**6-3**] at 10:30am
|
[
"41401",
"4019",
"25000"
] |
Admission Date: [**2147-1-2**] Discharge Date: [**2147-1-9**]
Date of Birth: [**2089-4-7**] Sex: F
Service: OME
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
female with a history of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau disease and
metastatic renal cell carcinoma being admitted for cycle one,
week one high dose IL2 therapy. Her oncologic history began
in [**2130**], when she was diagnosed with bilateral renal masses
consistent with renal cell carcinoma and underwent bilateral
partial nephrectomy. She did well until [**2139-9-9**], when
disease progression was noted in her right kidney and a liver
lesion was noted. Needle biopsy of the liver lesion
confirmed metastatic renal cell carcinoma. She received IL2
and Interferon phase III protocol with stable disease. She
underwent resection of an isolated thyroid met in [**2141-12-9**], and had radiofrequency ablation of renal masses in
[**2142**], [**2143**], and [**2144**]. Recent scans revealed progression of
disease in her liver and an enlarging mass in her left
kidney. She was planned for high dose IL2, but developed
pyelonephritis/urosepsis and was hospitalized from
[**2146-12-14**], through [**2146-12-19**], for intravenous fluids and
intravenous antibiotics. She has recovered well and
completed her last antibiotic dose this morning. Her MG has
returned to 100 percent. She is now being admitted for cycle
one, week one high dose IL2 therapy.
PAST MEDICAL HISTORY: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau disease.
History of seizures.
Recent urosepsis.
History of hemangioma, status post cerebellar resection times
two.
Hypothyroidism.
ALLERGIES: Levofloxacin causes a rash.
MEDICATIONS ON ADMISSION:
1. Levoxyl 50 mcg p.o. daily.
2. Phenobarbital 64.8 mg p.o. three times a day.
3. Fosamax 70 mg p.o. weekly.
PHYSICAL EXAMINATION: General reveals a well appearing
middle age female in no acute distress. Vital signs revealed
temperature 97.8 heart rate 68, respiratory rate 20, blood
pressure 136/83, oxygen saturation 96 percent in room air.
Head, eyes, ears, nose and throat is normocephalic and
atraumatic. Sclera anicteric. The mucous membranes are
moist without lesions. The neck is supple, no jugular venous
distention. Lymph nodes - No cervical, supraclavicular,
axillary or bilateral inguinal lymphadenopathy. Heart is
regular rate and rhythm, S1 and S2, without murmurs, rubs or
gallops. The chest is clear to percussion and auscultation
bilaterally. Abdomen is soft, positive bowel sounds,
rounded, soft, nontender, no hepatosplenomegaly or masses.
Extremities revealed no lower extremity edema. Skin intact
without breakdown. On neurologic examination, the patient is
alert and oriented times three. Speech clear and fluent.
She is moving all extremities well with strength 5/5.
LABORATORY DATA: On admission, white blood cell count 5.0,
hemoglobin 15.0, hematocrit 45.4, platelet count 323,000.
Blood urea nitrogen 26, creatinine 1.2. Sodium 136,
potassium 4.3, chloride 101, CO2 30, ALT 15, AST 18, LDH 138,
CK 24, alkaline phosphatase 156, total bilirubin 0.2, albumin
3.7, calcium 9.3, phosphorus 3.6, magnesium 1.9, uric acid
6.6. INR 1.0.
HOSPITAL COURSE: The patient was admitted for high dose IL2
therapy. Her admission weight was 56 kilograms and she
received Interleukin2 600,000 international units per
kilogram equaling 33.6 million units intravenously q8hours
times fourteen planned doses. During this week, she received
thirteen of fourteen doses with dose number four held related
to hypotension and hypoxia. Side effects initially included
chills improved with Demerol and nausea improved with Ativan.
She developed an erythematous pruritic skin rash treated with
topical lotion, as well as diarrhea improved with Lomotil.
On treatment day number five, she developed mild dyspnea on
exertion with oxygen saturation in the high 90s in room air
and examination consistent with small pleural effusions with
dullness at bilateral bases without crackles. She received
dose number thirteen of IL2 at approximately 3:00 p.m. and
three hours later became hypotensive requiring the initiation
of Dopamine. She developed crackles on her pulmonary
examination and was subjectively short of breath and 20 mg of
intravenous Lasix was given. She was started on Neo-
Synephrine to help support her blood pressure. She developed
mild chest pain and underwent electrocardiogram revealing
probable supraventricular tachycardia. Given need for
maximum doses of Dopamine and Neo-Synephrine with systolic
blood pressure remaining in the 80 range, she was transferred
to the Medical Intensive Care Unit for further management and
monitoring.
In the Medical Intensive Care Unit, she was fluid
resuscitated and cultured to rule out infection as a source
of her hypotension. She was maintained on Dopamine and Neo-
Synephrine for blood pressure support. During her initial
hypotension on seven [**Hospital Ward Name 1826**], she was also noted to be
hypoxic with an oxygen saturation in the mid 80s, markedly
improved with oxygen by face mask. She initially remained in
supraventricular tachycardia but ruled out for myocardial
infarction by CK and troponin. She was maintained overnight
in the Medical Intensive Care Unit with vasopressor support
slowly weaned. By the evening of [**2147-1-7**], her blood
pressure had stabilized and she had been weaned completely
off Neo-Synephrine. Her systolic blood pressure was
maintaining over 90 on Dopamine. Her oxygen saturation was
in the 90s in room air. She had spontaneously converted to
normal sinus rhythm after transfer to the Medical Intensive
Care Unit. Her Dopamine was successfully weaned down and was
discontinued early in the morning of [**2147-1-8**]. She
underwent echocardiogram on [**2147-1-9**], revealing left
ventricular wall thickness, cavity size and systolic function
to be normal with a left ventricular ejection fraction
greater than 55 percent. Regional left ventricular wall
motion normal. There was mild pulmonary artery systolic
hypertension and a small pericardial effusion without
echocardiographic signs of tamponade.
Laboratory abnormalities during this week included creatinine
rise to 2.6, improved to 2.1 on the day of discharge;
hyperbilirubinemia with a peak bilirubin of 3.8, improved to
1.7 on the day of discharge; metabolic acidosis with a
bicarbonate low at 16, improved to 25 on the day of
discharge; and an elevated alkaline phosphatase with peak
alkaline phosphatase [**Location (un) 1131**] of 383 on the day of discharge.
She had no transaminitis during her hospitalization. She
developed mild INR elevation on [**2147-1-7**], improved the next
day to 1.1 after Vitamin K administration, and she had no
evidence of myocarditis based on enzymes or echocardiogram.
She was mildly anemic with a hemoglobin of 12.1 and
hematocrit of 35.1 without need for packed red blood cell
transfusion. She was thrombocytopenic with a platelet count
low of 27,000 on the day prior to discharge which had
improved to 36,000 on the day of discharge. She had no
evidence of bleeding throughout her hospitalization. She
required intermittent electrolytes repletion throughout her
hospitalization. By [**2147-1-9**], she had recovered
sufficiently from side effects to allow for discharge to
home. She had significant weight gain of approximately
thirty pounds during her hospitalization. Her blood cultures
drawn during her Medical Intensive Care Unit stay were
negative. Her central line tip was sent for culture upon
discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with her husband.
DISCHARGE INSTRUCTIONS: The patient is to notify us for
persistent fever, chills or fluid retention.
MEDICATIONS ON DISCHARGE:
1. Nystatin 5 cc p.o. four times a day.
2. Keflex 500 mg p.o. twice a day times five days.
3. Ranitidine 150 mg p.o. twice a day p.r.n. nausea, acid
stomach or while taking nonsteroidals.
4. Lomotil one to two tablets p.o. q6hours p.r.n. diarrhea.
5. Compazine 10 mg p.o. q6hours p.r.n. nausea.
6. Ativan 1 mg p.o. q6hours p.r.n. nausea, anxiety or for
sleep.
7. Benadryl 25 to 50 mg p.o. q6hours p.r.n. pruritus.
8. Tylenol p.r.n.
9. Ibuprofen p.r.n.
10. Lasix 20 mg p.o. four times a day times five days or
until achieves baseline weight.
</DISCHARGE DIAGNOSIS>
Metastatic renal cell carcinoma, status post high dose IL2
therapy complicated by hypotension and hypoxia.
[**First Name11 (Name Pattern1) 449**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**MD Number(1) 21348**]
Dictated By:[**Last Name (NamePattern1) 18853**]
MEDQUIST36
D: [**2147-1-13**] 16:11:51
T: [**2147-1-14**] 12:10:55
Job#: [**Job Number 21349**]
cc:[**Numeric Identifier 21350**]
|
[
"5849",
"5119",
"2762",
"42789"
] |
Admission Date: [**2195-9-19**] Discharge Date: [**2195-9-25**]
Service: MEDICINE
Allergies:
Penicillins / Evista / Tetanus / Fosamax / Actonel / Ibuprofen /
Fluoxetine
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
C2 Fracture and PE
Major Surgical or Invasive Procedure:
Placement of IVC filter
History of Present Illness:
The patient is an 87 yo woman with h/o osteoporosis, multiple
recent falls, CAD, who presents from nursing home with C2
fracture and evidence of pulmonary embolus. The patient was in
her usual state of health at her nursing home until yesterday
morning when she sustained a fall when trying to get up to go to
the bathroom. The fall was not witnessed, but the patient
reportedly did not lose consciousness. At 3:30 that afternoon,
the patient complained of neck and rib pain. She was taken to
OSH, where she was found to have a comminuted fracture of C2.
She was transferred to [**Hospital1 18**] for further evaluation. Of note,
the patient was recently treated for CDiff infection at her
nursing facility, per discussion with her daughter.
.
In the ED, the patient's VS were T 99.1, BP 106/42, P 101, R 24.
She had an ECG which showed sinus tachycardia and ST
depressions in V3 and V4. CT head was negative for ICH. She
was seen by Trauma surgery, who recommended stabalization with a
cervical collar for the next six to eight weeks, but they deemed
that she is not an operable candidate. While imaging the
patient's cervical spine, she was found to have a large saddle
pulmonary embolism. After discussion with the surgery team and
the patient's family, agreement was made to start the patient on
systemic anticoagulation. She was thus transferred to the ICU
for further monitoring.
.
In the MICU, the patient states that she still has pain in her
neck, but it has decreased from previously. The patient is a
poor historian. Per discussion with the patient's daughter, she
is interested in initiating anticoagulation if recommended.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
DM2 (due to pancreatic injury)
CAD s/p MI
Depression
COPD
Dementia
HTN
Anxiety
CHF
Social History:
The patient currently lives at [**Hospital 82992**] Nursing and Rehab center.
Her family is actively involved in her care.
Family History:
Non-contributory
.
Physical Exam:
Admission physical exam:
Vitals: T: 100.0, P 116, BP: 118/39, R 14 O2: 98% on 2L
General: Elderly woman, lying flat in bed with cervical collar,
in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Cervical collar in place
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Tachycardic. no murmurs, rubs, gallops appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission laboratories:
[**2195-9-18**] WBC-31.1* RBC-3.19* Hgb-10.2* Hct-32.1* MCV-101*
MCH-31.9 MCHC-31.7 RDW-14.2 Plt Ct-342
[**2195-9-18**] Neuts-92.7* Lymphs-4.9* Monos-2.2 Eos-0.2 Baso-0.1
[**2195-9-18**] PT-11.7 PTT-23.0 INR(PT)-1.0
[**2195-9-18**] Glucose-53* UreaN-38* Creat-1.2* Na-140 K-4.1 Cl-103
HCO3-28 AnGap-13 Calcium-8.5 Phos-3.3 Mg-1.8
Iron studies:
[**2195-9-22**] 04:24AM BLOOD calTIBC-124* VitB12-[**2121**]* Folate-10.9
Hapto-224* Ferritin-780* TRF-95* LD(LDH)-299* Ret Aut-3.2
FDP-0-10
Cardiac enzymes:
[**2195-9-18**] 09:57PM BLOOD CK(CPK)-21* cTropnT-0.02* CK-MB-NotDone
[**2195-9-19**] 07:43AM BLOOD CK(CPK)-15* CK-MB-NotDone cTropnT-0.01
EKG: ([**9-19**]): Sinus tachycardia. Non-specific ST-T wave changes.
No previous tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
106 150 76 324/[**Telephone/Fax (2) 82993**]
Laboratories on discharge:
[**9-25**]: INR=3.0
*/21: WBC count=14.6
Imaging studies:
CT of the spine: IMPRESSION:
Comminuted fracture of the C2 vertebral body extending to the
transverse
foramina bilaterally and involving the base with a minimally
displaced
fragment anteriorly. A CTA or MRA of the neck is recommended to
exclude
vertebral arterial injury.
Minimal anterolisthesis of C3 on C4 with widening of the disc
space
anteriorly, which may suggest ligamentous injury. MRI is
recommended for
further evaluation.
Linear slightly hyperdense material extending from the clivus,
along the
anterior spinal canal, to the C3-C4 level, may represent
epidural hemorrhage. No evidence of spinal cord compression.
This can be evaluated at the time of MRI of the cervical spine.
Disc bulges at C3-C5 with narrowing of the central canal.
CT of the neck:
IMPRESSION:
No definite evidence for dissection. MRA would be more sensitive
for
detection of mural hematoma using fat-sat T1-weighted images.
Filling defects suggesting pulmonary emboli in the right greater
than left
pulmonary arteries. These findings were discussed by Dr [**Last Name (STitle) 82994**]
with Dr. [**Last Name (STitle) **] at 12:05 a.m. on [**2195-9-19**].
Lower extremity doppler: IMPRESSION:
1. Fairly extensive thrombus in the right superficial femoral
vein.
2. No thrombus on the left.
Echo ([**9-21**]): The left atrium and right atrium are normal in
cavity size. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is mild functional mitral stenosis (mean
gradient 6 mmHg) due to mitral annular calcification. No mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild functional mitral stenosis. Mild pulmonary artery systolic
hypertension.
Brief Hospital Course:
The patient is an 87 yo woman with h/o osteoporosis, DM2,
dementia, depression, and anxiety who presents s/p fall with
evidence of C2 fracture, bilateral pulmonary emboli and C. diff
colitis.
.
# Pulmonary emboli: CTA of the patient's neck showed evidence
of right and left pulmonary artery emboli which straddle the
bifurcation but it is not occlusive. Given that the patient had
a recent hospitalization for pneumonia, she might have developed
the PE while in the hospital, i.e. this was a provoked PE. The
patient remained hemodynamically stable and required 2L of
oxygen initially. An echo revealed a normal right ventricle with
mild pulmonary artery systolic hypertension. The patient was
anticoagulated with a heparin gtt and started on Coumadin. On
transfer to the general medicine floors, the patient remained
stable. The family decided for placement of an IVC filter which
will be removed in four weeks. Her INR on the day of
discharge=3.0. She will need INR checks for the next 5 days with
a goal INR=[**3-10**].
.
# C2 Fracture: The patient has a transverse comminuted fracture
of C2. Neurosurgery evaluated her and determined that she is not
a surgical candidate. The neurosurgery team recommends a
cervical collar until after her followup appointment on [**11-5**].
Her pain is controlled with Tylenol 1 g QID and breakthrough
Oxycodone.
.
# C diff colitis: The patient presented with a WBC count to 30K
on admission and diffuse abdominal pain. Vancomycin was added to
her Flagyl while in the ICU. On transfer to the floors, the
Flagyl was discontinued. Vancomycin will be continued until
[**10-4**]. On discharge, the patient's WBC count has been trending
downwards. She still has left-sided abdominal tenderness.
.
Urinary tract infection: The patient was diagnosed with a UTI,
urine culture pending at discharge. She has been on a three day
course of Cipro that will end on [**9-26**].
# DM2: The patient has a history of DM2, for which she takes
Lantus daily and Novalog insulin SS. Her SSI does not start
until FSBG of 300, as the patient reportedly has very brittle
DM2. She was continued on her home regimen and there were no
episodes of hypoglycemia or glucose>400.
# CAD s/p MI: The patient had some complaints of atypical chest
pain overnight. The pain was reproducible, no EKG changes. The
patient says that she always has the pain. Her home aspirin and
Zocor were continued. Continue ASA and Zocor. She was started on
her home dose of metoprolol on discharge.
Heart failure: Her home medications of Enalapril and Lasix were
held due to adequate BP and no signs of fluid overload. She had
an Echo which showed mild symmetric left ventricular hypertrophy
with preserved global and regional biventricular systolic
function. Mild functional mitral stenosis. Mild pulmonary artery
systolic hypertension.
Outpatient followup:
1. Has an appointment to remove IVC filter
2. Need to check PT/INR until [**10-1**] for a goal INR=[**3-10**].
3. Holding Enalapril and Lasix on discharge. If patient develops
HTN or signs of fluid overload, consider starting these
medications.
4. Ortho spine followup appointment on [**11-5**]. Keep hard collar in
place until after that appointment.
Medications on Admission:
Singulair 10 mg daily
Wellburtin 75 mg daily
Sliding scale insulin (301-350 --> 4 U Novalog; 351-399 --> 6 U
Novalog; 400-500 --> 8 U Novalog
Lantus 25 U daily
Ativan 0.5 mg PO TID prn agitation
Ativan 0.25 mg PO qid
Percocet PO q4h prn pain
Percocet PO TID
Duonebs q4h while awake
ASA 81 mg daily
Calcium 500 mg daily
Vit D daily
Citalopram 20 mg daily
Colace 100 mg [**Hospital1 **]
Aricept 10 mg qhs
Enalapril 5 mg daily
Advair 100/50 [**Hospital1 **]
Lasix 40 mg daily
Lopressor 25 mg PO BID
Florastor 250 mg PO BID
Senna 2 tabs PO qhs
Zocor 20 mg PO daily
Prednisone 5 mg daily?
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Novolog 100 unit/mL Cartridge Sig: see below cartridge
Subcutaneous qachs: Sliding scale:
301-350: 4 units of novalog
351-399: 6 units of novalog
400-500: 8 units of novalg.
4. Lantus 100 unit/mL Cartridge Sig: Twenty Five (25) units
Subcutaneous once a day.
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation.
6. Lorazepam 0.5 mg Tablet Sig: half Tablet PO Q6H (every 6
hours).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H:PRN as
needed for pain: Please hold for RR<12.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours):
mix with ipratropium.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours): Mix with albuterol.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
16. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
18. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 9 days: Last day=[**10-4**].
19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days: Last day=[**9-26**] (needs PM dose on
[**9-25**]).
20. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP<100 or HR<60. Tablet(s)
21. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34004**] Nursing & Rehabilitation Center - [**Location (un) 14663**]
Discharge Diagnosis:
Primary:
1. Bilateral pulmonary embolism
2. C. diff colitis
3. C2 neck fracture
.
Secondary
1. diabetes mellitus, Type II
Discharge Condition:
Stable. Patient breathing room air.
Discharge Instructions:
You came to the hospital after suffering a fall at your nursing
home. You were found to have a fracture in your neck. There will
be no surgical intervention. You need to wear the hard collar
around your neck for 5 more weeks.
.
While scanning your neck to assess for the fracture, you were
also found to have bilateral pulmonary emboli, or blood clots.
Heparin, a blood thinner, was started. You were also found to
have a clot in your right leg and a filter was placed in your
vein to prevent that clot from going into your lungs. You have a
followup appointment with interventional radiology to remove
that filter--it can be removed at any time. You are also on
Coumadin, a blood thinner, to prevent future clots. You are no
longer on heparin.
.
You were also treated for C. diff colitis with Vancomycin, an
antibiotic. You should continue to take this antibiotic until
[**10-4**].
.
You also have a urinary tract infection and you will be treated
with Cipro until [**9-26**].
.
You should come back to the hospital if you become short of
breath, have increased leg swelling, have increased chest pain,
or have increased abdominal pain.
Followup Instructions:
Appointment #1
MD: Dr. [**Last Name (STitle) 9441**] (might change though due to schedule)
Specialty: Interventional Radiology
Date and time: [**2195-10-27**]-Tuesday, 9:30am pt should arrive @
daycare
Location: [**Hospital1 7768**], [**Hospital3 **] Hospital, [**Hospital Ward Name 121**] 1
(daycare unit)
Phone number: [**Telephone/Fax (1) 41473**]( daycare unit, daytime #)
[**Telephone/Fax (1) 53981**]( actual angio suite #)
Special instructions if applicable: Interventional radiology
(removal of IVC filter)
If problems or questions, call [**First Name8 (NamePattern2) **] [**Name (NI) 6745**]: [**Telephone/Fax (1) 6747**]
Appointment #2:
MD: Dr. [**Last Name (STitle) 1352**]
Specialty: Orthopedic Spine
Date and time: 10/01/09-2:00pm
Location: [**Location (un) **], [**Location (un) 86**], MA Floor 2
Phone number: [**Telephone/Fax (1) 3736**]
|
[
"5990",
"4280",
"41401",
"496",
"4019",
"V5867"
] |
Admission Date: [**2197-4-4**] Discharge Date: [**2197-4-6**]
Date of Birth: [**2128-2-1**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Tremor
Major Surgical or Invasive Procedure:
Attempt at Stage 1 DBS, Stereotactic frame and burr hole
placement
History of Present Illness:
Mr. [**Known lastname 80234**] is a 69 year old gentleman with a 20 year history
of Parkinsons disease. Presenting symptom, right arm tremor. Now
things are progressed
and they are still strongly asymmetric with the right side still
being the worse. Major problems are tremor, rigidity, muscle
cramping, bradykinesia, and dyskinesias as well. Gait is not as
bad. Freezing is an issue as well. Poor balance and dysarthria
is also a problem. [**Name (NI) 28118**] problems are stooped posture and
swallowing trouble, whereas he has [**Last Name **] problem with memory loss
or
hallucinations. He needs assistance when he is walking and he is
off. He has to to use a walker. The difference between his best
on and worst off is extreme and he thinks he spends at the most
about 50% on during the day. He takes Sinemet six times a day.
Past Medical History:
PD, R>L tremor, gait Ds, mild hypothyroidism, knee surgery,
pilonidal cyst surgery
Social History:
Lives with family
Family History:
Non contributory
Physical Exam:
Upon discharge:
Patient afebrile and heamodynamically stable.
He is oriented to person, place, day, date, time of the day.
Mild difficulties in obeying commands. But otherwise no clear
cranial nerve deficits. Able to move all 4 limbs. Power grossly
normal in all 4 limbs.
Motor: Appears dyskinetic all over, hypomimic and hypophonic.
There was no rest, action, or postural tremor.
He had mild cogwheeling bilaterally, right more than left
Pertinent Results:
[**2197-4-4**] CT Head
FINDINGS: The patient is status post cannulation of the left
frontal bone for deep brain stimulation procedure. A small
amount of subarachnoid hemorrhage adjacent to the surgical
defect interdigitates along left frontal sulci, which
demonstrate mild cortical swelling. A small subdural hemorrhage
may be present in this location as well. A moderate amount of
expected pneumocephalus is seen. As seen on prior MR, there is
moderate dilatation of the ventricles. A small hypodense area in
the left temporal lobe ( se 2, im 6) is likely artifactual.
Basal cisterns appear patent. The visualized paranasal sinuses
are clear. Globes and orbits are intact.
IMPRESSION: Status post aborted DBS with small amount of
subarachnoid
hemorrhage, mild cortical swelling, and possibly a small
subdural hematoma
present adjacent to the surgical site.
[**2197-4-5**] CT Head
FINDINGS: Small left frontal subarachnoid hemorrhage with
minimal associated sulcal effacement adjacent to craniotomy due
to aborted attempt of place deep brain stimulator is stable.
Previously suspected thin left frontal subdural hematoma is more
evident on current study, but measures only 2-3 mm at greatest
depth (2:21). Stable moderate amount of post-procedural
pneumocephalus evident. Moderate ventriculomegaly is unchanged.
The mastoid air cells and middle ear cavities are clear. Minimal
mucosal thickening identified within the ethmoid air cells.
IMPRESSION: Status post aborted DBS, with stable small amount of
subarachnoid hemorrhage layering in the left frontal sulci with
mild sulcal effacement; there is a very thin subdural hematoma
at the surgical site, minimally-increased and measuring only [**2-17**]
mm in maximal thickness.
Brief Hospital Course:
69M elective admission for stage 1 DBS which was aborted
secondary to bleeding. Post-op head CT showed a small SAH on the
left side. He was admitted to the Neuro ICU. He had a repeat
head CT for an episode of freezing/ increased tremor/
unresponsive. CT head was stable. Heme was called to consult. On
[**4-5**] his exam was stable and appeared at his baseline. Heme felt
the increased bleeding could be from a platelet dysfunction
secondary to herbal supplements and recommended that patient
discontinue taking these supplements.
On [**4-6**], PT evaluation was obtained and they recommended home.
Additionally, a CXR and UA was obtained to ensure that is post
op confusion was not infectious. This was essentially negative.
Now DOD, he is afebrile, VSS, and neuro stable. He is
ambulating at baseline. He is set for d/c home in stable
conditon and will follow-up accordingly.
Medications on Admission:
Sinemet 25/100 two tablets six times per day
ReQuip XL 2 mg at 8:00 a.m. and 10:00 a.m
Discharge Medications:
1. carbidopa-levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO 6
TIMES DAILY ().
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/temp/ha.
4. Requip XL 2 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO daily ().
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Healthcare of [**Location (un) **] CT
Discharge Diagnosis:
Parkinson's Disease
SAH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please remove your dressing on [**2197-4-6**]. Keep sutures clean and
dry until they are removed.
Followup Instructions:
Please call [**Telephone/Fax (1) 1272**] to re-schedule your surgery and for a
suture removal appointment in [**7-25**] days from the date of your
surgery.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2197-4-6**]
|
[
"2449"
] |
Admission Date: [**2125-9-7**] Discharge Date: [**2125-9-10**]
Date of Birth: [**2050-1-19**] Sex: M
Service: CCU/MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 75 year-old male with
a history of diabetes, coronary artery disease. He is status
post a silent myocardial infarction and also has a history of
chronic obstructive pulmonary disease (he has 100 pack year
of smoking tobacco and is still smoking). He also has a
history of hypercholesterolemia, hypertension. He also has a
history of lower gastrointestinal bleed and anemia. The
patient presented to the [**Hospital 882**] Hospital on [**2125-9-7**]
with shortness of breath and diaphoresis. He was found to
have an ST segment elevation myocardial infarction and
congestive heart failure at the [**Hospital1 882**] and was transferred
to the [**Hospital1 69**] for cardiac
catheterization. In the catheterization laboratory revealed
three vessel disease, 100% left anterior descending coronary
artery and right coronary artery, short left main carotid
artery without any lesions, and an 80% left circumflex artery
and an 80% OMI. There were no interventions done during the
catheterization. Many collaterals were noted at the time.
CT Surgery was consulted in the catheterization laboratory
during the procedure for a potential coronary artery bypass
graft. The patient's catheterization was uncomplicated and
he was scheduled to undergo coronary artery bypass graft on
Monday [**2125-9-10**].
In preparation preoperatively he had an echocardiogram, which
showed an ejection fraction of 15 to 20% and apical inferior
and basal akinesis. This was in contrast to his
transthoracic echocardiogram study in [**2124-5-5**] that
showed an ejection fraction of 50%, mild hypokinesis of the
inferobasal wall. The patient was also noted post
catheterization to have a mild groin hematoma. Further
preoperative evaluation included diuresis with Lasix as well
as carotid doppler ultrasound studies, which demonstrated 60%
occlusion in the left carotid artery and essentially clean
right carotid artery. The patient was stable throughout his
course of his hospitalization until the morning of [**2125-9-10**] when the house staff was called for an expanding
hematoma of the right groin. Initially his vital signs were
stable. Repeat hematocrit showed that this was stable since
the prior study four hours earlier.
Over the next couple of minutes the patient's blood pressure
was noticed to drop from the systolic high 110s to 80/40.
The patient was given wide open fluids and a code was called
and eventually Dopamine was started. The patient's blood
pressure responded to this intervention. During the code a
unit of packed red blood cells was ordered and begun to
transfuse. Shortly after this time the patient was noted to
seize briefly and then go into ventricular fibrillation
rhythm. The patient was shocked repeatedly for ventricular
fibrillation. He subsequently went in and out of asystole
alternating with ventricular fibrillation. The patient had
over the course of the one hour code received multiple
shocks, calcium carbonate, bicarbonate, magnesium, amiodarone
as well as atropine. None of these measures were sufficient
to sustain life and the patient expired at approximately 1:05
p.m. on [**2125-9-10**]. The family, which included his two
sisters [**Name (NI) **] and [**First Name8 (NamePattern2) 1743**] [**Name (NI) 12163**] were notified in a timely
fashion and they refused the postmortem examination.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Doctor Last Name 25109**]
MEDQUIST36
D: [**2125-9-10**] 15:28
T: [**2125-9-13**] 13:33
JOB#: [**Job Number 25110**]
|
[
"496",
"41401",
"4019"
] |
Admission Date: [**2157-12-4**] Discharge Date: [**2157-12-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
Upper endoscopy [**2157-12-5**]
History of Present Illness:
Ms. [**Known lastname 303**] is an 88-year-old woman with a history of diabetes,
hypertension, prior episode of UGIB in distant past, who
presents with hematemesis. She was in USOH until this evening
when, after having an uneventful dinner, she awoke in the middle
of the night and had one episode of approximately 500 cc of
hematemesis. She denied abdominal pain, diarrhea, or blood in
her stool, but she did have a single brown, nonbloody bowel
movement per her daughter. She was transported to the E.D. for
further evaluation. Her recent history is negative for alcohol,
aspirin, or other NSAID use.
.
In the ED, vital signs were initially: 95.4 112 156/94 16 98.
Labs were notable for a hct of 32 down from a baseline of 35-40,
and an NGL was positive for blood and coffee grounds and
remained pink in color after lavage with ~1L. She was guaiac
negative per rectum. GI was consulted and felt that she was
hemodynamically stable with a plan for EGD in the a.m. She was
started on pantoprazole and given 2L IVF and admitted to the
[**Hospital Unit Name 153**] for further management.
.
REVIEW OF SYSTEMS:
No fevers, chills, weight loss, diaphoresis, headache, visual
changes, sore throat, chest pain, shortness of breath, diarrhea,
melena, pruritis, easy bruising, dysuria, skin changes,
pruritis.
Past Medical History:
- Diabetes, diet controlled.
- Choledocholithiasis status post sphincterotomy in [**2150**]
- Distant history of hepatic abscess s/p drainage
- UGIB in [**Country 3587**] in distant past, no work-up performed
- Hypertension
- Hypercholesterolemia
Social History:
No tobacco or alcohol. She splits her time between this country,
living with her granddaughter, and [**Country 3587**].
Family History:
No history of bleeding disorders.
Physical Exam:
VS: 94 154/71 20 100%
GEN: The patient is in no distress and appears comfortable
SKIN: No rashes or skin changes noted
HEENT: No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST: Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES: trace peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**5-10**], and BLE [**5-10**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.
.
Pertinent Results:
STUDIES:
Upper endoscopy [**2157-12-5**]:
Erythema in the antrum compatible with gastritis
Angioectasia in the fundus (endoclip)
Abnormal mucosa in the stomach
Otherwise normal EGD to third part of the duodenum
.
.
LABS:
[**2157-12-4**] 09:55PM BLOOD WBC-9.5 RBC-3.66* Hgb-10.4* Hct-32.9*
MCV-90 MCH-28.5 MCHC-31.7 RDW-14.1 Plt Ct-248
[**2157-12-5**] 12:59AM BLOOD WBC-8.6 RBC-3.51* Hgb-10.3* Hct-31.0*
MCV-88 MCH-29.5 MCHC-33.3 RDW-13.4 Plt Ct-229
[**2157-12-5**] 05:04AM BLOOD Hct-28.4*
[**2157-12-5**] 02:48PM BLOOD Hct-31.0*
[**2157-12-5**] 11:45PM BLOOD WBC-8.5 RBC-3.58* Hgb-10.4* Hct-30.4*
MCV-85 MCH-29.0 MCHC-34.2 RDW-14.4 Plt Ct-181
[**2157-12-6**] 06:55AM BLOOD WBC-7.5 RBC-3.41* Hgb-10.0* Hct-29.7*
MCV-87 MCH-29.2 MCHC-33.5 RDW-14.7 Plt Ct-170
[**2157-12-6**] 04:10PM BLOOD WBC-7.7 RBC-3.45* Hgb-10.2* Hct-30.2*
MCV-88 MCH-29.7 MCHC-33.9 RDW-14.5 Plt Ct-174
[**2157-12-4**] 09:55PM BLOOD Neuts-47.0* Lymphs-43.1* Monos-4.1
Eos-5.0* Baso-0.8
[**2157-12-6**] 04:10PM BLOOD Plt Ct-174
[**2157-12-4**] 09:55PM BLOOD PT-12.5 PTT-18.9* INR(PT)-1.1
[**2157-12-4**] 09:55PM BLOOD Glucose-202* UreaN-32* Creat-1.2* Na-140
K-4.3 Cl-102 HCO3-28 AnGap-14
[**2157-12-5**] 12:59AM BLOOD Glucose-206* UreaN-30* Creat-1.1 Na-138
K-4.4 Cl-102 HCO3-27 AnGap-13
[**2157-12-6**] 06:55AM BLOOD Glucose-126* UreaN-22* Creat-1.1 Na-141
K-4.1 Cl-107 HCO3-26 AnGap-12
[**2157-12-6**] 06:55AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0
MICRO:
Time Taken Not Noted Log-In Date/Time: [**2157-12-5**] 10:03 am
SEROLOGY/BLOOD CHEM # 00229F [**12-5**].
HELICOBACTER PYLORI ANTIBODY TEST (Negative):
Brief Hospital Course:
Ms. [**Known lastname 303**] is an 88-year-old woman with a history of diabetes,
hypertension, prior episode of UGIB in distant past, who
presents with hematemesis.
.
# Hematemesis: Hct 33 from baseline of 35-40. Upper endoscopy
showed Angioectasia in the fundus, which was clipped. She was
initially treated with IV pantoprazole [**Hospital1 **]. She was transferred
to the medical floor, where her PPI was switched to an oral
preparation [**Hospital1 **]. Her HCT remained stable without additional
transfusion. Her diet was advanced without difficulty.
.
An H pylori antibody was negative. She was instructed to avoid
NSAIDs or aspirin until seeing her primary care physician [**Name Initial (PRE) 176**]
2-3 weeks. She was instructed to arrange for a follow-up
appointment within 2-3 weeks.
.
# Hypertension: Her home regimen was initially held due to
acute bleeding, but were restarted upon arrival to the medical
floor without difficulty (HCTZ, lisinopril).
.
# Diabetes, Type 2 - diet controlled as an outpatient. Pt was
covered with sliding scale insulin, this was discontinued upon
discharge.
.
# Disposition - pt was evaluated by physical therapy due to
deconditioning and weakness. She walks with a walker at home at
baseline, but lives with her daughter only. She was felt to
benefit from 24 hour supervision, which her daughter was
initially unable to provide. Additional family members
ultimately arrived, and she was discharged into their care with
24 hour supervision.
Medications on Admission:
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth
daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE - 40 mg Capsule - 1 Capsule(s)by mouth daily
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
hemetemesis
gastric AV malformation, s/p clipping.
Discharge Condition:
Tolerating oral diet.
Discharge Instructions:
You were admitted to the hospital because you were vomiting
blood. You were found to have an artery-vein malformation in
you stomach, which was the source of the bleeding, and was
clipped to stop the bleeding.
The following changes were made in your medication regimen:
1. You were started on a regimen of protonix 40mg by mouth twice
daily.
Followup Instructions:
Upon arriving home, please arrange to be seen by your primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 2-3 weeks. [**Last Name (LF) **],[**First Name3 (LF) **] J.
[**Telephone/Fax (1) 7976**]
|
[
"2851",
"25000",
"2720"
] |
Admission Date: [**2155-5-15**] Discharge Date: [**2155-5-21**]
Date of Birth: [**2081-4-2**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Ischemic ulcer of the right great toe.
Major Surgical or Invasive Procedure:
Right below-knee popliteal artery to dorsalis pedis artery
bypass with non-reverse right greater saphenous vein and
angioscopy.
History of Present Illness:
This 74-year-old gentleman has a nonhealing
ischemic ulcer of his right great toe. He underwent an
arteriogram recently which showed extensive tibial occlusive
disease with reconstitution of the dorsalis pedis artery at
the level of the ankle. The ulcer has shown no signs of
healing and he is advised to have bypass to heal his foot.
He has had longstanding type 2 diabetes and takes insulin.
Past Medical History:
PMH: PAD, DM, CAD, s/p MI, HTN, Hyperlipidemia, Obesity
PSH: [**2149**] CABG x 5; Cholecystectomy
Social History:
He is widowed, lives alone. He has never smoked or drank.
Family History:
There is a history of heart disease and vascular disease in his
family.
Physical Exam:
On physical examination, he is an elderly obese gentleman in no
acute distress. He is 5'7" and 250 lbs. Blood pressure is
179/89. Pulse is 60. Respirations are 16. He has no cervical
bruits. Chest is clear. Heart is in regular rhythm. Abdomen
is
very obese. His femoral and popliteal pulses are palpable. His
left dorsalis pedis pulse is faintly palpable. He has
nonpalpable foot pulses on the right. He has some suggestion of
diabetic neuropathy with some bony deformities of his feet,
although not Charcot foot or rocker bottom deformities, but more
prominent metatarsal heads and some interosseous muscle wasting.
On the lateral aspect of the right metatarsophalangeal joint,
there is a black eschar. It is approximately 4 mm in diameter
and slightly tender to the touch and does not look infected.
Pertinent Results:
[**2155-5-19**] 05:00AM
BLOOD WBC-7.0 RBC-3.38* Hgb-10.4* Hct-29.5* MCV-87 MCH-30.7
MCHC-35.1* RDW-13.6 Plt Ct-198
[**2155-5-19**] 05:00AM BLOOD
Plt Ct-198
[**2155-5-20**] 04:42AM BLOOD
Glucose-141* UreaN-27* Creat-0.9 Na-143 K-3.7 Cl-108 HCO3-27
AnGap-12
[**2155-5-18**] 09:22AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
URINE Blood-LG Nitrite-NEG Protein-30 Glucose-1000 Ketone-10
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
URINE RBC->182* WBC-8* Bacteri-FEW Yeast-NONE Epi-0
URINE CastHy-3*
CXR:
Cardiomegaly, widened mediastinum and elongated aorta are
stable.
Mild-to-moderate pulmonary edema is new. Right IJ catheter
remains in place. Bilateral pleural effusions are small.
Sternal wires are aligned. The patient is status post CABG.
ECHO:
Suboptimal image quality. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve is not well
seen. The mitral valve leaflets are not well seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname **],[**Known firstname **] was admitted on [**5-15**] with Ischemic ulcer of the
right great
toe.
He agreed to have an elective surgery. Pre-operatively, he was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preparations were made.
It was decided that she would undergo a:
Right below-knee popliteal artery to dorsalis pedis artery
bypass with non-reverse right greater saphenous vein and
angioscopy.
He was prepped, and brought down to the operating room for
surgery.
Before the procedure, there was difficulty placing the Foley
catheter. Urology was consulted. They found a Urethral
stricture. They placed a Foley catheter. This was kept in place
for 5 days.
Intra-operatively, he was closely monitored and remained
hemodynamically stable. He tolerated the procedure well without
any difficulty or complication.
Post-operatively, he was extubated and transferred to the PACU
for further stabilization and monitoring.
Pt was experiencing chest pressure in the PACU. A cardiology
consult was obtained. pt was given Nitro drip, started on
Labetalol drip, and a ASA. With these medications the chest
pressure improved. Pt transferred to the CVICU for monitoring.
We cycled his troponins. The were elevated.
Pt diuresed in the CIVU.
He was then transferred to the VICU for further recovery. While
in the VICU he received monitored care. His labetalol drip was
DC'd, changes to Lopressor, The IV Nitro was DC'd changed to
Imdur. His troponins continued to rise.
It was decided to an echo:
Suboptimal image quality. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve is not well
seen. The mitral valve leaflets are not well seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
With the continued rise in troponins it was decided to do a
cardiac cath.
Cath: patent vein grafts/LIMA, LAD occluded, elevated PA
pressures.
With the elevated PA pressures it was decided to add Lasix to
his regime
When stable he was delined. His diet was advanced. A PT consult
was obtained, he was transferred to floor status
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home with VNA in stable
condition.
POd #5, the Foley was DC'd, the pt had [**Last Name **] problem urinating.
He is to follow up with his PCP regarding his BP.
Medications on Admission:
carvedilol 12.5 mg [**Hospital1 **]; Lantus 100 unit/mL Solution 75 units
every morning; isosorbide mononitrate xr 60 mg qd; lisinopril 40
mg qd; nitroglycerin prn; rosuvastatin 40 mg qd; tamsulosin 0.4
mg qd; valsartan-hydrochlorothiazide 320 mg-12.5 mg qd; aspirin
325 mg qd; Humulin R 100 unit/mL Solution
20 units with meals (adjusts per SS)
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: prn for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Diovan HCT 320-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: 1.5 tabs Tablet Extended Release 24 hrs PO DAILY (Daily):
90 mg total.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*6*
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*6*
6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
8. INSULIN
Sliding Scale & Fixed Dose
Fingerstick q4hours
Insulin SC Fixed Dose Orders
Breakfast
Glargine 37 Units
Insulin SC Sliding Scale
q6hrs
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
> 350 mg/dL Notify M.D.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. metoprolol tartrate 50 mg Tablet Sig: 1.5 tabs Tablets PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*6*
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day.
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
care for life, [**Hospital 89927**] health care
Discharge Diagnosis:
Ischemic ulcer of the right great toe.
HTN
Increase in Troponins, demand ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-13**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2155-6-9**] 9:15
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Location (un) 35593**], [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 35276**]
Fax: [**Telephone/Fax (1) 35649**]
Completed by:[**2155-5-21**]
|
[
"41071",
"25000",
"4019",
"2720",
"41401",
"V5867",
"V4581"
] |
Admission Date: [**2187-5-1**] Discharge Date: [**2187-5-8**]
Date of Birth: [**2108-10-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Known sinus of Valsalva aneurysm for surgical repair. Same day
admit
Major Surgical or Invasive Procedure:
AVR
Sinus of Valsalva Aneurysm repair
History of Present Illness:
78 yoM known sinus of valsalva aneurysm from previous
admission([**2187-4-8**]) for scheduled surgical repair
Past Medical History:
h/o prostate cancer s/p XRT
Epidermal inclusion cysts
Right inguinal hernia s/p repair in [**2183**]
Emphysema, negative smoking history
Osteoporosis
Social History:
The patient lives alone in a 1 story apartment. He is
independent with his own ADLs. He drinks on occasion on the
weekends but denies any smoking history. His father and brother
were heavy smokers.
Family History:
Father deceased at 71 from MI
Mother died suddenly
Brother deceased at 70 from MI
Physical Exam:
Preop
T 98 HR71 BP 120/60 RR 18 Sat 97%RA
Gen NAD
Psych A&Ox3 MAE folows commands non focal exam
CV RRR 3/6 SEM
Pulm CTAB
Abdm Soft NABS
Ext Warm well perfused no edema
Discharge
T 98.5 HR 84 SR BP 122/62 RR 20 O2 sat 98% 3LNP
Gen NAD
Psych A&Ox3 MAE non focal exam
Pulm CTA
CV RRR, sternum stable, Wound clean and dry no erythema or
drainage
Abdm soft NT/ND/NABS
Ext Warm, well perfused, no C/C/E
Pertinent Results:
[**2187-5-1**] 04:55PM UREA N-19 CREAT-0.8 CHLORIDE-116* TOTAL
CO2-24
[**2187-5-1**] 04:55PM WBC-12.9* RBC-3.25* HGB-10.5* HCT-30.0*
MCV-93 MCH-32.3* MCHC-34.9 RDW-15.3
[**2187-5-1**] 04:55PM PLT COUNT-151
[**2187-5-8**] 06:10AM BLOOD WBC-7.9 RBC-3.40* Hgb-11.0* Hct-31.8*
MCV-94 MCH-32.2* MCHC-34.4 RDW-15.2 Plt Ct-228#
[**2187-5-8**] 06:10AM BLOOD UreaN-21* Creat-0.9 K-4.5
Brief Hospital Course:
Pt admitted directly to operating room where he underwent
AVR(#23pericardial) and repair of aneurysm of the sinus of
valsalva w/dacron patch. Seee OR report for full details.
Pt was transferred from OR to Cardiac surgery recovery unit. The
patient was somewhat hypoxic in the immediate postop period and
remained intubated and sedated throughout the day of surgery. On
POD1 a TEE was done, it showed good LV and valvular function
w/no signs of tamponade. Interventional pulmonary was also
consulted. Additionally the patient had an episode of atrial
fibrilllation for which he was started on Amiodarone and
Metoprolol, following which he converted to SR.
Following the echo the sedation was discontinued and over the
next day the patient was weaned from the ventilator and
successfully extubated on POD2.
On POD3 the patient was transferred to the cardiac surgery floor
for continued postop recovery. He had an uneventful recovery
once on the floors and on POD 7 it was decided that he was ready
for discharge to rehabilitation
Medications on Admission:
Colace 100mg [**Hospital1 **]
Metoprolol 25mg [**Hospital1 **]
Flomax 0.4mg QD
MVI 1 tab QD
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks. Tablet(s)
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 2 weeks.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1wk then 400mg QD x1wk
then 200mg QD.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
sinus of valsalva aneurysm repair
aortic regurgitation s/p AVR
COPD
prostate CA
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
take all medications as preescribed
no lifting > 10# for 10 weeks
call for any fever redness or drainage from wounds
no creams, lotions or powders to any incisions
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (STitle) 2204**] in [**2-16**] weeks
with Dr. [**Last Name (STitle) **] in [**2-16**] weeks
with Dr. [**Last Name (Prefixes) **] in 4 weeks
Completed by:[**2187-5-8**]
|
[
"4241",
"496",
"42731"
] |
Admission Date: [**2187-12-25**] Discharge Date: [**2188-1-3**]
Date of Birth: [**2123-1-24**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 32226**] is a pleasant
64-year old gentleman who presented to [**Hospital1 **]
for a cardiac catheterization after an equivocal stress test.
His catheterization on [**2187-12-25**] showed left dominant
system with three vessel disease. The left main had a distal
20% stenosis, mid LAD had 60-70% stenosis. There was a 50%
distal LAD stenosis. The circumflex was large with a tubular
70% stenosis of mid vessel and a long 70-80% stenosis before
the left PDA. The first marginal had an 80% stenosis, the
left PDA was diffusely diseased. RCA was non-dominant and
was totally occluded proximally. The distal vessels filled
via left-sided collaterals. The ventriculogram showed
severely reduced systolic function with an ejection fraction
of 30%. There was global hypokinesis present with
inferoposterior basal segments reversed. The valves were
normal. Given this, Mr. [**Known lastname 32226**] was assessed to require a
coronary bypass as the best option for his care. He elected
for this surgery after the risks and benefits were explained
to him and elected to have this done during this admission.
PAST MEDICAL HISTORY:
MEDICATIONS ON ADMISSION:
ALLERGIES:
PHYSICAL EXAMINATION:
LABORATORY:
HOSPITAL COURSE: He received a coronary bypass on [**2187-12-27**] with the following anatomy:
1. LIMA to LAD.
2. Vein to OM.
3. Vein to distal circumflex.
4. Vein to D2.
PDA was not grafted because it was too small.
Mr. [**Known lastname 32226**] was transferred to the CTICU for his
postoperative care and was transferred out without any
complications on postoperative day #2 to the floor. During
his recovery, he was found to have a slight wobble with his
walk. According to a family member, this was an exacerbation
of a condition that existed prior to the operation. Given
this neurological change, a Neurology consult was obtained
for evaluation. There was an initial question of a mid
cerebellar hypoperfusion, however over time as the patient
improved and his gait improved, as per Neurology, cerebellar
infarct was unlikely. An MRI of the brain focusing on the
cerebellum is recommended and given that the patient is post
coronary bypass, it will be scheduled as an outpatient basis.
Mr. [**Known lastname 32226**] is ambulating with some assist, tolerating a
regular diet. He is being transferred to rehabilitation for
further recuperation. He is to follow up with Neurology
after his MRI with Dr. [**First Name (STitle) 10102**] within a month and with his
primary care physician. [**Name10 (NameIs) **] is also to follow up with
Cardiology.
Pertinent tests - Cardiac catheterization: Low cardiac index
of 2.2 liters per minute per meter squared. Left
ventriculography shows reduced systolic function with an
ejection fraction of 30%, and a global hypokinesis with
inferoposterior basal segments reversed. There was no mitral
regurgitation. Selective coronary arteriography shows left
dominant system with three vessel disease. Left main has
distal 20% stenosis, mid LAD has 60-70% stenosis. There is a
50% distal LAD stenosis. The circumflex is large with a
tubular 70% stenosis of mid vessel and a 70-80% stenosis
before the left PDA. The first marginal has an 80% stenosis.
The left PDA is diffusely diseased. RCA is non-dominant and
totally occluded proximally. The distal RCA fills via left
left-sided collateral. In summary, Mr. [**Known lastname 32226**] has three
vessel coronary artery disease with moderate to severe
systolic and diastolic ventricular dysfunction and moderate
pulmonary hypertension. This report is obtained prior to his
coronary bypass.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 milligrams p.o. q.d.
2. Glyburide 5 milligrams p.o. q.d.
3. Glucophage 500 p.o. b.i.d.
4. Lasix 20 milligrams p.o. b.i.d.
5. Lopressor 50 milligrams p.o. b.i.d.
6. Carafate 1 gram t.i.d.
7. Colace 100 milligrams p.o. b.i.d.
8. Ibuprofen 600 milligrams every 6 hours p.r.n.
9. Captopril 6.25 p.o. b.i.d.
10. Potassium chloride 20 milliequivalents p.o. q.d.
11. Sliding scale insulin for 200-260, give 6 units, for
260-299, give 9 units, for 300-350, give 12 units. For
sugars above 350, please call house officer.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES:
1. Coronary artery bypass graft.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13625**]
Dictated By:[**Name8 (MD) 180**]
MEDQUIST36
D: [**2188-1-3**] 13:52
T: [**2188-1-3**] 13:56
JOB#: [**Job Number 32227**]
|
[
"41401",
"4280",
"4019",
"4168",
"2720"
] |
Admission Date: [**2131-2-15**] Discharge Date: [**2131-2-26**]
Date of Birth: [**2088-1-5**] Sex: M
Service: CCU
ADDENDUM: This dictation is for the [**Hospital 228**] hospital
course up to [**2131-2-18**]. Later events will be dictated at a
later date.
HISTORY OF THE PRESENT ILLNESS: This is a 43-year-old male
with a history of tobacco use but otherwise previously
healthy, transferred from an outside hospital after
presenting with a large anterior ST elevation MI with Q waves
at that time. The patient was transferred to [**Hospital1 18**] for
cardiac catheterization and was found to have a totally
occluded LAD which could not be revascularized despite
attempts at PTCA and thrombolytics at the outside hospital.
The patient was sent from his chiropractor to the Emergency
Room at an outside hospital today after presenting with two
days of upper back, chest, and neck pain. He complained of
[**11-2**] pain between his scapula and at the outside hospital
was found to have a CK of 2,827, MB 235, and troponin of 33.
The patient was given Retivase lytics, Lopressor, heparin,
nitroglycerin, aspirin at the outside hospital. In the
Emergency Room, an echocardiogram showed large anterior wall
motion abnormality and he was sent to [**Hospital1 18**] for
catheterization.
In the Catheterization Laboratory, the patient's hemodynamics
showed a wedge of 31, right atrial pressure of 28, aortic
pressure of 115/88, PA pressure 46/83, right ventricle 48/26.
He had a totally occluded LAD which could not be opened up.
Otherwise, he had a normal MCA, D1, D2 circumflex and RCA all
without flow-limiting lesions. He received 200 cc of
contrast. After catheterization, the patient had an
intra-aortic balloon placed. His cardiac index pre balloon
pump was 1.3 and increased to 2.2 after his balloon pump. He
had an SVR of 6,092, PVR 92. His PA saturation went from 58
before the balloon pump to 75 after the balloon pump.
PAST MEDICAL HISTORY: None.
MEDICATIONS AT HOME: None.
ALLERGIES: None.
SOCIAL HISTORY: Two packs per day of cigarette smoking,
alcohol use that was initially said to be occasional and now
known to be heavy. The patient is a construction worker who
is currently unemployed. His significant other is [**Name (NI) **], phone
number [**Telephone/Fax (1) 46012**] or [**Telephone/Fax (1) 46013**].
FAMILY HISTORY: Father with CAD.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
100.6, blood pressure 116/76, mean arterial pressure of 91,
pulse 108, respirations 14, 99% on AC800/14/5/50%, PA
pressure 32/22. The intra-aortic balloon pump with assisted
systole of 91, augmented diastole of 112, 1:1. General:
Intubated and sedated. HEENT: Pupils equal and reactive.
Anicteric sclerae. The mucous membranes were moist. Neck:
The patient was lying flat. Chest: Rhonchorus. Vented
breath sounds bilaterally. Cardiac: Tachycardiac, regular,
no rubs, gallops, or murmurs. Normal S1, S2. Abdomen:
Mildly distended, bowel sounds present, nontender, no
organomegaly. Extremities: Right femoral Swan in place with
A line. No clubbing, cyanosis or edema. Dorsalis pedis
pulses were 2+ bilaterally. Neurological: He was sedated on
propofol and paralyzed with succinylcholine.
LABORATORY DATA AT THE OUTSIDE HOSPITAL: White blood count
23,000, hematocrit 51, platelets 295,000. The differential
showed 84% polys, 6% lymphs. Sodium 138, potassium 4.2,
bicarbonate 27, chloride 100, BUN 9, creatinine 1.3, glucose
135. INR 1.1, PTT 22.
The EKG showed normal sinus rhythm at 104, ST elevations in
I, II, aVL, V2 through V6 of 5 mm with Q waves in V1 through
V4.
Chest x-ray showed evidence of heart failure, no infiltrate.
HOSPITAL COURSE: From [**2131-2-15**] to [**2131-2-18**].
The patient is a 43-year-old male with positive tobacco use
admitted with ST elevation anterior MI with Q waves already
present and found to have a total occlusion of LAD which
could not be revascularized. The patient was admitted with
cardiogenic shock with an index of 1.3 and increased to 2.2
status post intra-aortic balloon pump and a wedge pressure of
30.
1. CORONARY ARTERY DISEASE: The patient is status post LAD
occlusion with no revascularization possible after attempted
lytics and PTCA. He was continued on aspirin. His beta
blocker was started slowly and increased to the current dose
of 75 p.o. b.i.d. His CKs had peaked at the outside hospital
and trended down at his first CK here.
PUMP: The patient had a large anterior MI. His cardiac
index was initially down to 1.3 and increased to 2.2 after
intra-aortic balloon pump. He was maintained on an
intra-aortic balloon pump times 48 hours to rest his
ventricle. His cardiac index did increase to 3.2 on the
morning after admission.
The patient was found to have an EF of 20-25% by
echocardiogram with large anterior and apical akinesis and a
likely apical thrombus. For this reason, he was started on
heparin with the plan to eventually start him on Coumadin at
a later date.
The intra-aortic balloon pump was discontinued on [**2131-2-17**] and the patient did well, maintaining stable blood
pressures. We will currently increase his dose of Captopril
as his blood pressure tolerates, is currently at 25 mg p.o.
t.i.d. This will be to reduce his afterload.
EP: Mr. [**Known lastname 46014**] has sinus tachycardia status post his MI and
low EF. Other contributing factors are also likely alcohol
withdrawal and infection. We will continue to give him
Tylenol, a cooling blanket, benzodiazepines to treat his
alcohol withdrawal and Captopril to decrease his afterload
and increase his cardiac output. We will continue the beta
blocker as well and increase that to 100 as tolerated if
required.
2. PULMONARY/ID: The patient initially had a white count
and fever on admission and was found to have gram-negative
rods which are likely Hemophilus influenzae. He was started
on vancomycin, and piperacillin/Tazobactam initially and the
vancomycin has been discontinued when the gram-negative rods
were found. He was continued on pip/tazo which can likely be
further narrowed in spectrum when he can take p.o.
The patient was initially on a ventilator for agitation in
the Catheterization Laboratory with an intra-aortic balloon
in place. The sedation required him to be intubated. He was
extubated with no adverse problems on [**2131-2-18**]. He
did tolerate extubation well.
3. ALCOHOL WITHDRAWAL: The patient was agitated on
admission and required a large dose of benzodiazepines and
intubation. He will be continued on standing dose Valium for
his alcohol withdrawal and be on a CIWA scale.
4. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient has had
to have his potassium repleted; however, his other
electrolytes and renal function have been stable this
hospitalization. He will be started on a p.o. diet when he
can take p.o. which will likely be on [**2131-2-19**]. He
is currently euvolemic.
5. PROPHYLAXIS: Continue the H2 blocker. Start the patient
on a bowel regimen. Continue his heparin drip.
6. TUBES/LINES/AND DRAINS: He has a right radial A line,
and Foley in place. His right femoral Swan has been
discontinued.
MEDICATIONS AT THE TIME OF THIS DICTATION:
1. Valium 5 t.i.d.
2. Heparin 2,000 units an hour.
3. Lopressor 75 b.i.d.
4. Atorvostatin 20 q.d.
5. Aspirin 325 mg q.d.
6. Famotidine.
7. Captopril 25 t.i.d.
8. Piperacillin/Tazobactam 4.5 q. six hours.
The patient has a chest x-ray pending at this time to further
evaluate his pneumonia.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2131-2-18**] 06:05
T: [**2131-2-18**] 19:03
JOB#: [**Job Number 46015**]
|
[
"4280",
"5070",
"41401"
] |
Admission Date: [**2172-10-30**] Discharge Date: [**2172-11-9**]
Date of Birth: [**2102-5-29**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient was admitted on
[**2172-10-30**], for coronary artery bypass grafting. On
[**11-3**], the patient underwent coronary artery bypass
grafting times four.
PAST MEDICAL HISTORY: The patient is with significant
medical history of diabetes, anemia, hypertension,
hypercholesterolemia, and coronary artery disease.
HOSPITAL COURSE: Postoperatively the patient did well. The
only complication was folliculitis which was treated with
Clindamycin. Upon discharge, the patient's condition was
stable, ambulatory status was 4.
DISCHARGE MEDICATIONS: Lopressor 75 mg p.o. b.i.d., Zocor 40
mg p.o. q.i.d., Protonix 40 mg p.o. q.d., Clindamycin 450 mg
p.o. q.a.h. x 7 more days, Lasix 20 mg p.o. q.12h., KCl 20
mEq p.o. q.a.h., Docusate Sodium 100 mg p.o. b.i.d., ASA 81
mg p.o. q.d., Glynase 6 mg p.o. b.i.d., Percocet [**2-11**] p.o.
q.4-6h. p.r.n.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 70**] in
[**4-12**] weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2172-11-9**] 08:16
T: [**2172-11-9**] 08:12
JOB#: [**Job Number 36675**]
|
[
"41401",
"25000",
"4019",
"2720",
"2859"
] |
Admission Date: [**2149-1-17**] Discharge Date: [**2149-2-22**]
Date of Birth: [**2081-11-28**] Sex: M
Service: Cardiothor
DATE OF EXPIRATION: [**2149-2-22**].
REASON FOR ADMISSION: A 67 year-old known vascular path who
has history of coronary artery disease, peripheral vascular
disease and carotid stenosis. The patient presented to [**Hospital6 3622**] on [**2149-1-12**] status post MVA. He had been
watching the Patriot's game, went for a couple of beers and
then on his drive home sustained crushing chest pain
accompanied by visual changes and shortness of breath, right
leg numbness, nausea, diarrhea, diaphoresis. He had a blood
alcohol level of 0.170 and was arrested for DWI.
He was brought to the [**Hospital6 33**] where he had an
extensive work up revealing critical stenosis of his left
internal carotid artery, total occlusion of his right carotid
artery and RCI in his right internal carotid artery. Given
his known cardiac history he was transferred to the [**Hospital1 1444**] for diagnostic
catheterization which showed 80% PLAD, 90% PRCA right CIH was
stented.
Cardiac surgery was consulted. Vascular surgery was
consulted. The patient was then seen by Drs. [**Last Name (STitle) 1537**] and
[**Name5 (PTitle) **] who felt the patient would undergo a combined
procedure of coronary artery bypass graft and a left CEA.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Carotid stenosis. 90% left internal carotid artery, 80%
right internal carotid artery. Patent right vertebral, left
vertebral no visualization.
3. History of coronary artery disease.
4. Chronic obstructive pulmonary disease.
5. Alcohol abuse.
6. ASAI.
7. Hypertension.
MEDICATIONS:
1. Lopressor.
2. Cardizem.
3. Isordil.
4. Folate.
5. Thiamin.
6. Multi vitamins.
7. Zocor.
8. Inderal.
9. Trental 400 milligrams po four times a day.
PHYSICAL EXAMINATION: He is a well appearing white male in
no apparent distress. Neck - 1+ carotids. There is a III/VI
systolic ejection murmur heard. Lungs are clear. COR - rate,
regular rhythm, III/VI systolic ejection murmur at the right
upper sternal border. Abdomen is benign. Extremities - no
cyanosis, clubbing or edema. Neuro is nonfocal.
HOSPITAL COURSE: Preoperatively the patient underwent a
stent on [**2149-1-17**] to his RCIA. The patient was on the
Cardiac [**Hospital Unit Name 196**] service. At this time the work up between
cardiac and vascular continues. Dr. [**Last Name (STitle) **] saw the
patient and discussed it with Dr. [**Last Name (STitle) 1537**] and the patient agreed
to combined carotid coronary artery bypass graft procedure.
On [**2149-1-21**] the patient went to the operating room and
underwent a left carotid artery endarterectomy by Dr.
[**Last Name (STitle) **] and a coronary artery bypass graft surgery times
three; LIMA to LAD, saphenous vein to OM, saphenous vein to
RPL by Dr. [**Last Name (STitle) 1537**]. The patient tolerated the procedure well and
was transferred to the CSIU in satisfactory, hemodynamically
stable condition.
The patient was extubated that night and was doing well.
Vascular Surgery saw him and felt he was doing well. From
cardiac surgery point of view he was doing excellent. He was
then transferred to the .................... floor. He had
his large chest tube discontinued as scheduled. However on
[**2149-1-22**] the patient developed respiratory insufficiency at
the same time the patient was being worked up for an ischemic
leg. Because the patient was acidotic the patient was
intubated by anesthesia. At this point though Vascular
Surgery turned their attention to his ischemic right leg.
The patient was taken to the operating room and underwent fem
fem bypass operation.
The patient also had a head CT scan which showed a large
right .................... infarct with a small left para
.................... infarct.
At this point GI was involved because they thought he had
some infarct of his bowel due to persistent acidosis. CT scan
of his abdomen showed some little contrast and hepatic artery
but no defects to the [**Female First Name (un) 899**] or the SMA of bowel infarcts could
be determined.
The patient continued to do poorly. He had developed acute
renal failure, ARF. He was seen by Renal. He was also seen by
Hematology for what was thought to be possibly a platelet
dysfunction. Hematology felt that giving him platelets and
fresh frozen plasma for any bleeding would be appropriate.
At this point he continued to be intubated. He was seen
daily by Renal and had not yet at this point started on
dialysis.
At this point the patient was consulted to the SICU service
for long term care. Infectious Disease was consulted and
felt at the present time his abdominal exam was benign.
However it would be possible that gram negative rods may end
up being an enteric organism and they felt that starting him
on Cipro Ceftazidine today and Vancomycin would be okay and
also continue Flagyl and in the ensuing days they would be
able to get a definite organism out of a culture.
The patient from Renal received a left femoral venous
dialysis catheter. This was placed by Cardiothoracic Surgery
nurse practitioner. The patient continued to do poorly in
the CTVSIU he however was on the SICU service being seen
every day by the SICU team as well as Renal, Infectious
Disease. He was then seen by critical nutrition for
nutritional support. He was on CVVH. Renal was following him
for that. Despite all intensive measures the patient
continued to do poorly. The patient's abdomen continued to
do poorly. They had a CT scan of his abdomen which showed no
free fluid but he still underwent an exploratory laparoscopy.
At that point he underwent the exploratory laparoscopy for
questionable ischemic bowel, gangrene in his gallbladder.
Postoperative diagnosis was ischemic small bowel. Exploratory
laparotomy, SMA exploration, cecotomy, jejunostomy, mucous
fistula with mesh closure. The findings show small bowel
ischemia, LOT to TI in cecum, normal gallbladder, stomach and
colon. SMA had a water .................... applicable
explored and demonstrated flow in it. Small bowel
demarcation at 8 cm from LOT to cecum.
The patient was then returned to recovery room. However he
continued to do poorly hemodynamically. He developed
acidosis. The family at this point felt that they would not
like any extraordinary measures and eventually the patient on
[**2149-2-4**] underwent a PermaCath placement and a
tracheostomy. The patient continued with dialysis. He was in
ATN. The prognosis was poor at this point.
Despite all intensive measures the patient became more and
more acidotic over the ensuing days and on [**2149-2-22**] at 12:45
despite all aggressive measures Mr. [**Known lastname 37938**] continued to have
severe, persistent acidosis and became asystolic. Atropine
and Sodium bicarb were administered with no response. He was
pronounced dead at 12:43 A.M. Family was informed. Dr. [**Last Name (STitle) 1537**]
was informed.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 37939**]
MEDQUIST36
D: [**2149-3-25**] 13:24
T: [**2149-3-26**] 09:58
JOB#: [**Job Number 37940**]
|
[
"41401",
"5845"
] |
Admission Date: [**2191-11-30**] Discharge Date: [**2191-12-4**]
Date of Birth: [**2135-8-26**] Sex: F
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Fulminant hepatic failure.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year old
female of Indian origin with no known prior history of liver
disease and a past medical history significant for rheumatoid
arthritis and hypercholesterolemia who had been on Arava and
Lipitor who was transferred from [**Hospital 59596**] to [**Hospital1 1444**] for acute hepatic failure.
The patient has a history of rheumatoid arthritis and has
been on Arava on 10 mg once daily with an increasing dose of
20 mg once daily since [**2191-6-16**]. The patient was also on
Lipitor 20 mg by mouth once daily which was also increased to
40 mg by mouth once daily at the time of [**Month (only) **] of [**2191-6-16**]. The patient traveled to [**Country 11150**] during the Summer and
while there developed some fatigue, anorexia, nausea, and
dark urine. The patient was worked up as an outpatient in
the United States. Subsequently, the patient developed a
fever, nausea, vomiting, abdominal pain, and diarrhea, and
jaundice. The patient was found to have elevated liver
function tests and was noted to have mild ascites on
ultrasound on [**2191-11-23**].
The patient was admitted to [**Hospital3 8544**] on [**2191-11-25**] and was found to have an elevated INR to 4 and an
elevated bilirubin. She underwent a paracentesis at [**Hospital3 52139**] which demonstrated 4500 white cells per cc. The
patient was started on third-generation cephalosporin for
concern of spontaneous bacterial peritonitis. The patient's
mental status worsened over the next 24 hours with elevations
in INR and bilirubin, and the patient was transferred to [**Hospital1 1444**].
PAST MEDICAL HISTORY: Rheumatoid arthritis,
hypercholesterolemia, hypertension, and hypothyroidism.
HOME MEDICATIONS: Arava 20 mg by mouth once daily and
Lipitor 50 mg by mouth once daily (both of which were stopped
on [**2191-11-4**]), Tylenol as needed for pain relief
(which was stopped on [**11-18**]), and Levoxyl.
ADDITIONAL MEDICATIONS ON TRANSFER: Zofran, Protonix,
Demerol, Aldactone, Lasix, vitamin K, cholestyramine, and
Cefotetan.
ALLERGIES: SULFA.
SOCIAL HISTORY: No alcohol use. No tobacco use.
FAMILY HISTORY: No known history of liver disease.
PHYSICAL EXAMINATION ON ADMISSION: The temperature was 96.6,
the heart rate was 110 and regular, sinus tachycardia, the
blood pressure was 147/69, the respiratory rate was 19, and
100 percent on nonrebreather. Obtunded. On mental status,
responding only to painful stimuli. Markedly jaundiced with
icteric sclerae. The pupils were equally round and reactive
to light. The neck was supple. Cardiovascular examination
revealed a regular rhythm, sinus tachycardia. No murmurs.
The lungs were clear to auscultation bilaterally. The
abdomen was mildly distended, soft, and nontender. The right
flank with ecchymosis noted.
PERTINENT LABORATORY DATA ON ADMISSION: On admission to [**Hospital1 1444**] the white count was 9.3, the
hematocrit was 34.4, and the platelets were 104. Chemistries
revealed the sodium was 134, potassium was 3.7, chloride was
106, bicarbonate was 21, blood urea nitrogen was 13,
creatinine was 0.8, and glucose was 125. AST was 541, ALT
was 469, alkaline phosphatase was 162, total bilirubin was
23.9, albumin was 2.4, and amylase was 174. Coagulations
revealed PT was 34.8, PTT was 138.5, and INR was 7.6.
RADIOLOGY STUDIES: A CT of the abdomen and pelvis done at
[**Hospital3 8544**] on [**2191-11-28**] with the report from
Study Hospital of small nodule in the liver, normal size
spleen, moderate ascites, bilateral pleural effusion, and
positive gallstones.
BRIEF HOSPITAL COURSE: The patient was admitted to the
Surgical Intensive Care Unit late in the evening of [**2191-11-30**]. The patient was given 4 units of fresh frozen
plasma given her severe coagulopathy. Because of continued
deteriorated mental status, the patient was intubated.
Early in the morning of [**2191-12-1**] the patient's
mental status changes were deemed to be due to hepatic
encephalopathy and received a head CT STAT after intubation
which was within normal limits without any masses or
bleeding. The patient was found to be tachycardic, and
reexamination was found to have a systolic ejection murmur.
A cardiac echocardiogram was done which revealed a left-to-
right shunt consistent with an atrial septal defect or patent
foramen ovale. The patient also had increased pulmonary
artery pressures. The patient also underwent an ultrasound
of the abdomen which showed a very small nodule in the liver
and some ascites. A CT of the abdomen also done at the same
time showed generalized anasarca with edematous small bowel,
again a small nodule in the liver about the size of a spleen.
The patient's liver function tests and bilirubin continued to
rise with the total bilirubin peaking at 31.7. This was
fulminant hepatic failure. The patient's renal system
continued to be poor. The patient did not make much urine on
arrival, and her creatinine - while it was normal - did not
explain her cause of oliguria. Because the patient was
oliguric, the patient became volume overloaded given the
medication that was necessary to sustain her life.
Eventually, the patient was started on continuous venovenous
hemofiltration. Because the patient had severe coagulopathy,
the patient was put on a fresh frozen plasma drip and
received packed red blood cells as needed to keep her
hematocrit from falling. The patient also received platelets
as needed to keep her platelets above 100.
The patient's respirations were difficult to maintain. A
chest x-ray revealed possible right-sided consolidative
processes, and it there was concern that the patient might
have had an aspiration event. The patient underwent a
bronchoscopy which did not show any pockets of thickened
sputum or purulence within the bronchial system.
The patient was maintained on ceftriaxone prophylaxis as well
as on Levaquin. Despite all our best efforts, the patient
went into multisystem failure with pulmonary hypertension
with left-to-right shunting, respiratory failure with
possible aspiration pneumonia, fulminant liver failure, and
acute renal failure. The multisystem failure became
overwhelming, and the patient's life could not be sustained
despite our best efforts.
The patient was comfort measures only [**2191-12-3**] - on
the fourth day of her Intensive Care Unit stay at the [**Hospital1 1444**] - after conferring with the
family who understood the patient's grave prognosis. The
patient's supports were turned off. The patient was placed
on a morphine drip, and the patient expired without
discomfort in the early morning of [**2191-12-4**].
DISCHARGE STATUS: Expired.
DISCHARGE DIAGNOSES:
1. Acute fulminant hepatic failure; likely due to medication
toxicity from Arava and Lipitor.
2. Multisystem organ failure with cardiovascular failure,
respiratory failure, hepatic failure, and renal failure.
DATE OF DEATH: [**2191-12-4**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 12164**]
MEDQUIST36
D: [**2191-12-26**] 16:41:10
T: [**2191-12-26**] 17:28:10
Job#: [**Job Number 59597**]
|
[
"486",
"42789",
"4019",
"2449"
] |
Unit No: [**Numeric Identifier 70939**]
Admission Date: [**2186-12-15**]
Discharge Date: [**2186-12-25**]
Date of Birth: [**2186-12-15**]
Sex: F
Service: Neonatology
ID/CC: [**Female First Name (un) **] was delivered at 28 5/7 weeks and was admitted
to the newborn ICU for management of prematurity and
respiratory distress syndrome of prematurity.
MATERNAL HISTORY: The mother is a 35-year-old G1, para 0 to
1 woman with past medical history notable for hypertension,
nephrolithiasis status post stent placement, and recent
sinusitis treated with azithromycin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: No illicit substance use. Both parents are
GI fellows here at [**Hospital1 18**].
PRENATAL SCREENS: A positive, DAT negative, hepatitis B
surface antigen negative, RPR nonreactive, rubella immune,
group B strep unknown.
ANTENATAL HISTORY: [**Last Name (un) **] [**2187-3-4**] by LMP with confirmatory
7.5 week ultrasound. Estimated gestational age 28 5/7 weeks
at delivery. Pregnancy was complicated by preeclampsia,
oligohydramnios and growth restriction leading to admission 6
days prior to delivery. Treatment with betamethasone,
nifedipine and magnesium sulfate with eventual cesarean
section under spinal anesthesia. Rupture of membranes
occurred at delivery and yielded clear amniotic fluid. There
was no labor and no intrapartum fever or other clinical
evidence of chorioamnionitis.
NEONATAL COURSE: The infant was vigorous at delivery. Orally
and nasally, bulb suctioned, dried. Facial CPAP administered
for mild to moderate intercostal retractions. Apgars were 7
at 1 minute and 8 at 5 minutes. The infant was transferred
uneventfully to the NICU on CPAP and intubated with
surfactant administered at approximately 20 minutes of age.
ADMISSION PHYSICAL EXAMINATION: Preterm infant on warmer with
moderate respiratory distress. Birth weight 940 grams, [**9-13**]
percentile. OFC 25.5 cm, 25% percentile. Length 35th to 5.5
cm, 25th percentile. Heart rate 158, respiratory rate 50s-60s.
Temperature 96.9. BP 49/22, mean 33. SaO2 96% in 25% oxygen.
HEENT: Anterior fontanel soft, flat, nondysmorphic, palate
intact. Neck and mouth normal, normal cephalic, red reflex
bilaterally with vitreous haze, 2.5 endotracheal tube in
place orally. Chest: Mild to moderate intercostal
retractions, fair breath sounds bilaterally, no adventitious
sounds. CVS: Well perfused, regular rate and rhythm. Femoral
pulses normal. S1, S2 normal. No murmur. Abdomen soft,
nondistended, no organomegaly, no masses, bowel sounds
active. Anus patent. Three vessel umbilical cord. GU: Normal
preterm female genitalia. CNS: Active, alert, responsive to
stimulation. Tone appropriate for gestational age and
symmetric, moves all extremities symmetrically. Gag intact.
Faces symmetric. Integument: Normal preterm. Musculoskeletal:
Normal spine, limbs, hips and clavicles.
HOSPITAL COURSE:
1. Respiratory: [**Female First Name (un) **] received her initial dose of
surfactant at 20 minutes of age. She was extubated to
CPAP of 6 cm in 29-35% FIO2. A cap gas of 7.33/38 was
noted on CPAP. She was started on caffeine citrate for
apnea of prematurity.
On day of life 3, she developed a spontaneous left sided
pneumothorax which was treated with a thoracentesis and
then chest tube drainage. The infant was reintubated
orally and placed back on conventional mechanical
ventilation with settings of 18/5 and a rate of 30 and
30% oxygen. The air leak persisted and multiple
replacements and manipulations of the left thoracostomy
tube were necessary to maintain drainage of the air leak.
In spite of these maneuvers, the air leak persisted and
on day of life 9, a second chest tube was placed,
positioned subpulmonic to relieve reaccumulation of the
air leak on the left side. On day of life 9, a persistent
airleak was present in the posterior subpulmonic region
necessitating a third chest tube on the morning of day 10
of life.
On day of life 8, [**Female First Name (un) **] developed atelectasis versus
consolidation on the right side. Over this period to day
of life 10 she required increased ventilatory support.
Due to issues of inadequate ventilation, she was changed
from conventional ventilation to high frequency
ventilation on [**12-23**], DOL 8. On DOL 9, due to
acidosis and hypoxemia, various ventilator strategies
were tried, but ultimately returned to high frequency
ventilation. On the morning of DOL 10, she was last
tried on conventional ventilation.
2. Cardiovascular. Access: An umbilical venous catheter was
placed upon admission and was utilized for fluid and
nutrition administration throughout her hospital stay.
On day of life 9, a peripheral arterial line was placed
for increasing severity of illness and need for additional
monitoring.
There was no evidence of a patent ductus or other
cardiovascular compromise until day of life 9 when
[**Female First Name (un) **] started to become hypotensive requiring volume
and vasopressor resuscitation.
The baby alternated between periods of tachycardia and
sinus bradycardia over the last few days of life. On the
morning of [**2186-12-25**] She had sinus bradycardia to
the 60s and required a short interval of chest
compressions and a single dose of epinephrine to improve
cardiac output.
3. Fluids, electrolytes and nutrition. [**Female First Name (un) **] was
maintained n.p.o. throughout her hospital stay. On day of
life 8, she was given initial trophic feeding of breast
milk which was subsequently discontinued in light of her
worsening clinical status.
Serial electrolytes were
monitored and [**Female First Name (un) 61633**] course initially was complicated
by hyponatremia, necessitating up to a maximum of 8.8 mEq
of sodium per kilo in her parenteral nutrition to correct
her sodium deficits.
Over the last 48 hours, [**Female First Name (un) **] developed a metabolic
acidosis despite aggressive bicarbonate replacement.
She was transiently hyperglycemic in the initial phase of
illness, necessitating a decreased glucose infusion rate;
however, on day of life 10, likely in the setting of
sepsis, she was noted to be significantly hypoglycemic
with a glucose of 7. She was treated with multiple
boluses of 2 ml/kilogram of D10W infused followed by an
increase in her glucose IV infusion rate. Subsequent
glucoses were in the 60 range.
4. GI. [**Female First Name (un) **] was treated with phototherapy for physiologic
unconjugated hyperbilirubinemia and light therapy was
discontinued on day of life 8. A rebound was obtained on
day of life 9 at 2.6.
5. Heme/ID. A CBC and blood culture were initially obtained
upon admission with initial CBC notable for a white count
of 5.9 with 7 polys and 0 bands, 89 lymphs and an
absolute neutrophil count of 413. Hematocrit 41.8%,
243,000 platelets. [**Female First Name (un) **] received multiple packed red
blood cell transfusions. Her hematocrit dropped by day of
life 6 to 29.6 at which time she received her initial
transfusion. On day of life 9 with the return to it was
noted that her hematocrit was again in the 30% range and
she was again neutropenic with a white blood cell count
of 4.2 and 26 polys, 6 bands, 47 lymphs, 280,000
platelets. Metas and myelos also present as well as toxic
granulation. She received another blood transfusion at
this time. On day of life 10, she was noted to be
extremely neutropenic with a white blood cell count of
1.6 with 0 neutrophils, 0 bands, 70 lymphs, and 23,000
platelets.
Due to the persistent neutropenia, [**Female First Name (un) **] was
continually on antibiotics. Initially, she received a 7
day course of ampicillin and gentamicin for the first 7
days with appropriate gentamicin levels. She was started
on vancomycin and gentamicin on day of life 8 for the
initial decompensation and concerning CBC as explained
above. She was also given oxacillin for her multiple
manipulations of the thoracostomy tubes and was started
on cefotaxime for broader coverage on day of life 10. The
blood cultures remained negative to date. Lumbar
puncture was performed by DOL 7 which ruled out spinal
meningitis.
6. Neurologic. [**Female First Name (un) **] had an initial head ultrasound on day
of life 4 which was normal. It was repeated on day of
life 10 and it remained without evidence for intracranial
hemorrhage. She received morphine sulfate p.r.n. when
intubated and during chest tube insertion. She was
started on a fentanyl drip which was escalated to 5 mcg
per kilogram and continued to get morphine p.r.n. and
fentanyl p.r.n. mostly for procedures.
Given the persistent hypoxemia and acidemia especially over
the final 12 hours of [**Female First Name (un) 61633**] life, discussion with the
family ensued regarding the likely neurodevelopmental
compromise that may result given the prolonged nature and
severity of her metabolic acidosis and hypoxemia. With regard
for the futility in continuing to provide [**Hospital 17073**] medical
ervention, the decision was made to discontinue support. t.
The parents held the infant as the lines were clamped off and
the endotracheal tube was removed. The fentanyl infusion
continued. The time of death was 1 p.m. The parents had
multiple friends with them at the bedside for support. They
declined clergy presence. Limited autopsy request obtained
for the chest only and the parents will be made aware of any
new information that is received. Social worker was present
as well to assist the family.
DIAGNOSES:
1. Intrauterine growth restriction, small for gestational
age premature infant at 28-5/7 weeks.
2. Respiratory distress syndrome requiring Surfactant
replacement.
3. Left pneumothorax.
4. Right pulmonary atelectasis versus consolidation.
5. Presumed sepsis.
6. Severe metabolic acidosis.
7. Hyperbilirubinemia.
8. Neutropenia.
9. Hyperglycemia/hypoglycemia.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 70940**]
MEDQUIST36
D: [**2186-12-25**] 19:44:48
T: [**2186-12-25**] 21:50:39
Job#: [**Job Number 70941**]
|
[
"7742",
"2761"
] |
Admission Date: [**2174-11-14**] Discharge Date: [**2174-11-22**]
Date of Birth: [**2109-8-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex / Latex / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2174-11-14**] - Coronary artery bypass grafting x3 (Left internal
mammary artery sequential graft to the diagonal and left
anterior descending artery, Free right internal mammary artery
to the obtuse marginal artery)
History of Present Illness:
65 year old female who developed dyspnea on exertion in [**Month (only) 958**],
now with progression, occurring with less activity and more
frequently. She underwent a Dobutamine stress in [**Month (only) 216**] which
was negative, however due to ongoing symptoms she underwent an
Adenosine stress test where she reported DOE and developed 1mm
planar ST depressions inferior/laterally. Imaging revealed a
medium area of moderate stress induced ischemia. She was started
on Aspirin and beta blockers last week without any change in her
present symptoms. She was referred for cardiac catheterization
which found her to have severe two vessel coronary artery
disease. She was seen by Dr. [**Last Name (STitle) **] in [**Month (only) 359**] while an
inpatient and returns today for preadmission testing. Her
surgery is scheduled for Monday [**2174-11-14**]. She has had a recent
upper respiratory infection treated with azithromycin and
albuterol.
Past Medical History:
Hypertension
Diabetes
Mild PVD
Hypercholesterolemia
Right Breast CA in [**2166**] s/p lumpectomy and radiation therapy
with recurrence in [**2170**] s/p right breast mastectomy and
reconstruction
Left great toe to left shin cellulitis s/p Cephalexin and
Bactrim course completed 1-2 weeks ago with resolution. This is
an intermittent problem.
Depression
Restless leg syndrome
Hypothyroidism
DVTs in the past
s/p appendectomy
Social History:
Lives with:daughter
Occupation:retired meat manager at grocery store
Cigarettes: Smoked no [] yes [x] Hx:1ppd for 15 years and quit
25
to 30 years ago
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-17**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
non-contributory
Physical Exam:
Pulse:70 Resp:14 O2 sat:95/RA
B/P Right:no BP in right arm d/t mastectomy Left:155/64
Height:5'3" Weight:191 lbs
General:NAD, alert and cooperative
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 [] no Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] 1+ (B) LE Edema. Left
lower extremity with edema, venous stasis changes, shiny and
tense. It is nontender to touch and no significant erythema
noted. The calf muscle feels tight/knotted causing an abnormal
appearance of LE with a tense softball like calf and then an
abruptly thin LE distal to calf.
Right with venous stasis changes however not as significant as
left lower leg. Negative [**Last Name (un) **] signs bilaterally.
Varicosities: Multiple varicosities noted on bilateral lower
extremities particularly in thighs. Likely thrombosis of GSV vs
Superficial vein just above right knee and Left Lesser saphenous
vein.
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2174-11-14**] ECHO: PRE BYPASS No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest. Left
ventricular wall thickness, cavity size and regional/global
systolic function are 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) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is chordal systolic
anterior motion without systolic anterior motion of the mitral
valve leaflets. There is no left ventricular outlow tract
obstruction. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **]
was notified in person of the results in the operating room at
the time of the study.
POST BYPASS There is normal biventricular systolic function. No
change in valvular function. The left to right flow across the
interatrial septum at the foramen ovale is no longer seen. The
thoracic aorta is intact after decannulation. No other changes
from the pre bypass study.
.
[**2174-11-16**] CT Head: An ill-defined hypodensity involving the dorsal
aspect of the right thalamus, just lateral to the third
ventricle is noted. The chronicity of this finding cannot be
determined given the lack of prior imaging. In the setting of
high clinical suspicion for acute infarction, may consider MR
for further assessment if not contra-indicated or close followup
with CT if MRI cannot be obtained. No acute hemorrhage or mass
effect. Out of proportion dilation of the lateral and third
ventricles compared to cerebral sulci- while this can be due to
central volume loss, other etiologies such as normal pressure
hydrocephalus can look similar and need clinical correlation.
.
[**2174-11-18**] Head MRI: 1.Three small foci of high signal intensity
identified on the diffusion-weighted sequences, suggesting
acute/subacute thromboembolic ischemic event. There is no
evidence of hemorrhagic transformation. 2. Chronic microvascular
ischemic disease is identified. Small chronic lacunar infarct is
noted on the left cerebellar hemisphere.
3. Bilateral mucosal thickening noted on the maxillary sinuses
with air-fluid level on the left side, the possibility of an
ongoing inflammatory process is a consideration.
.
[**2174-11-20**] CXR: Postoperative widening of the cardiomediastinal
silhouette is slightly larger today than yesterday. Small left
pleural effusion is presumed. There is no pulmonary edema or
pneumothorax. Right jugular line ends at the junction of
brachiocephalic veins.
.
[**2174-11-14**] 02:15PM BLOOD WBC-7.5 RBC-3.65* Hgb-10.6* Hct-31.7*
MCV-87 MCH-29.1 MCHC-33.5 RDW-14.9 Plt Ct-100*
[**2174-11-20**] 06:51AM BLOOD WBC-9.6 RBC-3.79* Hgb-10.6* Hct-33.0*
MCV-87 MCH-28.1 MCHC-32.3 RDW-14.5 Plt Ct-236
[**2174-11-14**] 02:15PM BLOOD PT-13.6* PTT-32.9 INR(PT)-1.3*
[**2174-11-17**] 01:57AM BLOOD PT-14.5* PTT-23.8* INR(PT)-1.4*
[**2174-11-14**] 02:15PM BLOOD UreaN-25* Creat-0.9 Na-140 K-5.2* Cl-111*
HCO3-23 AnGap-11
[**2174-11-21**] 05:35AM BLOOD UreaN-34* Creat-0.9 Na-138 K-4.4 Cl-100
[**2174-11-18**] 01:49AM BLOOD ALT-57* AST-68* LD(LDH)-309* AlkPhos-92
Amylase-33 TotBili-0.5
[**2174-11-21**] 05:35AM BLOOD Albumin-PND Mg-2.3
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2174-11-14**] for surgical
management of her coronary artery disease. She was taken to the
operating room where she underwent coronary artery bypass
grafting to three vessels. Please see operative note for
details. Postoperatively she was taken to the intensive care
unit for monitoring. On postoperative day one she was extubated.
Neurologically she did not follow commands and her speech was
delayed. She was seen by neurology who felt she had a stroke
involving the left cerebral hemisphere - either deep or frontal.
The major finding was abulia - a lack of spontaneity, prolonged
latency in response and short terse replies with easy
distractibility. A CT scan was performed which showed an
ill-defined hypo density involving the dorsal aspect of the
right thalamus was noted. MRA done on [**11-18**] showed three small
foci of high signal intensity identified on the
diffusion-weighted sequences, suggesting acute/subacute
thromboembolic ischemic event. Neurology felt she had a Left PCA
embolic stroke. Her right-sided weakness improved. She was seen
by Speech and swallow who recommended regular diet with thin
liquids. Long and short acting insulin was continued to maintain
blood sugars < 150. Chest tubes and epicardial wires were
removed without complications. She was gently diuresed toward
her preoperative weight. Patient was transferred to the
step-down unit on post-op day 4 for further recovery. She
remained in sinus rhythm and hemodynamically stable. She was
followed by physical and occupational therapy for strength and
mobility. She was discharged to rehab - [**Hospital1 **] [**Location (un) **] on
post-op day seven with the appropriate medications and follow-up
appointments.
Medications on Admission:
CITALOPRAM 20mg daily
ERGOCALCIFEROL (VITAMIN D2) 50,000 unit [**Unit Number **] Capsule
weekly/saturday
INSULIN GLARGINE 110 units SQ at bedtime
INSULIN LISPRO SQ below with meals 56 units AM, 16 units a
lunch, and 60 units at dinner time
LEVOTHYROXINE 50 mcg daily
LOSARTAN-HYDROCHLOROTHIAZIDE 50 mg-12.5 mg Tablet daily
METFORMIN 500 mg 2 [**Hospital1 **]
METOPROLOL SUCCINATE 25 mg daily
OMEPRAZOLE 20 mg [**Hospital1 **]
PRAVASTATIN 40 mg 2 Tablets daily
ASPIRIN 325 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
10. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation q2h as needed for
shortness of breath or wheezing.
12. Lantus 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous QBreakfast : home dose 110 units please continue to
titrate up to home dose based on BG .
13. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
14. Imdur 60 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day for 3 months.
15. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO
qsaturday.
16. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. Insulin scale insulin
Humalog
10 units premeal plus sliding scale
100-140 - 4 units
141-180 - 8 units
181-210 - 12 units
211-240 - 14 units
241-280 - 16 units
281-320 - 18 units
18. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
TBD
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Left PCA embolic stroke
Hypertension
Diabetes Mellitus
Mild PVD
Hypercholesterolemia
Right Breast CA in [**2166**] s/p lumpectomy and radiation therapy
with recurrence in [**2170**] s/p right breast mastectomy and
reconstruction
Left great toe to left shin cellulitis s/p Cephalexin and
Bactrim course completed 1-2 weeks ago with resolution. This is
an intermittent problem.
Depression
Restless leg syndrome
Hypothyroidism
DVTs in the past
s/p appendectomy
Discharge Condition:
Alert and oriented x3 right arm weakness
Ambulating with assistance
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Edema: Trace bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Doctor Last Name **] [**Telephone/Fax (1) 170**] Date/Time: [**2174-12-21**] 1:30
Location: [**Hospital Unit Name **] [**Last Name (NamePattern1) **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 101253**] office will call with
appt.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (2) 6803**]in 4-5 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:[**2174-11-21**]
|
[
"41401",
"25000",
"V5867",
"4019",
"2720",
"2449",
"V1582"
] |
Admission Date: [**2148-10-30**] Discharge Date: [**2148-11-16**]
Date of Birth: [**2083-1-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
malaise, dry cough
Major Surgical or Invasive Procedure:
DCCV
avj modification
Intubation and mechanical ventilation
central line placement
Swan Ganz placement
FNA of right axillar lymph node
pounch biopsy of anterior mass/nodule
Throcentesis
arterial line placement
History of Present Illness:
This is a 65 year old male with a PMH significant for HTN,
dyslipidemia, DMII, who presented to the ED with malaise, poor
appetite, and dry cough for 5 days PTA. 3 days prior to
admission he noted onset of bilateral lower extremity edema. 1
day prior to admission, noted severe generalized weakness. He
notes he has been sleeping in a chair for the last 2 nights
because he could not get into bed. He denies any recent HA,
visual changes, chest pain, palpitations, shortness of breath,
orthopnea, PND, abd. pain, N/V/D, fevers, chills, rash, or
dysuria. He sleeps on 2 pillows normally and this has not
changed. He notes prior to this episode that he was able to walk
for 30 minutes a day without any symptoms.
.
In the ED, initial vitals were 97.8, 118/90, 88, 96% RA.
However, shortly there after he went into a.fib with RVR, rates
in the 130s to 150s.
Given diltiazem 10 x 3, without improvement. Then given
metoprolol 5 x 1 without improved. Started on amiodarone load
but stopped due to hypotension, with SBP in the 80's. Then he
was given 100mg PO metoprolol and levofloxacin for ? infiltrate
on exam. Received KCL 60 mg and 2L IVF. Noted to be more
tachypneic after the fluids with cxr showing large heart, ?
effusion. He was then admitted to the CCU for further management
of RVR with hypotension.
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, hemoptysis, black stools
or red stools. S/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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
.
On arrival the patient states that he feels generally weak but
otherwise well.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes Mellitus II,
(+)Dyslipidemia, (+)Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
.
-OTHER PAST MEDICAL HISTORY:
- Arthritis
- Gout
- Obesity
Social History:
He is a retired funeral home director. Lives with wife, and son.
[**Name (NI) **]-time helps his son with his work. The patient has never
smoked. One to two cans of beer per month, never more, no
drinking recently. No illicits.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. The patient is
married with two children ages 26 and 28 who are healthy and
well. Family history of hypertension and mother died of reported
questionable food poisoning at age 38.
Physical Exam:
VS: 98, 94/67, 140, 98% 2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to just below angle of the jaw.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachy, [**Last Name (un) **], normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 3+ bilateral LE edema No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2148-10-30**] 08:50AM BLOOD WBC-5.4 RBC-3.84*# Hgb-10.6*# Hct-30.9*#
MCV-81* MCH-27.6 MCHC-34.2 RDW-16.7* Plt Ct-196
[**2148-11-16**] 06:19AM BLOOD WBC-12.1* RBC-3.00* Hgb-8.0* Hct-23.7*
MCV-79* MCH-26.8* MCHC-33.9 RDW-17.3* Plt Ct-68*
[**2148-10-30**] 08:50AM BLOOD Neuts-57 Bands-1 Lymphs-31 Monos-8 Eos-1
Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-2*
[**2148-10-30**] 08:50AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-1+ Microcy-1+ Polychr-1+
Spheroc-OCCASIONAL Target-1+ Tear Dr[**Last Name (STitle) 833**]
[**2148-10-30**] 08:50AM BLOOD PT-13.0 PTT-24.8 INR(PT)-1.1
[**2148-11-4**] 03:06AM BLOOD Fibrino-960*
[**2148-11-8**] 08:55PM BLOOD Fibrino-1004*#
[**2148-11-9**] 11:34PM BLOOD Fibrino-1061*#
[**2148-11-12**] 11:19AM BLOOD Fibrino-957*
[**2148-11-12**] 11:19AM BLOOD FDP-40-80*
[**2148-11-4**] 03:06AM BLOOD CD5-DONE CD23-DONE CD45-DONE HLA-DR[**Last Name (STitle) 7735**]
[**Name (STitle) 7736**]7-DONE Kappa-DONE CD10-DONE CD19-DONE CD20-DONE Lambda-DONE
[**2148-11-4**] 03:06AM BLOOD CD3%-DONE
[**2148-11-1**] 06:46AM BLOOD Ret Aut-2.3
[**2148-11-8**] 04:17AM BLOOD Ret Aut-1.1*
[**2148-11-12**] 01:43PM BLOOD Fact V-133 FacVIII-345*
[**2148-10-30**] 08:50AM BLOOD Glucose-236* UreaN-46* Creat-1.2 Na-135
K-2.8* Cl-89* HCO3-33* AnGap-16
[**2148-11-16**] 06:19AM BLOOD Glucose-223* UreaN-115* Creat-2.5* Na-133
K-4.1 Cl-88* HCO3-29 AnGap-20
[**2148-10-31**] 01:05AM BLOOD ALT-50* AST-69* LD(LDH)-4410*
CK(CPK)-230* AlkPhos-143* TotBili-0.6
[**2148-11-15**] 02:05AM BLOOD ALT-71* AST-109* LD(LDH)-4210*
AlkPhos-213* TotBili-1.0
[**2148-10-30**] 08:50AM BLOOD CK-MB-7 proBNP-2677*
[**2148-10-30**] 08:50AM BLOOD cTropnT-0.07*
[**2148-10-31**] 01:05AM BLOOD CK-MB-7 cTropnT-0.06*
[**2148-10-31**] 11:02PM BLOOD CK-MB-7 cTropnT-0.06*
[**2148-10-30**] 08:50AM BLOOD Calcium-9.5 Phos-5.6* Mg-2.6
[**2148-11-8**] 08:55PM BLOOD Calcium-9.0 Phos-4.6* Mg-2.1 UricAcd-7.1*
[**2148-11-16**] 06:19AM BLOOD Calcium-7.7* Phos-6.2* Mg-2.0
[**2148-10-30**] 03:30PM BLOOD calTIBC-239 Hapto-460* Ferritn-GREATER TH
TRF-184*
[**2148-11-4**] 03:06AM BLOOD D-Dimer-9918*
[**2148-11-12**] 01:43PM BLOOD D-Dimer-[**Numeric Identifier 10112**]*
[**2148-11-12**] 11:19AM BLOOD Hapto-270*
[**2148-10-30**] 08:50AM BLOOD TSH-2.2
[**2148-11-4**] 03:06AM BLOOD Cortsol-32.7*
[**2148-10-30**] 08:14PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2148-11-5**] 04:23AM BLOOD Digoxin-1.4
[**2148-10-30**] 04:53PM BLOOD pO2-52* pCO2-41 pH-7.49* calTCO2-32* Base
XS-7
[**2148-11-15**] 06:12AM BLOOD Type-ART Temp-37.4 Rates-20/0 Tidal V-600
PEEP-12 FiO2-50 pO2-110* pCO2-49* pH-7.43 calTCO2-34* Base XS-6
-ASSIST/CON Intubat-INTUBATED
[**2148-10-30**] 08:57AM BLOOD Glucose-228*
[**2148-10-30**] 03:30PM BLOOD Lactate-2.2* K-3.4*
[**2148-11-15**] 06:12AM BLOOD Lactate-1.9
[**2148-11-10**] 05:25PM BLOOD freeCa-1.11*
[**2148-11-15**] 02:12AM BLOOD freeCa-1.07*
Portable TTE (Complete) Done [**2148-10-30**]
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 is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20 %). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. RV with
moderate global free wall hypokinesis. 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 left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The tricuspid valve leaflets are mildly
thickened. There is severe pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
IMPRESSION: Dilated cardiomyopathy (tachycardia mediated?)
Portable TEE (Complete) Done [**2148-10-31**]
IMPRESSION: No left atrial/appendage thrombus. Severely
depressed left ventricular systolic function (EF 20%).
UNILAT LOWER EXT VEINS PORT LEFT Study Date of [**2148-11-1**]
FINDINGS: Please note, the study is somewhat limited due to
patient's inability to Valsalva. Grayscale and Doppler
evaluation of the left common femoral, superficial femoral, and
popliteal veins was performed. There is normal compression,
augmentation and flow. The posterior tibial and peroneal veins
are also visualized and patent. IMPRESSION: No evidence of DVT.
ECG Study Date of [**2148-11-2**]
Sinus rhythm. Left atrial abnormality. Left bundle-branch block.
Compared to the previous tracing of [**2148-11-1**] sinus rhythm has
appeared. There is occasional atrial ectopy. Clinical
correlation is suggested.
CT CHEST/ABDOMEN/PELVIS W/CONTRAST Study Date of [**2148-11-2**]
IMPRESSION:
1)Multiple subcutaneous nodules with larger necrotic masses in
the right axilla and further nodules in the left perinephric
region are highly suspicious for metastases, possible melanoma.
Biopsy of the right axillary lymph node is recommended.
2)Loculated large left pleural effusion with atelectasis in the
left lung and small right pleural effusion.
3)Moderately large pericardial effusion in the presence of
moderate cardiomegaly. Subcentimeter hypodensities in the liver
and lower pole of the left kidney could be cysts.
Brief Hospital Course:
# Atrial fibrillation with RVR: Pt was admitted with symptoms of
HF for several months and was found to be in afib with RVR.
During the admission, he was cardioverted several times without
success, loaded on amiodarone, and also administered an esmolol
gtt during periods of refractory tachycardia, which did not help
improve his rate but did make him hypotensive. In general, the
above interventions were ineffective at controlling his rate
until he was fully loaded on amiodarone and went for partial AV
nodal ablation and pacemaker placement, at which point he
remained in sinus rhythm for several days. Shortly thereafter
he was also started on low dose digoxin. He had periods of
return to AF c RVR, initially rate controlled with PO
amiodarone, digoxin and PRN metoprolol, with rates generally in
the 90s-100s and stable BPs. Later in the hospital course the
patient developed RVR refractory to amiodarone gtt + IV
metoprolol. The etiology of his refractory afib was unclear but
likely resulting from chronic hypertension. There was also
concern for tumor mets or catecholamine surge from
neuroendocrine tumor that may be contributing to his refractory
afib. He continued to have periodic atrial fibrillation that
respond to metoprolol or self-resolves throughout the rest of
his hospitalization.
# Cardiomyopathy: Newly found EF of 20% with globally dilated
RV. The etiology of his cardiomyopathy was unclear. [**Name2 (NI) **] was
treated with rate control as above and diuresis with lasix gtt
and PRN lasix boluses + PRN metolazone.
# Hypotension: Patient became significantly hypotensive during
this admission and required substantial pressor support while on
nodal agents to control his arrhythmia. The etiology of his
hypotension was thought to be cardiogenic vs. septic shock. He
continued to require pressors to the time of his passing.
# [**Location (un) 5668**] cell tumor: Mr [**Known lastname 10113**] had multiple concerning nodules
on exam and by CT which were biopsied and showed [**Location (un) 5668**] cell
carcinoma. Later in the hospitalization pOncology was consulted
but given his tenuous state treatement was deferred. CT scan
and MRI of the head was performed and multiple intracranial
metastasis were found with a possible intraparenchial bleed in
the cerebellum.
# Respiratory distress: Pt was intubated early in the admission
out of concern for changing mental status and inability to
protect his airway. On [**11-4**], pt had increasing oxygen
requirements and was found to have white-out of the left lung by
CXR. 600 ccs were drained from L pleural effusion. He was also
bronched out of concern for a mucus plug and secretions were
removed from his airways with subsequent improvement of his
respiratory status. However, he was not able to come off the
ventilator.
# Altered mental status: On admission to the hospital, pt was
alert and oriented x3 but his mental status rapidly deteriorated
and he required intubation to help protect his airway. CT head
was obtained on [**11-4**] and showed no acute intracranial proccess,
no bleed, but did showed extra-axial lesions which were
concerning for meningiomas vs. metastiatic cancer.
Additionally, his hypoxia/hypercarbia were likely contributing
to his altered mental status, as well as his poor perfusion in
the context of cardiogenic shock.
.
# Fever: most likely represents B sxs related to his new
malignancy, however also concerning for infection in the context
of sputum cxs growing gram neg rods and gram positive cocci as
well as positive influenza testing. He was treated with 6 day
course of vanc/cefepime/cipro, then ID consulted for persistent
fevers despite abx tx. These antibiotics were then discontinued
and he was started on ceftriaxone given that there was no growth
in any other cultures.
# Influenza: pt tested positive for influenza A, which may
explain the URI sxs that the patient complained of the week
prior to admission. He was placed on droplet percautions and
treated with osteltamavir and ramantidine. Samples sent to
state lab for further analysis and results were pending.
# Anemia: No clear source of bleed during the admission however
crit was lower than baseline and pt required PRBCs to stabilize
his crit.
# Hyperlipidemia: Cholesterol not well controlled according to
last lipid panel measured in [**11-24**]. Chol: 295, LDL: 192, HDL:
79, TG: 120. His statin dose was increased to 80 mg PO daily.
# DMII: Last A1c in [**2-26**] was 7.4%. He was initially treated with
long acting insulin/ISS but later transitioned to insulin gtt
for better control of his sugars.
# LE edema: LE doppler performed early in the admission out of
concern for DVT unequal edema of the LEs, however studies were
negative and the LE edema was attributed to his heart failure
and he was treated with diuresis.
# Epistaxis: pt with significant nosebleed and was seen by ENT
who packed the bleed. No further bleeding after this
intervention.
# Thrombocytopenia: HIT abx negative. DIC labs WNL.
# Arthritis: Stable.
# Gout: Stable. Allopurinol continued
Medications on Admission:
MEDICATIONS:
- allopurinol 600mg PO daily
- glipizide 10mg PO BID with meals
- hydrochlorothiazide 50mg PO qam
- lisinopril 10mg PO qam
- metformin 500mg SR daily with dinner
- salsalate 500mg PO TID
- simvastatin 20mg PO qhs
- verapamil 180mg SR PO daily
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
shock
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"42731",
"51881",
"5849",
"4280",
"2875",
"25000",
"2724",
"4019"
] |
Admission Date: [**2192-7-5**] Discharge Date: [**2192-7-17**]
Date of Birth: [**2118-12-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfonamides / Lasix
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
bioprosthetic mitral regurgitation
Major Surgical or Invasive Procedure:
[**2192-7-6**] redo sternotomy, reoperative mitral valve replacement/
resection of Left Atrial Appendage and subsequent re-exploration
for bleeding
History of Present Illness:
This 73 year old Hispanic male underwent mitral valve repair in
[**2179**]. he developed hemolytic anemia requiring valve replacement
later the same year. He now has heart failure, pulmonary
hypertension and progressive silattion of ther left atrium. he
was admitted for reoperation.
Past Medical History:
hypercholesterolemia
congestive heart failure with pulmonary hypertension
mitral stenosis
aortic stenosisfibrillation
h/o hemolytic anemia
gastric erosions
syncope
h/o subdural hematoma
h/o subarachnoid hematoma
Insomnia
Depression
Bilateral Carotid Artery Disease, Right carotid bruit
[CTA showing cath fragment in right common carotid artery
probaly since in MVR [**12/2179**]] - [**2189-7-15**]
Social History:
Retired clinical psychologist. Quit tobacco in [**2164**]. Lives with
wife [**Name (NI) 5627**] in [**Location (un) 3146**] and HCP is son, [**Name (NI) **] [**Name (NI) 14763**]
([**Telephone/Fax (1) 14764**]) and is full code. Reports to be independent in
ADLs and still drives but finances taken care per wife.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother died of breast cancer. Father died of
Parkinson' Disease, lung cancer (smoker).
Physical Exam:
Admission:
heart rate of 58 which is regular.
Respiratory rate is 20. Blood pressure is 140/70. Height is
5'2". Weight is 131 pounds.
HEENT, normocephalic and atraumatic. Pupils are equal, round,
and reactive to light and accommodation. Extraocular movements
are intact. Oropharynx is within normal limits.
Chest is clear to auscultation bilaterally except for some mild
crackles at the bases bilaterally.
Cardiac examination shows the pulse shows an irregular rhythm
with a IV/VI systolic murmur heard best at the left parasternal
border and left apex which radiates to left axilla.
Abdomen is soft, nontender, and nondistended. Bowel
sounds are present. There is no costovertebral angle
tenderness.
Extremities are warm and well perfused. There is
1+ edema. There are no varicosities. Pulses are 2+
Pertinent Results:
Intra-op TEE
[**2192-7-6**]
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is mildly
depressed (LVEF= 45-50 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is dilated with
focal severe hypokinesis of the mid and apical free wall. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Trace aortic regurgitation
is seen. A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral valve leaflets are thickened. There is
prolapse of the prosthetic mitral valve leaflets. The gradients
are higher than expected for this type of prosthesis. There is
mild valvular mitral stenosis (area 1.5-2.0cm2). Moderate to
severe (3+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Mild pulmonic regurgitation is
seen. There is a trivial/physiologic pericardial effusion. Dr.
[**Last Name (STitle) 914**] was notified in person of the results in the operating
room at the time of the study.
POST BYPASS The patient is receiving milrinone and epinephrine
by infusion. The patient is AV paced. The right ventricular free
wall shows some mild improvement of the mid and apical segments
but there is still moderate hypokinesis. The left ventricle
dispalys somewhat improved systolic function with an ejection
fraction of about 55%. There is a bioprosthesis in the mitral
position. It appears well seated. There is occassional trace
valvular mitral regurgitation. No perivalvualr regurgitation is
seen. Leaflet motion appears normal. The thoracic aorta appears
intact status post decannulation. No other significant changes
from the pre-bypass study.
Admission:
[**2192-7-5**] 06:20PM BLOOD %HbA1c-5.5 eAG-111
[**2192-7-5**] 06:20PM PT-17.9* PTT-27.8 INR(PT)-1.6*
[**2192-7-5**] 06:20PM PLT COUNT-200
[**2192-7-5**] 06:20PM WBC-7.2 RBC-3.07* HGB-9.7*# HCT-29.0* MCV-95
MCH-31.4 MCHC-33.2 RDW-17.2*
[**2192-7-5**] 06:20PM ALBUMIN-3.8
[**2192-7-5**] 06:20PM LIPASE-33
[**2192-7-5**] 06:20PM ALT(SGPT)-37 AST(SGOT)-61* LD(LDH)-879* ALK
PHOS-144* AMYLASE-48 TOT BILI-1.0
[**2192-7-5**] 06:20PM GLUCOSE-114* UREA N-47* CREAT-1.7* SODIUM-134
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-14
[**2192-7-5**] 08:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
Discharge:
[**2192-7-17**] 05:41AM BLOOD WBC-9.0 RBC-3.61* Hgb-11.1* Hct-32.2*
MCV-89 MCH-30.6 MCHC-34.4 RDW-15.7* Plt Ct-230
[**2192-7-17**] 05:41AM BLOOD Glucose-99 UreaN-34* Creat-1.4* Na-137
K-3.6 Cl-98 HCO3-34* AnGap-9
[**2192-7-17**] 05:41AM BLOOD PTT-31.5
[**2192-7-15**] 05:19AM BLOOD PT-27.4* INR(PT)-2.7*
[**2192-7-14**] 09:19AM BLOOD PT-26.1* INR(PT)-2.5*
[**2192-7-13**] 05:15AM BLOOD PT-21.0* INR(PT)-1.9*
[**2192-7-12**] 03:02AM BLOOD PT-15.6* PTT-26.6 INR(PT)-1.4*
Radiology Report CHEST (PA & LAT) [**2192-7-16**] 1:58 PM
Final Report
CHEST RADIOGRAPH, PA AND LATERAL VIEWS: Patient is status post
CABG and
median sternotomy. A right upper extremity PICC is again seen
coiled in the mid SVC, with tip terminating likely in the upper
SVC. This appears unchanged since [**2192-7-9**].
Small right greater than left pleural effusions remain, slightly
decreased on the right. There is adjacent bibasilar atelectasis.
Otherwise, there is no evidence of pulmonary edema.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Brief Hospital Course:
On [**7-6**] he went to the Operating Room where redo sternotomy and
redo mitral valve replacement were performed. He required
reexploration for bleeding in the immediate post-op course, then
remained stable. Within 24 hours he woke neurologically intact
was extubated and weaned from all vasoactive infusions. All
tubes lines and drains were removed per cardiac surgery
protocol. He remained in the ICU for close monitoring and was
ultimately transferred to the floor on POD #6. Once on the
stepdown floor he began to increase his activity level. He was
treated with amiodarone/coumadin for recurrent atrial
fibrillation. Speech and swallow team evaluated him for possible
aspiration risk with weak mastication. Diet recommendations made
by team. He was cleared for a regular diet. He took several
days to diurese adequately and to wean from oxygen. He was
aggressively diuresed for a moderate right sided pleural
effusion and general volume overload. The patient was
re-started on his home dose of sotalol. He remained in SR with
1st degree AV block for the remainder of the hospital course.
By the time of discharge on POD 11 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions. Dr [**Last Name (STitle) **] will follow his
INR and adjust the Coumadin dose accordingly.
Medications on Admission:
Proventil 90 mcg two puffs inhaler p.r.n.,
Pulmicort Flexhaler, Symbicort, Edecrin 50 mg p.o. daily,
Lisinopril 20 mg p.o. daily, Ativan 0.5 mg p.o. p.r.n.,
Singulair 10 mg p.o. daily, Nifedipine 90 mg p.o. daily,
Sertraline 50 mg p.o. daily, Simvastatin 20 mg p.o. daily,
Sotalol 80 mg quarter tablet p.o. t.i.d., Trazodone 100 mg p.o.
q.h.s., Warfarin 3.5 mg p.o. daily, Folic Acid 1 mg p.o. daily,
Multivitamin one p.o. daily, and Omeprazole 20 mg p.o. daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
bioprosthetic mitral regurgitation
s/p mitral valve replacement x2
s/p reoperation for postoperative bleeding
s/p mitral valve repair
pulmonary hypertension
congestive heart failure
paroxysmal atrial fibrillation
h/o hemolytic anemia secondary to valve dysfunction
chronic obstructive pulmonary disease
hypercholesterolemia
h/o subdural hematoma
h/o subarachnoid hematoma
erosive gastritis
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with percocet
Sternal Incision: healing well, no erythema or drainage
Edema: 2+ bilateral LEs
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**]).
**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: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2192-8-7**] 1:15
Please call to schedule appointments with:
Primary Care: Dr.[**Last Name (STitle) 131**] [**Telephone/Fax (1) 133**] in [**1-7**] weeks
Cardiologist: Dr. [**Last Name (STitle) **] in [**2-8**] weeks [**Telephone/Fax (1) 5768**]
**Dr. [**Last Name (STitle) **] to resume management of INR/coumadin dosing**
1st INR draw [**2192-7-18**]
**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:[**2192-7-17**]
|
[
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"9971",
"5119",
"2851",
"4240",
"4168",
"42731",
"2724",
"4280",
"2720",
"2875"
] |
Admission Date: [**2165-6-4**] Discharge Date: [**2165-7-3**]
Date of Birth: [**2112-7-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
SAH
Major Surgical or Invasive Procedure:
[**6-3**]: Rt EVD
[**6-4**]: Distal L ICA aneurysm coiling
[**6-26**]: PEG placment
History of Present Illness:
52F w/o PMH, reportedly collapsed in early evening of [**6-4**];
transported to OSH where whe was intubated; head CT showed
diffuse SAH; tx to [**Hospital1 18**] for definitive treatment
Past Medical History:
None
Social History:
unknown
Family History:
unknown
Physical Exam:
On Admission:
102/64 107 20 100%
Intubated, not sedated.
Pupils: 3 mm, trace reactive, bilat.
No eye opening. No vocal response.
Motor: internal rotation/flexion of UE to stim, symetrically.
Min. withdrawal LE to stim, symetrically.
DTRs 2+ throughout and symetric; toes downgoing; tone: normal;
On Discharge:
XXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2165-6-3**] 10:38PM BLOOD WBC-14.9* RBC-3.83* Hgb-12.5 Hct-39.2
MCV-102* MCH-32.7* MCHC-31.9 RDW-12.8 Plt Ct-258
[**2165-6-3**] 10:38PM BLOOD Neuts-73.8* Lymphs-21.1 Monos-3.9 Eos-0.7
Baso-0.5
[**2165-6-4**] 04:28AM BLOOD PT-13.9* PTT-23.7 INR(PT)-1.2*
[**2165-6-3**] 10:38PM BLOOD Glucose-245* UreaN-22* Creat-0.9 Na-140
K-3.5 Cl-105 HCO3-20* AnGap-19
[**2165-6-4**] 04:28AM BLOOD CK(CPK)-304*
[**2165-6-4**] 04:28AM BLOOD cTropnT-0.96*
[**2165-6-4**] 12:31PM BLOOD CK-MB-21* MB Indx-6.2* cTropnT-0.51*
[**2165-6-4**] 09:36PM BLOOD CK-MB-12* MB Indx-4.5 cTropnT-0.31*
[**2165-6-5**] 02:55PM BLOOD cTropnT-0.13*
[**2165-6-3**] 10:38PM BLOOD Calcium-7.5* Phos-5.2* Mg-2.0
Labs on Discharge:
XXXXXXXXXXXXXX
Imaging:
CTA Head [**6-5**]:
IMPRESSION:
Diffuse subarachnoid hemorrhage as described above with a
multilobulated left ICA terminus aneurysm measuring
approximately 4 x 6 mm as the presumed source. Traditional
angiography pending.
Cardiac Echo [**6-4**]:
Conclusions
Overall left ventricular systolic function is severely depressed
(LVEF= 20--25%). There is severe regional left ventricular
systolic dysfunction with akinesis of mid-to-apical myocardioum.
Basal and Apex areas are spared. Right ventricular chamber size
and free wall motion are normal. The left atrium is normal in
size. No atrial septal defect is seen by 2D or color Doppler.
The number of aortic valve leaflets cannot be determined. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. No mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal.
IMPRESSION: Severe left ventricular systolic dysfunction (EF
20-25 %) with regionality; akinesis of mid-to-apical walls with
sparing of the apex. Right ventricular systolic function and
size is normal. Moderate to severe (3+) tricuspid regurgitation.
CT C-spine [**6-4**]:
IMPRESSIONS:
1. No acute traumatic injury seen in the cervical spine.
2. Blood in the basal cisterns tracking inferiorly and
anteriorly along the brainstem and upper spinal cord. Thecal sac
contents are not adequately assessed on the present study. MR
can be considered if there is concern based on neurological
examination.
3. Airspace consolidation in the posterior lung apices with
smooth septal
thickening. Findings along with chest radiograph likely
represents some
pulmonary edema, although aspiration cannot be excluded.
CT Head [**6-5**]:
FINDINGS: The diffuse subarachnoid hemorrhage appears stable in
extent.
Overall, ventricular size has further decreased, compared to the
prior study. The ventriculostomy catheter terminating in the
region of the third ventricle remains present. There has been
further interval progression of bilateral regions of
hypoattenuation involving the medial inferior frontal lobes.
There is no associated parenchymal hemorrhage. There is no shift
of normally midline structures. The streak artifact produced by
left distal internal carotid artery coils obscures evaluation in
area. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Trace
intraventricular hemorrhage layering posteriorly in the
occipital horns as well as small amount in the third ventricle
are stable. The mastoid air cells and imaged paranasal sinuses
remain well aerated.
IMPRESSION:
1. Slight decrease in ventricular size, compared to the prior
study.
2. Further evolution of bifrontal hypoattenuation, which may
represent
infarcts rather than non-hemorrhagic contusion, given the
progression. No
parenchymal hemorrhage. MR [**First Name (Titles) **] [**Last Name (Titles) **] head can be considered, if
necessary to
assess extent and vessels as recommended earlier.
3. Stable extent of diffuse subarachnoid hemorrhage.
CXR [**2165-6-5**]
Final Report
INDICATION: 52-year-old female with subarachnoid hemorrhage,
dilated
cardiomyopathy. Evaluate for pulmonary edema.
Single AP chest radiographs compared to 13 hours prior shows no
change. ET
tube tip is 2.3 cm above the carina. Left internal jugular
central venous
catheter terminates in the mid SVC. The NG tube tip is in the
stomach, the
sidehole slightly below the gastroesophageal junction. The
cardiomediastinal silhouette is stable. Again seen are bilateral
perihilar opacities consistent with pulmonary edema, not
significantly changed from prior exam. There is no pneumothorax
or pleural effusion.
IMPRESSION: Compared to prior exam from [**2165-6-5**], there is
no change in the extent of pulmonary edema.
Cardiac Echo : [**2165-6-11**]
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is good (>20 cm/s). No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. No masses or
thrombi are seen in the left ventricle. Overall left ventricular
systolic function is severely depressed (LVEF= 20-25 %). with
mild global free wall hypokinesis. with focal hypokinesis of the
apical free wall. There is no mass/thrombus in the right
ventricle. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are structurally normal. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2165-6-4**], left ventricular systolic function has improved.
Akinesis of mid-to-apical walls with sparing of the apex has
resolved.
Final Report
PORTABLE CHEST [**2165-6-19**]:
COMPARISON: Study of earlier the same date.
INDICATION: Feeding tube assessment.
FINDINGS: Feeding tube tip is directed cephalad in region of
gastroduodenal
junction. Appearance of the chest is similar to the recent
radiograph of
about 2 hours earlier except for minimal improved aeration in
the left
retrocardiac region.
[**2165-6-25**] 12:25 PM CT
HEAD CT: Axial imaging was performed through the brain without
IV contrast
administration.
COMPARISON: CT head [**2165-6-23**].
FINDINGS: There is a tract of hypodensity extending along the
course of the prior right frontal approach ventriculostomy
catheter (2:13). There is no hyperdensity along this tract to
suggest the presence of hemorrhage. The ventricles are unchanged
in size and configuration. There is streak artifact from a left
ICA aneurysm coil. [**Doctor Last Name **]-white matter differentiation remains
well preserved. There is no evidence of prior subarachnoid
hemorrhage. There is no shift of normally midline structures.
There is hypodensity in the territory of the left MCA related to
prior infarct (2:15), which appear stable without evidence for
hemorrhagic transformation. There is a right frontal burr hole
otherwise osseous structures are intact. The paranasal sinuses,
ethmoid, and mastoid air cells are clear.
IMPRESSION:
1. Post-right frontal approach ventriculostomy catheter removal
without
evidence for hemorrhage. Stable ventricular size.
2. Unchanged appearance to region of infarction in the left MCA
distribution without hemorrhagic transformation.
SAT [**2165-6-22**] 12:08 PM
Final Report
INDICATION: 52-year-old female with transaminitis and fevers.
Evaluate right
upper quadrant.
COMPARISON: CT chest dated [**2165-6-7**].
FINDINGS: The liver is normal in contour and echotexture. There
is a single 1.2-cm cyst identified in the periphery of the right
dome. There are no other focal liver lesions identified. There
is no intrahepatic or extrahepatic biliary ductal dilatation.
The common bile duct measures 5 mm. The gallbladder is
unremarkable, with no wall thickening, no pericholecystic fluid.
There are no stones or sludge identified within the gallbladder.
There is normal antegrade flow identified in the main portal
vein. The spleen measures 8.7 cm and is normal in appearance.
There is no free fluid in the abdomen. Small right pleural
effusion is noted.
IMPRESSION:
1. 1.2-cm cyst in the right lobe of the liver, as appreciated on
CT of the
chest dated [**2165-6-7**]. Liver is otherwise unremarkable.
2. No son[**Name (NI) 493**] evidence for acute cholecystitis. No
cholelithiasis.
Brief Hospital Course:
52F admitted to [**Hospital1 18**] after transfer from OSH following a
witnessed syncopal episode. Head CT performed showing diffuse
SAH. CTA of head also performed with preliminarily identified an
aneurysm at the left ICA bifurcation. She was loaded with
dilantin, and started on nimodipine, and emergent bedside
external ventricular drain was placed. She also had a cardiac
echo done for concerns of a catacholamine induced
cardiomyopathy(had developed pulmonary edema), which showed
significantly depressed cardic function. She was placed on a
[**Last Name (un) 18821**] monitor to more closely monitor for this. She had an
angiogram done on [**6-4**], when the left distal ICA aneurysm was
coiled. She then returned to the ICU postoperatively.
On [**6-5**](overnight) she had a ICP elevation to 50 and the drain
was promplty dropped to 10cm, and ICP normalized. Emergent head
CT was done which showed likely evolving brifrontal
hypoattenuations/possible stroke. She again returned to angio on
[**6-6**] to further evaluate vascualar patency given this new CT
finding.The patient was febrile with a Tmax 101.6 and was pan
cultured,the urine and cerebral spinal fluid cultures were both
neagtive. On [**6-6**] The Dobutamine intravenous drip was off,
vasopressors Levophed and neo cont. The Nimodipine cut in [**12-21**]
to maintain goal blood pressures. The patient was brought to
angio, there was no significant spasm and given 5mg
verapamil-aneurysm stable. Blood cultures were found to be
negative. The sputum culture was positive for rare yeast.On
[**6-7**]: The patient had an acute PaO2 decrease to 50%. There was
a concern for Pulmonary embolusE. The CTA of the Chest was not
consistent with Pulmonary embolus. The CT Head was unchanged.
The patient was moniotored for possible Central Diabetes
Insipidus. The urine and sputum cultures were both negative. On
[**6-8**], The patient was pan-cultured for a fever to 102. A head
CT ordered for elevated ICP to 44, Mannitol was initiated for
increased ICPs. A CTA was performed which was consistent with a
slight decrease in intercranial vasospasm. On [**6-9**], The patient
required 3 doses of mannitol for sustained ICP levels of 23.
There were no changes in the patients mental status with these
ICP increases.On exam the patient was intermitently following
commands in the right upper extremity, the left upper extremity
moved to command, the left lower extremity and Right upper
extremity withdrew to pain,the patients eyes were open and
tracked with her eyes. On [**6-10**], The patient was back on a
dobutamine gtt continuously to maintain a goal blood pressure,
The patient had a TEE which was consistent with Ejection F of
20%. The LENIS were negative for deep vein thrombosis, The CSF
and sputum cultures were negative. On [**6-11**], The patient
underwent an angio which was consistent with mild to mod
vasospasm. She recieved 2 doses of verapamil.Nimodipine at 15mg
every 2 hours was restarted. On [**6-12**], The patient was bolused
with dilantin 300mg for a 7.9 level. The Head CT was repeated
and was stable. The patient was extubated and stopped nimodpine
for systolic blood pressure in 60's.The goal MAP > 100 and
dobutamine was restarted.
[**6-14**] CT shows:new stroke in the posterior left MCA distribution
CTA shows diffuse, severe vasospasm involving the bilateral MCAs
(left worse than right)the following day she underwent a
cerebral angiogram which showed Mild to moderate spasm Left A1,2
and M1,2 segments though her exam seemed to slightly improve
with brisk localization on LUE and localization on RUE though
not as brisk as left. She had some intermittent eye opening. A
stroke neurology consult was obtained and they agreed with our
continued HHH management and requested starting a Statin.
On [**6-17**], she was again febrile, and pan cultured. CVL
access was changed and catheter tip sent. OR was cancelled for
the day for her temperature, and possibly to re-attempt [**6-19**] or
[**6-20**] if afebrile and no positive cultures. Positive blood cx from
arterial line and appearance of axillary A line, concerned for
line infection and she was treated for line associated
bacteremia for 7 day course. PEG placed by surgery team on
[**2165-6-26**] without event. Meds and diet were advanced through PEG
as recommended without issue.
On discharge her neurological exam she preferred her eyes closed
would open to voice, questionable following commands with left
side. She is essentially plegic on right side but will withdraw
both arm and leg to pain. Her pupils are 4mm and reactive, her
incision are well healed. She was tolerating her tube feeds
without difficulty. Speech and swallow recommends video swallow
before initiating any oral feeds.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fevers.
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. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) as needed for fever.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (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 stridor.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Levetiracetam 100 mg/mL Solution Sig: One (1) PO BID (2
times a day).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
14. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
SAH
Left ICA bifurcation aneurysm
dysphagia
pulmonary edema
cerebral vasospasm
cardiogenic shock d/t sympathetic surge
stroke left MCA distribution
bifrontal strokes
fever / central
bacteremia / coag neg staph
altered mental status
mutism
Discharge Condition:
Neurologically with right sided plegia and mutism intermittently
follows commands
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest Eme
Followup Instructions:
Please call [**Telephone/Fax (1) 1669**] to schedule an appointment to be seen
by Dr. [**First Name (STitle) **] in approx 4 weeks after your discharge. You will
need to have a CT scan of the head without contrast at that time
Completed by:[**2165-7-3**]
|
[
"51881",
"2761",
"4280",
"2859"
] |
Admission Date: [**2198-3-12**] Discharge Date: [**2198-3-22**]
Date of Birth: [**2147-7-28**] Sex: M
HISTORY OF PRESENT ILLNESS: This is a 50 year old male with
a history of HIV, Hepatitis C, intravenous drug abuse and
poly-substance abuse, who was admitted from an outside
hospital with continued mental status changes after being
[**2198-3-9**]. He was taken initially to [**Hospital 1474**] Hospital
where he was given Narcan for presumed opiate overdose. He
became awake and agitated following the Narcan and was
admitted to the [**Hospital 1474**] Hospital Intensive Care Unit with
the diagnosis of acute renal failure and rhabdomyolysis. His
creatinine at that time was 13.2 and he had an initial CK of
14,000. He was treated with intravenous fluids, urine
His mental status continued to be abnormal as he demonstrated
both agitation and excessive somnolence. He was transferred
to [**Hospital1 69**] on [**3-12**], for
further evaluation of change in mental status after he had
become progressively lethargic and unresponsive to questions
at [**Hospital 1474**] Hospital. Of note, he was treated with Tequin
for a three-day course at [**Hospital 1474**] Hospital for a urinary
tract infection.
On arrival to [**Hospital1 69**], the
patient was noted to have a temperature of 100.2 F., and an
examination notable for delirium, nuchal rigidity, and
questionable right sided weakness. Head CT scan showed a 6
mm left posterior frontal hemorrhage. Lumbar puncture showed
approximately 1400 red blood cells and one white blood cell.
The patient was placed on empiric Acyclovir for coverage of
HSV encephalitis pending results of HSV PCR from
cerebrospinal fluid. An MRI and MRA study was consistent
with focal leukoencephalopathy of toxic, HIV, PML or other
origin.
In the Medical Intensive Care Unit, the patient received a
five day course of Fluconazole for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**] albicans urinary
tract infection. He defervesced. He was transfused with a
total of three units of blood for a hematocrit of 20. He was
treated aggressively for hypertension including diastolic
hypertension. An EEG performed in the Intensive Care Unit
showed encephalopathic but not epileptiform activity. On [**3-19**], he was transferred to the ACOVE Service for continued
care.
REVIEW OF SYSTEMS: Negative for headache, visual changes,
shortness of breath, cough, chest pain, back pain, abdominal
pain.
PAST MEDICAL HISTORY:
1. Human Immunodeficiency Virus diagnosed in [**2194**]; recent
CD4 count 309; HIV viral load less than 50.
2. Intravenous drug abuse with cocaine and heroin.
3. Poly-substance abuse.
4. Status post laparotomy for abdominal stab wound.
5. Herpes zoster in [**2194-8-14**].
ALLERGIES: No known drug allergies.
MEDICATIONS: (Outpatient)
1. Neurontin 600 mg p.o. three times a day.
2. Zerit 40 mg p.o. twice a day.
3. Sulfamethoxazole.
MEDICATIONS: (Transfer from Intensive Care Unit)
1. Prevacid 30 mg p.o. twice a day.
2. Multivitamin one p.o. q. day.
3. Nystatin 5 cc swish and swallow twice a day.
4. Folate 1 mg p.o. q. day.
5. Thiamine 100 mg p.o. q. day.
6. Ativan 1 mg p.o. twice a day.
7. Dyazide 50/25 q. day.
8. Lisinopril 40 mg p.o. q. day.
9. Haldol 5 mg p.o. twice a day.
10. P.R.N. Tylenol, Lomotil, Haldol, Ativan.
SOCIAL HISTORY: Positive for marijuana, cocaine, heroin,
alcohol use. The patient is married with three children. He
is currently unemployed.
PHYSICAL EXAMINATION: At admission, temperature 101.2 F.;
heart rate 90; blood pressure 150/92; respirations 14; pulse
oximetry 98% on room air. Generally, somnolent but arousable
African American male not following commands. HEENT: Pupils
equally round and reactive to light. Dry mucous membranes.
Neck: Nuchal rigidity present. Lungs: Coarse breath sounds
bilaterally with no wheezes. Cardiovascular: Regular rate
and rhythm, without murmurs, rubs or gallops. Abdomen:
Laparotomy scar present. Soft, nontender, nontender. Bowel
sounds present. Liver palpated at the right costal margin.
Extremities: Warm without edema. A left groin line is
intact. Foley catheter is present. There is an NG tube.
Neurologic: Somnolent and minimally arousable. Unable to
follow simple commands. Grossly intact strength and
sensation throughout. Reflexes two plus bilaterally.
LABORATORY STUDIES: (At admission) white blood cell count
of 5.7, hematocrit of 23.9, platelets 152, 68% neutrophils,
21% lymphocytes. PT 13.7, PTT 32.5, INR 1.3. Sodium 148,
potassium 3.3, chloride 115, bicarbonate 23, BUN 27,
creatinine 1.0. Arterial blood gas is 7.47/29/86 on room
air.
ALT 82, AST 249, alkaline phosphatase 55, total bilirubin
1.1, calcium 7.7, albumin 2.9, magnesium 1.9.
EKG normal sinus rhythm at 95 beats per minute, without
ischemic changes.
Urinalysis: Cloudy, specific gravity 1.010, large blood, 100
protein, pH 7.0, moderate leukocytes, 26 red cells, 110 white
cells, no bacteria, no epithelial cells.
Chest x-ray: No evidence of pneumonia.
Other laboratory studies: Serum tox screen positive for
opiates. Direct COOMBS test negative. LD 557, total
bilirubin 1.0, haptoglobin less than 20, fibrin split
products 10 to 40, D-Dimer 500 to 1000, fibrinogen 206, B12
491, folate 5.6. Iron 110, total iron binding capacity 221,
ferritin 280. ESR is 4. Reticulocyte count 3.0.
HOSPITAL COURSE: This is a 50 year old male with history of
HIV, Hepatitis C, intravenous drug and poly-substance abuse
who was admitted with persistent mental status changes from
[**Hospital 1474**] Hospital on [**2198-3-12**], for continued care.
1. Mental status: The patient was noted to be somnolent and
unable to follow simple commands and unable to answer
questions on admission. The differential diagnosis of
meningitis, HSV encephalitis, subarachnoid hemorrhage,
seizure activity or post-ictal state, or toxic metabolic
ingestion were considered. Given the patient's admission
fever, nuchal rigidity and questionable right sided
neurologic findings, a lumbar puncture was performed showing
1405 red blood cells and one white blood cell. At this
point, a differential was considered that included
subarachnoid hemorrhage or HSV encephalitis.
Acyclovir was empirically started on [**3-13**] and an HSV PCR
was sent from the cerebrospinal fluid. A head CT scan showed
a 6 mm left posterior frontal hemorrhage. A Neurologic
consultation was obtained and recommended MRI/MRA, which
showed diffuse white matter, T2 hyperintensity, involving the
cerebral and cerebellar white matter, brain stem, internal
capsule. These findings were considered to be consistent
with a toxic demyelinating process, HIV leukoencephalopathy
or progressive multi-focal leukoencephalopathy.
An EEG was performed showing left temporal lobe slowing, but
no evidence of epileptiform activity. There were
encephalopathic findings.
On [**3-18**], Acyclovir was discontinued when the HSV PCR from
cerebrospinal fluid result was negative. During the
Intensive Care Unit course, the patient required Haldol,
Ativan and at one point, restraints for patient's safety.
The patient was transferred from the Intensive Care Unit to
the ACOVE Unit on [**3-19**]. He continued to demonstrate
clearing of his mental status over the next 48 hours and at
the time of discharge, had returned to his baseline mental
status.
2. Infectious Disease:
HIV - The patient was noted to have a recent viral load of
less than 50 and a CD4 count in the 300s, and so these levels
were not repeated. His HIV medications were held on
admission per his primary care physician's request, and then
restarted on [**3-21**].
Urine - The patient was noted to have a urinary tract
infection at [**Hospital 1474**] Hospital treated with Tequin and was
also noted to have a urinary tract infection on admission to
the Intensive Care Unit at [**Hospital1 188**]. He was initially treated with Ceftriaxone from [**3-12**] through [**3-15**], as it was presumed to be bacterial.
Ceftriaxone was discontinued on [**3-15**], and Fluconazole was
started for a five-day course at that time when urine
cultures showed 100,000 colonies of [**Female First Name (un) 564**] albicans.
Blood - The patient was treated between [**3-14**] and [**3-15**],
with Vancomycin when one out of four blood cultures bottles
grew Gram positive cocci. The Vancomycin was discontinued
when the identification showed coagulase negative
Staphylococcus. The patient also had a positive serum RPR.
At the time of this dictation, a quantitative RPR is pending
at the State Laboratory.
Cerebrospinal fluid - At the lumbar puncture, the patient had
1,405 red blood cells and one white blood cell. HSV PCR was
negative; Cryptococcal antigen negative; [**Male First Name (un) 2326**] virus PCR is
pending at the time of this dictation. There was no viral,
bacterial, fungal growth from the cerebrospinal fluid culture
at the time of this dictation. On [**3-21**], the Infectious
Disease Service was consulted regarding need for continued
Acyclovir therapy. Infectious Disease recommended no further
treatment with Acyclovir as there was a very low suspicion
that the mental status changes were of HSV origin.
Stool - The patient was found to have diarrhea during
Intensive Care Unit stay. It was thought that this was
possibly due to opiate withdrawal. Stool studies were
negative for infectious etiologies.
3. Renal: The patient initially presented at the outside
hospital with acute renal failure and rhabdomyolysis. The
patient returned to baseline renal function and had resolving
rhabdomyolysis at the time of his admission to [**Hospital1 346**].
4. Gastrointestinal: The patient was noted on admission to
have a trans-aminitis consistent with chronic alcohol abuse.
He also presented, as mentioned, with diarrhea which was
thought to be due to opiate withdrawal as his stool studies
where negative. He was noted to have guaiac positive stool
during the admission. He was prophylaxed with Protonix
initially and then changed to Prevacid after he developed
thrombocytopenia. Otherwise, he tolerated a regular diet and
had no further gastrointestinal issues.
5. Genitourinary: Note is made that the patient was treated
during his entire hospital course for a total of two urinary
tract infections with yeast. This may require outpatient
follow-up.
6. Hematologic: The patient was noted to have an anemia at
admission which was thought to be multi-factorial related to
but not limited to HIV, HIV medications, nutritional
deficiencies and alcohol abuse. Iron studies were consistent
with anemia of chronic disease. The patient was transfused a
total of three units of packed red blood cells for a
hematocrit of 20, beginning on [**3-16**]. There were some
abnormalities of the hemolysis labs suggesting hemolysis, but
this was thought to be due to possible effect of blood
transfusion.
7. Cardiovascular: At a concern that the patient may have
had endocarditis, a transthoracic echocardiogram was
performed on [**3-15**], which showed an ejection fraction of
greater than 55% and no obvious vegetations. The patient was
also noted to be hypertensive at times during the Intensive
Care Unit stay and his blood pressure was successfully
controlled by the time of discharge with Lisinopril and
Dyazide.
8. Nutrition: The patient tolerated a regular diet which
was supplemented with a multivitamin, supplemental thiamine
and folate.
9. Musculoskeletal: The patient developed bilateral elbow
abrasions as well as a coccyx abrasion secondary to profound
agitation during Intensive Care Unit admission. These
abrasions were dressed with Duoderm and will be dressed as an
outpatient by visiting nurses.
10. Psychiatric: A Code Purple was called on the morning of
[**3-19**], when patient became agitated, began swearing and
attempted to leave the hospital. The patient was treated
with Haldol for acute delirium. Per the Psychiatry Consult
Service, the patient was continued on Haldol for agitation as
well as restraints, given that he was unable to be
re-oriented successfully. He was also maintained on a sitter
for periods of the hospital stay. Per Psychiatry
recommendations, a TSH was sent which was normal.
In terms of the patient's poly-substance abuse, he is to be
followed at the [**Hospital 96653**] Health Center as an outpatient as he
has declined inpatient therapy at this time.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient is being discharged to home.
DISCHARGE INSTRUCTIONS:
1. Diet regular.
2. Activity as tolerated.
DISCHARGE DIAGNOSES:
1. Mental status change.
2. Human Immunodeficiency Virus.
3. Hepatitis C.
4. Poly-substance abuse.
5. Intravenous drug abuse.
6. Leukoencephalopathy of uncertain origin.
7. Hypertension.
8. Acute renal failure.
9. Rhabdomyolysis.
MEDICATIONS AT DISCHARGE:
1. Multivitamin one p.o. q. day.
2. Dyazide 50/25 p.o. q. day.
3. Lisinopril 40 mg p.o. q. day.
4. Kaletra 3 capsules p.o. twice a day.
5. Didanosine 400 mg p.o. q. day.
6. Stavudine 40 mg p.o. twice a day.
7. Vitamin C 500 mg p.o. twice a day.
8. Zinc 220 mg p.o. q. day.
9. Oxycodone 10 mg p.o. q. four to six hours p.r.n. pain.1 week
supply6 ONLY
10. Neurontin 600 mg p.o. three times a day or as directed.
11. Duoderm CGF to bilateral elbows and coccyx, change q. 48
hours, normal saline cleansing at dressings changes; extra
thin Duoderm to the right ear, change q. 48 hours.
FOLLOW-UP INSTRUCTIONS:
1. Dr. [**First Name (STitle) **] [**Name (STitle) 2340**], [**Hospital1 69**]
Neurology, [**4-25**], at 03:00, in [**Hospital Ward Name 23**], [**Location (un) 858**].
2. [**Hospital 96653**] Health Center, phone number [**Telephone/Fax (1) 75084**]55, with Dr. [**Last Name (STitle) 724**], within one to two weeks.
3. Follow-up with Dr. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **] after [**5-7**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17014**], M.D. [**MD Number(1) 17015**]
Dictated By:[**Last Name (NamePattern1) 737**]
MEDQUIST36
D: [**2198-3-22**] 15:11
T: [**2198-3-22**] 18:44
JOB#: [**Job Number 96654**]
|
[
"5849"
] |
Admission Date: [**2102-7-27**] Discharge Date: [**2102-7-29**]
Date of Birth: [**2063-8-23**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Morphine
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Sore throat
Major Surgical or Invasive Procedure:
Needle aspiration of abscess
History of Present Illness:
38yo F p/w progressive sore throat for 4 days and fever. She
noted sore throat became worse on the left, and developed AS
otalgia. She's had progressive odynophagia, now w/ significantly
limited POs. Report fever to 104 at home. She usually gets 1
sore throat per year, but has never had a PTA. No difficulty
breathing. She was given dilaudid and Clindamyin in the ED.
Of note, she finished chemotherapy for breast cancer 2 months
ago.
Past Medical History:
Past Medical History:
Metastatic breast cancer with verterbral metastasis s/p XRT to
thoracic spine
HTN
Morbid Obesity
Depression
Anemia
Post partum cardiomyopathy- EF now improved to 45-50%
Social History:
Lives at home with husband and children. smoking [**1-16**] cigarettes
per day
Family History:
Aunt with [**Name2 (NI) 499**] cancer at 46. Grandmother had
leukemia. Mother: diabetes. [**Hospital 5772**] medical history unknown to
patient.
Physical Exam:
101.1 98.9 90 120/74 16 97%RA
NAD, no stridor, no work of breathing, appears uncomfortable
[**Name Prefix (Prefixes) **] - [**Last Name (Prefixes) **] without edema/erythema, TM intact without erythema
Nose - normal mucosa anteriorly bil, no drainage middle meatus
bil
OC - no trismus, tongue- no edema, soft FOM
OP - + erythema, 2+ tonsils thin exudate, uvula midline,
asymmetry of left anterior tonsillar fossa- which is displaced
toward midline inferiorly
Neck - + tender LAD on left, no stiffness
Fiberoptic exam: NP - no mass or drainage, patent ET bil, left
pharyngeal wall w/ significant edema narrowing OP by about 30%,
starting at inferior aspect of OP, partially obliterating left
vallecue, and extending into hypopharynx, left piriform sinus
partially obliterated by lateral pharyngeal wall edema, AE
folds- no edema, arytenoids- no edema, bil normal VC motion, VC
without edema, small amt pooled secretions in postcricoid space,
crisp epiglottis, normal R valleculae and piriform sinus
Pertinent Results:
[**2102-7-27**] 05:47AM BLOOD WBC-6.8 RBC-4.03* Hgb-11.6* Hct-34.9*
MCV-87 MCH-28.9 MCHC-33.3 RDW-14.2 Plt Ct-336
[**2102-7-27**] 05:47AM BLOOD Neuts-73.5* Lymphs-17.1* Monos-7.1
Eos-1.9 Baso-0.5
[**2102-7-27**] 05:47AM BLOOD Glucose-116* UreaN-17 Creat-0.8 Na-141
K-3.8 Cl-103 HCO3-27 AnGap-15
[**2102-7-28**] 06:30AM BLOOD Calcium-10.0 Phos-3.9 Mg-2.5
CT NECK W/CONTRAST
IMPRESSION:
1. A 1.7 cm rim enhancing collection in the left palatine
tonsil that
represents phlegmon or developing abscess.
2. New lytic lesions in the cervical spine are concerning for
progression of
known breast malignancy.
Brief Hospital Course:
Ms. [**Known lastname 3444**] was admitted to the MICU from the ER for continuous O2
sat monitoring, IV abx and steroids given the concern for
possible airway compromise. She was started on all of her home
medications. A repeat fiberoptic exam was done on the afternoon
of admission which showed a persistent mass/edema in the L
pharyngeal wall to within 1/2 cm from the epiglottis. An
attempt was made at aspiration of the peritonsillar area which
failed to return any purulent drainage. She was transferred out
of the MICU on HD 2 as she was clinically improving. She
received a total of 3 doses of steroids. On the floor she
continued to improve clinically. We suggested 24 hours
additional of IV antibiotics but the patient refused. Given her
refusal to stay and her clinical improvement we have decided on
a discharge plan including 10 days of high dose oral antibiotics
and close follow up. She will be seen on Wednesday in clinic
and was instructed to immediately return to the ER should she
experience any worsening symptoms.
Patient is being discharged: afebrile, tolerating regular diet
without nausea/vomiting, voiding, and ambulating well.
Medications on Admission:
Medications:
1. Lisinopril 40 mg daily
2. Metoprolol Succinate 50 mg daily
3. Hydrochlorothiazide 50 mg daily
4. Aspirin 325 mg daily
5. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H prn pain
6. Zofran 4 mg q8hr prn nausea
7. Ferrous Sulfate 325 mg daily
8. Docusate Sodium 100 mg [**Hospital1 **] prn
9. Senna 8.6 mg [**Hospital1 **] prn
10. Morphine 15 mg [**Hospital1 **] prn
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
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) as needed.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
8. Amoxicillin 250 mg Capsule Sig: One (1) Capsule PO twice a
day for 10 days: take in addition to Augmentin.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
peritonsillar phlegmon
Discharge Condition:
Stable
Discharge Instructions:
Seek immediate medical attention for fever >101.5, chills,
shortness of breath, change in your voice, chest pain or
anything else that is troubling you. Resume all home
medications. Call your surgeon to make follow up appointment.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 5773**]/Dr. [**Last Name (STitle) **] in ENT on Wednesday.
Call [**Telephone/Fax (1) **] on Monday to schedule an appointment
|
[
"4019"
] |
Admission Date: [**2179-10-22**] Discharge Date: [**2179-11-16**]
Date of Birth: [**2104-10-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / Lisinopril
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath/chest pain x 3.5 weeks
Major Surgical or Invasive Procedure:
[**2179-10-29**] Coronary artery bypass grafting x4: Left
internal mammary artery to the left anterior descending,
saphenous vein graft to the obtuse marginal, saphenous vein
graft to the posterior descending artery and saphenous vein
graft to the diagonal
.
[**2179-11-1**]
Exploratory laparotomy and liver biopsy
History of Present Illness:
75M with a history of atrial fibrillation, HTN, diastolic heart
failure, ESRD s/p renal transplant in [**2176**], CAD s/p 2-vessel
PCI/DESx2 in [**3-/2178**], possible new inferolateral reversible
defect on p-MIBI in [**12/2178**], worsening exertional CP/SOB over
the last month. He also complains of significant claudication
symptoms. He describes the chest pain as sub-sternal,
squeezing/sharp with radiation to his arms. He has been
pre-medicating himself with nitroglycerin prior to exertion. He
also complains of orthopnea, PND and cough productive of whitish
sputum. He has been experiencing abdominal pain for the past
month (RUQ) a/w mild nausea, no vomiting/diarrhea/constipation.
History of mild dilation of distal aorta. No recent long travel,
no recent surgeries. Came to ED today because granddaughter
called his cardiologist who recommended evaluation. He denies
fevers, chills, and diaphoresis.
In the ED, initial vitals were 99 75 155/70 18 95% RA. No new
EKG changes. Labs significant for TnT 0.05, CK:MB 135:3, BUN/Cr
35/2.2, proBNP 3083 and INR 1.1. The patient was totally chest
pain-free in the emergency department. Patient given aspirin
81mg x 4. Vitals on transfer were 58 110/85 24 96%.
On arrival to the floor, the patient is borderline tachypnic and
in mild respiratory distress. He is actively wheezing,
complaining of orthopnea and PND.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Cardiac review of systems is notable for absence syncope or
presyncope.
Past Medical History:
Coronary artery disease
Acute systolic heart failure
Atrial fibrillation
PMH:
Coronary Artery Disease
s/p stents to OM and LCx
Myocardial Infarction [**2167**] and [**2176**]
Hypertension
Hyperlipidemia
Atrial Fibrillation
Diastolic heart failure
ESRD, s/p renal transplant [**2176**]
Peripheral vascular disease
H/o CMV infection c/b pancytopenia
Dry eye syndrome
GERD
H/o Gastrointestinal bleed
Past Surgical History
S/p left brachiocephalic AV fistula
S/p L3-L4 spinal fusion
Social History:
Patient lives alone and is divorced. He has 2 children and 5
grandchildren. His granddaughter is frequently with him and
helps with his meds. He has a distant smoking history, quit
20yrs ago. Denies EtOH and illicits.
Family History:
Brother worked with tiles and passed from lung disease at age
59. Father died at age 79 of cancer. Mother died at 82 of old
age. Other siblings alive in their 80s and otherwise healthy. No
family history of early MI, arrhythmia, cardiomyopathy, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS- T= 97.4 BP= 161/77 HR= 62 RR= 20 O2 sat=96%
GENERAL- Mild respiratory distress. 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 14 cm.
CARDIAC- PMI located in 5th intercostal space, midclavicular
line. Irregular rhythm, normal S1, variably split S2. [**1-8**]
systolic murmur at RUSB. No thrills, lifts. No S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse wheezes. Fine
crackles 1/4 up lung fields.
ABDOMEN- Soft, NTND. No HSM. RUQ tenderness worse with
inspiration. Abd aorta not enlarged by palpation. No abdominial
bruits.
EXTREMITIES- No c/c/e. No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ECHOCARDIOGRAM
[**2179-10-23**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
inferior and inferolateral walls. The remaining segments
contract normally (LVEF = 45-50 %). Overall left ventricular
systolic function is mildly depressed. Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild regional systolic dysfunction
c/w CAD. Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2177-1-30**],
regional wall motion abnormalities are new and systolic function
is not as vigorous.
.
[**2179-10-25**] Cardiac Cath:
1. LMCA and three vessel heavily calcified coronary artery
disease, progressed from [**2178-3-3**], with moderate in-stent
restenosis of the OM1 stent, mild in-stent restenosis of the AV
groove CX, and stable collateralized chronic totally occlusive
in-stent restenosis of the RCA.
2. Systemic systolic arterial hypertension.
3. Moderate-severe left ventricular diastolic heart failure in
the setting of known mild regional left ventricular systolic
dysfunction.
4. Routine post-TR Band care.
5. Reinforce secondary preventative measures against CAD,
hypertension, left ventricular systolic dysfunction and
diastolic
heart failure.
6. Suboptimal imaging due to body habitus.
7. Cardiac surgery evaluation for suitability for CABG,
although
distal targets are not ideal. There are no lesions appealing for
PCI, and presence of heavily calcified LMCA stenosis extending
past the origin of the LAD is strong relative contraindication
to
PCI.
8. Heparin infusion without bolus may be resumed in 6 hours as
clinically indicated.
.
[**2179-10-26**] Carotid Doppler:
Impression: Right ICA with<40% stenosis.
Left ICA with <40% stenosis.
[**2179-11-16**] 08:45AM BLOOD WBC-7.5 RBC-2.68* Hgb-8.2* Hct-26.5*
MCV-99* MCH-30.6 MCHC-30.9* RDW-20.1* Plt Ct-143*
[**2179-11-15**] 03:40PM BLOOD WBC-6.0 RBC-2.54* Hgb-8.0* Hct-24.7*
MCV-97 MCH-31.4 MCHC-32.3 RDW-20.1* Plt Ct-130*
[**2179-11-15**] 06:31AM BLOOD WBC-8.2 RBC-2.68* Hgb-8.1* Hct-25.8*
MCV-96 MCH-30.3 MCHC-31.5 RDW-19.6* Plt Ct-140*
[**2179-11-14**] 05:15AM BLOOD WBC-10.5 RBC-2.83* Hgb-8.8* Hct-27.8*
MCV-98 MCH-31.0 MCHC-31.5 RDW-20.0* Plt Ct-156
[**2179-11-16**] 08:45AM BLOOD PT-14.1* INR(PT)-1.3*
[**2179-11-15**] 03:40PM BLOOD PT-14.7* INR(PT)-1.4*
[**2179-11-14**] 05:15AM BLOOD PT-15.2* PTT-35.7 INR(PT)-1.4*
[**2179-11-16**] 08:45AM BLOOD Glucose-161* UreaN-46* Creat-5.4*#
Na-132* K-4.5 Cl-94* HCO3-24 AnGap-19
[**2179-11-15**] 03:40PM BLOOD Glucose-131* UreaN-32* Creat-4.2*# Na-135
K-3.8 Cl-97 HCO3-25 AnGap-17
[**2179-11-15**] 06:31AM BLOOD Glucose-160* UreaN-77* Creat-8.6*#
Na-131* K-4.7 Cl-93* HCO3-19* AnGap-24*
[**2179-11-14**] 05:15AM BLOOD Glucose-117* UreaN-62* Creat-7.5*# Na-135
K-4.6 Cl-93* HCO3-22 AnGap-25*
[**2179-11-13**] 05:20AM BLOOD Glucose-110* UreaN-47* Creat-6.0*# Na-133
K-4.5 Cl-96 HCO3-24 AnGap-18
Brief Hospital Course:
Mr. [**Known lastname **] is a 75 year old male with a history of atrial
fibrillation, diastolic heart failure, hypertension, and renal
transplant in [**2176**], CAD s/p 2-vessel PCI in [**3-/2178**], possible new
inferolateral reversible defect on p-MIBI in [**12/2178**], and
worsening exertional heart failure symptoms over the last month.
On catheterization he was found to have progression of three
vessel coronary artery disease and was scheduled for bypass
grafting. While his work-up was ensuing he was diuresed and his
heart failure symptoms began to abate. Renal saw him in consult
for end stage renal disease secondary to hypertensive
nephropathy. His baseline creatinine due to allograft
nephropathy was 2.3-2.7.
On [**11-1**] Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a coronary artery bypass grafting
times four (LIMA to LAD, SVG to PDA, SVG to OM, SVG to Diag).
Please see the operative note for details. He tolerated the
procedure well and was transferred in critical but stable
condition to the surgical intensive care unit. On the following
day he was extubated and neurologically intact. He [**Last Name (Titles) 1834**]
hemodialysis for hyperkalemia and fluid overload, and continued
to need periodic hemodialysis post-operatively. On
post-operative day three a lasix infusion was started for
oliguria and fluid overload but he did not respond sufficiently
to it, and by the following day he was reintubated with acute
acidosis. He [**Last Name (Titles) 1834**] a left chest tube placement for 1100mL
of serous drainage. He was also started on broad spectrum
antibiotics with a white blood cell count of 27 thousand. He
went into atrial fibrillation with a controlled ventricular
response and was given beta blockers. The transplant staff was
asked to consult given concern for mesenteric ischemia and an
exploratory laporatomy was performed [**2179-11-1**]. Please see the
operative note for details. This procedure revealed normal
intra-abdominal organs, although a liver biopsy was performed
intra-operatively later indicated acute hepatic ischemia. His
ex-lap wound healed poorly so a wound VAC was placed to aid
healing. He extubated successfully on post-operative day six.
He was thrombocytopenic and was found to be HIT positive.
Hematology was consulted as he was autoanticoagulated with an
INR in the mid twos. Hemodialysis was aborted after an
infiltration of his AV fistula. A temporary HD catheter was
placed and CVVHD was performed. A serotonin assay was performed
to assess for the need for anticoagulation. His SRA was negative
and subcutaneous Heparin was started for DVT prophylaxis. The
decision was made to not start Coumadin for chronic atrial
fibrillation, given that he was not on Coumadin preop and had a
history of GI bleed. His leukocytosis resolved and his
antibiotics were discontinued. He had a large amount of serous
drainage from his abdominal wound and this was opened by the
transplant team and VAC dressings were applied. By the time of
discharge on POD 18, he was tolerating a full oral diet with
some loose stools (C diff negative [**11-12**]), ambulating with
assistance and his wound was healing well with eschar at the
lower pole. His liver functiion tests continued to decrease.
Pravastatin was stopped due to elevated liver function tests and
this should be restarted once LFT's have normalized. Calcitriol
was also stopped due to an elevated phosporus by the renal
transplant team. Tacrolimus levels were stable and he is to
continue at his current dose of 1 mg in the AM and 0.5 mg Q HS
with tacrolimus levels to be followed. VAC dressing x 2 were
changed to the abdominal wound on [**2179-11-15**] and last HD was
[**2179-11-15**] through left arm fistula. It was felt that the patient
was safe for transfer to [**Hospital **] Rehab in [**Location (un) 86**] at this time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 80 mg PO DAILY
2. Allopurinol 100 mg PO BID
3. Tacrolimus 1 mg PO QAM
4. Tacrolimus 1 mg PO QPM
5. Metoprolol Succinate XL 100 mg PO BID
6. Arava *NF* (leflunomide) 20 mg Oral daily
7. Amlodipine 10 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Calcitriol 0.5 mcg PO DAILY
10. Aspirin 325 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
Discharge Medications:
1. Arava *NF* (leflunomide) 20 mg Oral daily Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
2. Aspirin EC 81 mg PO DAILY
3. Tacrolimus 1 mg PO QAM
4. Acetaminophen 650 mg PO Q4H:PRN fever, pain
5. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
indigestion
6. Calcium Acetate 1334 mg PO QIDWMHS
7. Tacrolimus 0.5 mg PO QPM
8. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
9. Metoprolol Tartrate 25 mg PO TID
10. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
11. Nephrocaps 1 CAP PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Quetiapine Fumarate 25 mg PO HS:PRN sleep
14. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Coronary artery disease
Acute systolic heart failure
Atrial fibrillation
PMH:
Coronary Artery Disease
s/p stents to OM and LCx
Myocardial Infarction [**2167**] and [**2176**]
Hypertension
Hyperlipidemia
Atrial Fibrillation
Diastolic heart failure
ESRD, s/p renal transplant [**2176**]
Peripheral vascular disease
H/o CMV infection c/b pancytopenia
Dry eye syndrome
GERD
H/o Gastrointestinal bleed
Past Surgical History
S/p left brachiocephalic AV fistula
S/p L3-L4 spinal fusion
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with Tylenol
Sternal Incision - healing well, no erythema or drainage, eschar
at lower pole
VAC changes Q 72 hours to abdominal wound - last changed
[**2179-11-15**]
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2179-12-7**] 1:30
Cardiologist Dr. [**Last Name (STitle) **] [**2179-12-23**] at 3:20pm [**Hospital Ward Name 23**] 7
Translant Surgeon:Provider: [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-11-24**] 9:15
Renal: Dr [**Last Name (STitle) **] [**2180-1-24**] @ 8:40 AM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 1576**],[**First Name3 (LF) 1575**] [**Telephone/Fax (1) 6662**] in [**4-8**] 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2179-11-16**]
|
[
"41401",
"0389",
"99592",
"5845",
"78552",
"42731",
"V4582",
"2724",
"V1582",
"4168",
"4280",
"412",
"40390",
"53081",
"2767"
] |
Admission Date: [**2171-5-13**] Discharge Date: [**2171-5-16**]
Date of Birth: [**2128-7-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
accidentally swallowed cleaner
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
42 year old man with h/o depression, ADD, and who is otherwise
healthy, who reportedly accidently swallowed a mouth full of
ammonium chloride on day of admission. He was storing the
cleaner in a diet coke can, and accidently took a sip of of the
cleaner. He immediately spit the cleaner out and then repeatedly
washed his mouth out with tap water for about a half an hour.
After "one to two hours" he went to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where he did
not receive endoscopy.
.
He was transferred to [**Hospital1 18**], where he was seen by ORL, GI, and
then transferred to the ICU for observation. While in the ICU,
he was made NPO, had daily scopes to assess airway and an EGD
that showed grade 2 burn (desquamation of superficial layer). He
was advanced to clears but still complaining of pain on
swallowing. Has a cough that causes pain in throat area too.
Tolerated a milk shake prior to being transferred. Psychiatry
saw him to rule out suicide. No previous history of suicide.
.
Transferred to the floor with AVSS.
Past Medical History:
GERD
Attention deficit disorder
Depression
?Asthma
Social History:
no tob/etoh history
One of 4 sibs. Sister and mother have visited. Works currently
as night auditor at a hotel. Lives alone and has a cat.
Family History:
noncontributory
Physical Exam:
AVSS
GENERAL: Well appearing, no acute distress
HEENT: EOMI, PERRL, OP non erythematous, no oral lesions.
NECK: No cervical lymphadenopathy, no JVD, no carotid bruit
CARD: RRR, normal S1/S2, no m/r/g
RESP: CTA bilaterally, no wheezes/rales/rhonchi
ABD: Soft, nontender, nondistended, normoactive bowel sounds, no
hepatosplenomegaly
BACK: No spinal tenderness, no CVA tenderness
EXT: No clubbing/cyanosis/edema, 2+ DP pulses
NEURO: CN II-XII, A&O x 3, Strength 5/5 in both upper and lower
extremities bilaterally, no sensory deficits, ambulates well
PSYCH: Feels fine but is anxious about "the plan is"
Pertinent Results:
[**2171-5-13**] 04:19PM BLOOD WBC-17.7* RBC-5.37 Hgb-16.5 Hct-47.1
MCV-88 MCH-30.7 MCHC-35.0 RDW-14.1 Plt Ct-290
[**2171-5-14**] 04:14AM BLOOD WBC-12.7* RBC-4.62 Hgb-14.4 Hct-43.1
MCV-93 MCH-31.2 MCHC-33.5 RDW-14.3 Plt Ct-256
[**2171-5-14**] 06:42AM BLOOD WBC-13.7* RBC-4.98 Hgb-15.3 Hct-46.5
MCV-93 MCH-30.8 MCHC-33.0 RDW-14.2 Plt Ct-271
[**2171-5-15**] 04:50AM BLOOD WBC-8.6 RBC-5.31 Hgb-16.2 Hct-46.6 MCV-88
MCH-30.5 MCHC-34.8 RDW-14.1 Plt Ct-264
[**2171-5-16**] 06:40AM BLOOD WBC-6.3 RBC-5.02 Hgb-15.4 Hct-44.8 MCV-89
MCH-30.7 MCHC-34.3 RDW-14.0 Plt Ct-246
[**2171-5-13**] 04:19PM BLOOD Neuts-92.8* Lymphs-4.2* Monos-2.4 Eos-0.3
Baso-0.2
[**2171-5-13**] 04:19PM BLOOD Plt Ct-290
[**2171-5-13**] 04:19PM BLOOD Glucose-120* UreaN-17 Creat-1.1 Na-144
K-3.9 Cl-104 HCO3-24 AnGap-20
[**2171-5-14**] 06:42AM BLOOD Glucose-103 UreaN-11 Creat-0.9 Na-140
K-3.6 Cl-106 HCO3-25 AnGap-13
[**2171-5-15**] 04:50AM BLOOD Glucose-88 UreaN-9 Creat-0.9 Na-142 K-3.6
Cl-103 HCO3-26 AnGap-17
[**2171-5-16**] 06:40AM BLOOD Glucose-91 UreaN-9 Creat-1.0 Na-141 K-3.7
Cl-101 HCO3-28 AnGap-16
[**2171-5-14**] 06:42AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
[**2171-5-14**] 06:42AM BLOOD ALT-21 AST-22 LD(LDH)-139 AlkPhos-69
TotBili-0.5
EGD:
Indications: Caustic ingestion of ammonium salts
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
conscious sedation. Supplemental oxygen was used. The patient
was placed in the left lateral decubitus position and an
endoscope was introduced through the mouth and advanced under
direct visualization until the second part of the duodenum was
reached. Careful visualization of the upper GI tract was
performed. The procedure was not difficult. The patient
tolerated the procedure well. There were no complications.
Findings: Esophagus:
Lumen: A small size hiatal hernia was seen, displacing the
Z-line to 38cm from the incisors, with hiatal narrowing at 40cm
from the incisors.
Mucosa: Erythema with sloughing/ulceration of the superficial
layer of the esophagus was noted in the lower third of the
esophagus, most significant at the GE junction. There was
intermittent patchy sloughing in the upper third of the
esophagus and pharynx. There was one small discrete ulcer in the
midesophagus. Findings are consistent with a grade 2
injury/burn.
Stomach:
Mucosa: Normal mucosa was noted.
Duodenum: Normal duodenum.
Impression: Erythema in the lower third of the esophagus and
upper third of the esophagus
Small hiatal hernia
Normal mucosa in the stomach
Otherwise normal EGD to second part of the duodenum
Recommendations: Clear liquids for 24 hrs.
Hold PPI overnight.
Carafate prn discomfort.
There is no evidence for steroids in caustic injestions as
related to the esophagus, regardless of the severity of the
burn.
Advance to soft solids in 24 hrs.
Additional notes: The attending physician was present during the
entire procedure.
_________________________________
[**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 79**], M.D.
_________________________________
[**First Name4 (NamePattern1) **] [**First Name8 (NamePattern2) 3037**] [**Name8 (MD) 349**], MD
Brief Hospital Course:
Mr. [**Name13 (STitle) **] is a 42 year old man with h/o depression, ADD, and
who is otherwise healthy, who reportedly accidently swallowed a
mouth full of ammonium chloride on day of admission. He was
initially treated in the ICU as there was concern for airway
compromise given the significant esophageal burns he suffered
after this toxic ingestion. He was seen by GI and ENT/ORL with
daily endoscopic evaluations of his esophagus. On his 2nd
hospital day he was transferred to floor. He was tolerating a
clears/liquid diet and had AVSS. His medical course is as
follows:
1. accidental alkali ingestion/Esophageal caustic injury:
Patient reportedly accidently swallowed an alkaline based
cleansing [**Doctor Last Name 360**]. There was initial concern for airway
compromise and esophageal perforation so he was treated
initially in the ICU. His EGD showed superficial caustic burns
to esophagus. Patient's course in [**Hospital Unit Name 153**] was significant for
tolerating clears and not requiring intubation for airway
management. He was started on Clindamycin for a 2 week course
prophylactically for possible superficial infection. He
tolerated soft solids on the floor, remained afebrile, and was
discharged home with close follow up to Dr. [**First Name (STitle) **], ENT/ORL. He
was advised about short and long term consequences of his toxic
ingestion-namely that he is at risk esophageal perforation,
infection in the short term and in the long term, stricture,
dysphagia, and possibly cancer.
2. Depression/Anxiety/ADD: The patient was evaluated by
psychiatry and reported no suicidal ideation or previous suicide
attempts or thoughts. He was continued on his home medications
and has close follow up with his outpatient therapist.
#) Prophylaxis: Patient was given Subcu hep; bowel regimen; and
his home PPI.
Medications on Admission:
Protonix 40 mg daily
Wellbutrin XR 150 mg [**Hospital1 **]
Adderall 30 mg [**Hospital1 **]
Klonipin 1 mg [**Hospital1 **]
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*14 Tablet(s)* Refills:*0*
2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 13 days: two week course .
Disp:*52 Capsule(s)* Refills:*0*
3. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: Six (6) Tablet
PO BID (2 times a day).
4. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
5. Clonazepam 1 mg Tablet Sig: One (1) 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) as
needed for GERD.
7. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for pain.
Disp:*1 unit* Refills:*0*
8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) as needed for esophageal discomfort/pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Toxic ingestion
Secondary:
Depression
Attention Deficit Disorder
Discharge Condition:
Stable, tolerating normal food.
Discharge Instructions:
You were admitted for treatment of toxic ingestion of an
alkaline liquid (cleaning [**Doctor Last Name 360**]). You were evaluated by doctors
who [**Name5 (PTitle) **] in the gastrointestinal system and ear, nose, and
throat. You had studies done that showed how you suffered burns
of your esophagus. You were given medications and put on a
diet to minimize the effects of this ingestion.
Your medications have been modified in the following manner:
1. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO
Q6H (every 6 hours): two week course (first dose was [**5-15**]).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets
PO Q4H (every 4 hours) as needed for pain.
3. Lidocaine HCl 2 % Solution Sig: PRN ML Mucous membrane
TID (3 times a day) as needed for pain.
4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for esophageal discomfort/pain
You should follow up with the ear, nose and throat specialist on
[**Last Name (LF) 766**], [**2171-5-20**].
Should you feel any worsening of your symptoms such as
increasing pain on swallowing, difficulty breathing, shortness
of breath, or fevers, chills please seek medical attention.
Additionally, you should be aware of the long term consequences
that could occur to you. For example, you are increased risk
for esophageal scarring, perforation, and cancer. You should
see a gastrointestinal specialist in 10 to 15 years to follow up
for these potential consequences.
Followup Instructions:
Please keep the following appointments:
Follow up with Dr. [**First Name (STitle) **], on [**Last Name (LF) 766**], [**5-20**], at 1:00 PM.
Please call [**Telephone/Fax (1) 31733**] for directions to her office.
Outpatient therapist appointment on [**Last Name (LF) 766**], [**First Name3 (LF) **] 1s at 1130 AM
Completed by:[**2171-5-16**]
|
[
"53081"
] |
Admission Date: [**2187-9-3**] Discharge Date: [**2187-9-9**]
Date of Birth: [**2124-7-31**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
Prostate Cancer
Major Surgical or Invasive Procedure:
Radical Prostatectomy with B/L lymph node dissection
History of Present Illness:
Increased PSA, [**3-24**] pos pr bxs, mod lower urinary symptoms,
decreased erectile fxn
Past Medical History:
HTN
Borderline Type II DM
Physical Exam:
PE: Gen - AAOx3 NAD
CV - S1 S2 RRR
Chest - CTA B/L
Abd - pos BS, soft, NT/ND, incisions C/D/I
GU - nml phallus
Extrem - no c/c/e, no edema
Pertinent Results:
[**2187-9-8**] 06:24AM BLOOD WBC-6.5 RBC-3.10* Hgb-9.4* Hct-26.8*
MCV-87 MCH-30.4 MCHC-35.1* RDW-13.2 Plt Ct-246
[**2187-9-7**] 05:03PM BLOOD Hct-26.4*
[**2187-9-7**] 06:10AM BLOOD WBC-6.4 RBC-2.90* Hgb-9.1* Hct-25.0*
MCV-86 MCH-31.4 MCHC-36.5* RDW-13.2 Plt Ct-167
[**2187-9-6**] 03:21AM BLOOD WBC-8.3 RBC-3.26* Hgb-9.6* Hct-28.3*
MCV-87 MCH-29.4 MCHC-34.0 RDW-13.9 Plt Ct-113*
[**2187-9-5**] 05:09PM BLOOD WBC-8.7 RBC-3.24* Hgb-9.7* Hct-26.9*
MCV-83 MCH-29.9 MCHC-35.9* RDW-13.9 Plt Ct-110*
[**2187-9-5**] 02:59AM BLOOD WBC-9.6 RBC-3.35* Hgb-10.0* Hct-28.2*
MCV-84 MCH-29.8 MCHC-35.5* RDW-14.1 Plt Ct-102*
[**2187-9-4**] 08:15AM BLOOD Hct-33.1*
[**2187-9-4**] 05:53AM BLOOD Hct-26.5*
[**2187-9-4**] 04:09AM BLOOD WBC-10.3 RBC-2.85* Hgb-8.5* Hct-24.0*
MCV-84 MCH-30.0 MCHC-35.6* RDW-13.6 Plt Ct-111*
[**2187-9-3**] 09:40PM BLOOD WBC-13.7* RBC-3.65* Hgb-11.0* Hct-31.9*
MCV-87 MCH-30.0 MCHC-34.4 RDW-13.9 Plt Ct-134*
[**2187-9-3**] 05:08PM BLOOD Hct-33.1*
[**2187-9-3**] 01:17PM BLOOD WBC-11.2*# RBC-3.68* Hgb-11.5*#
Hct-32.2*# MCV-88 MCH-31.2 MCHC-35.6* RDW-12.7 Plt Ct-135*
[**2187-9-5**] 02:59AM BLOOD PT-12.6 PTT-31.1 INR(PT)-1.0
[**2187-9-4**] 04:09AM BLOOD PT-12.8 PTT-33.0 INR(PT)-1.1
[**2187-9-3**] 09:40PM BLOOD PT-12.5 PTT-29.6 INR(PT)-1.0
[**2187-9-3**] 01:17PM BLOOD PT-13.9* PTT-32.4 INR(PT)-1.3
[**2187-9-8**] 06:24AM BLOOD Glucose-103 UreaN-11 Creat-1.0 Na-138
K-3.6 Cl-102 HCO3-25 AnGap-15
[**2187-9-7**] 06:10AM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-138
K-4.1 Cl-104 HCO3-24 AnGap-14
[**2187-9-7**] 01:47AM BLOOD Glucose-105 UreaN-13 Creat-0.9 Na-137
K-4.3 Cl-103 HCO3-24 AnGap-14
[**2187-9-6**] 03:21AM BLOOD Glucose-94 UreaN-11 Creat-0.8 Na-137
K-3.6 Cl-106 HCO3-23 AnGap-12
[**2187-9-4**] 04:09AM BLOOD Glucose-124* UreaN-11 Creat-1.3* Na-140
K-3.8 Cl-113* HCO3-21* AnGap-10
[**2187-9-3**] 09:40PM BLOOD Glucose-199* UreaN-12 Creat-1.5* Na-141
K-4.6 Cl-113* HCO3-20* AnGap-13
[**2187-9-3**] 01:17PM BLOOD Glucose-108* UreaN-10 Creat-0.9 Na-142
K-4.3 Cl-116* HCO3-18* AnGap-12
[**2187-9-4**] 05:05PM BLOOD CK(CPK)-2177*
[**2187-9-4**] 04:09AM BLOOD CK(CPK)-1170*
[**2187-9-3**] 09:40PM BLOOD CK(CPK)-1083*
[**2187-9-3**] 01:17PM BLOOD CK(CPK)-686*
[**2187-9-4**] 05:05PM BLOOD CK-MB-11* MB Indx-0.5 cTropnT-0.02*
[**2187-9-4**] 04:09AM BLOOD CK-MB-6 cTropnT-0.07*
[**2187-9-3**] 09:40PM BLOOD CK-MB-6 cTropnT-<0.01
[**2187-9-3**] 01:17PM BLOOD CK-MB-3 cTropnT-<0.01
[**2187-9-7**] 06:10AM BLOOD Calcium-7.2* Phos-2.7 Mg-2.2
[**2187-9-7**] 01:47AM BLOOD Calcium-7.4* Phos-2.8 Mg-2.3
[**2187-9-6**] 03:21AM BLOOD Calcium-7.0* Phos-2.6* Mg-2.0
[**2187-9-5**] 12:41PM BLOOD Calcium-7.0* Phos-2.7 Mg-2.3
[**2187-9-4**] 04:09AM BLOOD Calcium-7.2* Phos-3.0# Mg-1.7
[**2187-9-3**] 09:40PM BLOOD Calcium-7.9* Phos-5.0* Mg-2.3
[**2187-9-3**] 01:17PM BLOOD Calcium-7.8* Mg-1.2*
[**2187-9-6**] 03:35AM BLOOD Type-ART pO2-118* pCO2-41 pH-7.40
calHCO3-26 Base XS-0
[**2187-9-5**] 12:57PM BLOOD Type-ART pO2-149* pCO2-41 pH-7.41
calHCO3-27 Base XS-1
[**2187-9-5**] 11:46AM BLOOD Type-ART pO2-83* pCO2-38 pH-7.42
calHCO3-25 Base XS-0
[**2187-9-5**] 04:32AM BLOOD Type-ART pO2-86 pCO2-38 pH-7.40
calHCO3-24 Base XS-0
[**2187-9-5**] 03:34AM BLOOD Type-ART pO2-63* pCO2-44 pH-7.36
calHCO3-26 Base XS-0
[**2187-9-4**] 04:47AM BLOOD Type-ART pO2-118* pCO2-35 pH-7.36
calHCO3-21 Base XS--4
[**2187-9-3**] 11:50PM BLOOD Type-ART pO2-150* pCO2-43 pH-7.30*
calHCO3-22 Base XS--4
[**2187-9-3**] 10:26PM BLOOD Type-ART pO2-213* pCO2-44 pH-7.25*
calHCO3-20* Base XS--7
[**2187-9-3**] 06:11PM BLOOD Type-ART Temp-37.1 Rates-[**9-13**] Tidal V-750
FiO2-50 pO2-212* pCO2-46* pH-7.27* calHCO3-22 Base XS--5
Intubat-INTUBATED Vent-IMV
[**2187-9-3**] 01:48PM BLOOD Type-ART Temp-36.8 Tidal V-750 PEEP-5
FiO2-50 pO2-217* pCO2-46* pH-7.21* calHCO3-19* Base XS--9
Intubat-INTUBATED
[**2187-9-3**] 11:41AM BLOOD Type-ART pO2-223* pCO2-39 pH-7.27*
calHCO3-19* Base XS--8
[**2187-9-3**] 10:33AM BLOOD Type-ART Tidal V-700 pO2-236* pCO2-41
pH-7.31* calHCO3-22 Base XS--5
[**2187-9-6**] 03:35AM BLOOD Glucose-98
[**2187-9-5**] 12:57PM BLOOD Glucose-113*
[**2187-9-4**] 04:47AM BLOOD Glucose-110* Lactate-2.9*
[**2187-9-3**] 10:33AM BLOOD Lactate-3.3*
[**2187-9-3**] 10:15AM BLOOD Lactate-3.4*
[**2187-9-3**] 11:41AM BLOOD Hgb-10.0* calcHCT-30
[**2187-9-6**] 03:35AM BLOOD freeCa-1.07*
[**2187-9-5**] 12:57PM BLOOD freeCa-1.06*
[**2187-9-4**] 04:47AM BLOOD freeCa-1.02*
[**2187-9-3**] 10:33AM BLOOD freeCa-1.72*
[**2187-9-3**] 10:15AM BLOOD freeCa-1.00*
CXR [**9-5**]
HISTORY: Fever following radical prostatectomy.
IMPRESSION: AP chest compared to [**9-3**] at 2357 hours:
Lung volumes have improved slightly. There is relatively
symmetric perihilar
opacification accompanied by increased mediastinal venous
caliber, most likely
due to pulmonary edema and small pleural effusions. Endotracheal
tube and
right subclavian line are in standard placements and a
nasogastric tube loops
in the stomach.
Brief Hospital Course:
On [**9-3**] pt underwent RRP with B/L pelvic node dissection.
During the case he lost about 3200 cc of blood. He received
about 8 L of crystalloid and 4 U PRBC during the case and was on
neo intermittently. He was left intubated in the PACU and
required neo for BP control. He was Tx from the PACU to the
SICU for his hypotension. In SICU he had good pain control and
was weaned off of the vent and extubated on POD #2. He was
given Levophed to keep his BP at nml levels. His mental status
was good and he made adequate urine. on POD #3 he was
transferred to the floor. On the floor his diet was advanced as
tolerated, he had good pain control, and he ambulated well. His
JP tube was d/c'd on POD #4. He was in good condition and was
D/C'd home on POD #6.
Medications on Admission:
Benicar 40'
Tylenol for allergies
Nasal Spray
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.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day for
7 days.
Disp:*14 Capsule(s)* Refills:*0*
3. Medications
Please take pre admission medications at home
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day:
Start one day before you remove foley cath.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Gentiva/[**Location (un) 86**]
Discharge Diagnosis:
Prostate cancer
Discharge Condition:
Good
Discharge Instructions:
Can shower
Use cane if needed to move around
If you have a fever >101.4, pain, intractable nausea and
vomiting, discharge from wound or bleeding, or chest pain or
shortness of breath please return.
Start Levofloxacin one day before foley removal.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 4229**] ([**Telephone/Fax (1) 4230**]
|
[
"4280",
"2762"
] |
Admission Date: [**2161-6-17**] Discharge Date: [**2161-6-21**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
dyspnea, hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 year old Female with history of severe COPD on 2L Home
Oxygen, pulmonary hypertension, renal insufficiency and carotid
insufficiency was referred to the ED for hyponatremia and
dyspnea. Mrs. [**Known lastname **] was brought to the ED by EMS with dyspnea
x 2 days, recieving multiple nebulizer treatments in route to
the ED. Dyspnea started 2 days prior to admission, accompanied
with bilateral leg swelling. Denies any chest pain. No
palpitations. Says her urine output seems unchanged.
Symptoms started "when the weather got hot." She reports having
a poor apetite over the last few days and drinks very little. Of
note, Mrs. [**Known lastname **] was recently started on Lasix ([**6-3**]) for
symptom control of her cor pulmonale. Her sodium was noted to
decline gradually on subsequent with nadir of 122 on the morning
of referral to the emergency room. She has continued to take her
daily lasix, despite her PCP notifying her of her low sodium and
encouraging her to stop taking that med. Additionally, Mrs.
[**Known lastname **] was recently started on home O2, 2L, and is supposed to
wear it at all times, previously just at night. Her
granddaughter notes she often takes her oxygen off, particularly
while at her day program.
In the ED, initial vs were: T=98.1, HR=81, BP=121/76, RR=16
98%4LNC. Patient was given lasix, nitro gtt and BiPap, ASA 325,
for a presumed CHF exacerbation. Her CXR came back clear. She
was additionally treated for a COPD exacerbation with albuterol
and ipatropium nebs, azithromycin and solumedrol.
Past Medical History:
Pulmonary hypertension
COPD on 2L Home
carotid stenosis
Stage III CKD
Social History:
lives with family with good support, widowed, has VNA sevice.
past smoker, quit 50 yrs ago, smoked for about 20 years. Lost 2
children.
Family History:
Non-Contributory
Physical Exam:
Vitals: T: 95.1 BP: 129/57 P: 78 R: 18 O2: 97% on 4L by NC
General: Alert, oriented, appears tachypneic
HEENT: Sclera anicteric, MMM, oropharynx clear, pale
conjunctiva, dry mouth,d ry mucosa
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bases bilaterally, few expiratory wheezes.
CV: Regular rate and rhythm, systolic murmur at left sternal
border non radiating, no murmurs, rubs, gallops
Abdomen: soft, nt, nd, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: Foley in place to gravity
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. mild
pitting edema
Pertinent Results:
[**2161-6-21**] 06:30AM BLOOD WBC-10.8 RBC-4.76 Hgb-13.1 Hct-40.3
MCV-85 MCH-27.6 MCHC-32.6 RDW-13.6 Plt Ct-508*
[**2161-6-18**] 04:40AM BLOOD WBC-12.1* RBC-4.27 Hgb-11.6* Hct-34.8*
MCV-82 MCH-27.2 MCHC-33.4 RDW-13.6 Plt Ct-401
[**2161-6-16**] 10:30PM BLOOD WBC-11.1* RBC-4.92 Hgb-13.3 Hct-40.6
MCV-83 MCH-27.0 MCHC-32.7 RDW-14.0 Plt Ct-524*
[**2161-6-18**] 04:40AM BLOOD Neuts-86.6* Lymphs-7.8* Monos-5.4 Eos-0.1
Baso-0.1
[**2161-6-16**] 10:30PM BLOOD PT-11.5 PTT-25.6 INR(PT)-1.0
[**2161-6-21**] 06:30AM BLOOD Glucose-77 UreaN-18 Creat-1.2* Na-138
K-4.3 Cl-97 HCO3-35* AnGap-10
[**2161-6-18**] 01:33PM BLOOD Glucose-117* UreaN-27* Creat-1.3* Na-132*
K-5.5* Cl-97 HCO3-28 AnGap-13
[**2161-6-17**] 07:27PM BLOOD Glucose-121* UreaN-30* Creat-1.4* Na-122*
K-5.7* Cl-89* HCO3-26 AnGap-13
[**2161-6-17**] 05:54AM BLOOD Glucose-161* UreaN-35* Creat-1.7* Na-116*
K-5.6* Cl-83* HCO3-24 AnGap-15
[**2161-6-16**] 10:20AM BLOOD UreaN-33* Na-122* K-5.2* Cl-86* HCO3-24
AnGap-17
[**2161-6-17**] 05:54AM BLOOD CK(CPK)-140
[**2161-6-17**] 05:54AM BLOOD CK-MB-8 cTropnT-0.03*
[**2161-6-16**] 10:30PM BLOOD cTropnT-0.02*
[**2161-6-16**] 10:30PM BLOOD proBNP-2439*
[**2161-6-21**] 06:30AM BLOOD Calcium-10.1 Phos-3.5 Mg-2.1
[**2161-6-17**] 02:28PM BLOOD Calcium-9.1 Phos-4.0 Mg-2.1
[**2161-6-16**] 10:30PM BLOOD Calcium-9.8 Phos-4.1 Mg-2.4
[**2161-6-17**] 07:27PM BLOOD Osmolal-266*
[**2161-6-17**] 05:54AM BLOOD Osmolal-257*
[**2161-6-17**] 05:54AM BLOOD TSH-0.70
[**2161-6-17**] 09:40AM BLOOD Cortsol-95.6*
[**2161-6-16**] 10:30PM BLOOD Cortsol-39.0*
[**2161-6-17**] 01:24AM BLOOD Type-ART FiO2-100 O2 Flow-4 pO2-90
pCO2-43 pH-7.33* calTCO2-24 Base XS--3 AADO2-582 REQ O2-95
Intubat-NOT INTUBA
[**2161-6-16**] 10:43PM BLOOD Glucose-168* Lactate-1.8 Na-123* K-4.9
[**2161-6-18**] 01:33PM URINE Hours-RANDOM UreaN-207 Creat-17 Na-49
K-12 Cl-47 TotProt-<6
[**2161-6-18**] 08:13AM URINE Hours-RANDOM Creat-14 Na-46 K-8 Cl-39
[**2161-6-17**] 09:38PM URINE Hours-RANDOM Creat-30 Na-26 K-20 Cl-25
[**2161-6-17**] 05:54AM URINE Hours-RANDOM Creat-22 Na-59 K-25 Cl-73
[**2161-6-18**] 01:33PM URINE Osmolal-199
[**2161-6-18**] 08:13AM URINE Osmolal-172
[**2161-6-17**] 05:54AM URINE Osmolal-237
[**2161-6-17**] 4:05 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2161-6-19**]**
MRSA SCREEN (Final [**2161-6-19**]): No MRSA isolated.
Brief Hospital Course:
1. COPD with Acute Exacerbation:
- Pts dyspnea, hypoxemia, but normal CO2, was thought to be
secondary to Pulmonary HTN exacerbation in setting of low
intravascular volume. Patient had poor PO intake several days
prior to admission and continued her daily lasix which likely
volume depleted her. She had an echocardiogram which showed
severe pulmonary HTN but no sigificant changes from her [**2157**]
echo. She was given nasal canula O2 and weaned down to her home
dose of 2L. She was then given a steroid taper with prednisone
from [**6-17**] through [**6-21**] at the direction of the pulmonary
consultation team in concert with her primary pulmonologist Dr.
[**Last Name (STitle) 2168**].
2. Hyponatremia:
Found to have hypo-osmolar hyponatremia. Likely secondary to low
volume state after several days of poor PO intake and persistent
lasix with free water repletion. She was given lasix in ED as
patient was thought to initially present with CHF exacerbation.
Fluids were then repleted and Na levels normalized from
116-->138 over the admission. She was not restarted on
diuretics.
3. Pulmonary Hypertension:
- Unclear etiology as patient was known in OMR to have severe
pulmonary HTN but mild obstructive pattern on PFTs. Echo
revealed peristent severe pulmonary HTN with no signs of left or
right heart failure. Patient should meet with pulmonologist
outpatient to follow up.
4. Acute Renal Failure on Stage III CKD:
- Patient was pre-renal with low volume status. Cr peaked at 1.8
and baseline is 1.6. Gave IVF and Cr trended down to 1.3.
5. Hyperkalemia:
- Pt had hyperkalemia on admission. Cortisol level was 39 making
adrenal insuficiency unlikely. Losartan likely contributed to
hyperkalemia and was discontinued.
6. Benign Hypertension:
Her hypertension mends were all held while in the ICU. And her
beta-blocker and calcium channel blocker were restarted prior to
discharge on the floor.
DISPO: She was sent for short term rehabilitation for mobility
and strengthing, along with stability training while carrrying
her oxygen.
Medications on Admission:
Atneolol 50 mg [**Hospital1 **]
Cilostazol 100 mg qday
Advair 100/50 1 puff daily
Lasix 20 mg qday (stopped)
Nifedipine ER 60 mg qday
Ranitidine 150 mg [**Hospital1 **]
Spiriva 18 mcg daily
Valsartan 160 mg qday
Calcium
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheezing, SOB.
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
COPD With Acute Exacerbation
Hyponatremia
CKD Stage 4
Hyperkalemia
Pulmonary Hypertension
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:
It is very important that you continue to wear your oxygen,
particularly when out and about, such as at your day program.
While at rehab, you should use your oxygen contininously
particularly when exercising. You should practice moving around
with your oxygen with the physical therapist.
We have made some changes to your medications as you had a very
low sodium, and we have stopped your furosemide (lasix). Dr.
[**Last Name (STitle) **] and [**Doctor Last Name 2168**] will address this after you return home.
Followup Instructions:
Please make an appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 133**]
when you are leaving the rehab.
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2161-8-5**] at 8:00 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"5849",
"2761",
"40390",
"2767"
] |
Admission Date: [**2180-1-20**] Discharge Date: [**2180-1-25**]
Date of Birth: [**2113-4-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
OPCABx3(LIMA->LAD, SVG->Diag, PDA) [**1-21**]
History of Present Illness:
66 yo with recent symptoms while shoveling, EKG at well visit
with changes, cath with 3VD referred for surgery.
Past Medical History:
CAD s/p RCA stent [**2171**], HTN, lipids, DM, cataracts, T&A
Social History:
wine buyer
denies tobacco, etoh
Family History:
sister with heart problems in 70s
mother deceased from MI at 72
Physical Exam:
Admission exam unremarkable with the exception of bilateral
groin cath sites C/D/I.
Pertinent Results:
[**2180-1-24**] 08:00AM BLOOD WBC-7.7 RBC-2.60* Hgb-8.4* Hct-25.0*
MCV-96 MCH-32.5* MCHC-33.7 RDW-13.1 Plt Ct-212
[**2180-1-23**] 02:28AM BLOOD WBC-8.8 RBC-2.67* Hgb-8.7* Hct-25.1*
MCV-94 MCH-32.5* MCHC-34.7 RDW-13.0 Plt Ct-162
[**2180-1-24**] 08:00AM BLOOD Plt Ct-212
[**2180-1-21**] 11:49AM BLOOD PT-13.8* PTT-26.3 INR(PT)-1.2*
[**2180-1-24**] 08:00AM BLOOD Glucose-273* UreaN-20 Creat-1.1 Na-137
K-3.8 Cl-99 HCO3-30 AnGap-12
CHEST (PA & LAT) [**2180-1-25**] 10:05 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate effusion
HISTORY: Status post CABG.
FINDINGS: In comparison with the study of [**1-22**], the patient has
taken a better inspiration. Residual atelectatic changes persist
at the left base with blunting of the costophrenic angle.
No evidence of acute pneumonia.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 29375**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 29376**] (Complete)
Done [**2180-1-21**] at 8:57:54 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2113-4-30**]
Age (years): 66 M Hgt (in): 69
BP (mm Hg): 134/78 Wgt (lb): 169
HR (bpm): 72 BSA (m2): 1.92 m2
Indication: Intraoperative TEE for CABG procedure
ICD-9 Codes: 786.51, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2180-1-21**] at 08:57 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine: [**Pager number 29377**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Small secundum ASD.
LEFT VENTRICLE: Normal regional LV systolic function. Mild
global LV hypokinesis. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Off pump CABG
1. A small secundum atrial septal defect is present.
2.Regional left ventricular wall motion is normal. There is mild
global left ventricular hypokinesis (LVEF = 45 %). Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7. Post revascularization inferior wall is moderately
hypokinetic. EF 40%
Brief Hospital Course:
He was transferred to cardiac surgery. On [**1-21**] he was taken to
the operating room on where he underwent an off pump CABG x 3.
He was transferred to the ICU in stable condition. He was
extubated later that same day. He was transferred to the floor
on POD#2. He did well postoperatively and was ready for
discharge home on POD #4.
Medications on Admission:
atenolol 100', norvac 2.5', benicar-hct 40-25, glipizide er 10',
lantus 25/25, byetta [**5-8**], metformin 1500/500, crestor 20, asa,
MVI, fish oil
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*60 Tablet(s)* Refills:*0*
10. Metformin 500 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
Disp:*90 Tablet(s)* Refills:*0*
11. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*0*
13. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous twice a day.
Disp:*qs 1 month* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD now s/p CABG
Chronic systolic heart failure
CAD s/p RCA stent [**2171**], HTN, lipids, DM, cataracts, T&A
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 29378**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 5874**] 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2180-1-25**]
|
[
"41401",
"4280",
"25000",
"4019",
"2724",
"V4582"
] |
Admission Date: [**2197-11-18**] Discharge Date: [**2197-11-20**]
Date of Birth: [**2141-4-27**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 56-year-old male
with no previous medical history, who was out shoveling snow
on the day of admission. Five to 10 minutes into shoveling,
the patient experienced very heavy chest pressure associated
with shortness of breath, diaphoresis, and general weakness.
The patient has never experienced anything like this before.
The patient exercises regularly and has noticed that his
exercise tolerance has not changed recently. He jogs
approximately three miles every day and bikes regularly. The
patient immediately called 911 and was taken to the Emergency
Department, where he was found to have ST segment elevations
in leads II, III, and aVF as well as a Q wave in leads II,
III, and aVF.
PAST MEDICAL HISTORY: None.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: None.
SOCIAL HISTORY: The patient has a 30 pack year smoking
history, but quit three years ago. He drinks half a bottle
of wine everyday. He is employed and moved from Europe three
years ago with his wife due to her job. He is not currently
employed, but does fly planes.
FAMILY HISTORY: The patient's maternal grandfather had a
heart attack at age 60. Otherwise, his mother and father are
both alive with no coronary artery disease.
PHYSICAL EXAMINATION: Physical exam is notable for a heart
rate of 64 and a blood pressure of 99/60. His lungs are
clear. His heart is regular, rate, and rhythm with no
murmur. The remainder of his physical exam is unremarkable.
LABORATORIES ON ADMISSION: Notable for a CK of 64 and a
troponin of less than 0.01. The remainder of his
laboratories are all within normal limits.
EKG: Shows sinus bradycardia at a rate of 58. There are 2
mm ST segment elevations in leads II, III, and aVF. There
are also Q waves in leads II, III, and aVF. There is left
atrial enlargement and borderline left ventricular
hypertrophy.
HOSPITAL COURSE: The patient was admitted with a ST segment
elevation MI in the inferior leads. He was taken immediately
to cardiac catheterization, where he was found to have
complete occlusion of his right coronary artery. The artery
was stented. There was no evidence of stenosis in any of the
other arteries.
Following procedure, the patient became briefly hypotensive
and was started on a dopamine drip. He was admitted to the
CCU for close monitoring. The patient was quickly weaned off
dopamine with systolic blood pressures in the 90s to low
100s. The patient had several episodes of nonsustained VT,
which he spontaneously broke out of in the day following
cardiac catheterization. These episodes of NSVT most likely
represent reperfusion injury. Throughout the remainder of
the hospitalization, the patient experienced no further
episodes of chest pain, diaphoresis, shortness of breath,
nausea, or vomiting.
Post cardiac catheterization EKG showed resolution of ST
elevations. The patient was started on aspirin, Plavix, and
Lipitor. He was started on a low dose of a beta blocker
which he tolerated well. It was decided not to start ACE
inhibitor prior to discharge due to a borderline blood
pressure with a systolic blood pressure of 100. The patient
was advised to never take up smoking again, and was asked to
reduce his alcohol intake to a maximum of two drinks per day.
Patient was also advised not to fly planes at least until he
sees a cardiologist.
An echocardiogram was performed prior to discharge, which
showed a mildly depressed left ventricular ejection fraction
of 45-50% with marked inferior hypokinesis. There was also
1+ mitral regurgitation and a mildly dilated left atrium.
CONDITION ON DISCHARGE: Stable, chest pain free with no
shortness of breath, and ambulating well without assistance.
DISCHARGE STATUS: The patient is discharged to home without
any home services.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post ST segment elevation
myocardial infarction with stenting of the right coronary
artery.
2. Hypotension.
3. Hyperlipidemia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d. x3 months.
3. Lipitor 10 mg p.o. q.d.
4. Atenolol 25 mg p.o. q.d.
FOLLOW-UP PLANS:
1. The patient is asked to followup with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 53713**] on Friday, [**11-24**]. A phone
call was made to Dr. [**Last Name (STitle) 53713**] and a message was left
explaining the reason for hospitalization, and the
recommendation that the patient be started on an ACE
inhibitor if his blood pressure can tolerate it.
2. Patient is scheduled to followup with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] in
Cardiology on [**2197-12-15**] at 3 p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.12.222
Dictated By:[**Name8 (MD) 4993**]
MEDQUIST36
D: [**2197-11-20**] 13:45
T: [**2197-11-22**] 07:31
JOB#: [**Job Number 53714**]
|
[
"41401",
"2720"
] |
Admission Date: [**2116-4-29**] Discharge Date: [**2116-5-11**]
Date of Birth: [**2042-5-31**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Synchronous rectal cancer and sigmoid colon cancer
Major Surgical or Invasive Procedure:
Laparoscopic converted to open proctosigmoidectomy with partial
colectomy and end colostomy with takedown of splenic flexure and
prophylactic placement of Surgisis preperitoneal patch to
prevent parastomal hernia
History of Present Illness:
This is a 73 year-old male with locally advanced rectal cancer
with and biopsy-proven liver metastasis who presented electively
on [**2116-4-29**] for a laparoscopic converted to open
proctosigmoidectomy with partial colectomy and end colostomy,
takedown splenic flexure, and prophylactic placement of Surgisis
preperitoneal patch to prevent parastomal hernia.
Past Medical History:
PMH: locally advanced rectal cancer w/ liver mets, viral
cardiomyopathy EF 30%, A.fib on coumadin, multiple episdoes of
V.fib s/p ICD firing
PSH: Early stage urothelial carcinoma of the bladder status post
cystoscopic resection on [**2116-1-30**]
Social History:
Primarily Italian-speaking. He is married and lives at home with
his wife. His son and daughter are local and he is close to
them. He is originally from central [**Country 2559**] and tries to spend
time in [**Country 2559**] yearly. He smoked two packs per day for 40 years,
quitting in the past two years. He drinks two glasses of wine
per day and denies recreational substance use.
Family History:
Father: Died young of unknown causes.
Mother: Lived to 94 and was healthy with no known cancers.
Other: No other known cancer history in his family.
Physical Exam:
VITALS: T 98.2 HR 80 BP 133/64 RR 22 O2sat 99%RA
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2.
RESP: Clear to auscultation bilaterally without adventitious
sounds, minimally decreased breath sounds at bases bilaterally.
No wheezing, rhonchi or crackles.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs. Left sided colostomy
stoma is pink-purple, protuberant with mild friability and is
healing well with liquid-brown/green stool output and gas in his
ostomy appliance.
EXTR: 2+ peripheral pulses, without cyanosis, clubbing or edema.
INCISION/WOUND: Midline abdominal incision has mild erythema
extending 1-2 cm from the wound edge without fluctuance,
purulence or induration. [**4-17**] staples have been removed with
granulating tissue and minimally serosanginous drainage
underlying the exposed superficial fascia. The wound appears
clean.
Pertinent Results:
[**2116-5-10**] 06:00AM BLOOD WBC-9.2 RBC-3.58* Hgb-9.7* Hct-31.4*
MCV-88 MCH-27.1 MCHC-30.8* RDW-18.4* Plt Ct-650*#
[**2116-5-9**] 07:55AM BLOOD PT-13.2 PTT-24.7 INR(PT)-1.1
[**2116-5-10**] 06:00AM BLOOD PT-14.6* PTT-25.2 INR(PT)-1.3*
[**2116-5-11**] 03:50AM BLOOD PT-17.1* PTT-27.3 INR(PT)-1.5*
[**2116-5-10**] 06:00AM BLOOD Glucose-97 UreaN-21* Creat-1.2 Na-135
K-3.8 Cl-100 HCO3-27 AnGap-12
CXR ([**2116-5-5**]) - Stable postoperative findings indicative of
CHF. Fluid overload, as suggested in the requisition, may be a
cause of these findings provided other cardiogenic factors are
excluded.
LUE US ([**2116-5-2**]) - No evidence of left upper extremity deep
venous thrombus. Cephalic vein not visualized.
Pathology ([**2116-4-29**]) -
Rectum and sigmoid colon: Two synchronous colonic
adenocarcinomas. Thirty-five lymph nodes; no malignancy
identified.
Brief Hospital Course:
NEURO/PAIN: The patient was maintained on PCA/IV Morphine for
pain medication in the immediate post-operative period and
transitioned to PO narcotic medication with adequate pain
control on POD#[**6-19**]. The patient remained neurologically intact
and without change from baseline. The patient remained alert and
oriented to person, location and place.
CARDIOVASCULAR: The patient experienced a single episode of
what was suspected ventricular tachycardia and his AICD fired a
single time intra-operatively, as previously mentioned. The
event occurred soon after insufflation of the abdomen during
attempted laparoscopy. In light of the rhythm concerns, the
procedure was converted to an open approach. The procedure
progressed without further hemodynamic or arrhythmic issues and
he was transferred to ICU in stable condition, intubated. The
EP/cardiology service was consulted for further management, they
recommended continuing his outpatient anti-arryhthmic [**Doctor Last Name 360**]
(dofetilide) and initiating post-op beta-blockade with IV
metoprolol. Serial EKGs were closely monitored without issue. He
was transitioned to oral Metoprolol, continued his dofetilide,
and started Digoxin with resolve of cardiac issues by POD#4.
Vitals signs were closely monitored via telemetry. Lopressor
increased to provide better appropriate rate control.
RESPIRATORY: The patient was extubated POD# 1 successfully. The
patient had no episodes of desaturation. The patient denied
cough or respiratory symptoms. Pulse oximetry was monitored
closely and the patient maintained adequate oxygenations. serial
CXRs did reveal some evidence of atelectasis versus
consolidation, along with pleural effusions (improved with
diuresis) which was closely monitored. A sputum sample revealed
H. influenzae (non type-B) that was sensitive to Ampicillin.
Given diurnal temperature spikes and the respiratory source of
infection, empiric Vancomycin and Zosyn IV were started on
POD#2. He completed a course of Zosyn and his respiratory
status was stable.
GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#[**7-21**]. The
patient experienced no nausea or vomiting. His ostomy site began
functioning with liquid stool output and gas in the appliance on
POD# [**5-19**]. His stoma site appeared dusky and friable with some
edema that progressed post-op, but was cloesly monitored and
deemed clinically stable. The patient was transitioned to a
regular diet on POD#9 and IV fluids were discontinued once
adequate PO intake was established.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was
placed intra-operatively and removed on POD#6, at which time the
patient was able to successfully void without issue. The
patient's intake and output was closely monitored for > 30 mL
per hour output. The patient's creatinine was stable, his
baseline being above normal.
HEME: The patient remained hemodynamically stable and only
required transfusion of 2 units of packed red blood cells. The
patient's coagulation profile remained normal. The patient had
no evidence of bleeding from their incision.
ID: The patient was febrile immediately post-op and displayed a
nearly diurnal fever curve, the source likely being a sputum
sample which revealed H. influenzae (non type-B) that was
sensitive to Ampicillin. Given diurnal temperature spikes and
the respiratory source of infection, empiric Vancomycin and
Zosyn IV were started on POD#2. Their white count was stable
post-operatively and their incision was closely monitored for
any evidence of infection or erythema. Staples were removed from
the superior aspect of the incision on POD#5 given some
spreading peri-incisional erythema, and green-brown purulence
was expressed and cultured. Dry dressing were changed daily
following the staple removal. There was no induration,
fluctuance. Wound cultures demonstrated pan-sensitive
pseudomonas and he has been on oral ciprofloxacin, which will
continue until [**5-16**].
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op. The patient also had sequential compression
boot devices in place during immobilization to promote
circulation. GI prophylaxis was sustained with
Protonix/Famotidine. The patient was encouraged to utilize
incentive spirometry, ambulate early and was discharged in
stable condition.
Medications on Admission:
1. dofetilide 250 mcg Capsule Sig: Two (2) Capsule PO BID.
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pradaxa 150 mg Tablet Sig: One (1) Tablet, PO BID.
5. furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. metoprolol ER 50mg Tablet Sig: One (1) Tablet PO qday.
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Dose
to be adjusted based on INR.
8. colchicine 0.6mg Tablet Sig: One (1) Tablet PO DAILY.
9. simvastatin 40mg Tablet Sig: One (1) Tablet PO DAILY.
10. diovan 80mg Tablet Sig: One (1) Tablet PO DAILY.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
2. dofetilide 250 mcg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Dose
to be adjusted based on INR.
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days: Five more days of antibiotics - course to end on [**2116-5-16**].
9. oxycodone 5 mg Capsule Sig: [**2-16**] Capsules PO every 4-6 hours
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] at [**Location (un) 55**]
Discharge Diagnosis:
Synchronous sigmoid colon and rectal cancers
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a Laparoscopic converted
to open proctosigmoidectomy with partial colectomy and end
colostomy for surgical treatment of your colorectal cancer.
During this procedure a patch was also placed to prevent you
from developing a hernia near your colostomy site. You have
recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You
developed pneumonia during your hospitalization and this has
been treated with broad spectrum antibiotics. You will continue
antibiotics by mouth as an outpatient for the wound on your
abdomen. This antibiotic is called Ciprofloxacin which will end
on [**2116-5-16**]. You have tolerated a regular diet, passing gas and
your pain is controlled with pain medications by mouth. You may
be discharge to a rehabiliation facility to finish your
recovery.
Monitor your bowel function closely, if you have any of the
following symptoms please call the office for advice or go to
the emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonges loose stool, or
constipation. You have a new colostomy. It is important to
monitor the output from this stoma. It is expected that the
stool from this ostomy will be solid to semi-solid and formed
similar to regular stool. You should have [**2-16**] bowel movements
daily. If you notice that you have not had any stool from your
stoma in [**2-16**] days, please call the office. You may take an over
the counter stool softener such as colace if you find that you
are becoming constipated from narcotic pain medications. Please
watch the appearance of the stoma, your stoma has become darker
purple/bluish/slightly yellow which is from some compromised
blood flow after your procedure, occationally this happens with
stomas and we watch the stoma for improvement which yours has
shown. The stoma will likely shed dead tissues which is ok, and
the tissue underneath should be beefy red/pink. This is expected
to happen however it is importnat that this is watched by the
wound/ostomy nurses and surgery team for improvements. The skin
around the ostomy site should be kept clean and intact. Monitor
the skin around the stoma for buldging or signs of infection
listed above. Please care for the ostomy as you have been
instructed by the wound/ostomy nurses. You will be able to make
an appointment with the ostomy nurse in the clinic 5-7 days
after discharge, You will have a visiting nurse at home for the
next few weeks helping to monitor your ostomy until you are
comfortable caring for it on your own.
You have a long vertical incision on your abdomen that is
partially closed with staples. The incision had a small area of
infection , and was opened at the bedside. This dressing must be
cared for by yourself and visiting nurses with wet to dry
dressing changes twice daily. It is important to monitor the
wound for signs of infection listed below. You will take
antibiotics that will help treat infection inthe area and allow
the wound to heal. The staples will stay in place until your
first post-operative visit at which time they can be removed in
the clinic, most likely by the office nurse. Please monitor the
incision for signs and symptoms of infection including:
increasing redness at the incision, opening of the incision,
increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line/ wound and
pat the area dry with a towel, do not rub. Reapply a new
dressing after showering.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
excersise Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1120**].
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please see Dr. [**Last Name (STitle) 1120**] in the Colorectal surgery office on
Tuesday, [**2116-5-26**] at 10am. The phone number is
[**Telephone/Fax (1) 160**].
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2116-12-2**]
3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2116-12-2**] 4:00
Please make an appointment with your primary care provider to
update them on your position.
|
[
"5849",
"486",
"4280",
"5180",
"42731",
"9971",
"V5861",
"4019"
] |
Admission Date: [**2105-11-18**] Discharge Date: [**2105-12-1**]
Date of Birth: [**2033-3-4**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
pedestrian struck by car
Major Surgical or Invasive Procedure:
[**2105-11-20**]: s/p Bilateral open reduction internal fixation, tibial
plateaus
History of Present Illness:
72 year old male hit by car on [**2105-11-18**] resulting in bilateral
tibial plateau fractures requiring surgical management.
Past Medical History:
Atrial Fibrillation
COPD
CAD
T2DM
HTN
gout
chronic sinus infections
Social History:
Denies tobacco and drug use. Occ alcohol.
Family History:
n/a
Physical Exam:
On admission:
Temp:97.2 HR:102 BP:100/57 Resp:20 O(2)Sat:98
Constitutional: anxious, unable to follow commands
HEENT: hematoma R occiput
Chest: course BS with crackles, scattered
Cardiovascular: tachycardic, irregular
Abdominal: Soft, Nondistended
Extr/Back: lower extremity edema with ecchymosis around
bilateral malleoli, pulses palpable on L LE; non-dopplerable
PT on R, dopplerable DP on R, compartments soft, demarcation
distal R ankle; R posterior knee: ecchymosis with hematoma
and blistering; swelling along calf and posterior thigh
Neuro: unable to assess neurologic exam
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2105-11-18**] 12:09AM BLOOD freeCa-1.10*
[**2105-11-20**] 09:16AM BLOOD freeCa-1.10*
[**2105-11-20**] 10:49AM BLOOD freeCa-1.08*
[**2105-11-20**] 09:21PM BLOOD freeCa-1.14
[**2105-11-22**] 05:16PM BLOOD freeCa-1.09*
[**2105-11-18**] 12:09AM BLOOD Hgb-13.1* calcHCT-39
[**2105-11-20**] 09:16AM BLOOD Hgb-6.9* calcHCT-21 O2 Sat-83
[**2105-11-20**] 10:49AM BLOOD Hgb-8.1* calcHCT-24 O2 Sat-85
[**2105-11-20**] 09:21PM BLOOD O2 Sat-95
[**2105-11-21**] 05:56AM BLOOD O2 Sat-97
[**2105-11-18**] 12:04AM BLOOD Lactate-2.0 K-5.1
[**2105-11-18**] 12:09AM BLOOD Glucose-233* Lactate-1.9 Na-140 K-5.2
Cl-97*
[**2105-11-20**] 09:16AM BLOOD Glucose-77 Lactate-1.0 Na-140 K-4.1
Cl-99*
[**2105-11-20**] 10:49AM BLOOD Glucose-86 Lactate-1.8 Na-139 K-4.4
Cl-100 calHCO3-33*
[**2105-11-20**] 09:21PM BLOOD Lactate-1.3
[**2105-11-22**] 05:16PM BLOOD Lactate-1.6
[**2105-11-18**] 12:09AM BLOOD Type-ART pO2-73* pCO2-93* pH-7.19*
calTCO2-37* Base XS-4 Intubat-NOT INTUBA
[**2105-11-18**] 04:15AM BLOOD Type-ART Rates-/16 Tidal V-550 FiO2-100
pO2-362* pCO2-69* pH-7.29* calTCO2-35* Base XS-4 AADO2-318 REQ
O2-56 -ASSIST/CON Intubat-INTUBATED
[**2105-11-18**] 09:03PM BLOOD Type-ART Temp-36.4 Rates-22/ Tidal V-550
PEEP-5 FiO2-40 pO2-82* pCO2-52* pH-7.43 calTCO2-36* Base XS-8
-ASSIST/CON Intubat-INTUBATED
[**2105-11-20**] 09:16AM BLOOD Type-CENTRAL VE Tidal V-464 FiO2-54
pO2-53* pCO2-64* pH-7.36 calTCO2-38* Base XS-7 Intubat-INTUBATED
[**2105-11-20**] 09:21PM BLOOD Type-ART PEEP-5 FiO2-50 pO2-100 pCO2-76*
pH-7.29* calTCO2-38* Base XS-6 Intubat-INTUBATED
[**2105-11-20**] 11:55PM BLOOD Type-ART PEEP-5 FiO2-45 pO2-95 pCO2-58*
pH-7.37 calTCO2-35* Base XS-5 Intubat-INTUBATED Vent-SPONTANEOU
[**2105-11-21**] 05:56AM BLOOD Type-ART PEEP-5 FiO2-45 pO2-98 pCO2-58*
pH-7.37 calTCO2-35* Base XS-5
[**2105-11-21**] 09:27PM BLOOD Type-ART pO2-71* pCO2-59* pH-7.39
calTCO2-37* Base XS-7
[**2105-11-22**] 05:16PM BLOOD Type-ART Temp-37.8 Rates-/38 FiO2-50 O2
Flow-4 pO2-65* pCO2-58* pH-7.42 calTCO2-39* Base XS-10
Intubat-INTUBATED Comment-FACE TENT
[**2105-11-22**] 06:29PM BLOOD Type-ART Temp-37.8 Rates-/24 FiO2-40 O2
Flow-4 pO2-86 pCO2-57* pH-7.42 calTCO2-38* Base XS-9 Intubat-NOT
INTUBA Comment-FACE TENT
[**2105-11-17**] 11:00PM BLOOD Digoxin-2.5*
[**2105-11-22**] 02:01AM BLOOD Digoxin-0.8*
[**2105-11-17**] 11:00PM BLOOD Albumin-3.3*
[**2105-11-18**] 06:08AM BLOOD Albumin-2.9* Calcium-7.5* Phos-3.2 Mg-1.6
[**2105-11-18**] 04:50PM BLOOD Calcium-7.8* Phos-1.9* Mg-1.5*
[**2105-11-19**] 02:45AM BLOOD Calcium-7.9* Phos-1.8* Mg-1.5*
[**2105-11-20**] 01:12AM BLOOD Calcium-8.0* Phos-3.9# Mg-2.4
[**2105-11-20**] 04:27PM BLOOD Calcium-7.8* Phos-4.4 Mg-2.1
[**2105-11-21**] 09:06PM BLOOD Calcium-7.9* Phos-1.6*# Mg-2.3
[**2105-11-22**] 02:01AM BLOOD Calcium-7.9* Phos-1.7* Mg-2.4
[**2105-11-22**] 01:41PM BLOOD Phos-2.6*
[**2105-11-23**] 02:11AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.2*
Mg-2.0
[**2105-11-24**] 03:05AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.9
[**2105-11-17**] 11:00PM BLOOD cTropnT-<0.01 proBNP-1450*
[**2105-11-18**] 06:08AM BLOOD Lipase-705*
[**2105-11-19**] 02:45AM BLOOD Lipase-106*
[**2105-11-17**] 11:00PM BLOOD ALT-19 AST-33 LD(LDH)-338* AlkPhos-78
Amylase-585* TotBili-1.5
[**2105-11-18**] 06:08AM BLOOD ALT-20 AST-35 LD(LDH)-309* AlkPhos-67
Amylase-527* TotBili-2.1*
[**2105-11-19**] 02:45AM BLOOD ALT-20 AST-40 AlkPhos-56 Amylase-271*
TotBili-1.9*
[**2105-11-23**] 02:11AM BLOOD ALT-27 AST-54* AlkPhos-65
[**2105-11-17**] 11:00PM BLOOD Glucose-218* UreaN-26* Creat-1.9* Na-139
K-5.4* Cl-100 HCO3-31 AnGap-13
[**2105-11-18**] 04:50AM BLOOD Glucose-2275* UreaN-17 Creat-1.4* Na-74*
K-3.3 Cl-58* HCO3-16* AnGap-3*
[**2105-11-18**] 06:08AM BLOOD Glucose-344* UreaN-29* Creat-2.0* Na-135
K-5.6* Cl-97 HCO3-30 AnGap-14
[**2105-11-18**] 04:50PM BLOOD Glucose-157* UreaN-32* Creat-1.8* Na-142
K-4.2 Cl-102 HCO3-31 AnGap-13
[**2105-11-19**] 02:45AM BLOOD Glucose-80 UreaN-34* Creat-1.7* Na-138
K-3.9 Cl-99 HCO3-30 AnGap-13
[**2105-11-20**] 01:12AM BLOOD Glucose-80 UreaN-34* Creat-1.3* Na-141
K-4.5 Cl-104 HCO3-33* AnGap-9
[**2105-11-20**] 04:27PM BLOOD Glucose-106* UreaN-32* Creat-1.2 Na-144
K-4.5 Cl-106 HCO3-32 AnGap-11
[**2105-11-21**] 02:06AM BLOOD Glucose-66* UreaN-32* Creat-1.3* Na-143
K-4.3 Cl-105 HCO3-34* AnGap-8
[**2105-11-21**] 09:06PM BLOOD Glucose-146* UreaN-30* Creat-1.3* Na-145
K-3.8 Cl-106 HCO3-34* AnGap-9
[**2105-11-22**] 02:01AM BLOOD Glucose-44* UreaN-30* Creat-1.2 Na-142
K-3.5 Cl-105 HCO3-34* AnGap-7
[**2105-11-22**] 11:49AM BLOOD Glucose-144* Na-144 K-4.9 Cl-105
[**2105-11-22**] 01:41PM BLOOD Glucose-132* Na-142 K-4.9 Cl-103
[**2105-11-23**] 02:11AM BLOOD Glucose-116* UreaN-28* Creat-1.1 Na-140
K-4.4 Cl-103 HCO3-34* AnGap-7*
[**2105-11-24**] 03:05AM BLOOD Glucose-92 UreaN-29* Creat-1.0 Na-145
K-4.3 Cl-105 HCO3-34* AnGap-10
[**2105-11-25**] 04:40AM BLOOD Glucose-103* UreaN-34* Creat-1.3* Na-144
K-4.2 Cl-101 HCO3-36* AnGap-11
[**2105-11-26**] 04:46AM BLOOD Glucose-101* UreaN-37* Creat-1.3* Na-141
K-3.8 Cl-98 HCO3-37* AnGap-10
[**2105-11-17**] 11:00PM BLOOD PT-22.7* PTT-28.9 INR(PT)-2.1*
[**2105-11-17**] 11:00PM BLOOD Plt Smr-NORMAL Plt Ct-178
[**2105-11-18**] 04:50AM BLOOD PT-39.6* PTT-60.7* INR(PT)-4.1*
[**2105-11-18**] 04:50AM BLOOD Plt Smr-LOW Plt Ct-126*
[**2105-11-18**] 06:08AM BLOOD PT-22.6* PTT-30.5 INR(PT)-2.1*
[**2105-11-18**] 06:08AM BLOOD Plt Ct-128*
[**2105-11-18**] 04:50PM BLOOD PT-18.9* PTT-29.3 INR(PT)-1.7*
[**2105-11-18**] 04:50PM BLOOD Plt Ct-120*
[**2105-11-19**] 02:45AM BLOOD PT-16.3* PTT-29.0 INR(PT)-1.4*
[**2105-11-19**] 02:45AM BLOOD Plt Ct-127*
[**2105-11-20**] 01:12AM BLOOD Plt Ct-109*
[**2105-11-20**] 04:45AM BLOOD PT-13.2 PTT-27.4 INR(PT)-1.1
[**2105-11-20**] 04:27PM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0
[**2105-11-20**] 04:27PM BLOOD Plt Ct-142*
[**2105-11-20**] 04:27PM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0
[**2105-11-20**] 04:27PM BLOOD Plt Ct-142*
[**2105-11-21**] 02:06AM BLOOD Plt Ct-127*
[**2105-11-22**] 02:01AM BLOOD Plt Ct-106*
[**2105-11-22**] 05:05PM BLOOD Plt Ct-120*
[**2105-11-23**] 02:11AM BLOOD PT-14.5* PTT-31.6 INR(PT)-1.3*
[**2105-11-23**] 02:11AM BLOOD Plt Ct-119*
[**2105-11-24**] 03:05AM BLOOD Plt Ct-146*
[**2105-11-25**] 04:40AM BLOOD Plt Ct-222#
[**2105-11-26**] 04:46AM BLOOD Plt Ct-199
[**2105-11-17**] 11:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2105-11-17**] 11:00PM BLOOD Neuts-93* Bands-0 Lymphs-3* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2105-11-17**] 11:00PM BLOOD WBC-21.5* RBC-4.07* Hgb-12.9* Hct-39.2*
MCV-96 MCH-31.6 MCHC-32.9 RDW-16.1* Plt Ct-178
[**2105-11-18**] 01:17AM BLOOD Hgb-12.2* Hct-38.0*
[**2105-11-18**] 04:50AM BLOOD WBC-13.1* RBC-2.96*# Hgb-9.0*# Hct-32.5*
MCV-110*# MCH-30.5 MCHC-27.8*# RDW-16.2* Plt Ct-126*
[**2105-11-18**] 06:08AM BLOOD WBC-16.7* RBC-3.72*# Hgb-12.0*# Hct-35.4*
MCV-95# MCH-32.1* MCHC-33.7# RDW-16.4* Plt Ct-128*
[**2105-11-18**] 04:50PM BLOOD WBC-16.4* RBC-3.03* Hgb-9.5* Hct-28.6*
MCV-94 MCH-31.4 MCHC-33.4 RDW-16.3* Plt Ct-120*
[**2105-11-19**] 02:45AM BLOOD WBC-17.2* RBC-2.87* Hgb-9.1* Hct-27.4*
MCV-95 MCH-31.6 MCHC-33.2 RDW-16.5* Plt Ct-127*
[**2105-11-20**] 01:12AM BLOOD WBC-17.3* RBC-2.54* Hgb-8.1* Hct-24.3*
MCV-96 MCH-32.0 MCHC-33.4 RDW-16.7* Plt Ct-109*
[**2105-11-20**] 04:27PM BLOOD WBC-17.9* RBC-3.48*# Hgb-10.3*#
Hct-32.1*# MCV-92 MCH-29.5 MCHC-32.0 RDW-17.9* Plt Ct-142*
[**2105-11-21**] 02:06AM BLOOD WBC-14.4* RBC-3.17* Hgb-10.0* Hct-28.6*
MCV-90 MCH-31.4 MCHC-34.8 RDW-18.3* Plt Ct-127*
[**2105-11-22**] 02:01AM BLOOD WBC-8.8 RBC-2.55* Hgb-7.9* Hct-23.2*
MCV-91 MCH-31.2 MCHC-34.2 RDW-17.7* Plt Ct-106*
[**2105-11-22**] 05:05PM BLOOD WBC-13.1* RBC-3.33*# Hgb-10.4*#
Hct-30.2*# MCV-91 MCH-31.4 MCHC-34.6 RDW-17.2* Plt Ct-120*
[**2105-11-23**] 02:11AM BLOOD WBC-10.7 RBC-3.01* Hgb-9.7* Hct-27.5*
MCV-91 MCH-32.3* MCHC-35.3* RDW-17.1* Plt Ct-119*
[**2105-11-24**] 03:05AM BLOOD WBC-10.8 RBC-3.05* Hgb-9.6* Hct-28.3*
MCV-93 MCH-31.6 MCHC-34.1 RDW-16.9* Plt Ct-146*
[**2105-11-25**] 04:40AM BLOOD WBC-10.0 RBC-3.30* Hgb-10.3* Hct-31.5*
MCV-96 MCH-31.1 MCHC-32.6 RDW-16.4* Plt Ct-222#
[**2105-11-26**] 04:46AM BLOOD WBC-8.9 RBC-3.23* Hgb-10.2* Hct-30.5*
MCV-94 MCH-31.5 MCHC-33.4 RDW-16.9* Plt Ct-199
Brief Hospital Course:
Mr. [**Known lastname 1790**] was admitted to the General Trauma Surgery service
on [**2105-11-18**] after being hit by a car. In the ED he was
hypotensive and intubated for hypoxia then transferred to ICU.
The ICU team monitored him and replete his blood, fluid,
electrolytes and placed on pressors for hypotension. On
[**2105-11-20**] he underwent open reduction internal fixation of
bilateral tibial plateaus without complication. Post operatively
he was transferred back to the ICU. He was transfused for post
operative blood loss anemia and placed on sliding scales for his
electrolytes. On [**2105-11-20**] post operatively he went into AFib w/
RVR treated with Lopressor and digoxin. Then Dilt drip started
for AFib w/ RVR due to refractory to Lopressor and digoxin. On
[**2105-11-21**] he was extubated, c-spine cleared, diet advanced to
regular, weaned off dilt drip, started metoprolol 12.5mg. On
that evening he started sundowning. On [**2105-11-22**] he was
transfused 2U pRBC with Lasix in between for post operative
blood loss anemia. He became confused thus Haldol given. On
[**2105-11-23**] he aspirated and became agitated and delirious. The
chest xray did not show any interval change. On [**2105-11-23**] speech
and swallow test performed. On [**2105-11-24**] he was transferred out
of the ICU to the Orthopedic service. He remained confused
therefore the [**Female First Name (un) 1634**] service was consulted for post op delirium.
they recccomended for agigition use
Medications on Admission:
Home Medications:
coumadin,digoxin 250mcg daily, diovan 160mg daily, lasix 20mg
daily, lipitor 20mg daily, Toprol XL 200mg
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob, wheeze.
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
7. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*28 * Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
13. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Living
Discharge Diagnosis:
1. Bilateral tibial plateau fractures.
2. Hypercarbia.
3. Post operative Delirium.
4. Post operative blood loss anemia.
5. Fluid volume deficit
6. Hypotension
7. Hypoxia
8. Atrail Fib with rapid ventricular rate.
9. Aspiration
10. Hypoglycemia
11. Leukocytosis
12. Hypocalcemia.
13. Hypomagnesemia.
14. Hypophosphatemia.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Wound Care:
-Keep Incisions dry.
-Do not soak the incisions in a bath or pool.
Activity:
-Continue to be non weight bearing on both legs.
-Keep the braces dry, they may come off while in bed, but need
to be on when up and transferring
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
If urethral bleeding worsens or it becomes difficult/painful to
urinate please come to the ED
Physical Therapy:
Activity: Out of bed
Right lower extremity: Non weight bearing
Left lower extremity: Non weight bearing
[**Doctor Last Name **] braces bilaterally unlocked, ROM knees as tolerated
Treatments Frequency:
remove staples 14 days from date of surgery
Followup Instructions:
2 weeks in the [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.
Please call [**Telephone/Fax (1) 1228**] to make this appointment.
...
Follow up with urology in 2 weeks. Please call ([**Telephone/Fax (1) 772**] to
set up an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2105-12-1**]
|
[
"2762",
"2851",
"42731",
"496",
"41401",
"25000",
"4019"
] |
Admission Date: [**2153-6-12**] Discharge Date: [**2153-6-17**]
Date of Birth: [**2129-11-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Aortic insufficiency
Major Surgical or Invasive Procedure:
1. AVR (29mm CE pericardial)
History of Present Illness:
23M previously admitted [**Hospital3 1280**] for evaluation of migraines,
at which time a diastolic murmur was appreciated and subsequent
echocardiogram showed 4+ AI and a dilated aortic root.
Increasing DOE and chest pain. Referred for surgical repair.
Past Medical History:
1. Aortic insufficiency
2. + PPD
Social History:
Unremarkable
Family History:
Noncontributory
Physical Exam:
Unremarkable except for gr IV/VI diastolic murmur
Pertinent Results:
[**2153-6-14**] 05:05AM BLOOD WBC-14.0* RBC-3.29* Hgb-10.0* Hct-28.7*
MCV-87 MCH-30.4 MCHC-34.8 RDW-13.2 Plt Ct-110*
[**2153-6-14**] 05:05AM BLOOD Glucose-103 UreaN-21* Creat-0.8 Na-135
K-4.3 Cl-98 HCO3-31* AnGap-10
Brief Hospital Course:
To OR on [**2153-6-12**], underwent uneventful AVR (29mmCE). Post-op
transferred toCSRU on Neo for short period. Weaned from vent,
extubated the day of surgery. Transferred [**Last Name (un) 834**] ICU on POD # 1.
Began ambulation, pulm. toilet. Progressed well, chest tubes
and epicardial pacing wires removed on POD # 2. Has remained
stable, and is ready for discharge home today.
Medications on Admission:
TB meds for positive skin test (negative CXR)
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every
4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day for 5 days: then Q 8 hours prn pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Aortic insufficiency
2. Dilated aortic root
3. + PPD
Discharge Condition:
Good
Discharge Instructions:
1. Resume medications as directed.
2. Call office or go to ER if fever/chills, drainage from
incisions, chest pain, shortness of breath.
Followup Instructions:
PCP, 2 weeks, call for appointment.
Cardiologist, 2 weeks, call for appointment.
Dr[**Last Name (Prefixes) 4558**], 4 weeks, call for appointment.
Completed by:[**2153-6-15**]
|
[
"4241"
] |
Admission Date: [**2105-11-22**] Discharge Date: [**2106-1-8**]
Date of Birth: [**2048-12-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
56 year old Portuguese male with 1 day history of chest pain and
dizziness.
Major Surgical or Invasive Procedure:
AVR(27mm valve) Homograft/Ascending aorta tube graft [**2105-12-8**]
Tracheostomy
Percutaneous feeding tube placement
History of Present Illness:
56 y.o. male, Portugese speaking, with history of AS/AI who
presented to an OSH with CP and dizziness after walking up a
[**Doctor Last Name **]. Pt reports that he had been experiencing chest pain with
heavy exertion for quite some time. Pt presented to [**Hospital 8**]
Hospital for evaluation. Per OSH records, the pt described the
pain as substernal in nature with radiation to the shoulders
R>L. Pt had subjective palpitations and dizziness with the pain
but no fevers, chills, diaphoresis, nausea, or vomiting. On
arrival to the OSH, the pt's pain was relieved with tylenol.
However, he was found to have a fever of 101 so was admitted to
the ICU for further evaluation. On workup, pt's CXR was
significant for a sidened mediastinum with a tortuous aortic
shadow. CT with contrast revealed a ascending aortic aneurysm of
6.5 cm with a normal descending aorta. Pt was ruled out for MI.
Five sets of blood cultures were drawn. There was a concern for
endocarditis so the pt was started emperically on rocephin,
gentamicin, and nafcillin. The pt was then transferred to [**Hospital1 18**]
for CT surgical evaluation for repair of his aneurysm.
Past Medical History:
1. HTN
2. AS and AI- Seen on echo at [**Hospital 8**] Hospital on 08/[**2104**]. AV
area of 0.7 cm2 and a gradient of 77 mmGg. Moderate AI. LVEF of
75%.
3. Right VP shunt s/p trauma approximately 30 years ago
Social History:
Pt is married and lives with his wife and children. He works as
a mechanic. He is Portugese speaking. No tobacco, ETOH, or
drugs.
Family History:
[**Name (NI) 1094**] father had DM. No history of CAD or hypercholesterolemia.
Physical Exam:
Gen- Alert and oriented. NAD. Resting comfortably in bed.
HEENT- NC AT. PERRL. MMM.
Cardiac- Irregularly irregular. IV/VI harsh holosystomic murmur
radiating throughout precordium and up to carotids. No JVD
appreciated.
Pulm- CTAB.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Skin- Multiple cherry hemangiomas on abdomen and chest; no
stigmata of endocarditis
Extremities- Trace LE edema. 2+ DP pulses.
Neuro: CN 2-12 intact, sensation intact throughout, strength 5/5
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2106-1-7**] 06:36AM 6.6 3.82* 11.7* 35.7* 94 30.6 32.8 17.0*
463*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2106-1-7**] 06:36AM 463*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2106-1-7**] 06:36AM 20 0.7 4.1
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2106-1-6**] 02:46AM 1.7
Source: Line-Picc; GREEN TOP
Cardiology Report ECHO Study Date of [**2105-12-28**]
PATIENT/TEST INFORMATION:
Indication: Endocarditis. Evaluation for abscess. Prosthetic
valve function.
BP (mm Hg): 105/85
HR (bpm): 85
Status: Inpatient
Date/Time: [**2105-12-28**] at 11:20
Test: Portable TEE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2005W065-0:25
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 60% (nl >=55%)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2105-12-21**].
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the
body of the
LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast
in the body of the RA. No mass or thrombus in the RA or RAA. A
catheter or
pacing wire is seen in the RA and/or RV. No spontaneous echo
contrast in the
RAA. Normal interatrial septum.
LEFT VENTRICLE: Normal LV cavity size. Normal regional LV
systolic function.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Normal RV
systolic function.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR
leaflets. No masses or vegetations on aortic valve. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or
vegetation on
mitral valve. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or
vegetation on tricuspid valve.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was monitored
by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient
was sedated for
the TEE. Medications and dosages are listed above (see Test
Information
section). Local anesthesia was provided by benzocaine topical
spray. No TEE
related complications. The rhythm appears to be atrial
fibrillation. Compared
with the findings of the prior study, there has been no
significant change.
Echocardiographic results were reviewed by telephone with the
houseofficer
caring for the patient.
Conclusions:
1.The left atrium is normal in size. No spontaneous echo
contrast is seen in
the body of the left atrium or right atria.
2. A pacing wire is visualized in the right atrium and is free
of masses or
vegetations.
3. The left ventricular cavity size is normal. Regional left
ventricular wall
motion is normal. Overall left ventricular systolic function is
normal
(LVEF>55%).
4. Right ventricular chamber size and wall motion are normal.
5.The ascending, transverse and descending thoracic aorta are
normal in
diameter and free of atherosclerotic plaque.
6. A bioprosthetic aortic valve prosthesis is present. The
prosthetic aortic
leaflets appear normal. No masses or vegetations are seen on the
aortic valve.
No aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. No mass or
vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
The tricuspid
valve has no masses or vegetations.
8.There is a trivial/physiologic pericardial effusion.
Compared with the prior study (tape reviewed) of [**2105-12-21**] there
is no
diagnostic change.
RADIOLOGY Final Report
CT HEAD W/ CONTRAST [**2105-12-27**] 2:53 PM
CT HEAD W/ CONTRAST; CT 100CC NON IONIC CONTRAST
Reason: needs IV contrast to identify signs of infection w/in
fronta
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
57M s/p AVR, with persistent sepsis & CNS fluid collections
REASON FOR THIS EXAMINATION:
needs IV contrast to identify signs of infection w/in frontal
collections. last noncontrast study was inadequate
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Status-post aortic valve replacement with persistent
sepsis and CNS fluid collections.
COMPARISON: Same day approximately one (1) hour prior.
TECHNIQUE: Multiple axial images of the head were obtained
following the administration of 100 cc of Optiray.
CT HEAD W/IV CONTRAST: No enhancing intracranial collections
identified. Again seen, are bifrontal chronic subdural
collections, unchanged. There is a ventricular drainage catheter
via the right posterior approach, unchanged in position. There
is no shift of normally midline structures. No enhancing masses
are seen. There is no hydrocephalus.
IMPRESSION: Stable appearance of bifrontal chronic subdural
collections. No enhancing masses or enhancing collections
identified. Please note if meningeal infection is a concern, the
most sensitive test would be CSF analysis.
Brief Hospital Course:
The patient was admitted on [**2105-11-22**].On [**2105-11-23**], the pt was
also noted to be in new onset atrial fibrillation. He was loaded
with 200 mg of amiodarone and started on a heparin drip. On
arrival to [**Hospital1 18**], the pt was evaluated by CT [**Doctor First Name **] who delayed
valve repair until the patient was infection free. He was then
admitted to the CCU for further care. At that time, his
temperature was 102.9. Antibiotics were changed on admission to
gentamycin, vancomycin, and pen G. On the day following
admission ([**2105-11-23**]), it was found that all 10 bottles of
blood cultures from the OSH were growing gram positive cocci. ID
was consulted and the pt's antibiotics were changed to
vancomycin, gentamycin (until consistantly clean blood
cultures), and oxacillin. The pen G was discontinued. TTE was
significant for a LVEF of 30 to 35%; mild LA and RA enlargement;
severly dilated LV with diffuse hypokinesis; moderate dilation
of the aortic root; marked dilation fo the ascending aorta;
marked dilation of the aortic arch; severe AS; severe AR; mild
MR; mild TR; and mild PA systolic hypertension. TEE on
[**2105-11-24**] was negative for any vegitation or abcess suggestive
of endocarditis. At that time, ID felt that the infection was
most likely located [**Last Name (un) 7245**] in the aneurysm. By [**2105-11-25**], the
pt's fever curve was markedly decreased. He was transferred to
the [**Hospital Unit Name **] team for further care.
He grew out MSSA and the gentamycin was discontinued. He
developed fevers and an increased WBC again and was found to
have an abcess and vegitation on his aortic valve on TEE. He
blocked down and required temporary pacer placement. He was
restarted on Vanco and underwent cardiac cath prior to the OR.
On [**2105-12-8**] he underwent AVR homograft with a 27mm valve and
ascending aortic root replacement. He had purulent drainage
from his heart and aorta, and was transferred to the CSRU.
POD#1 he was on Epi and remained intubated. He was extremely
agitated and continued having high temps. He intermittently
required Neo and Vasopressin for profound hypotension. He was
closely followed by ID, Pulmonary, and EP. He was on Gent,
Vanco, Oxacillin, and Rifampin. He remained intubated and had
several TEEs which were all negative. Eventually his rhythm
recovered and the pacing wire was d/c'd. He had a negative LP
and head CT and was followed by neurology for agitation. All
cultures were negative. He was eventually started on
Casperfungin and POD #18 he defervesced and underwent a
tracheostomy on [**12-26**]. He continued to improve and the
Caspofungin was d/c'd. His antibiotics were eventually changed
to Rifampin and Oxacillin alone. He weaned quickly from the
vent., and failed a swallowing study, so he had a PEG placed on
[**1-5**]. On [**1-6**] he was transferred to the floor in stable
condition. He was discharged to acute rehab on POD#31 in stable
condition.
He needs to continue Oxacillin and Rifampin until [**1-22**]. He was
diagnosed with c. diff on [**1-3**] and should stay on Flagyl while
on abx.
Medications on Admission:
1. Amiodarone 200 mg QID
2. ASA 81 mg daily
3. Atorvastatin 20 mg daily
4. Docusate 100 mg [**Hospital1 **]
5. Gentamicin 100 mg IV Q8H
6. Weight based IV heparin
7. RISS
8. Oxacillin 2 gm IV Q4H
9. Pantoprazole 40 mg daily
10. Vancomycin 1000 mg IV Q12H
PRNs-
Tylenol
Bisacodyl
Ambien
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Acetaminophen 160 mg/5 mL Elixir Sig: Two (2) PO Q4-6H
(every 4 to 6 hours) as needed for temp>38.
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO PRN
(as needed) as needed for k < 4.4.
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): While on Oxacillin and Rifampin, pt. should stay
on Flagyl.
7. Rifampin 150 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours): D/C on [**2106-1-22**].
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. 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.
11. Oxacillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q4H (every 4 hours): D/C [**2106-1-22**].
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous twice a day.
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
Subcutaneous four times a day: SS: BS 110-150 2U
151-200 4U
201-250 6U
251-300 8U
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
MSSA endocarditis
Prolonged intubation
Aortic stenosis
Atrial fibrillation
HTN
s/p VP shunt 30 yrs ago
C. diff
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) **] when discharged from rehab.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Completed by:[**2106-1-8**]
|
[
"78552",
"9971",
"5119",
"99592",
"42731",
"4019",
"42789"
] |
Admission Date: [**2132-10-26**] Discharge Date: [**2132-10-29**]
Date of Birth: [**2097-4-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
No major surgical or invasive procedures.
History of Present Illness:
35 yo M w/ h/o asthma only on albuterol prn though multiple
hospital admission, p/w SOB and asthma flare x 1d. Seen at
[**Hospital 1263**] Hospital 1 week ago, improved rapidly on iv steroids but
pt refused inpt admission. He did not fill his prednisone rx
after d/c but has been using advair inhaler x past week, stopped
recently. Previously seen here in [**1-21**] and d/c on prednisone
taper from ED also. Neice with URI which pt caught. In ED
received prednisone 60 mg po x 1, combivent neb x 9, MgSO4 4g
iv, and Terbutiline 0.5 mg SC x 1, placed on continuous nebs at
10 mg/h at 3A. Pt w/ unknown PF but in ED ranged 400-480 post
nebs. Sent to [**Hospital Unit Name 153**] for continuous nebs and further monitoring.
.
ROS: + chest tightness, + "breathing through a straw" sensation,
+ recent congestion, rhinorrhea. No cough, chest pain, abd pain,
n/v/d, LE edema, orthopnea. + weight gain of 30-40 lbs in past
couple years. Does not exercise due to DOE.
Past Medical History:
PMH:
- Asthma: no h/o intubations. Past 2 yrs has had only 1 other ED
visit for asthma flare prior to last week. Uses albuterol MDI
and nebs occasionally up to several times daily when trigger
encountered, occasionally not at all. 1 mo ago sister brought
another dog over which pt believes triggered sxs last week.
- Seasonal allergies
Social History:
SH: Truck driver. No tob or EtOH. Lives with 5 neices who he
raised. Has great [**Male First Name (un) **] dog x many years.
Family History:
FH: Mom and sister with asthma, DM
.
Physical Exam:
PE:
VS: T 100 HR 127 BP 128/51 RR 24 O2 sat 99% on continuous neb
Gen: Obese pleasant M sitting in bed speaking in mostly full
sentences
HEENT: PERRLA, EOMI, mildly dry mm
Neck: No LAD
CV: RRR tachy nl S1 S2 no m/r/g
Pulm: Bilateral diffuse wheezing on expiration with increased
expiratory time
Abd: Obese soft NT/ND
Extr: No c/c/e
Neuro: AAOx3, moves all extremities equally and spontaneously
Skin: Multiple extensive areas of tattoos
Pertinent Results:
[**2132-10-29**] 07:00AM BLOOD WBC-20.4* RBC-4.56* Hgb-14.3 Hct-42.7
MCV-94 MCH-31.5 MCHC-33.6 RDW-12.6 Plt Ct-242
[**2132-10-29**] 07:00AM BLOOD Glucose-98 UreaN-24* Creat-1.1 Na-141
K-3.7 Cl-108 HCO3-23 AnGap-14
[**2132-10-27**] 06:50AM BLOOD Glucose-211* UreaN-15 Creat-1.3* Na-143
K-3.9 Cl-106 HCO3-15* AnGap-26*
[**2132-10-29**] 07:00AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.3
[**2132-10-27**] 02:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2132-10-27**] 10:17PM BLOOD Acetone-NEGATIVE
[**2132-10-27**] 04:00PM BLOOD Type-ART pO2-78* pCO2-31* pH-7.38
calHCO3-19* Base XS--5
[**2132-10-27**] 04:00PM BLOOD Lactate-5.3*
[**2132-10-27**] 10:44PM BLOOD Lactate-1.7
[**10-26**] EKG: ST at 132, nl axis/int, no STE/depressions/TWI
concerning for ischemia, isolated small qs in III.
.
[**10-26**] CXR: Cardiac, mediastinal and hilar contours, pulmonary
vasculature wnl. Lungs clear, but left CPA cut off and overall
hazy likely d/t body habitus. No clear pleural effusions.
Brief Hospital Course:
35 yo M w/ asthma flare likely [**2-20**] URI admitted for increased
nebs and further monitoring.
.
1. Asthma flare: Though recently pt w/ 2 flares in past week, he
seems to usually not have flares. He also may have been
underreporting sxs and has high tolerance of sxs at baseline. On
arrival to the [**Hospital Unit Name 153**], he was switched to IV methylprednisolone,
which he received for two days, and then switched to po
prednisone (60-40-30-20-10) 10 day taper for continuation as
outpatient. He was placed on continuous neb treatments
initially, and then switched to albuterol q2 then albuterol q4.
By HOD3, he required no prn albuterol nebulizer treatments. He
was placed on an albuterol inhaler prn, as well as Advair [**Hospital1 **].
His peak flows improved to 600.
Patient is fairly noncompliant with his medications - states he
is unwilling to have regular follow-up with doctors. He would
ideally need a PCP and outpatient [**Name9 (PRE) 11149**], and minimizing of
environmental triggers (pt unlikely to be getting rid of dog,
however). His URI symptoms appeared viral, and did have
productive yellow cough. He remained afebrile in [**Hospital Unit Name 153**], but did
have a rising white count in the context of steroids. No
antibiotics were started.
2. Metabolic acidosis with gap and lactate 5.3, as well as
ketones in urine. Patient's acidosis was likely secondary to
lactic acidosis from acute asthma flare. Lactate down to 1.7
with fluids. Urinalysis shows glucose and ketones, but in the
context of poor po intake and poor glycemic control on steroids.
No sx of DKA. ABG c/w compensated metabolic acidosis. He may
need outpatient followup for FSBG.
.
3. FEN: He was on a regular diet.
4. Glucose: ISS.
5. Proph: PPI on steroids. Bowel regimen.
6. Code: DNR/I- confirmed with pt
7. Comm: with pt
Medications on Admission:
Albuterol inh prn
Advair x 1 week
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day
for 10 days: Four (4) tablets a day x 2 days, then two (2)
tablets a day x 3 days, then one (1) tablet a day x 3 days, then
half ([**1-20**]) tablet a day x 2 days. .
Disp:*18 Tablet(s)* Refills:*0*
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
Disp:*1 1* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Asthma Exacerbation
2. Lactic acidosis
3. Ketoacidosis
Discharge Condition:
Stable
Discharge Instructions:
If you experience shortness of breath, or wheezing, please
report to the emergency room immediately. Please take all of
your medications. Monitor your peak flows and record them.
Please follow up with your physicians (see information below.)
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] on Monday, [**2132-11-24**] at
2:00 p.m. The number of the clinic is [**Telephone/Fax (1) 250**].
|
[
"2762"
] |
Admission Date: [**2189-1-3**] Discharge Date: [**2189-1-16**]
Date of Birth: [**2120-10-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
endotracheal intubation
central venous line placement
History of Present Illness:
68yoM, nursing home resident, w/ pmh sig for Alzheimer's
dementia and hydrocephalus s/p shunt who was sent to the [**Hospital1 18**]
ED from the NH today because of five days of diarrhea, one day
of vomitting, and increased confusion/agitation. Found to have
partial SBO, aspiration pneumonia, now with blood cultures
positive for GPC. On CTX/azithro/vanco/Flagyl There have been no
recent fevers or chills, sob. He has had a dry cough today.
Per so, a stool sample was sent for c diff at the nursing home.
Son states that at baseline pt can be combative and agitated but
is also more verbal. There has been no blood in diarrhea or
melena.
.
ROS: No suggestion of back pain, headache, visual changes,
dysuria, hematuria.
.
In the ED he had a CT of the head, abd, as well as a cxr.
Neurosurg evaluated pt and noted milf increase in ventricular
size, but felt that shunt malfuntion or infection was unlikely.
In addition, the surgical team evaluated the patient out of
concern for partial sbo given vomitting and ct abd with ? of
sbo. Per surgical note, pt has likely partial sbo or ileus. An
NG tube was placed and the team recommended no surgery, but NG
tube, npo.
.
In the ED patient had a fever to 103, leukocytosis, no other
abnl vital signs, lactate > 2. A femoral line was placed and pt
was given CTX, azithromycin, flagyl.
Past Medical History:
Alzheimer's dementia, Bipolar disorder, PVD, DM2,
Hydrocephalus s/p VP shunt (son says it was placed 3-5 years ago
at [**Hospital3 **] with no revisions, unknown cause of
hydrocephalus), H/o subdural hemorrhages (unknown if before or
after shunt placed), Hearing loss with hearing aids, Cataracts,
Hypertension, Hypercholesterolemia, SIADH with fluid restriction
of 1L per day.
Social History:
Used to work as an accountant, 100 pack year smoking
history, supportive family
Family History:
NC
Physical Exam:
Vitals: Tm 102.6 HR 88 RR 18 BP 186/72 98%
General: Was asleep but easily arousable for exam. Screaming
in
Italian and throwing arms around. NG in place with bilious
output.
HEENT: No conjunctivitis or discharge, mucous membranes moist
and pink, neck supple, no LAD. Burr hole on the right with
shunt
traveling down behind ear to neck. Resevoir depressable with
refilling immediately.
CV: Normal S1 and S2, no murmurs
Pulm: Mild wheeze, decreased bs b/l, transmitted upper airway
sounds.
Abdomen: Soft, distended, nontender.
Extremities: Warm and well perfused
Mental status: Following some commands, awake and alert during
the examination.
Neuro: MAE, nl tone throughout
Pertinent Results:
[**2189-1-3**] 06:39PM LACTATE-2.3*
[**2189-1-3**] 02:55PM LACTATE-2.4*
[**2189-1-3**] 02:45PM GLUCOSE-173* UREA N-8 CREAT-0.4* SODIUM-132*
POTASSIUM-4.0 CHLORIDE-91* TOTAL CO2-31 ANION GAP-14
[**2189-1-3**] 02:45PM estGFR-Using this
[**2189-1-3**] 02:45PM ALT(SGPT)-16 AST(SGOT)-14 ALK PHOS-83
AMYLASE-49 TOT BILI-0.2
[**2189-1-3**] 02:45PM LIPASE-11
[**2189-1-3**] 02:45PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-1.4*
[**2189-1-3**] 02:45PM WBC-16.1*# RBC-5.23 HGB-14.1 HCT-42.2 MCV-81*
MCH-26.9* MCHC-33.4 RDW-13.9
[**2189-1-3**] 02:45PM NEUTS-86.6* LYMPHS-8.2* MONOS-4.7 EOS-0.3
BASOS-0.2
[**2189-1-3**] 02:45PM MICROCYT-1+
[**2189-1-3**] 02:45PM PLT COUNT-356
[**2189-1-3**] 02:10PM URINE HOURS-RANDOM
[**2189-1-3**] 02:10PM URINE GR HOLD-HOLD
[**2189-1-3**] 02:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2189-1-3**] 02:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2189-1-3**] 02:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
.
pCXR: 1. Nasogastric tube seen within the body of the stomach
and coursing off the imaged field of view.
2. Bilateral airspace disease reflecting evolving pneumonia or
asymmetric pulmonary edema.
.
CXR: Interval removal of nasogastric tube.
Patchy airspace opacities, unchanged. Diagnostic considerations
again include pneumonia and asymmetric pulmonary edema.
.
CT Abd/pelvis: 1. Air-filled dilated loops of small bowel, with
collapsed distal loops, suggesting partial small bowel
obstruction. No free air or free intraabdominal fluid is
identified.
2. Confluent consolidative opacities in the right middle and
lower lobes. Differential includes pneumonia versus aspiration.
.
CT head: 1. Compared to previous study dated [**2187-3-6**],
the ventricles appear slightly more dilated and therefore
recommend evaluation to rule out shunt malfunction .
2. Interval resolution of right subdural collection.
.
Video swallow: Fluoroscopic assistance was provided for the
speech/language pathology service with the radiologist present.
The patient swallowed barium of varying consistencies (thin
liquid, nectar-thick liquid, and pureed consistency barium). No
aspiration was seen throughout this examination. Bolus formation
with swallow initiation were appropriate with no premature
spillover or retention. No penetration or aspiration occurred.
The patient was able to cough throughout the examination and
expectorated thick clear sputum. No aspiration was noted prior
to and during the patient's coughing episodes.
.
CT Head: Stable prominence of lateral ventricles compared to
[**1-3**]. No acute intracranial abnormality including no
sign of hemorrhage.
.
CT Abd: 1. Resolved partial obstruction of small bowel. No free
air or free intra- abdominal fluid is noted.
2. Resolving right middle and lower lobe pneumonia or
aspiration.
3. Diffusely mild thickened bladder wall. This might be due to
cystitis.
.
TTE: The left atrium is moderately dilated. There is moderate
symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of
[**2187-3-6**], the pericardial effusion has resolved.
Brief Hospital Course:
1) HTN: Had severely elevated BP while in house even >200/100 at
times. He also complained of chest pain and headache at times
with this, so he was started on long acting medications due to
him refusing meds at times. On toprol, hydralazine, and
lisinopril his BP was much better controlled.
2) Partial SBO: Initially presented with n/v. CT showed partial
SBO, surgery was consulted. Resolved with bowel rest. CT abd
showed resolved pSBO. Now toleating diet and passing stool.
3) Diastolic CHF: Had slightly elevated cardiac enzymes, but no
ECG changes. TnT peaked at 0.24, although MB fraction negative:
likely demand ischemia in the setting of HTN. TTE showed
preserved EF and no wall motion abnormalities. Improved with
aggressive BP control. Cont. ASA/toprol/lisinopril/statin.
4) h/o SIADH: on salt tabs at home, but Na stable off them
in-house. Cont. fluid restriction.
5) Hypothyroidism: continued on levothyroxine
6) Type II DM: holding glyburide/metformin for now. Continue pm
NPH; RISS. Can restart oral meds at NH as needed.
7) Diarrhea: C. diff (-) X 3, no diarrhea.
8) Aspiration PNA: developed sudden respiratory arrest while
eating dinner. Thought to be aspiration. Pt. was intubated and
transferred to ICU and started on levofloxacin and flagyl.
Patient passed video swallow.
9) GPC bactermia [**1-15**] bcx [**1-8**] CNS; [**1-4**] also w/ CNS.
Surveillance Cx negative.
10) Candiduria: d/c Foley
11) Fe def anemia: SPEP hypogamma; check folate, low/nl vit B12,
hold iron pending completion of levo course
12) Full Code
13) Dispo: Back to NH
Medications on Admission:
Trileptal 300 mg [**Hospital1 **]
Glyburide 2.5 mg [**Hospital1 **]
Glucophage 1000 mg [**Hospital1 **]
Ursodiol 300 mg [**Hospital1 **]
NaCl 2 tabs tid
1L fluid restiction
senna
Levothyroxine 25 mcg daily
Abilify 10 mg daily
Colace 100 mg [**Hospital1 **]
Prilosec 20 mg daily
Ativan 0.25 mg prn
NPH 40 units sc q4pm
Regular Insulin Sliding scale [**Hospital1 **]
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
13. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed.
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Six (36) units Subcutaneous qdinner.
19. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale sliding scale Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Partial Small Bowel Obstruction
aspiration Pneumonia
Severe Hypertension
Diastolic CHF
CAD
Alzheimer's dementia
Discharge Condition:
stable
Discharge Instructions:
Please continue meds as listed. Please follow up with your PCP
in the next 2 weeks.
Followup Instructions:
1. Please follow up with your PCP in the next 2 weeks.
|
[
"5070",
"4280",
"51881",
"41401",
"25000"
] |
Admission Date: [**2174-9-9**] Discharge Date: [**2174-10-7**]
Date of Birth: [**2152-3-29**] Sex: M
Service: MED
Allergies:
Benzocaine / Zosyn
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
fever and hypoxia, witnessed aspiration at rehabilitation
facility
Major Surgical or Invasive Procedure:
none
History of Present Illness:
22 y/o male w/ h/o [**First Name3 (LF) **]'s syndrome (DM, DI, optic atrophy,
deafness), presenting from [**Hospital3 **] after a witnessed
aspiration pna and 1 day of fevers. Pt also with central
hypoventilation requiring ventilation at night (now with trach,
peg for meds), h/o MRSA/pseudomonal pna's and persistent pulm
infitrates. Pt was on
Zosyn/caspofungin/amikacin/bactrim/linezolid at rehab (for 2 wk
course) and was scheduled to have CT at [**Hospital1 2025**] to evaluate
infiltrates. Pt also with intermittent agitation treated with
ativan/haldol prn. In ED, given versed, vanco, zosyn, put on
vent/PS.
Past Medical History:
[**Hospital1 **]'s (DIDMOAD) syndrome, Seizures [**12-27**] hypoglycemia, MRSA
pna, pseudomonas, trach collar, Hashimoto's thyroiditis,
anxiety/mdd, avnrt, central hypoventilation,
Social History:
Resident of [**Hospital3 **]; Full Code
Family History:
non-contributory
Physical Exam:
PE on admit to MICU:
Vitals: T 102.3, BP 110/50, HR 62, Vent settings: PS 20, PEEP 5,
Vt 590, RR 8, O2 97-100% O2
Gen: Sedated but in NAD
HEENT: non-icteric, mm dry
Chest: coarse BS bilat.
CV: RRR. no murmurs
Abd: Soft, NT/ND. PEG Tube
EXT: no c/c/e
Neuro: surgical pupils b/l; neuro exam difficult [**12-27**] sedation
Pertinent Results:
[**2174-9-9**] 08:01PM LACTATE-2.2*
[**2174-9-9**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2174-9-9**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2174-9-9**] 07:30PM GLUCOSE-250* UREA N-9 CREAT-0.8 SODIUM-132*
POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-23 ANION GAP-18
[**2174-9-9**] 07:30PM WBC-9.1 RBC-4.43*# HGB-13.7*# HCT-39.5*#
MCV-89 MCH-30.8 MCHC-34.6 RDW-15.3
[**2174-9-9**] 07:30PM NEUTS-85.3* LYMPHS-10.8* MONOS-2.8 EOS-1.0
BASOS-0.2
[**2174-9-9**] 07:30PM PLT COUNT-189#
[**2174-9-9**] 07:30PM PT-14.2* PTT-27.8 INR(PT)-1.3
[**9-9**] CXR: Bilateral pleural effusions, without definite focal
consolidation
[**9-15**] CTA-chest:
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusions with atelectasis and air
bronchograms in the lung bases.
3. Micronodular opacities are present in the right lung base,
consistent with pneumonia.
[**9-12**] Video Swallow Study:
The patient was unable to swallow the barium tablet with thin
liquid and demonstrated a moderate amount of thin liquid
aspiration during this attempt. There was no spontaneous cough,
and a cued cough was ineffective in clearing the
aspiration.
[**9-29**] Video Swallow Study:
Aspiration of thin and nectar thick barium. Penetration to the
vocal cords with pudding consistency barium. Prominence of the
cricopharyngeus muscle with episodes of apparent spasm.
Brief Hospital Course:
22 y/o M with h/o [**Month/Day (4) **]'s Disease (DIDMOAD), central
hypoventilation, recurrent PNA (h/o
MRSA/Pseudomonas/Klebsiella), presenting s/p witnessed
aspiration event, with intermittent fevers, afebrile since ABX
discontinued on [**9-16**].
1. Pneumonitis: Mr. [**Known lastname 37779**] was admitted on [**9-9**] following a
witnessed aspiration event at [**Hospital3 **]. He had recent
reported histoy of broad spectrum antibiotics over the last 2
weeks (Linezolid/Zosyn/Caspofungin/Bactrim/Amikacin). On
admission to [**Hospital1 18**] he was initially monitored in the ICU given
his central hypoventilation with ventilation dependence. Initial
CXR here was negative for infiltrate (reported as bilateral
atelectasis and small effusions). Sputum cultures grew
Pseudomonas/Klebsiella on two separate days. It was thought that
these organisms could represent colonization vs infection.
Given his persistent fever and bandemia, infection was suspected
and he was initially started on Vanco (D1=[**2174-9-11**]) and Zosyn.
Zosyn was changed to Merepenem (D1=[**2174-9-14**]) after final
sensitivies returned (Pseudomonas resistant to Zosyn and
Ceftaz). Given his persistent fevers, other etiologies of his
fever were pursued including PE and meds. CT-angio was performed
on [**9-15**] which demonstrated multi-nodular opacities in the right
lung base thought to be c/w pneumonia. No evidence of pulmonary
embolism. Non-pathologically enlarged lymph nodes were noted in
the mediastinum and hilar regions. However, repeat CXR's
continued to demonstrate no evidence of infiltrate. In addition,
the patient developed a rash that was thought to be consistent
with drug rash. All antibiotics were discontinued on [**9-16**] given
lack of clinical findings c/w pneumonia and given possible drug
rash/fever. He subsequently remained afebrile off antibiotics
for the next week. His rash subsequently resolved as well, with
suspected [**Last Name (un) **] to Zosyn (no respiratory compromise, no hives).
His respiratory status improved and he was able to maintain O2
sats >93% on 35% trach collar and off ventilation assistance
completely. Given his subsequent improvement without continued
antibiotics, the thought was that he was likely to have
pneumonitis rather than a new pneumonia.
His WBC count remained stable at 9-10 over the following week
off antibiotics. However, on [**9-28**], his WBC count increased to 18
with 3% bands. He remained afebrile, but he was noted to have
increased thick yellow sputum production. Repeat CXR
demonstrated evidence of a right lower lobe pna vs atelectasis.
Therefore he was re-started on antibiotics on [**9-28**] with Vanco
and Cefipime. However, he subsequently had resolution of his WBC
count the following day [**9-29**] (WBC =9, with 0 bands) and
antibiotics were discontinued. A new infection was thought to be
unlikely as he quickly recovered and remained afebrile and
clinically stable throughout the remainder of his course. On
discharge he is off all antibiotics and is afebrile with stable
respiratory status.
1a. Cricothyroid Muscle spasms: Given his recurrent aspirations
and secondary aspiration pnuemonitis/pneumonia he was evaluated
further by the speech and swallow service. Evaluation
demonstrated that he had paroxysmal cricothyroid muscle spasms
leading to aspiration. Spasm was noted to occur despite multiple
preceding normal swallows were documented. In addition he was
noted to have absent cough reflex. These spasms were thought to
be the likely etiology of his aspirations. In addition, GERD was
thought to be exacerbating his symptoms, with noted epiglottic
edema. Manometry [**9-27**] demonstrated no evidence of UES
dysfunction or spasm (over [**2-28**] swallows). However,there was
still concern over paroxysmal muscle spasm. Therefore he
underwent EGD w/dilatation of his UES on [**9-28**]. However, repeat
video swallow study on [**9-29**] demonstrated continued aspiration of
thin liquids with intermittent esophogeal spasms (please obtain
online medical record for full report). There was also noted
difficulty initating swallow. After consultation, we decided to
pursue conservative management of this problem. It is unclear
whether botox injections to his CM muscle would help at this
time. Therefore, we have resumed a diet of thickened liquids
with strict aspiration precautions, including maintaing the chin
down in postition while swallowing. He has tolerated thickened
liquids quite well and has had no evidence of pneumonia. If he
subsequently has reccurrent aspiration pneumonitis or pna, he
may follow-up with Dr. [**Last Name (STitle) 952**] for potential botox injection. He
has follow-up scheduled for [**2174-10-18**] for initial visit w/ Dr.
[**Last Name (STitle) 952**].
**He should have a repeat video swallow study to evaluate for
aspiration and potential advancement of diet.
2. Hyper/Hyponatremia: Over the course of his hospital stay,
Mr. [**Known lastname 37779**] had brittle sodium levels. His difficult sodium
balance was secondary to his central diabetes insipidus in the
setting of decreased PO intake (nutrition was given per tube
feeds). He does have an intact thirst reflex, however PO's were
initially held in the setting of his known aspiration risk. In
the ICU he developed hypernatremia with Na levels up to the
150's, treated with free water flushes. In addition he was
continued on his DDAVP (desmopressin) at 1.0mcg IV BID + and
additional mid-day dose at 0.5mcg. However, he subsequently
developed hyponatremia w/ Na down to 123. He remained
asymptomatic without seizure. His free water flushes were held
in addition to his DDAVP in setting of hyponatremia. He
persisted to have very brittle sodium control, with return of
sodium to 149. He was re-started on DDAVP at 1.0mcg IV BID. This
regimen lead to good sodium control. Of note, since he started
taking in PO's, he has been drinking thickened water,resulting
in sodium fall to 139. However, we do not want to discourage his
PO intake, so instead we have decreased his DDAVP dose. On
discharge we have him on 0.5mcg IV morning dose and 1.0mcg IV
evening dose.
3. Epilepsy: Continued on Dilantin with seizure precautions.
Dosed by levels. [**10-4**] dilantin level was 20.9, so we decreased
dilantin to 200mg [**Hospital1 **].
4. Hypothyroidism: Continued on Synthroid.
5. DMII- insulin dependent: Followed by [**Last Name (un) **] in the hospital.
He also was noted to have brittle diabetes with blood sugars
fluctuating from low's of 40's-50's with highs up to the 300's.
Eventually, he was able to be maintatined with good glycemic
control on the regimen as follows: NPH insulin 30qam/25qhs +
sliding scale humalog.
6. Anemia/Thrombocytopenia: Both stable, initially down from
admission. Concern for HIT/Zosyn-related low platelets. HIT
negative. Plts have since recovered; HCT stable.
7. FEN: Probalance Full strength via PEG. In addition, we would
recommend a calorie count if he continues to take in significant
PO's, since he may not need continued full strength tube feeds.
8. Allergic Derm Rxn: On [**9-11**] had fever,blanching erythematous
rash with non-blanching 1/2 mm papules. The rash abatted in
<2hrs after Benadryl IV. He was also given Albuterol Nebs, but
had no dyspnea. He has had resolution of his rash off of
antibiotics, with no current fever, so leading diagnosis is drug
rash/fever, likley secondary to Zosyn. Of note, he did not
develop rash on Cefipime.
9.Conjunctivitis: [**Month (only) 116**] be related to drug reaction. We do not
have high clinical suspicion that this is a bacterial
conjunctivitis, however have treated with erythromycin eye drops
for a 6 day total course. Clinically resolving.
10. Anxiety: On Ativan 2-4mg PO/IV q6h PRN. Paroxetine 30qday.
Trazadone prn at night.
Medications on Admission:
meds on tx from rehab: NPH 36 U qam/10qpm, DDAVP 1mcg IV BID,
0.5 mcg at 2pm, Zosyn 4.5gm IV q8 (day # 14),Caspofungin (day #
14), Amakacin 375mg IV q12, Dilantin 100mg PO BID, Mag Gluconate
1000mg TID, Protonix 40mg PO QD, Bactrim DS 1 tab po bid (day
#14), Linezolid 600mg PO BId, Synthroid 150 mcg PO Qday, haldol
5mg q 2-4 hours prn, Ativan 1-2 mg q 4-6 hrs prn, colace 100mg
PO TID
Discharge Medications:
1. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO QD
().
2. Phenytoin 100 mg/4 mL Suspension Sig: Two (2) PO twice a
day.
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Desmopressin Acetate 4 mcg/mL Solution Sig: One (1) mcg
Injection qpm.
12. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: One (1)
units Subcutaneous as scheduled: NPH 30 Units qam
NPH 25 Units qhs.
13. DDAVP 4 mcg/mL Solution Sig: 0.5 mcg Injection qam.
14. Lorazepam 1 mg Tablet Sig: 2-4 Tablets PO Q4-6H (every 4 to
6 hours) as needed for agitation.
15. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed.
16. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID
(4 times a day) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Aspiration pneumonitis
[**Location (un) **] (DIDMOAD) syndrome
Drug fever- secondary to Zosyn
Diabetes II-insulin requiring
Hyper/Hyponatremia
Discharge Condition:
Good. HD stable. Off vent dependence. Afebrile. No evidence of
pneumonia. Able to take in pre-thickened liquids while on strict
aspiration precautions.
Discharge Instructions:
Call your doctor if you experience fever greater than 100.4,
shaking chills, seizure, shortness of breath or worsening cough.
[**Hospital1 **]: Please do a repeat Video Swallow study to evaluate
for aspiration and potential advancement of diet. thank you.
Followup Instructions:
1. Pleae follow-up with Dr. [**Last Name (STitle) 952**] on [**2174-10-18**] at 1pm:
[**Hospital1 69**]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 170**]
2. If you would like to f/u with podiatry, you may call to
schedule an appt at [**Telephone/Fax (1) 543**]
|
[
"5070",
"51881",
"2875",
"2760",
"2761",
"2449"
] |
Admission Date: [**2175-10-30**] Discharge Date: [**2175-11-8**]
Date of Birth: [**2115-8-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
mental status change
Major Surgical or Invasive Procedure:
Incision and drainage of right groin abscess
History of Present Illness:
60 YO M w CHF, distant MI, VT s/p pacer/ICD/VT ablation who
presented with cloudy thinking and dizziness for 1 week in the
setting of polydypsia and polyuria.
.
Symptoms started about 1 week prior to presentation the [**Hospital1 18**],
with anorexia and sleeping constantly, followed by incontinence,
weakness, and dizziness. 2 days prior to admission, his wife
noted that he became disoriented, which persisted until the day
of admission, which was Monday evening [**10-30**], when the patient
requested to be taken to the hospital. He was transported by
Ambulance because he felt unable to make it down the stairs with
assistance only from his wife. [**Name (NI) **] never lost consiousness. Of
note, he did not take any of his medications the weekend prior
to admission because he dropped his pill box and his wife did
not know his usual regimen.
.
In the ED, he was noted to have a BS of >800, creat 2.8 (from
1.5) with a gap but no ketones. He was given levaquin and
admitted to the ICU for insulin gtt which was stopped within
24h. [**Last Name (un) **] was consulted and recommended starting lantus and
humalog. His BS decreased to 100s-200s but then his BS increased
to 300s on MICU day 2, [**11-1**], so his glargine was increased and
his humalog sliding scale was titrated up. His mental status
improved back to his baseline with improvement in his BS.
.
The patient has a known sacral decubitus ulcer, which he has had
for 3 weeks. He had no signs or symptoms of infection per his
wife - no fever, chills, cough, abdominal pain, diarrhea,
dysuria.
.
Never diagnosed with diabetes. Does not take diabetes
medications at home.
Past Medical History:
CAD s/p inferoposterior MI with PTCA [**2159**], [**2173**]
Dyslipidemia
Hypertension
Chronic Systolic Heart Failure, EF 25-30%.
Nonsustained ventricular tachycardia with ICD [**8-/2170**]
S/p VT ablation [**4-/2174**]
Hypertension
Hyperlipidemia
Obstructive sleep apnea
H/o vitamin B12 deficiency
Nephrolithiasis
Peripheral neuropathy
Remote history of peptic ulcer disease
GERD
Status post tonsillectomy and adenoidectomy.
Social History:
lives with wife, works part time in computer, quit smoking
couple months ago and uses an electronic tobacco relacement,
denies ETOH/IVDU
Family History:
Father - atrial fibrillation
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Otherwise non-contributory
Physical Exam:
VSS 98 74 97/54 25 96% 2L
GEN: Alert, oriented to person, place, but not time. Poor
attention - able to count 10 to 1, but not months of year.
HEENT: PERRLA. MMM. no LAD. neck supple.
Cards: Quiet heart sounds. Limited auscultory exam. Pulse
regular.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: Protuberant obese abdomen. NT, +BS. no rebound/guarding.
neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL.
*Sacral Decubitus Ulcer: Erythematous gluteal cleft with
erosions to subcutaneous tissue
*Groin Rashes: Right > Left crural rashes, with R > L edema and
warmth
Brief Hospital Course:
60-year-old male with hx of CHF (EF 40%), MI [**2159**], paroxysmal
ventricular tachyarrhythmia s/p pacemaker/ICD placement and VT
ablation in [**4-/2174**] presenting with altered mental status in
setting of severe hyperglycemia.
.
#Hyperosmolar hyperglycemic non-ketotic coma (HHNK):
Pt did not have diagnosis of DM on admission. Pt presented with
altered mental status and labs concerning for HHNK - blood
glucose [**Telephone/Fax (1) 62434**] glucose in UA, anion gap of 18, with absence
of ketones in urine favoring HHS over DKA. A1c on [**1-/2175**] was
6.5; A1c on admission was 13.3. The patient was placed on an
insulin drip for approximately 90 minutes. [**Last Name (un) **] Diabetes
Center was consulted and he was transitioned to a Lantus +
Humalog insulin sliding scale regimen and aggressively volume
resuscitated with 4L NS. Hyperglycemia rapidly improved and gap
closed. His lantus was gradually titrated to 30 units [**Hospital1 **] with
appropriate sliding scale with good glycemic control. In the
setting of WBC of 20 on admission, the trigger of the HHNK was
thought to be infectious with the source ultimately found to be
a right groin cellulitis as detailed below. Other infectious
etiologies were considered, but the work-up was negative, with
CXR showing no consolidation, and UA/UC negative.
.
#Right groin ulcer:
Right groin ulcer identified upon physical exam following
transfer from ICU. Evaluated by surgery who ultimately
performed I&D, recovering necrotic tissue that ultimately
cultured Staph Aureus and coagulase negative Staph sensitive to
Bactrim. Treated with IV Vancomycin and Zosyn for a total
course of 14 days and transitioned to Bactrim prior to
discharge.
.
#Hyponatremia:
Na 119 on admission due hyperglycemia. Normalized with treatment
of HHNK.
.
#Altered mental status:
Altered mental status was most likely secondary to HHNK. With
resolution of HHNK, mental status cleared markedly and pt was
oriented x 3 and answered questions appropriately once
transferred to the floor.
.
#Acute renal failure:
Cr was 2.8 on admission, up from 1.5 one month prior. Initially
acute renal failure was believed to be prerenal as pt appeared
severely volume depleted. Cr continued to rise, peaking at 3.6,
despite IV hydration. In setting of elevated CKs, acute renal
failure was attributed to rhabdomyolysis for which he was given
additional IV hydration, although this rise in CK was ultimately
attributed to a significant right groin abscess. Nephrotoxic
meds, including his home lasix, allopurinol, diovan and
spironolactone, were held during the majority of his hospital
course. As the patient recovered from his HHNK, his renal
function improved markedly to a creatinine of 1.8. He was
eventually restarted on his lasix and discharged on his home
regimen of allopurinol, diovan, and spironolactone.
.
#Anemia, guiac positive stool (OUTPATIENT FOLLOW-UP REQUIRED)
The patient had an initial Hgb of 14 and Hct of 40.1 on the day
of admission [**10-30**]. Over the next three days he developed a
slight anemia that remained stable at approximately Hgb 10 Hct
29 for the remaining five days of his administration. This was
attributed to anemia of inflammation. He did have one episode
of blood stained stool, and was guiac positive. Upon interview
the patient attributed this to a known history of hemorrhoids.
Given his age, however, outpatient colonoscopy is still
appropriate to work up his anemia and bloody stool. The patient
has otherwise been asymptomatic with regard to this anemia.
.
#Depression:
The patient has a history of depression, and his daughter
expressed concern near the end of his hospitalization that he
may try to harm himself. The patient denied suicidal ideation
and made no concerning statements during his hospital course.
He was seen by psychaitry, who cleared him for discharge and
confirmed no suicidal ideation.
.
#Chronic Systolic CHF, LV aneurysm, INR:
Pt with hx of systolic CHF with EF 40% on TTE. He required IV
hydration for both HHS and initial concern for rhabdomyolysis
but this was given judiciously given his reduced EF. TTE was
obtained that showed unchanged EF of 40% and mid inferior and
inferolateral akinesis which had previously been hypokinetic on
TTE from [**3-/2175**]; there was also an inferobasal left ventricular
aneurysm. Lasix was held due to acute renal failure until late
in his hospitalization but restarted several days prior to
discharge in the setting of dependent pitting edema. On
discharge, lungs were clear to auscultation and the patient was
clinically mildly hyper- to eu-volemic. Per OMR records, pt had
been started on coumadin after ablation for LV aneurysm. INR was
supratherapeutic 2 days prior to discharge in the setting of
antibiotics; coumadin was held for 1 day then restarted; the
patient was discharged on a lower dose than his prescribed 5mg
daily. **His INR will need to be followed-up and coumadin
redosed 2-3 days after discharge.**
.
#CAD:
Pt with extensive cardiac comorbidities, including CAD, CHF (EF
40%), prior MI, and paroxysmal ventricular tachyarrhythmia. MI
was considered as a possible etiology for his acute
hyperglycemic presentation. EKG was grossly unchanged with new
T wave inversions in V2-3. Troponin was elevated to 0.03 on
admission but this was in setting of acute renal failure. CK
was elevated to 600s on admission and increased to [**2165**] for
reasons discussed above. As TTE was grossly unremarkable,
suspicion for MI was low. He was continued on his aspirin;
statin was held due to elevated CKs in the setting of initial
concern for rhabdomyolysis and restarted on discharge.
.
#Paroxysmal Ventricular tachyarrhythmia:
Patient was s/p ablation and s/p pacer/ICD. Monitored on tele
for the duration of the hospitalization with no episodes of VT
or defibrillation.
.
#Hypothyroidism:
Pt had history of hypothyroidism and had been started on
levothyroxine as outpatient. He was treated with levothyroxine
and his TSH remained normal. He reported noncompliance with
levothyroxine. **[**Last Name (un) **] diabetes consult recommended thyroid
function tests as outpatient.**
.
Remained full code for the duration of the hospitalization.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
AMIODARONE - 200 mg Tablet - 2 Tablet(s) by mouth daily
CALCITRIOL - 0.25 mcg Capsule - one Capsule(s) by mouth every
other day
CARVEDILOL - 12.5 mg Tablet - 1 Tablet(s) by mouth twice a day
VITAMIN D 400 UNITS - - take 1 tablet by mouth twice a day
DULOXETINE [CYMBALTA] - 60 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth once a day
FUROSEMIDE - 40 mg Tablet - one and [**1-7**] Tablet(s) by mouth twice
a day
GABAPENTIN [NEURONTIN] - 300 mg Capsule - as directed Capsule(s)
by mouth 2 TID and 3 qhs
HYDROMORPHONE [DILAUDID] - 4 mg Tablet - 1 Tablet(s) by mouth
four times a day as needed for for pain
LORAZEPAM [ATIVAN] - 0.5 mg Tablet - [**1-7**] Tablet(s) by mouth at
bedtime
NIACIN [NIASPAN] - 500 mg Tablet Sustained Release - 1 Tablet(s)
by mouth once a day
NITROGLYCERIN - 0.3 mg Tablet, Sublingual - 1 Tablet(s)
sublingually q3 minutes as needed for chest pain
OXYCODONE - 5 mg Tablet - [**1-7**] Tablet(s) by mouth four times a
day
as needed for for nueropathy
PRAMIPEXOLE - 0.25 mg Tablet - 1 Tablet(s) by mouth once a day
ROSUVASTATIN [CRESTOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day
SPIRONOLACTONE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth
once a day
VALSARTAN [DIOVAN] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day
WARFARIN - 5 mg Tablet - [**1-7**] Tablet(s) by mouth once a day as
[**Name8 (MD) **]
MD [**First Name (Titles) **] [**Last Name (Titles) 62435**]IN [JANTOVEN] - 2 mg Tablet - [**2-8**] Tablet(s) by mouth once
a
day
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
B COMPLEX VITAMINS [B-50] - Tablet - 1 Tablet(s) by mouth once
a day
CALCIUM CARBONATE - 500 mg (1,250 mg) Tablet - 1 Tablet(s) by
mouth twice a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
ERGOCALCIFEROL (VITAMIN D2) - 400 unit Capsule - 1 Capsule(s) by
mouth once a day
MAGNESIUM - (Prescribed by Other Provider) - 250 mg Tablet - one
Tablet(s) by mouth once a day
OMEGA-3 FATTY ACIDS-VITAMIN E [OMEGA-3 FISH OIL] - (Prescribed
by Other Provider) - 1,000 mg-5 unit Capsule - 1
SENNA - 8.6 mg Capsule - 1 Capsule(s) by mouth twice a day as
needed for constipation
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
4. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO three times
a day.
9. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
10. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for pain.
11. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime.
12. niacin 500 mg Tablet Sig: One (1) Tablet PO once a day.
13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
14. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO daily ().
15. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
17. valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
21. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
22. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
23. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
24. ergocalciferol (vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
25. magnesium 250 mg Tablet Sig: One (1) Tablet PO once a day.
26. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1)
Capsule PO once a day.
27. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
28. insulin lispro 100 unit/mL Insulin Pen Sig: Two (2) units
Subcutaneous four times a day: According to scale.
Disp:*440 units* Refills:*2*
29. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Thirty
(30) units Subcutaneous twice a day: Before breakfast and before
bedtime.
Disp:*1800 units* Refills:*2*
30. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
31. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
Disp:*500 grams* Refills:*2*
32. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
33. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for itching.
Disp:*1 tube/unit* Refills:*0*
34. Kerlex Sig: One (1) Sterile dressing twice a day: Twice
daily dressing changes for right groin wound.
Disp:*60 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Diabetes Mellitus II
Hyperosmolar Hyperglycemic Non-Ketotic coma (HHNK)
Right groin abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
1. Be sure to attend your follow-up appointment with your
primary doctor Dr. [**Last Name (STitle) 4922**] on Tuesday [**2175-11-14**] at 10:45 AM.
You have some new medications and will need to make changes to
how you take care of yourself to prevent future episodes like
this, and your primary doctor will be the best person with which
to discuss these issues.
Location: [**State **] ([**Location (un) **], MA) [**Location (un) **]
2. Be sure to attend your appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9978**] at
the [**Last Name (un) **] Diabetes Center on Thursday, [**2175-11-9**] at 9 AM for
your continued diabetes care.
Location: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
3. Be sure to attend your appoint with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] at
[**Hospital1 **] Surgical Specialties for continued care of your right groin
wound on Monday, [**11-13**] at 3:30 PM.
Location: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
|
[
"4280",
"5859",
"41401",
"412",
"V4582",
"40390",
"2724",
"32723"
] |
Admission Date: [**2101-2-4**] Discharge Date: [**2101-3-12**]
Date of Birth: [**2101-2-4**] Sex: F
Service: NEONATAL
HISTORY: Baby Girl [**Known lastname 174**] is the 1445 gram product of a 33
week gestation born to a 32 year old Gravida 2, Para 0
mother. Serology was A positive, antibody positive (DAT
positive, antiwarm autoantibody). Hepatitis B surface
antigen negative. RPR nonreactive. Rubella immune. GBS
unknown.
Maternal history was significant for chronic hypertension
since [**15**] years of age maintained on Aldomet 500 mg p.o. four
times a day; asthma maintained on inhaler p.r.n.; pulmonic
stenosis, mitral valve prolapse requiring antibiotic
prophylaxis.
PAST SURGICAL HISTORY:
1. Breast reduction in [**2093**].
2. Tonsillectomy in [**2094**].
MATERNAL MEDICATIONS:
1. Aldomet.
2. Labetalol.
ALLERGIES: Maternal allergies include penicillin,
tetracycline, Vancomycin (red man's syndrome).
COMPLICATIONS: This pregnancy was complicated by underlying
chronic hypertension. On [**1-25**] she presented with
bloody spotting. Evaluation was benign.
She presented on day of delivery with increased hand and
pedal edema for past few days. No signs or symptoms or
laboratory evidence of pre-eclampsia.
Fetal biophysical profile was 8 out of 8, however, monitoring
also revealed possible intrauterine growth restriction with
an estimated weight in the 3rd percentile. In addition,
oligohydramnios with an AFI of 3.0, also nonreassuring fetal
heart rate pattern with fetal decelerations. Given noted
concerns infant delivered by cesarean section.
At delivery infant emerged with good color, tone and
spontaneous respirations. Dry bulb suctioned and stimulated
and provided brief blow-by O2. The infant responded well
with Apgar's of 9 and 9 and was transported to the Newborn
Intensive Care Unit for further management or prematurity.
PHYSICAL EXAMINATION: On admission, birth weight was 1455,
10th to 25th percentile. Length 38-3/4, 10th percentile.
Head circumference 28 centimeters, 10th percentile. Anterior
fontanel open and flat. Palate intact. General appearance:
Small for gestational age. Lungs with fair to good aeration,
equal but with fine crackles bilaterally. Normal S1, S2, no
audible murmur. Abdomen benign. No hepatosplenomegaly.
Three vessel cord. Normal external female genitalia
appropriate for gestational age. Hips stable. Spine intact.
Moves all extremities well.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: [**Known lastname 12536**] has remained stable on room air
throughout hospitalization. Had a brief period of apnea of
bradycardia with the most recent apnea spell on [**2101-3-2**]. She did not require any methylxanthine therapy. Her
most recent desaturation was associated with Nystatin oral
solution and it was self resolved. That was on [**2101-3-7**].
2. CARDIOVASCULAR: The infant has been cardiovascularly
stable throughout the hospital course. She was noted to have
an intermittent murmur which has since resolved. No further
issues.
3. Fluids, Electrolytes and Nutrition: Birth weight was
1445. Discharge weight is 2410 grams . The infant
was initially started on 80 cc. per kilo per day of D10W.
Enteral feedings started on day of life number one. The
infant achieved full enteral feedings by day of life number
three. Maximum enteral intake is 150 cc. per kilo per day of
PE30 with ProMod. The infant is currently ad lib feeding.
NeoSure 26 calories, concentrated by NeoSure concentrated to
24 calories per ounce and 2 calories per ounce of corn oil
added.
5. GASTROINTESTINAL: Her peak bilirubin was on day of life
three of 6.9/0.2. The infant received phototherapy for a
total of three days and the issue has resolved.
6. HEMATOLOGY: Hematocrit on admission was 51. The infant
has not required any blood transfusions and her most recent
hematocrit was 32.6 with a reticulocyte count of 4.9% on
[**3-3**]. The patient's blood type is A negative and Coombs
negative.
7. INFECTIOUS DISEASE: A CBC and blood culture was obtained
on admission. The CBC was benign. Blood cultures remained
negative and the infant did not receive any antibiotics
during this hospitalization. Urine for CMV was sent and the
result was negative. The infant received Nystatin oral
solution for a total of five days for oral thrush. Nystatin
was discontinued on [**2101-3-11**].
8. NEUROLOGICAL: The infant has been appropriate for
gestational age. On day of life ten, head ultrasound
demonstrated a small germinal matrix hemorrhage. Follow-up
at 30 days of age on [**2101-3-8**], demonstrated a resolving
germinal matrix with a recommended follow-up in two to four
weeks with another head ultrasound. The infant has been
appropriate for gestational age.
9. SENSORY: Audiology: Hearing screen was performed with
automated auditory brain stem responses and the infant passed
both ears.
10. OPHTHALMOLOGY: The patient has been most recently
examined on [**2101-3-7**], by Dr. [**Last Name (STitle) 36137**] from [**Hospital3 18242**] revealing mature retina bilaterally. Recommended
follow-up at eight months of age.
11. PSYCHOSOCIAL: A Social Worker has been involved with the
family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To Home.
PRIMARY PEDIATRICIAN. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] from [**Location (un) 1468**].
Telephone number [**Telephone/Fax (1) 38385**].
MEDICATIONS:
1. Fer-In-[**Male First Name (un) **] Supplementation of 2 mg per kg per day.
Car seat position screening test was performed on the infant
State newborn screens have been sent for protocol and have
been within normal limits.
IMMUNIZATIONS: The patient infant received hepatitis B
vaccine on [**2101-2-1**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV Prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants that meet
any of the three criteria: 1) Born at less than 32 weeks; 2)
born between 32 and 35 weeks with plans for day care during
RSV season, with a smoker in the household, or with preschool
siblings or 3) with chronic lung disease.
FOLLOW-UP INSTRUCTIONS:
1. Recommend Ophthalmology with Dr. [**Last Name (STitle) 36137**] at [**Hospital3 18242**] at eight months of age for Ophthalmology follow-up.
2. Recommend head ultrasound in two to four weeks to follow
resolving germinal matrix bleed.
DISCHARGE DIAGNOSES:
1. Premature female born at 33 weeks gestation, corrected to
37-1/7 weeks gestation.
2. Status post rule out sepsis.
3. Status post mild apnea and bradycardia of prematurity.
4. Status post oral thrush.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (un) 48948**]
MEDQUIST36
D: [**2101-3-11**] 18:20
T: [**2101-3-11**] 21:07
JOB#: [**Job Number 48949**]
1
1
1
DR
|
[
"7742",
"V290"
] |
Admission Date: [**2186-10-30**] Discharge Date: [**2187-11-8**]
Date of Birth: [**2187-10-30**] Sex: M
Service: NEONATOLOGY
HISTORY: [**Known lastname **] [**Known lastname 5395**] was born at 35 weeks gestation to a
35-year-old gravida II, para 0 now I woman by cesarean
section for breech presentation and pregnancy-induced
hypertension. The mother's prenatal screens were blood type
A positive, antibody negative, rubella immune, RPR
strep unknown. This pregnancy was complicated by gestational
diabetes diet controlled, and increased blood pressure
beginning at 26 weeks gestation. The mother was treated with
magnesium sulfate prior to delivery for worsening blood
pressures. The infant emerged with spontaneous respirations
and good cry. Apgars were 8 at one minute and 9 at five
minutes.
The infant's birth weight was 2500 grams, birth length 48 cm,
and birth head circumference 33 cm.
PHYSICAL EXAMINATION: Reveals a premature, non-dysmorphic
infant, anterior fontanel soft and flat, positive bilateral
red reflex, palate intact. Positive grunting, flaring and
retracting with scattered inspiratory crackles throughout the
lung fields. A Grade III/VI systolic ejection murmur at the
left lower sternal border, femoral and brachial pulses +2 and
equal, and a normal split S2. Soft abdomen, no
hepatosplenomegaly, testes descended bilaterally, patent
anus, intact spine, negative hip examination and a nonfocal
neurological examination.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant developed grunting, flaring and
retracting at about one-half hour of age, and so was admitted
to the Newborn Intensive Care Unit. He required
nasopharyngeal continuous positive airway pressure for the
first 48 hours of life, and then weaned to room air, where he
has remained. He does have some episodes of bradycardia and
desaturation with oral feedings, felt to be due to immature
suck, swallow and breathing reflex. On examination, his
respirations are comfortable. Lung sounds are clear and
equal.
2. Cardiovascular: At the time of admission, he did have a
Grade III/VI systolic murmur. He had a cardiac evaluation.
An electrocardiogram was within normal limits. He passed a
hyperoxia test, and the murmur was resolved by 24 hours of
age. He has remained normotensive throughout his Newborn
Intensive Care Unit stay, and there are no further
cardiovascular issues.
3. Fluids, electrolytes and nutrition: Enteral feeds were
begun on day of life number two, and advanced without
difficulty to full volume feeding by day of life five. The
infant is taking Enfamil 20 or breast milk and breast feeding
at total fluids of 150 cc/kg/day. He is requiring
approximately half of those feedings by gavage. He continues
to have incoordinated feedings. He initially required some
intravenous dextrose for some hypoglycemia, which resolved
within the first few hours after admission to the Newborn
Intensive Care Unit, and he has remained euglycemic since
that time.
4. Gastrointestinal: The infant never required any
phototherapy. His peak bilirubin occurred on day of life
number five, and was total 8.7, direct 0.2.
5. Genitourinary: The infant was circumcised on [**2187-11-7**]
without complications.
6. Hematology: The infant has never received any blood
product transfusions during his Newborn Intensive Care Unit
stay. His hematocrit at the time of admission was 46.2, and
the platelets were 103,000.
7. Infectious Disease: The infant was started on ampicillin
and gentamicin at the time of admission for sepsis risk
factors. The antibiotics were discontinued after 48 hours
when the infant was clinically well and the blood cultures
remained negative. He has received no further antibiotics.
8. Sensory: Audiology: Hearing screening was performed
with automated auditory brain stem responses, and the infant
passed in both ears.
9. Psychosocial: The parents have been visiting during his
Newborn Intensive Care Unit stay, and are very involved in
the infant's care. They are very pleased with the transfer
to a hospital closer to home.
CONDITION ON DISCHARGE: The infant is being discharged in
good condition.
DISCHARGE STATUS: The infant is being transferred to
[**Hospital3 **] Level II Nursery for continuing care.
PRIMARY PEDIATRIC CARE: Will be provided by [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 47323**],
M.D.
CARE RECOMMENDATIONS:
1. Feedings: Breast milk or Enfamil 20 calories/ounce at
150 cc/kg/day.
2. Medications: The infant is on no medications.
3. A car seat position screening test has not yet been done
and is recommended prior to discharge.
4. A state newborn screen was sent on [**2187-11-2**].
5. Immunizations received: The infant has received his
first hepatitis B vaccine on [**2187-11-6**].
6. Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation; (2) Born
between 32 and 35 weeks, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
Influenza immunization should be considered annually in the
fall for pre-term infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSIS:
1. Prematurity, 35 weeks
2. Status post transient tachypnea of the newborn due to
retained fetal lung fluid
3. Sepsis ruled out
4. Infant of a diabetic mother
5. Immature suck/swallow reflex
6. Status post circumcision, [**2187-11-7**]
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2187-11-8**] 03:28
T: [**2187-11-8**] 04:12
JOB#: [**Job Number 47324**]
|
[
"V053",
"V290"
] |
Admission Date: [**2196-11-14**] Discharge Date: [**2196-11-19**]
Service: NEUROSURGERY
Allergies:
Sulfonamides / Epinephrine / Diltiazem / Pletal
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Depressed Mental status
Major Surgical or Invasive Procedure:
Left Craniotomy for SDH evacuation
History of Present Illness:
86 y/o female with history of afib on Coumadin. Ms [**Known lastname 97533**]
was with her son yesterday and fell getting bundles out of her
car. She hit her head on the pavement and did not have a loss of
consciousness. She was able to do her normal activities she went
to bed last night and her son attempted to arrouse her at 2am
for
which he stated "she did not fully awake" this morning when his
mother did not wake up he found her in her room and was able to
minimally arrouse her. She was brought by ambulance here.
Past Medical History:
Atrial fibrillation, Diabetes, HTN, Menieres Disease, S/P
multiple falls recent radius/humeral fractures.
Social History:
Retired nurse, lives with son, non [**Name2 (NI) 1818**], no alcohol
Family History:
NC
Physical Exam:
O: T: BP:169/78 HR:80 R17 O2Sats 100%
Gen: Seen prior to intubation, [**Name (NI) 91248**] respirations, no
commands
HEENT: Pupils: surgical bilateral 2mm
Neck: In collar
Neuro:
Does not follow commands
Does not open eyes
Extensor postures in upper extremities will slightly withdraw
legs left greater than right
Face symmetric
Toes mute
Normal tone
Difficult to obtain any reflexes most likely hyporeflexic and
symmetric
Pertinent Results:
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 97534**],[**Known firstname **] [**2109-12-5**] 86 Female [**-8/4553**]
[**Numeric Identifier 97535**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd
SPECIMEN SUBMITTED: left subdural hematoma, left subdural
hematoma.
Procedure date Tissue received Report Date Diagnosed
by
[**2196-11-14**] [**2196-11-14**] [**2196-11-17**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
Previous biopsies: [**Numeric Identifier 97536**] EGD (3).
[**Numeric Identifier 97537**] (Not on file)
DIAGNOSIS:
Left subdural hematoma:
Blood clot.
Clinical: Left subdural hematoma.
Gross:
The specimen is received fresh in a container labeled with the
patient's name, "[**Known lastname 97533**], [**Known firstname **]", and the medical record number
and additionally labeled "left subdural hematoma". It consists
of a blood clot measuring 6 x 2 x 0.2 cm. Representative
sections are submitted in cassette A.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Cardiology Report ECG Study Date of [**2196-11-14**] 9:15:36 AM
Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy with
ST-T wave abnormalities. Since the previous tracing of [**2196-5-4**]
further
ST-T wave changes are present.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 180 78 [**Telephone/Fax (2) 97539**]0
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2196-11-14**]
9:22 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2196-11-14**] 9:22 AM
CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 97540**]
Reason: fx, dislocation
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall and ams
REASON FOR THIS EXAMINATION:
fx, dislocation
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: LLTc MON [**2196-11-14**] 10:47 AM
NO acute fx or malalignment.
Final Report
INDICATION: 86-year-old female status post fall with acute
mental status
changes.
TECHNIQUE: CT of the C-spine without IV contrast.
COMPARISON: MR of the C-spine available from [**2191-6-5**].
FINDINGS: There are no acute fractures or traumatic
malalignment. There is
mild straightening of lordosis, consistent with the presence of
cervical
collar. There are moderate to severe degenerative changes
throughout the
cervical spine, including severe facet arthropathy, and loss of
intervertebral disc space, most severely at C5 through T1. There
is grade 1 anterolisthesis of C4 over C5. Diffuse disc bulging
is present at C5-C6 and C6-C7, resulting in moderate spinal
canal stenosis, most severely at C5-C6.
There is no prevertebral hematoma or adjacent soft tissue
abnormalities.
Included views of the lungs demonstrate mild dependent
atelectasis
bilaterally. There are multiple nodules within the slightly
enlarged right
thyroid lobe.
IMPRESSION:
1. No acute fractures or traumatic malalignment.
2. Moderate-to-severe degenerative changes throughout the
cervical spine,
most severely at C5-C6, with associated moderate spinal canal
stenosis.
3. Multiple right thyroid nodules.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2196-11-14**]
9:22 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2196-11-14**] 9:22 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 97541**]
Reason: ICH
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall and AMS
REASON FOR THIS EXAMINATION:
ICH
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: LLTc MON [**2196-11-14**] 10:44 AM
Left subdural hematoma with mixed hyperdensity, concerning for
active bleed, tracking along the left convexivity and left
tentorium.
Rightward shift of midline structures up to 17 mm, with
significant
effacement of the left lateral ventricle. Dilated temporal [**Doctor Last Name 534**]
of right
lateral ventricle concerning for early hydrocephalus.
Rightward subfaclcine herniation. Early righward uncal
herniation.
Final Report
INDICATION: 86-year-old female status post fall and acute mental
status
changes.
TECHNIQUE: CT of the head without IV contrast.
COMPARISON: CT of the head available from [**2193-12-12**].
FINDINGS:
There is a large left cerebral subdural hematoma, measuring up
to 17 mm in
thickness, with blood tracking along the left tentorium. There
is significant neighboring mass effect on left cerebral sulci
and the left lateral ventricle with subfalcine herniation and
17-mm rightward shift of normally midline structures. The
hematoma has mixed hyper and hypoattenuating components,
consistent with an acute on chronic bleeding. There is slight
effacement of the suprasellar cistern, concerning for an early
rightward uncal herniation. Slight hyperattenuation along the
suprasellar cistern borders may represent trace subarachnoid
blood. The quadrigeminal cistern is preserved but slightly
asymmetric. The right lateral ventricle is slightly effaced, and
the temporal [**Doctor Last Name 534**] is slightly dilated in comparison to the prior
CT exam from [**2193-12-12**], concerning for possible early
hydrocephalus.
Again, there is significant hypoattenuation of the
periventricular white
matter, consistent with chronic microvascular ischemic disease.
There are no acute fractures. There is a large subgaleal
hematoma overlying the left parietal and occipital regions, with
a more focal hyperattenuating region representing a more focal
hematoma. The middle ear cavities and included portions of the
mastoid air cells and paranasal sinuses are clear. The orbits
are symmetrical and intact.
IMPRESSION: Large acute left subdural hematoma with associated
mass effect, subfalcine herniation and left uncal herniation.
Findings were communicated with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 10:45 a.m.
on [**2196-11-14**].
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2196-11-15**]
2:09 PM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2196-11-15**] 2:09 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) **]
Reason: 86 year old woman with SDH, on coumadin. Eval for
interval c
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
REASON FOR THIS EXAMINATION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Addendum
Dedicated imaging of the intracranial arteries can be considered
with MRA.
DR. [**First Name (STitle) 10627**] PERI
Approved: [**Doctor First Name **] [**2196-11-17**] 11:04 AM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2196-11-15**] 2:09 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) **]
Reason: 86 year old woman with SDH, on coumadin. Eval for
interval c
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
REASON FOR THIS EXAMINATION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: 86-year-old woman with subdural hematoma on
Coumadin, status post
evacuation. Evaluate for interval change.
COMPARISON: Multiple head CTs most recent of [**2196-11-14**].
TECHNIQUE: Sagittal T1 and axial fat-saturated T2, FLAIR,
gradient echo, and diffusion-weighted images were obtained of
the head.
FINDINGS: Multiple areas of restricted diffusion are noted,
consistent with acute infarcts in the left anterior, middle, and
posterior cerebral artery vascular territories. In addition,
areas of acute infarct are noted in the right anterior and
posterior cerebral artery vascular territories, involving the
right thalamus. There is no evidence of hemorrhagic
transformation of these infarcts. There is persistent rightward
shift of midline structures which has improved since the
previous study, now measuring approximately 6 mm down from 10
mm. Previously noted pneumocephalus is resolving. Residual left
subdural hemorrhage and intraparenchymal hemorrhage are again
seen, unchanged. The ventricles remain unchanged in size. The
major vascular flow voids appear
patent.
IMPRESSION:
Acute multi vascular territorial infarcts most pronounced in the
left
hemisphere, as described above. While these can relate to
compression of the arteries from the extensive SDH and mass
effect, embolic etiology is also in the differential diagnosis.
Findings were discussed with Dr. [**Last Name (STitle) **] [**Name (STitle) **] shortly after
review on [**2196-11-15**].
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Ms. [**Known lastname 97533**] arrived to the ED intubated for airway protection.
She recieved Profiline 9 and several units of FFp to reverse her
coagulopathy and went emergently for a left sided craniotomy for
SDH evacuation. Post operatively she was left intubated and
transferred to the Surgical intensive care unit.
Her exam never improved. She was followed clinically for the
next few days. An MRI was performed for prognostics. She was
made CMO after a family meeting. She later expired.
Medications on Admission:
Medications prior to admission: Amiodarone 200 QD, Carvedilol
25mg [**Hospital1 **], Metformin 500mg tid, pravastatin 10 at HS, Januvia 100
QD, and Coumadin
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Left sided Acute on Chronic SDH
Hyperglycemia
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2196-11-28**]
|
[
"42731",
"V5861",
"25000",
"4019"
] |
Admission Date: [**2151-1-4**] Discharge Date: [**2151-1-14**]
Service:
ADMISSION DIAGNOSES:
1. Coronary artery disease.
2. Aortic stenosis.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Aortic stenosis.
3. Status post coronary artery bypass graft times one with
saphenous vein graft and left radial artery composite, atrial
valve replacement with 19 mm [**Last Name (un) 3843**]-[**Known firstname **] valve.
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
man with known coronary artery disease. He reports having
shortness of breath with exertion since [**2148**], but this has
gotten worse over the past month. He states that he has
dyspnea after climbing one flight of stairs, with carrying
ten pound trash barrels. He denies any chest pain. He
denies claudication, orthopnea, paroxysmal nocturnal dyspnea,
edema or lightheadedness. The patient is now referred for
cardiac catheterization. A previous cardiac catheterization
had shown a 70% apical LAD lesion, 90% circumflex lesion with
a subtotally occluding OM2, a 40-80% proximal RCA lesion and
a 60% MRCA lesion. The patient had stenting of the OM1,
distal circumflex/OM3 and PTCA of the small OM2.
Persantine/Myoview in [**2150-7-26**] was negative for angina
and an uninterpretable EKG. Negative for perfusion defects
with a calculated ejection fraction of 50-55%.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Nonhealing left foot ulcer.
3. Nephrolithiasis.
4. Small bowel obstruction.
5. Left superficial femoral artery to posterior tibial
bypass [**2149-4-1**].
6. Vein patch angioplasty of bypass [**2150-8-13**].
7. Laparoscopic cholecystectomy [**2145**].
MEDICATIONS:
1. Accupril 10 mg q. day.
2. Lopressor 25 mg b.i.d.
3. Glucophage 1000 mg b.i.d.
4. Aspirin 325 mg q. day.
5. Insulin NPH 52 units q. a.m., 22 units q. p.m.
6. Insulin regular 8 units q. a.m.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient is an elderly gentleman in
no acute distress. Vital signs are stable, afebrile. HEENT
is atraumatic, normocephalic. Extraocular movements intact.
Pupils equal, round and reactive to light. Anicteric.
Throat is clear. Neck is supple, midline with no masses or
lymphadenopathy. Chest is clear to auscultation bilaterally.
Cardiovascular is regular rate and rhythm without murmur, rub
or gallop. Abdomen is soft, non-tender, non-distended
without mass or organomegaly. Extremities are warm,
noncyanotic, nonedematous. There are venous stasis changes
in the legs. The patient also has scars consistent with his
left SFA to PT bypass grafts. Neuro is grossly intact.
LABS ON ADMISSION: CBC: 9.4/12.2/35.9/159. Chemistries:
142/4.6/104/27/22/0.9. INR 1.1.
HOSPITAL COURSE: The patient was admitted for cardiac
catheterization which revealed calculated ejection fraction
of approximately 50% and normal wall motion. Findings showed
codominant coronary artery system with severe two vessel
coronary artery disease and severe aortic valve stenosis.
There was also found to be biventricular diastolic
dysfunction and moderate pulmonary hypertension. The patient
was recommended for urgent revascularization surgery.
On [**2151-1-5**], the patient was taken to the Operating
Room for coronary artery bypass graft times one with
composite saphenous vein graft of the left radial artery to
the left posterior descending artery, he also had aortic
valve replacement performed with a 19 mm pericardial
[**Last Name (un) 3843**]-[**Known firstname **] valve. The patient tolerated the
procedure well with no complications. On postoperative day
zero, the patient was transfused two units of packed red
blood cells for an hematocrit of 21.7 in the CSRU. The
patient was also noted to have increased chest tube outputs
for which he was given protamine, four units packed red blood
cells and two units of platelets. The patient remained
intubated and had very thick secretions which were frequently
suctioned. The patient was extubated on postoperative day
one, but reintubated subsequent to difficulty with
respiration. The patient was again extubated on
postoperative day two and seemed to tolerate this well.
Levophed and dobutamine were both weaned off. On
postoperative day four, the patient was transferred to the
floor without further complication. He was noted to be quite
edematous and his remaining hospital course essentially dealt
with his diuresis. He was initially found to be poorly
responsive to Lasix and his Lasix dose was increased to 8 mg
b.i.d. He remained unresponsive to this with only slightly
negative I&O balance. Chest x-ray showed the patient was
moderately wet and a bedside echocardiogram revealed that
there was a high transaortic gradient but no wall motion
abnormalities. Mild mitral regurgitation was also detected
at that time. Lasix was increased to 120 mg b.i.d. on
postoperative day seven and a formal echocardiogram was
performed. Formal echocardiogram again showed a high
transaortic gradient as well as very mild global hypokinesis
of the left ventricle. No focal wall motion abnormalities.
Aggressive diuresis was continued at 120 mg of Lasix p.o.
b.i.d. The patient responded to this well and had
improvement in his clinical symptoms of extremity edema as
well as wheezing. The patient continued to work with
physical therapy and was ultimately discharged on
postoperative day nine tolerating a regular diet, adequate
pain control on p.o. pain medications and showing improvement
in his clinical symptoms of volume overload. The patient had
no further anginal symptoms during his hospital stay or at
the time of discharge.
PHYSICAL EXAMINATION ON DISCHARGE: General: No acute
distress. Vital signs are stable, afebrile. Chest clear to
auscultation bilaterally. Cardiovascular is regular rate and
rhythm with a 2/6 systolic ejection murmur. The patient's
abdomen is soft, non-tender, non-distended. The patient does
have 1+ peripheral edema. There is no sternal click or
sternal discharge. There is mild serosanguinous drainage
from the right lower extremity saphenous vein graft wound.
There is only minimal erythema.
CONDITION AT DISCHARGE: Good.
DISPOSITION: To home.
DIET: Cardiac and diabetic.
MEDICATIONS:
1. Lopressor 50 mg b.i.d.
2. Lasix 120 mg b.i.d. times ten days.
3. Keflex 500 mg b.i.d. times ten days (renal dose).
4. Potassium chloride 20 mEq b.i.d. times ten days.
5. Colace 100 mg b.i.d.
6. Aspirin 325 mg q. day.
7. Glucophage 500 mg b.i.d.
8. Percocet 5/325 one to two q. 4h. p.r.n.
9. Amiodarone 400 mg b.i.d.
10. Isosorbide mononitrate 60 mg q. day.
11. NPH insulin 15 units q. a.m. and 10 units q. p.m.
DISCHARGE INSTRUCTIONS: The patient is to continue elevating
his legs at rest and ambulating and incentive spirometry. He
is to follow up with Cardiology in one to two weeks' time and
address the need for continued diuresis as well as adjustment
of cardiac medications at that time. The patient should
follow up in four weeks with Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2151-1-14**] 16:28
T: [**2151-1-14**] 15:46
JOB#: [**Job Number 107068**]
|
[
"4241",
"41401",
"4280",
"25000",
"412",
"V4582"
] |
Admission Date: [**2136-12-26**] Discharge Date: [**2136-12-31**]
Date of Birth: [**2136-12-26**] Sex: F
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 36863**] was born at 34
4/7 weeks gestation by cesarean section to a 26 year old
Gravida 4, Para 1, now 3 woman. The mother's prenatal
screens are blood type 0 positive, antibody negative, Rubella
Group B Streptococcus unknown. The pregnancy was complicated
by preterm labor at 28 weeks gestation treated with magnesium
sulfate and Betamethasone. The mother has an intermittent
history of intravenous drug and crack Cocaine use during this
pregnancy. She has been in the [**First Name4 (NamePattern1) 36413**] [**Last Name (NamePattern1) **] Treatment
Program over the past few months. She presented on the day
of delivery in preterm labor and spontaneous decelerations of
The mother's medications during pregnancy were Synthroid and
Fluoxetine.
PHYSICAL EXAMINATION: This infant emerged with spontaneous
respirations and good cry. Apgars were 7 at one minute and 8
at five minutes. Birthweight is 1,990 gm, birth length 42
cm, and birth head circumference 30.25 cm.
Admission physical examination reveals a vigorous preterm
nondysmorphic infant, anterior fontanelle open and flat,
positive bilateral red reflex, intact palate, comfortable
respirations. Lungs have some inspiratory crackles and she
had some mild grunting, flaring and retracting. Normal S1
and S2 heartsound. No murmur. Pink and well perfused.
Abdomen is soft. Three vessel umbilical cord. Normal
external female genitalia, patent anus, intact spine.
Negative hip examination. Slightly decreased tone generally
but moving all extremities.
HOSPITAL COURSE: Respiratory status - The infant remained in
room air. Her respiratory distress resolved by approximately
two hours of age. She has never had any apnea or
bradycardia.
Cardiovascular status - She has been normotensive throughout
her Newborn Intensive Care Unit stay. She has a normal S1
and S2 heartsound, no murmur.
Fluids, electrolytes and nutrition status - Enteral feeds
were begun on day of life #1 and advanced without difficulty
to full volume. She is taking Enfamil 20 and breastfeeding
with a coordinated suck and swallow. She has been euglycemic
throughout her Newborn Intensive Care Unit stay.
Gastrointestinal status - Her bilirubin on day of life #3 was
total of 5.8, direct 0.2.
Hematological status - Her hematocrit at the time of
admission was 53.9 and platelets 335,000. She has received
no blood products during the Newborn Intensive Care Unit
stay.
Infectious disease status - The infant was started on
Ampicillin and Gentamicin at the time of admission for sepsis
risk factor. The antibiotics were discontinued after 48
hours when the blood cultures were negative and the infant
was clinically well.
Neurological status - She has not yet had an audiology
screen. Her neurological exam is normal.
Social status - The mother has been a resident of [**Name (NI) 36413**]
[**Last Name (NamePattern1) **] where she will remain until [**2137-9-24**]. She is
there with her 21 month old daughter and these two children
will go to stay with her there. She has been followed by
[**Hospital6 256**] social worker, [**Name (NI) 36130**]
[**Name (NI) 6861**].
CONDITION ON DISCHARGE: The infant is being transferred to
the Newborn Nursery. The infant is in good condition.
The mother has not yet identified a primary pediatric
provider but anticipates using the [**Hospital 12091**] Clinic.
CARE AND RECOMMENDATIONS:
1. Feedings at discharge - The infant is breastfeeding or
taking Enfamil 20 on an ad lib schedule.
2. Medications - The infant is discharged on no medications.
3. The infant will need a carseat position screening test
prior to discharge.
4. A newborn state screen was sent on [**2136-12-29**].
5. Due to the mother's hepatitis B vaccine, the infant
received her first hepatitis B vaccine in HBIG at the time of
admission to the Newborn Intensive Care Unit.
IMMUNIZATIONS RECOMMENDED:
1. Synagis respiratory syncytial virus prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria - I. Born at less than
32 weeks; II. Born between 32 and 35 weeks with plans for
daycare during respiratory syncytial virus season, with a
smoker in the household or with preschool siblings; III.
With chronic lung disease.
2. Influenza immunizations should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSIS:
1. Prematurity
2. Twin #1
3. Status post transitional respiratory distress
4. Sepsis, ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 36864**]
MEDQUIST36
D: [**2136-12-29**] 18:23
T: [**2136-12-29**] 19:26
JOB#: [**Job Number 36865**]
|
[
"V290",
"V053"
] |
Admission Date: [**2172-10-19**] Discharge Date: [**2172-10-30**]
Service: MEDICINE
Allergies:
Vancomycin / Oxycodone / Lorazepam
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Failure to decanulate
Major Surgical or Invasive Procedure:
T-tube and Y-stent placement - [**10-19**]
T-tube and Y-stent removal - [**10-26**]
Trach tube placement - [**10-26**]
Bronchoscopy
Trach change to Portex # 7 after patient pulled out trach
balloon during agitation
History of Present Illness:
This is an 88 year old male with history of COPD and CHF
presenting for failure to decanulate tracheostomy tube at rehab
with need for T-tube placement, with anatomy such that the
distal end of the T-tube will be telescoped into the Y stent. He
had a stent trial in the past which was unsuccessful due to
mucous plugging. Two months ago he was also admitted to [**Hospital1 **] with respiratory failure and had a tracheostomy placed
at that time. He has been at the rehab since but have failed to
decannulate him. At baseline, he is on a 50% trach mask with
sats around 95%. He is now being admitted for changeover of
tracheostomy to a T-tube with placement of its distal end into a
Y stent. The procedure was accomplished this morning and he is
doing well on the floor. He has no complaints currently.
Review of systems negative for fevers, chills, dyspnea, cough,
nausea/vomiting, dysuria.
Past Medical History:
PMH:
Tracheobronchomalacia s/p stent [**9-5**] and multiple bronchs
GOLD stage III COPD
p-Afib
Prostate Ca
CLL
HTN
Hyperlipidemia
GERD
Depression
CAD s/p CABG and then stent within last 10 years
CKD (baseline creatinine 1.5-2.1)
Aortic Stenosis
Vit B12 defic
Arthritis
Ventral hernia
Hx of enterococcal urosepsis
CCY
.
PSH: Silicon wire stent placement in [**8-/2171**], s/p CABG and then
stent within last 10 years, CCY
Social History:
He lives alone in a senior's facility. His wife died 2 [**Name2 (NI) 23087**]
ago. He is retired and formerly was in airline sales and is
also a veteran. He smoked a pipe for 10 years and quit 35 years
ago. He has no known exposure to asbestos or tuberculosis, and
has no
pets.
Family History:
No family history of pulmonary disease
Physical Exam:
VS 97.6, 124/70, 84, 16, 92% 5 L (trach mask)
Gen: Sitting up in bed in no apparent distress
Cardiac: nl s1/s2 RRR
Pulm: clear bilaterally, trach sounds present
Abd: soft, nontender, ND
Ext: no edema noted
Pertinent Results:
I. Microbiology
A. [**2172-10-19**] 8:00 am BRONCHIAL WASHINGS RIGHT.
**FINAL REPORT [**2172-10-28**]**
GRAM STAIN (Final [**2172-10-19**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2172-10-28**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
~6OOO/ML Commensal Respiratory Flora.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION REQUESTED PER DR.[**First Name (STitle) **] B.#[**Numeric Identifier 31201**] [**2172-10-24**]
10:00AM.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVE TO Piperacillin/Tazobactam sensitivity
testing performed
by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML..
CHLORAMPHENICOL <=8 MCG/ML SENSITIVE BY MICROSCAN.
TIMENTIN 32 MCG/ML INTERMEDIATE BY MICROSCAN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ESCHERICHIA COLI
| |
STENOTROPHOMONAS (XANTHOMON
| | |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R =>16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 2 S
LEVOFLOXACIN---------- =>8 R 1 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S =>16 R <=1 S
VANCOMYCIN------------ 1 S
B. Urine
[**2172-10-29**] 8:39 am URINE Source: Catheter.
**FINAL REPORT [**2172-10-30**]**
URINE CULTURE (Final [**2172-10-30**]):
GRAM NEGATIVE ROD #1. ~1000/ML.
C. Blood cultures x 2 - pending, no growth to date
II. Radiology
CXR [**2172-10-22**]:
FINDINGS: In comparison with the study of [**5-19**], the tracheal
stent is in
place. Continued low lung volumes with areas of atelectasis at
the bases. No evidence of pulmonary vascular congestion.
CXR [**2172-10-30**]
FINDINGS: In comparison with the study of [**10-29**], there is little
overall
change. Continued low lung volumes with mild prominence of
interstitial
markings and bibasilar atelectatic changes. Tracheostomy tube
remains in
place and the midline sternal wires are intact.
III. Labs
Admission Labs:
[**2172-10-19**] 04:15PM BLOOD WBC-7.1 RBC-2.92* Hgb-9.0* Hct-25.8*
MCV-88 MCH-31.0 MCHC-35.0 RDW-15.4 Plt Ct-185
[**2172-10-19**] 04:15PM BLOOD Glucose-141* UreaN-23* Creat-1.4* Na-139
K-4.4 Cl-102 HCO3-27 AnGap-14
[**2172-10-22**] 06:45AM BLOOD WBC-8.3 RBC-3.09* Hgb-9.4* Hct-28.6*
MCV-93 MCH-30.6 MCHC-33.0 RDW-15.8* Plt Ct-207
[**2172-10-22**] 06:45AM BLOOD Glucose-134* UreaN-27* Creat-1.5* Na-138
K-4.4 Cl-100 HCO3-27 AnGap-15
.
Discharge Labs:
WBC 7.1 Hgb 8.7 Hct 25.9 Plt 164 Glc 105 BUN 23 Cr 1.3 Na 141
K 3.7 Cl 103 HCO3 33 AG 9 Last ABG pO2 103 pCO2 50 pH 7.43 HCO3
34 ([**10-29**])
#### Pending studies - blood cultures x 2
Brief Hospital Course:
Medicine Floor Course [**Date range (1) **]:
The patient was admitted to the medicine service afer t-tube
placement on [**2172-10-19**]. On [**2172-10-20**] he was brought back to the
OR for repositioning of the t-tube. On [**2172-10-20**] he had
worsening of his secretions and was started on vancomycin and
levofloxacin. Bronchial washings came back with Staph aureus
coag+, E. Coli, and stenotrophomonas He is known to be a
colonizer with MRSA and Stenotrophomonas. His respiratory
status progressively worsened on [**2172-10-22**] and his antibiotics
were broadened to Vanc/Cefepime/Levo. He desatted occasionally
into the 80s with coughing and excessive secretions. He was
suctioned frequently. He was evaluated by IP who recommended
transferring him to the ICU for closer monitoring.
.
ICU Course 11-26-12/2:
88 year old male with tracheal stenosis, tracheobronchomalacia
s/p placement of Montogmery T-tube on [**10-19**] and revision on
[**10-20**] admitted to MICU with increased secretions and hypoxia
with coughing following procedure ([**2172-10-26**]) s/p Y-stent and
T-TUBE removal, mucous plugging s/p bronchoscopy and Portex
trach tube re-insertion ([**9-29**]) after patient agitated and
pulled out balloon. Hospital course complicated by delirium,
hypoxemia, and uncharacterized anemia.
# Tracheobronchomalacia with respiratory distress
On [**10-26**], the patient underwent removal of his T-tube and
Y-stent given minimal symptom improvement and hoarseness, and a
[**Last Name (un) 295**] # 7 trach was placed. Following the procedure, the
patient had an episode of respiratory distress, and he was
placed on pressure support ventilation. He was ultimately weaned
off pressure support ventilation, and placed on a TM, which he
tolerated well. The patient was evaluated by speech and swallow,
who cleared the patient for a full diet given previous concerns
about aspiration. On [**10-28**], he mucous plugged and turned ashen
acutely. IP did bronch and removed large plug with the patient
temporarily on [**4-6**] during this time then taken off vent.
Subsequently that evening, he became extremely agitated despite
zyprexa and haldol thought to be sundowning and pulled out the
balloon from his trach tube. This was replaced overnight with a
brief period of sedation with precedex. His [**Last Name (un) 295**] # 7 trach was
replaced with a perc portex # 7 trach. IP hopes to downsize the
trach in the future. There appears to be minimal options for
further treatment as he is not a stent candidate given he failed
trials and likely not an operative candidate. He will follow-up
with IP in [**11-30**] weeks after hospital discharge.
In the ICU, CPAP settings of 10 with FiO2 of 50 %
He was continued on xopenox and acetylcysteine nebs and will
need continued attention for secretion management.
#Tracheobronchitis:
Patient was thought to have teacheobronchitis given prominent
secretion component of symptoms with fever, leukocytosis, or
infiltrate on CXR. Patient's antibiotics were broadened from
cefepime to meropenem for E. coli EBSL and vancomycin was
switched to linezolid for history of vancomycin associated
ototoxicity. Levofloxacin was discontinued. *He is to continue
on meropenem and linezolid until [**2172-11-1**]*.
# Delirium
On [**10-28**], the patient appeared to have altered mental status,
believed to be consistent with delirium. This was attributed to
effect of medication, and specifically his benzodiazepenes,
codeine, and guiafenisen along with scolpamine patch were
stopped. He has a PARADOXICAL reaction to ativan causing
agitation, so ativan should be avoided. Guifenisen was also
discontinued. Infectious work-up including UA/UCx was negative.
He has both glasses and hearing aids that need to be utilized
with re-orientated. He is AAOx2 at baseline (person, place, time
only to year and does not know the month). He will continue on
olanzapine, avoid delirium-inducing drugs. He was responsive to
haldol during agitation episodes.
.
# Anemia
The patient's Hgb on admission was 9 with subsequent nadir to ~
7. He was transfused 1 unit of pRBC. There were no active signs
or symptoms of bleeding except some bloody secretions after a
procedure early in the hospital course. His stools were
hemoccult negative. Hemolysis labs in the setting of CLL were
not suggestive of hemolysis. Age appropriate cancer screening
and outpatient anemia work-up are advised.
# Abdominal distension
Pt noted to have distended abdominal, but no evidence of SBO or
ileus on KUB. He was disimpacted and placed on a bowel regimen.
# Atrial fibrillation
His coumadin is being held due to his recent procedures and can
likely be restarted once discharged and stable. He was continued
on amiodarone and metoprolol for his rate control.
#Chronic Kidney disease: The patient's Cr was stable at ~ 1.3 -
1.5.
# Hypertension: treated as above
# Hyperlipidemia: He was continued on atorvastatin at a
decreased dosage of 40 mg given concern of high dose statin with
amiodarone. Follow-up outpatient.
# Coronary Artery Disease: s/p CABG [**2156**]( LIMA->LAD,
SVG-diagonal, SVG-OM, SVG-LPL). On statin and BB, ASA.
# Aortic stenosis: Moderate with valve area of 1.0-1.2cm2.
# Depression: Continue olanzapine
# Vit B12 deficiency: Monthly injections as outpatient
# Access: peripherals, PICC (discontinue after antibiotic
course).
# Communication: Patient, HCP= [**Name (NI) **] [**Name (NI) 31202**] (son)
[**Telephone/Fax (1) 31203**]
# Mental status: Sometimes somnolent, usually AAOx 2 (to person,
place but not time - knows years but sometimes not month and
current date, can say months of year and days of week
backwards).
# GU - currently has foley in place.
# Code: DNR but ok to undergo short periods of ventilation via
tracheostomy if needed.
The patient's code status was re-adressed during his ICU stay
and his current status is DNR, but willing to undergo short
periods of ventilation via tracheostomy if needed.
Medications on Admission:
amiodarone 200 mg daily
Advair 50/250 1 puff twice a day
albuterol nebulizers,
Xopenex nebulizers every 4 hours
Lopressor 50 mg b.i.d.
Spiriva 1 capsule inhaled daily
Coumadin as directed
acetaminophen p.r.n.,
calcium and vitamin D.
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO twice a day.
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
5. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO qPM.
6. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation q 2 hr as needed for SOB.
7. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) mL Inhalation every six (6) hours.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs
Miscellaneous [**Hospital1 **] (2 times a day).
15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
16. Meropenem 500 mg IV Q8H
17. Linezolid 600 mg IV Q12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis: Respiratory Failure, tracheobronchitis
Secondary Diagnosis: Tracheomalacia, Bronchitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for placement of a T-tube to
assist with your breathing. You were unable to tolerate this
T-tube, and it was ultimately removed. A tracheostomy tube was
inserted in its place. You tolerated this replacement tube well.
You were also started on antibiotics for an infection in your
airway. These antibiotics will be continued upon discharge from
the hospital through [**10-30**].
Medication changes:
CHANGE atorvastatin from 80 mg to 40 mg
START acetylcysteine nebs
START linezolid and meropenem for tracheobronchitis for an 8-day
total course. End DATE [**2172-11-1**]
START Xopenex nebs every 2 hours as needed and every 6 hours
standing
** Please talk to you doctor about re-starting warfarin after
your acute illness **
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Location: [**Hospital1 18**] - Division of Pulmonary Medicine
Phone: ([**Telephone/Fax (1) 17398**]
Appt: We are working on a follow up appt for you within the
next week. THe office will call you at home with an appt. If
you dont hear from them by tomorrow, please call them directly.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
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"51881",
"5849",
"42731",
"2724",
"4241",
"40390",
"5859",
"53081",
"2859",
"311",
"V4581",
"V4582"
] |
Admission Date: [**2146-5-12**] Discharge Date: [**2146-5-19**]
Date of Birth: [**2080-7-11**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
gentleman with worsening vision in the left eye over the past
year, was seen by an ophthalmologist who questioned glaucoma.
He was therefore followed up, had visual field deficit and
had an magnetic resonance imaging scan, magnetic resonance
angiography which showed a large aneurysm at the A1 junction.
He was then referred for angiogram today. He was noted to
have a large left ACA aneurysm on the angiogram and also a
left-sided headache on Monday but computerized tomography
scan was negative for subarachnoid.
PHYSICAL EXAMINATION: On physical examination his blood
pressure was 150/73. His heart rate was 70. Respiratory
rate was 18. Saturations were 88 to 99% on room air. He was
awake, alert and oriented times three with fluent speech.
Cranial nerves II/XII were intact. Extraocular movements
full. Face symmetric. Tongue was midline. Visual fields
full. No drift. Moving all extremities with 4+/5 strength.
Sensation intact to light touch. His reflexes were 1+
throughout. He had no [**Doctor Last Name 937**] and no clonus. Cardiac,
regular rate and rhythm. Lungs were clear to auscultation.
Abdomen was soft, nontender, nondistended. Good pedal
pulses.
HOSPITAL COURSE: He was admitted for observation to the
Intensive Care Unit and then underwent an angiogram which
showed a left A1 aneurysm which was partially coiled. The
patient then returned to the Intensive Care Unit for
observation. He remained neurologically stable. On
postoperative check he was awake, alert and oriented times
three, following commands. Pupils were equal and brisk. His
groin sheath was in place. He had no hematoma. On [**2146-5-14**], the patient had an episode. He became suddenly
confused and agitated, wanted to go home. On examination he
was alert and cooperative initially and then abruptly became
angered, repetitive, perseverating about staff not attending
to his needs, having tangential thoughts, becoming mild
distracted. The patient had a stat magnetic resonance
imaging scan which showed a small area of restricted
diffusion and he had a corpus callosum. It was suspected
the patient had an embolic event causing change in mental
status and word-finding difficulties. On [**2146-5-15**], the
patient was taken back to angiography where he underwent
additional coiling at the neck of his aneurysm without
complication. Post procedure the patient was awake, alert and had
some persistent word-finding difficulties with good repetition,
difficulty with naming, oriented to person but not place.
Cranial nerves were intact. His grasps were full. On [**5-16**], he was awake and alert and oriented times three, able to
name fingers. Repetition was intact. Extraocular movements
were full, face was symmetric. Grips were full.
Interphalangeals were full. He had no drift. His sheath was
therefore removed and his blood pressure continued to be elevated
. He was on intravenous Nipride for blood pressure
control. His blood pressure was under better control by
[**2146-5-18**], and he was transferred to the regular floor.
He has remained neurologically stable, awake, alert and
oriented times three with no word-finding difficulty. Speech
is fluent. Extraocular movements full, no drift, strength
5/5 in all objects. His memory is intact.
He will be discharged to home on [**2146-5-19**] in stable
condition with follow up with Dr. [**Last Name (STitle) 1132**] in two weeks and with
Dr. [**Last Name (STitle) 7356**] from [**Hospital 4415**], his
ophthalmologist in two weeks as well. His vital signs remain
stable. He has been afebrile.
MEDICATIONS ON DISCHARGE: His medications at the time of
discharge include Percocet 1 to 2 tablets p.o. q. 4 hours
prn, Aspirin 81 mg p.o. q. day for one week, Metoprolol XL
200 mg p.o. q. day, Hydrochlorothiazide 25 q. day, Valsartan
160 mg p.o. q. day.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2146-5-19**] 11:16
T: [**2146-5-19**] 11:41
JOB#: [**Job Number 109332**]
|
[
"4019"
] |
Admission Date: [**2136-6-7**] Discharge Date: [**2136-6-13**]
Date of Birth: [**2085-7-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Multiple pulmonary emboli
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 yo with extensive past medical history recently discharged on
[**2136-6-6**] from [**Hospital1 18**] after prolonged hospitalization for CHF. The
patient had a mechanical fall and is now readmitted on [**2136-6-7**].
The patient presented with worsening right sided chest pain and
new rib fractures and pulmonary emboli.
Past Medical History:
*low back pain - Patient has narcotic contract. Please refer to
letter dated [**2135-5-17**] for updated doses. He is followed by pain
management and orthopedics
*cryptogenic organizing pneumonitis s/p RML wedge resection
*depression and PTSD
*obstructive sleep apnea, reports compliance with CPAP but that
machine was recently taken away due to financial issues + being
hospitalized
*moderate diastolic CHF
*hypertension
*hyperlipidemia
*DMII
*obesity
*Squamous cell carcinoma on dorsum of right hand s/p Moh's
micrographic surgery
*alcohol abuse
*tobacco abuse
*5 GSWs in L leg, 4 GSWs in R leg, 1 GSW in buttocks
*multiple orthopedic surgeries
*? pericarditis with pericarial effusion requiring drainage at
[**Hospital1 **] (patient report)
Social History:
- On disability, but formerly worked in construction doing
wrecking.
He was a certified asbestos remover and had significant asbestos
exposure
20-30 years ago.
- Tobacco history: Smokes 2pk/day x30 years, "quit" 1 month ago
but has had 3 cigs over past month
- ETOH: Drinks a large amount of vodka and a few beers daily,
not able to quantify the vodka
- Illicit drugs: marijuana as a teenager, no other drug use
- Pt lives at home alone, and is minimally active.
- He has a girlfried who he sees on weekends.
- He is divorced, but close with his ex-wife. Two children, son
died last year in [**Name (NI) 8751**].
Family History:
- Brother with heart transplant for pericarditis
- no other family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory
- mother had melanoma and died of perforated peptic ulcer at 71
- father alive and well
- 3 brothers and 3 sisters alive and well
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Temp:98.8 HR:78 BP:100/49 Resp:17 O(2)Sat:82 ra low
Constitutional: Comfortable
HEENT: Extraocular muscles intact
Oropharynx within normal limits
Chest: coarse breath sounds
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: + pulses, + edema
Skin: ecchymosis to abdomen from heparin injections
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2136-6-7**] 12:25PM GLUCOSE-123* UREA N-30* CREAT-1.2 SODIUM-133
POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-28 ANION GAP-15
[**2136-6-7**] 12:25PM cTropnT-<0.01
[**2136-6-7**] 12:25PM proBNP-47
[**2136-6-7**] 12:25PM WBC-12.7* RBC-4.06* HGB-13.0* HCT-37.6*
MCV-93 MCH-32.0 MCHC-34.6 RDW-16.3*
[**2136-6-7**] 12:25PM NEUTS-80.3* LYMPHS-15.3* MONOS-3.7 EOS-0.3
BASOS-0.6
[**2136-6-7**] 12:25PM PLT COUNT-221
[**2136-6-6**] 03:25PM CREAT-1.3* POTASSIUM-4.4
[**2136-6-6**] 06:35AM WBC-14.7* RBC-4.01* HGB-12.7* HCT-37.5*
MCV-94 MCH-31.7 MCHC-33.9 RDW-15.8*
Imaging:
IMPRESSION:
5/6/10CT Chest & Abdomen
1. Pulmonary emboli within the right upper lobe segmental and
subsegmental pulmonary arteries, as well as the right
interlobar pulmonary artery, and segmental right lower lobe
pulmonary artery without evidence of right heart strain.
2. Unchanged bilateral ground-glass opacities most pronounced in
the upper lobes consistent with patient's history of cryptogenic
organizing pneumonia.
3. Superior endplate compression fracture of L2, new compared to
[**2136-5-5**]. New acute and subacute bilateral rib fractures.
Brief Hospital Course:
He was admitted to the Trauma Service for pulmonary care; pain
management and anticoagulation for his multiple pulmonary
emboli. He was immediately bolused and started on a Heparin
drip. His Coumadin was started on [**6-9**] at 5 mg and increased to
7.5 mg due to sub therapeutic INR; his last INR on [**6-13**] was 1.5.
Once INR goal range of [**3-7**] reached his Heparin drip can be
stopped.
Mr. [**Known lastname 20400**] has a long history with chronic pain requiring long
and short acting narcotics at home to manage this. With his rib
fractures his pain was very difficult to manage and the decision
was made to consult with the Pain Service. Both his long and
short acting medications were increased; it was noted however
that the Oxycodone increased breakthrough dose was not offering
much relief for his rib fracture pain. He had been receiving
intermittent IV Dilaudid for severe breakthrough pain and this
was stopped and he was changed to oral Dilaudid. It should be
noted that he is requiring larger than usual doses of this
medication 12-14 mg every 3-4 hours prn. His adjunct
medications, Neurontin and Topamax were increased. Tizanidine
was added as well. He is on an aggressive bowel regimen.
He was also evaluated by the Orthopedic Spine surgery service
for the L2 compression fracture; there was no operative
intervention indicated. Activity as tolerated was recommended.
His oxygen saturations have ranged in the low 90's and he has
made very slow progress with Physical therapy who are
recommending acute rehab after his hospital stay. He requires
frequent monitoring of his oxygen saturations and respiratory
status in general.
Medications on Admission:
Prednisone 40', Asa 81', Gabapentin 300''', Glargine 10HS,
Metformin 500', Albuterol nebs q6hprn, atrovent neb q6hprn,
oxycodone 40q4p, oxycontin 60''', Bactrim 800/160''', Lopressor
25'', Simvastatin 80', Citalopram 10', Topiramate 25'', Prazosin
1hs, Tramadol 50''''prn,Lisinopril 5', Ca+D, Betadine + adaptic
to R big toe daily, Spirinolactone 25', lasix 120'
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Prazosin 1 mg Capsule Sig: One (1) Capsule PO QHS (once a day
(at bedtime)).
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF ([**Known lastname 766**]-Wednesday-[**Known lastname 2974**]).
16. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
18. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM: goal INR [**3-7**].
19. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
20. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
21. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
22. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
23. Topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
25. Tizanidine 6 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
26. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
27. Hydromorphone 4 mg Tablet Sig: [**4-4**] 1/2 Tablets PO Q3H (every
3 hours) as needed for breakthrough pain.
28. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1,950 units/hr Intravenous ASDIR (AS DIRECTED):
[**Month (only) 116**] discontinue Hep gtt once INR goal range of [**3-7**] reached.
29. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) Units
Subcutaneous at bedtime.
30. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for per sliding scale: see
attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
s/p Fall
1)Rib fractures
2)Pulmonary Emboli
3)L2 Fracture
Secondary diagnosis:
Heart failure
Chronic pain syndrome
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 to [**Hospital1 69**] after
falling and breaking your ribs. You were also diagnosed with
pulmonary emboli. You were treated with medication for pain as
well as blood thining medication for the pulmonary emboli (blood
clots in your lung).
For your heart failure you should weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma for evaluation of
your rib fractures; call [**Telephone/Fax (1) 600**] for an appointment. You
will need a standing end expiratory chest xray for this
appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 1007**], orthoepdic spine for your
L2 fracture, call [**Telephone/Fax (1) 1228**] for an appointment.
The following appointments were made for you prior to your
hospital stay:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2136-6-27**] 2:40
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2136-6-27**] 3:00
Completed by:[**2136-6-13**]
|
[
"25000",
"2724",
"4019",
"32723",
"311",
"3051",
"4280",
"496",
"2720"
] |
Admission Date: [**2142-11-18**] Discharge Date: [**2142-12-27**]
Date of Birth: [**2112-9-20**] Sex: F
Service: SURGERY
Allergies:
Vancocin Hcl
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
30 F s/p multiple gun shot wounds brought in by EMS in pulseless
electrical activity.
Major Surgical or Invasive Procedure:
1. Aortic arch and selective innominate, left carotid and left
subclavian arteriograms, inferior vena cava filter placement.
2. Median sternotomy and cervical incision for
exposure of upper thoracic and lower cervical spine.
Total vertebrectomy of C7 and T1.
3. Fusion C6-T2.
4. Anterior cage placement.
5. Repair of dural defect.
6. Autograft.
7. Flexible bronchoscopy and aspiration and lavage.
8. Percutaneous tracheostomy tube placement.
9. Percutaneous endoscopic gastrostomy tube placement.
History of Present Illness:
30 F who answered a knock on her door when she received multiple
gun shot wound including left leg, left clavicle, right
posterior trapezius. Found down in PEA, intubated in the field,
and sent to [**Hospital1 1474**] hosptial. Subsequently med-flighted to
[**Hospital1 18**] for further evaluuation. Hematocrit at outside hospital
=15, received 5 units PRBC on arrival to [**Hospital1 18**]. Initially no
dopplerable pedal pulses, decreased rectal tone, guiac postive.
Bilateral pulmonary contusions, C6-T1 burst fractures
Past Medical History:
No significant past medical history
Social History:
African american female with excellent family support.
No history of alcohol, tobacco, or drug abuse
Family History:
non-contributory
Physical Exam:
Neuro:Alert and oriented. Communicates when cuff down with
interrupted speach. Lip talks well.
Cardiac:RRR
Respiratory:Lungs clear bilaterally. Incision on neck and chest
clean and dry
Abdomen:soft nontender, obese, non-distended. G tube site clean.
Extremities:Moves right upper extremity only.
Pertinent Results:
Laboratories on Discharge
wbc:8.3
Hct: 28.9
Plts: 265
Sodium: 136
Potassium:3.7
Bun:21
Creatinine:0.3
Brief Hospital Course:
Ms [**Known lastname 12330**] was admitted to the trauma service after multiple
gunshot wounds. The one with consequence entered left neck and
exited right posterior neck causing spinal cord injury at
approximately c6 level leaving her quadraplegic with some
movement of right arm. Studies included arteriogram of neck
showing left vertebral disruption. Procedures included cervical
and superior thoracic spine fixation by anterior and posterior
approach, tracheostomy tube, gastrostomy tube, and ivc filter.
She is completely neurologically intact but has had little
improvement with her paralysis. Majority of her hospital course
has been due to fevers that go as high as 103. complete
infectios disease workup including CT of chest and abdomen,
wound checks, lumbar puncture have been negative. She has fevers
despite normal white count off antibiotics. Infectious disease
consultants have cleared her and she is being discharged to
rehabilitation alert and oriented, tolerating tube feeds,
comfortable, speaking with cuff down for short periods of time,
still with occasional fevers, and hemodynamically stable.
Medications on Admission:
None
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
units Injection TID (3 times a day).
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
5. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) 300 mg PO Q8H
(every 8 hours) as needed.
6. Gabapentin 250 mg/5 mL Solution Sig: One (1) 300 mg PO TID (3
times a day).
7. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) 150 mg PO BID (2
times a day).
8. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours): 25 mcg/hr. wean as tolerated.
9. Lorazepam 0.5 mg Tablet Sig: One (1) 0.5 mg PO TID (3 times a
day): wean as tolerated.
10. Lorazepam 1 mg Tablet Sig: One (1) 1 mg PO HS (at bedtime):
wean as tolerated.
11. Mirtazapine 15 mg Tablet Sig: One (1) 15 mg PO HS (at
bedtime).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection ASDIR (AS DIRECTED): Insulin regular
sliding scale.
13. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
15. Acetaminophen 160 mg/5 mL Solution Sig: One (1) 325 mg PO
Q4-6H (every 4 to 6 hours) as needed.
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
17. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
18. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
19. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
20. [**Location (un) **] Oil Oil Sig: One (1) Miscell. prn (): patient
taking own med. ([**Location (un) 2452**] oil).
21. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Multiple gun shot wounds
C6 spinal cord injury
Quadraplegia (with some movement of right arm)
Respiratory failure
Status post cervical spine fixation
Status post tracheostomy
Status post gastrostomy tube
Status post inferior vena cava filter placement
Discharge Condition:
Good.
Discharge Instructions:
Neuro: pain meds and ativan as required
Cardiac: Stable
Respiratory: Wean vent as tolerated. Routine trach care (#7
fenestrated cuffed)
GI: Goal tube feeds
ID: No antibiotics. Has fevers without source of infection. WBC
stable off antibiotics.
Renal: Foley. wean as tolerated
Prophylaxis: Ivc filter, heparin sq, tube feeds
Followup Instructions:
Trauma clinic 2-3 weeks at [**Hospital1 18**]. [**Numeric Identifier 50514**]
Completed by:[**0-0-0**]
|
[
"5180",
"2851",
"42789"
] |
Admission Date: [**2163-6-21**] Discharge Date: [**2163-7-2**]
Date of Birth: [**2098-8-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
SOB, Fever
Major Surgical or Invasive Procedure:
Aline, central line
History of Present Illness:
Ms. [**Known lastname 108231**] is a 64 yo F w/ h/o pulm fibrosis after radiation
for Hodgkins, esophageal candidiasis, GERD, ? adrenal
insufficiency (orthostatic hypotension at PCP last wk when
dropped pred), esophageal HSV, SVT, unprovoked PE on coumadin
who presented to her PCP today [**Name Initial (PRE) **]/ 2D SOB and cough productive of
greenish brown sputum which is worse than her baseline. The
cough is assoc with left sided sharp 7/10 chest pain x1d. Pt
also reports nausea this am and vomiting mucus no blood after
albuterol. + chills, subj fevers, lightheaded, HA, weakness.
Recent PNA [**1-19**].
.
Has chronic SOB since [**1-19**] on pred taper. No hemoptysis.
.
In the ED, initial vs were: T 99.9 P 118 BP 120/49 R O2 sat
100%. Access 2 PIVs (18/20). Got 3 LNS, vanc 1gm, levo, aspirin,
tylenol. EKG diffuse ST depressions, improved since starting
fluids, initial troponin negative. CXR perimediastinal fibrosis
unchanged, incr linear opacities in apices bilat with nodular
opacities in RLL c/w multifocal PNA. CTA no PE, bilateral tree
and [**Male First Name (un) 239**] with RML consolidation. INR subtherapeutic 1.6.
.
Prior to transfer from the ED, vitals: T 99.5 P 110 BP 105/49 R
23 100% on BIPAP FIO2 100%, PEEP 5, PSV 8. Diffusely wheezy,
tachycardic. Pt waiting for a bed on [**Hospital Ward Name **] when HR rose to
140s, RR to 30, BP 120/80 and started BIPAP, got SL NTG, rpt CXR
without flash, started on ceftri as well (had already gotten
levo and vanco).
.
On arrival to the ICU, pt acknowledge feeling like she was
"drowning" in ED, but since starting BiPAP much improved.
Decreased SOB. Denies HA/CP/N/V/D/C.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-Reactive airways disease/Pulmonary Fibrosis
-Pneumonia [**2162-12-12**], CAP tx with levofloxacin. Cx's neg.
-Hodgkin's disease stage 2 in '[**22**] treated with total body
radiation
-Functional Asplenism s/p radiation treatment
-Radiation induced ovarian failure s/p total hysterectomy and
estradiol therapy
-Hypothyroidism
-Supraventricular tachycardia
-GERD
-?Coronary vasospasm
-Pulmonary emoblism in '[**54**] on longterm low-dose Coumadin
-Right chest lentigo
-H/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**]/HSV esophagitis in setting of being on steroids
-Outpatient question of adrenal insufficiency with
lightheadedness with decreasing steroids
Social History:
Patient is married and lives in [**Location 1514**], MA with her husband.
She works as an administrator at a private high school. She is
independent and performs ADLs without limitation. Physically,
she has difficulty climbing stairs and participating in sports
due to her radiation-induced lung fibrosis. She drink EtOH
socially on the weekendsremote tobacco history in college but
no current use, , no ilicit drug use.
Administrator in high school, rare alcohol, no tobacco, daily
cup caffeine
Family History:
No family history of lung or cardiac diseases.
Mother: [**Name (NI) 2481**]
Maternal GM: Uterine cancer
Physical Exam:
General Appearance: Well nourished, No acute distress, No(t)
Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: bases b/l)
Abdominal: Soft, Non-tender, b/l papular rash below both breasts
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
[**2163-6-21**] 08:12PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2163-6-21**] 08:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2163-6-21**] 08:12PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2163-6-21**] 04:07PM LACTATE-2.0
[**2163-6-21**] 04:00PM GLUCOSE-112* UREA N-27* CREAT-1.2* SODIUM-139
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
[**2163-6-21**] 04:00PM ALT(SGPT)-27 AST(SGOT)-32 CK(CPK)-41 ALK
PHOS-135* TOT BILI-0.6
[**2163-6-21**] 04:00PM LIPASE-17
[**2163-6-21**] 04:00PM CK-MB-NotDone cTropnT-<0.01
[**2163-6-21**] 04:00PM IRON-10*
[**2163-6-21**] 04:00PM calTIBC-308 FERRITIN-157* TRF-237
[**2163-6-21**] 04:00PM WBC-21.3*# RBC-3.37* HGB-10.4* HCT-30.1*
MCV-89 MCH-30.9 MCHC-34.6 RDW-14.5
[**2163-6-21**] 04:00PM NEUTS-85* BANDS-3 LYMPHS-2* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2163-6-21**] 04:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2163-6-21**] 04:00PM PLT SMR-HIGH PLT COUNT-486*
[**2163-6-21**] 04:00PM PT-18.0* PTT-26.6 INR(PT)-1.6*
CTA CHEST: 1. No evidence of pulmonary embolism or aortic
dissection.
2. Tree-in-[**Male First Name (un) 239**] nodular opacities in both lungs, most pronounced
in the
superior segment of the right lower lobe, compatible with a
small airways
infectious or inflammatory process.
3. Partial collapse of the right middle lobe.
4. Paramediastinal fibrotic changes secondary to radiation, with
neighboring
traction bronchiectasis.
TTE [**2163-6-22**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with basl to mid septal
hypokinesis to akinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the report of the prior study (images unavailable
for review) of [**2155-12-16**], regional LV systolic dysfunciotn is
new.
Brief Hospital Course:
# Respiratory Failure - Mrs. [**Known lastname 108231**] was admitted to the ICU
due to hypoxia and tachypnea on presentation to the ED. PE was
ruled out by CTA, which also showed RLL pneumonia with tree [**First Name8 (NamePattern2) **]
[**Male First Name (un) 239**] opacities throughout lungs. In ED, she acutely worsened in
setting of tachycardia, thought likely secondary to flash
pulmonary edema. She was given diuretics, placed on BiPap with
some improvement, however ultimately required intubation for
hypoxic respiratory failure. She was admitted to the ICU. She
was treated for her pneumonia. She was intermittantly
hypotensive, requireing pressors. She was extubated after 24
hours with steady improvement in her oxygen requirement over the
course of her admission. Blood pressure was closely monitored
to avoid repeat flash pulmonary edema. On dishcarge, she was
breathing comfortably on room air.
# Pneumonia- Atypical distribution on CT with a RLL
consolidation. She was started on Vancomycin and Zosyn. ID was
consulted. While intubated, bronchoscopy was performed which
showed thick secretions, but no other pathology. Cultures were
taken and all were negative to date at time of discharge. Per
ID, antibiotic regimen was changed to Ceftriaxone given no
positive cultures. She was treated with Ceftriaxone for planned
10 day course. Oxygen requirement improved throughout
admission. Mrs. [**Known lastname 108231**] was discharged on a 2 day course of
Levoquin to complete a 10 day antibiotic course.
# Chest pain/NSTEMI - Mrs. [**Known lastname 108231**] presented with persistant,
pleuritic chest pain over lateral left chest in setting of
pneumonia on CT. EKG in the ED with SD depressions, first set
of cardiac enzymes were negative. Repeat enzymes in the ICU
were positive for troponin > 0.1 and she was started on
treatment for NSTEMI.
She was placed on high dose aspirin, beta-blocker, ace-inhibitor
and statin. Heparin was not given as she was
theapeutic/supratherapeutic on INR. Her EKG returned to
baseline. Cardiac catheterization was done after improvement in
acute infection. Catheterization showed diffuse coronary artery
disease; no internvention was done. Mrs.[**Known lastname 108232**]
[**Name (STitle) 10708**] was discontinued due to continued orthostatic
hypotension and restarting should be readdressed as an
outpatient. Aspirin, plavix, atorvostatin and metroprolol were
continued on discharge.
# Orthostatic Hypotension- Reportedly manifest as orthostasis
and lightheadedness over several weeks as patient tried to self
taper her prednisone that she has been on since last bout of PNA
in [**12-20**] - concern for adrenal insufficiency. She was given
stress dose steroids in the ICU and returned to outpatient dose
of prednisone (3 mg/day) after completion. Two days prior to
discharge, Mrs. [**Known lastname 108231**] experienced asymptommatic hypotension
in the morning that responded to small IV bolus. She continued
to hypotensive to systolic 80's the next two days. Cortisol
stimulation test was normal (however, patient was on prednisone
at the time). Patient was discharged on admission dose of
prednisone (3 mg). Salt in her diet was liberalized and patient
was discharged on Florinef with plans to follow-up with her PCP.
# Anemia - Anemia below baseline on admission, stable throughout
admission. Iron studies, B12 and folate normal. Transfused 1
unit PRBCs with no side effects.
# History of PE - Mrs. [**Known lastname 108231**] continues outpatient warfarin
for prophylaxis after PE approximately 10 years ago. She became
supratherapeutic during admission and this was held. Coumadin
was continued to be held in anticipation of cardiac
cathterization. After catheterization, coumadin was restarted.
After discharge, home VNA was arranged and INR checks will be
called into [**Hospital3 **] [**Hospital3 271**].
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs INH every four to six hours as needed for cough
ATENOLOL - 50 mg Tablet - 1 (One) Tablet(s) by mouth every day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 inhalation twice a day - RINSE MOUTH AFTER EACH
USE
LEVOTHYROXINE [SYNTHROID] - 112 mcg Tablet - 1 (One) Tablet(s)
by
mouth every day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
PREDNISONE - 2-3 mg daily
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth at bedtime
WARFARIN - 5 mg on Tuesday nights, 2.5 mg every other night.
CALCIUM CARBONATE-VITAMIN D3 500 mg (1,250 mg)-400 unit [**Hospital1 **]
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcium Carbonate-Vitamin D3 500 mg(1,250mg) -400 unit Tablet
Sig: One (1) Tablet PO once a day.
5. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO Once Daily at 4
PM: As directed by your PCP/coumadin clinic. Change dose as
instructed after coumadin/INR checks.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Hypotension
Respiratory Failure
Heart Attack - NSTEMI
Anemaia
Orthostatic Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
determined to have pneumonia. Due to your pneumonia and
difficulty breathing, you were briefly put on a machine to
breath for you. You also briefly required medications to
maintain your blood pressure. Antibiotics were continued
throughout your admission and you will need to take one dose of
antibiotics after discharge to complete the treatment for
pneumonia for which you were treated with an 11 day course. You
also suffered a small heart attack during your hospitalization.
You were started on medication for this and had a cardiac
cathterization that showed coronary artery disease, but no
intervention was required. Your blood pressure was low at times
and it is felt that you have orthostatic hypotension. You
recieved one blood transfusion to treat your low blood count.
You are being started on a medication to help your blood
pressure. It is important that you follow-up with the
specialist appointmnents arranged for you.
CHANGES IN MEDICATION:
START Metoprolol 12.5 mg twice a day
START Plavix 75 mg daily
START Atorvastatin 80 mg daily
START Aspirin 325 mg daily
START Fludrocortisone 0.1mg daily
START Levofloxacin 750mg daily
STOP Atenolol
Please continue all other medications as previously prescribed.
Followup Instructions:
The following appointments have been arranged for you:
Department: [**Hospital3 249**]
When: TUESDAY [**2163-7-12**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11917**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This is a follow up of your hospitalization. You will be
reconnected to your primary care physician after this visit.
Department: DIV OF ALLERGY AND INFLAM
When: TUESDAY [**2163-7-19**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: CARDIAC SERVICES
When: FRIDAY [**2163-7-22**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*We are working on a follow-up appointment for you in the
Pulmonary department. The office will contact you with an
appointment. If you do not hear from them or have questions,
please contact them at ([**Telephone/Fax (1) 3554**].
|
[
"486",
"51881",
"41071",
"5119",
"4280",
"41401",
"2859",
"53081",
"V5861",
"42789",
"2449"
] |
Admission Date: [**2172-3-19**] Discharge Date: [**2172-3-24**]
Date of Birth: [**2089-12-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82M past medical history of renal failure on dialysis, stroke
with residual left-sided weakness, recent toe amputation with
vascular surgery, and atrial fibrillation on Coumadin, who
presents with several episodes of bright red blood per rectum
from his nursing home or rehabilitation. The patient reports no
sx, he reports taht he has been eating normally (ground food and
with a poor appetite at baseline) and has had no abdominal pain,
n/v/d/c. The patient has had a large decline in his baseline
health over the past month, beginning with vascular surgery in
which they did angioplasty on the posterior tibial artery and
they initiated [**First Name3 (LF) 4532**] at that time, [**2172-3-3**]. Since then, he has
been less mobile and more somnolent, with baseline fatigue and
decreased appetite. He is on warfarin for afib/flutter and on
Aspirin for his history of CVA. He reports that he had a fall in
which he hit his left shoulder and buttock, it is unclear the
situation surrounding this but he endorses pain in his left
shoulder and lidocaine patch is in place, he reports that this
has happened since his admission to [**Hospital1 18**] for surgery at the
beginning of [**Month (only) 956**].
.
When EMS arrived, he was observed to be "difficult to arouse."
In the ED, initial VS: 96.7 111 108/52 22 100% 2L Nasal Cannula.
In ED passed 700-800cc of BRPBR. Patient received Pantoprazole
bolus +ggt. CTA done and revealed no source of bleeding and
stool in the ascending bowel. IR aware for possible angio. VS
prior to transfer SBPs 99/50, with a baseline SBP 90-100. Access
established is 18g, triple lumen in groin. Received 1u FFP.
Received 10mg IV vitamin K. CXR with concern for PNA so started
on vanc, zosyn ordered. Missed HD today; last HD on Tuesday,
renal consult was obtained and they will not proceed with HD
today but do recommend DDAVP.
.
On arrival to the MICU, the patient is somnolent but responsive
and interactive. He had 100cc of bright red blood per rectum
with clots, no stool. He remains hemodynamically stable although
hypothermic with T 95, HR 80-90 and SBP 100-110/50s, which is
his baseline.
Past Medical History:
- ESRD on HD (Tu, Th, Sat)
- h/o CVA w R sided weakness
- DM
- Glaucoma
- Hypercholesteremia
- Atrial flutter
- PVD
- Gout
- Vit D Deficiency
Social History:
Patient lives with daughter but has recently been at rehab in
setting of amputation. Has wife who he did not live with. Has a
son also in the area.
- Tobacco: Former [**2-3**] ppd smoker, quit 10 years ago
- Alcohol: no recent EtOH
- Illicits: no illegal drug use
Family History:
Mother-deceased of "heart attack" in old age
Father-deceased of "leg wound" in 50s
Children-healthy
Physical Exam:
Vitals: T: 95 BP: 103/62 P: 93 R: 12 18 O2: 97% on 3L NC
General: somnolent but arousable. oriented to self, date but not
year and says "[**Hospital 882**] Hospital", no acute distress
HEENT: dry mucous membranes, oropharynx clear, poor dentition.
Pupils are non-reactive. Cloudy pupils
Neck: supple, JVP not elevated, no LAD
CV: irregular rate, rapid rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: poor air movement bilaterally. decreased breath sounds at
the bases. dyspneic with lying supine.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, dopplerable pulses. 2+ edema. Very swollen left UE.
LUE fistula with bruit. No large toe on left foot and there are
stitches in place. Wound on back of left leg.
Neuro: very limited neuro exam [**3-5**] cooperation, 3/5 strength
upper/lower extremities, grossly normal sensation, gait deferred
but ataxic and not ambulatory at baseline. Baseline weakness on
the left noted.
Pertinent Results:
Initial labs:
[**2172-3-19**] 01:30PM WBC-4.6 RBC-2.78* HGB-9.7* HCT-31.2* MCV-112*
MCH-34.9* MCHC-31.1 RDW-17.7*
[**2172-3-19**] 01:30PM NEUTS-86* BANDS-0 LYMPHS-3* MONOS-8 EOS-2
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2172-3-19**] 01:30PM PLT SMR-LOW PLT COUNT-80*
[**2172-3-19**] 12:35PM GLUCOSE-219* UREA N-40* CREAT-5.3* SODIUM-137
POTASSIUM-5.4* CHLORIDE-94* TOTAL CO2-33* ANION GAP-15
[**2172-3-19**] 12:35PM ALT(SGPT)-10 AST(SGOT)-31 ALK PHOS-240* TOT
BILI-1.2
[**2172-3-19**] 12:35PM LIPASE-40
[**2172-3-19**] 12:35PM ALBUMIN-3.0* CALCIUM-9.0 PHOSPHATE-6.3*#
MAGNESIUM-2.6
[**2172-3-19**] 12:10PM PT-40.0* PTT-42.9* INR(PT)-3.9*
[**2172-3-19**] 01:30PM TYPE-[**Last Name (un) **] PO2-57* PCO2-66* PH-7.30* TOTAL
CO2-34* BASE XS-3 COMMENTS-GREEN TOP
[**2172-3-19**] 01:30PM LACTATE-2.4*
[**2172-3-19**] 01:34PM HIV Ab-NEGATIVE
[**2172-3-19**] 03:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-300
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG
[**2172-3-19**] 03:10PM URINE RBC-57* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-<1
[**2172-3-19**] 03:10PM URINE HYALINE-10*
CT angiogram:
IMPRESSION:
1. Hyperdense fluid within the sigmoid colon consistent with
hemorrhage. No clear source for active bleeding on this
mesenteric CTA. No bowel wall
inflammation and diverticulosis.
2. Moderate nonhemorrhagic bilateral pleural effusions with
associated compressive atelectasis.
3. Moderate simple ascitic fluid, diffuse mesenteric edema and
subcutaneous edema consistent with anasarca.
CXR:
IMPRESSION: Findings suggesting mild-to-moderate pulmonary
vascular congestion with bilateral pleural effusions and
opacities at the lung bases likely due to associated
atelectasis.
Brief Hospital Course:
82 year old male with peripheral vascular disease on warfarin,
[**Last Name (LF) 4532**], [**First Name3 (LF) **] presenting with painless BRBPR, current hemodynamic
stability. In brief, he had GIB in the ICU requiring massive
transfusion protocol. Per ICU team, after discussion with family
the decision was made to transition him to CMO status and he was
managed with CMO protocol morphine gtt on the medical floor. He
passed away overnight on [**3-24**].
.
# BRBPR: Patient presenting with about 500cc of bright red blood
per rectum in the emergency room. It is painless and no
hemorrhoids have been visualized. The most likely etiology is
diverticular bleed. Also in the ddx is AVM, hemorrhoids,
ischemia, ulcer or other etiology of UGIB. Given bright red
blood while hemodynamically stable, it was suspected to be a
lower GI source. On admission INR 3.9, improved with FFP and
vitmain K. He was transfused 1 unit PRBC and one dose of DDAVP
20mcg over one hour given his uremia.
A CT angiogram was done that did not reveal a source of
bleeding. After reversal of his INR the bleeding slowed, and GI
held off on endoscopy. The patient then began passing clots per
rectum and was transfused several units, platelets, and FFP.
Despite all this, his hct and bp continued to drop. A left
femoral CVL was placed and he was started on pressors. A family
meeting was held and the decision to transition goals of care to
CMO was made. He was taken off pressors.
Pt was monitored for Si/Sx of pain, anxiety, discomfort; no
vitals, transfusions, hemodialysis, labs were pursued. Pt was
maintained on morphine gtt per Comfort Care Guidelines with prn
ativan for breakthrough pain or anxiety, with scopolamine patch
if necessary for use when suctioning airway. He passed away
overnight [**3-24**].
.
#Aflutter: patient had atrial fibrillation during his previous
hospitalization and was started on metoprolol for rate control
and warfarin. The patient was not a considered a candidate for
acute intervention but the patient is intolerant of high
ventricular rates. Warfarin and metoprolol were held in setting
of GIB.
.
#Peripheral vascular disease: complicated by bilateral gangrene
requiring admission at the beginning of [**2172-3-4**], s/p
Balloon angioplasty of left posterior tibial artery with
additional angioplasty and stenting of left posterior tibial
artery occlusion along with amputation of left great toe. He was
advised to continue [**Year (4 digits) **] for at least 30 days, until [**2172-4-6**].
His [**Month/Day/Year **] was held given GI bleed.
.
#ESRD: On dialysis qT-TH-SAT. Last HD tuesday ([**2171-3-18**]) with 3
Kg UF (post HD wt 80, EDW 76.5 kgs). Has working Lt UA AVF for
access. The patient has anasarca which is out of proportion of
missing one dialysis session. Continued nephrocaps and
sevelamer. Received dialysis [**2172-3-21**].
.
# Hypotension: the patient's systolic blood pressure is recorded
as baseline 90-110 systolic during previous admission. He did
have a requirement for pressors in the setting of afib during
his previous admission. Current blood pressure is 102/60, which
is baseline, but will monitor carefully, especially in the
setting of hypovolemia with GIB.
.
# Baseline Macrocytic Anemia: concern for liver disease although
hepatitis work up wsa negative. B12 and folate were high at the
beginning of [**Month (only) 956**]. MCV is 112.
.
#Hx CVA: Residual L-sided weakness. Requires assistance for
feeding.
- holding home [**Month (only) **] and warfarin
.
#Hx DM: insulin sliding scale. HgA1c of 6.0 in 01/[**2172**]. Was
on lantus 6 units at bedtime.
.
#Glaucoma:
- Continued on brimonidine, latanaprost, dorzolamide eyedrops
.
#Gout:
- Continued on allopurinol
Medications on Admission:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
10. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
14. midodrine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q 8H
(Every 8 Hours).
16. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Lantus 100 unit/mL Solution Sig: Six (6) Subcutaneous at
bedtime.
18. Warfarin dose is unclear
Discharge Medications:
none; pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
- Gastrointestinal bleed
- End Stage Renal Disease
- Diabetes
- Atrial flutter
- Peripheral vascular disease
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2172-3-24**]
|
[
"2851",
"42731",
"V5861",
"25000",
"2720"
] |
Admission Date: [**2153-3-25**] Discharge Date: [**2153-4-4**]
Date of Birth: [**2067-11-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Shortness of breath. Transfer for NSTEMI/GIB/PNA
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
85yoM with no primary care for 25+ years presenting from [**Hospital 89271**]
Hospital with NSTEMI, PNA, and GI bleed.
.
The patient reports acute onset shortness of breath which began
last night which has been progressively worsening. He denies
chest pain, lightheadedness, dizziness, or pedal edema,
orthopnea, PND. He also reports 2-3 weeks of increasing dyspnea
on exertion and cough. He presented to [**Hospital3 **] and was
found to have an NSTEMI. He was given ASA 325 but reported
intermittent bloody bowel movements and was found to have gross
blood on rectal exam, and was not started on Heparin gtt. When
asked, the patient reported he has intermittent BRBPR for the
past 2 weeks. D-dimer was elevated. He underwent a CTA at
[**Location (un) **] which showed a question of b/l PNA and was given
Levofloxacin, negative for PE. He was transferred to [**Hospital1 18**] for
further management.
.
In the ED, initial vitals were: 97.9 105 133/74 18 97% 2L NC
ECG was significant for anterolateral ST depressions. Cardiology
was made aware. Troponin was 0.31. WBC was 21.9 and portable CXR
showed bilateral infiltrates. The patient had another rectal
exam which showed frank blood in the rectal vault. NG lavage was
negative. GI was made aware, and agreed the source of bleed is
likely lower source. Hct was 28.0. He was given Pantoprazole
80mg IV and type and screened. He was admitted for further
management.
Past Medical History:
none per patient
Social History:
35 pack years, recently less. 1 drink/week. Retired.
Family History:
non-contributory
Physical Exam:
On admission:
VS: 98, 111/58, 84, 20, 97%RA
GENERAL: alert, interactive, lying supine, NAD
HEENT: Sclerae anicteric. PERRL, EOMI. MMM.
NECK: Supple. JVP 3 cm above sternal angle at 30deg
CARDIAC: RRR, II/VI HSM heard best at apex. No S3 or S4. No
thrills, lifts.
LUNGS: Clear
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no C/C/E. Extremities warm and well perfused.
SKIN: No ulcers, scars, or xanthomas. Mild hyperpigmentation of
anterior shins
PULSES:
Right: Femoral 2+ Carotid 2+ Dopplerable DP/PT
[**Name (NI) 2325**]: Femoral 2+ Carotid 2+ Dopplerable DP/PT
On discharge: unchanged
Pertinent Results:
On admission:
[**2153-3-25**] 08:10PM BLOOD WBC-21.9* RBC-2.91* Hgb-9.6* Hct-28.0*
MCV-96 MCH-33.1* MCHC-34.4 RDW-14.2 Plt Ct-349
[**2153-3-25**] 08:10PM BLOOD Neuts-88.6* Lymphs-6.0* Monos-5.2 Eos-0.1
Baso-0.1
[**2153-3-25**] 08:10PM BLOOD PT-14.0* PTT-24.4 INR(PT)-1.2*
[**2153-3-25**] 08:10PM BLOOD Glucose-137* UreaN-40* Creat-1.3* Na-135
K-4.1 Cl-101 HCO3-21* AnGap-17
[**2153-3-25**] 08:10PM BLOOD CK(CPK)-330*
[**2153-3-26**] 06:30AM BLOOD ALT-19 AST-39 CK(CPK)-230 AlkPhos-70
TotBili-0.8
[**2153-3-26**] 06:30AM BLOOD Albumin-3.9 Calcium-8.8 Phos-4.0 Mg-1.9
Cholest-203*
[**2153-3-26**] 06:30AM BLOOD Triglyc-66 HDL-77 CHOL/HD-2.6 LDLcalc-113
[**2153-3-26**] 07:08AM BLOOD %HbA1c-6.1* eAG-128*
[**2153-3-26**] 03:04AM BLOOD Lactate-2.5*
Hematocrit and WBCs
[**2153-3-25**] 08:10PM BLOOD WBC-21.9* Hct-28.0*
[**2153-3-26**] 03:45PM BLOOD WBC-17.8* Hct-28.0*
[**2153-3-27**] 07:00PM BLOOD Hct-23.0*
[**2153-3-30**] 07:00AM BLOOD WBC-13.0* Hct-26.5*
[**2153-4-4**] 07:50AM BLOOD WBC-11.4* Hct-28.8*
Creatinine
[**2153-3-25**] 08:10PM BLOOD Creat-1.3*
[**2153-3-26**] 03:45PM BLOOD Creat-1.4*
[**2153-3-27**] 08:36PM BLOOD Creat-1.6*
[**2153-3-28**] 05:53PM BLOOD Creat-1.7*
[**2153-4-1**] 09:30AM BLOOD Creat-1.2
[**2153-4-4**] 07:50AM BLOOD Creat-1.3*
Cardiac enzymes
[**2153-3-25**] 08:10PM BLOOD CK-MB-32* MB Indx-9.7*
[**2153-3-25**] 08:10PM BLOOD cTropnT-0.31*
[**2153-3-25**] 08:10PM BLOOD CK(CPK)-330*
[**2153-3-26**] 02:11AM BLOOD CK-MB-21* MB Indx-8.0* cTropnT-0.36*
[**2153-3-26**] 02:11AM BLOOD CK(CPK)-262
[**2153-3-26**] 06:30AM BLOOD CK-MB-16* MB Indx-7.0* cTropnT-0.44*
[**2153-3-26**] 06:30AM BLOOD CK(CPK)-230
[**2153-3-28**] 03:43AM BLOOD CK-MB-4 cTropnT-0.54*
[**2153-3-28**] 03:43AM BLOOD CK(CPK)-107
MICROBIOLOGY
Blood, urine, sputum cultures - no growth
IMAGING
TTE ([**3-26**]): IMPRESSION: extensive inferior-posterior myocardial
infarct with secondary moderate-to-severe mitral regurgitation;
"severe" aortic stenosis (most likely with a component of low
flow/low gradient physiology); reduced stroke volume and cardiac
output
CXR: IMPRESSION: Acute pulmonary edema with underlying
centrilobular emphysema, an extensive pneumonia is a less likely
possibility.
CARDIAC CATH: 1. Selective coronary angiography in this right
dominant system demonstrated three vessel disease. The LMCA had
a 40-50% eccentric and calcified stenosis. The LAD had an 80%
calcified mid LAD stenosis with
100% distal occlusion. The LCx had a 100% ramus branch
occlusion, an 80% tubular OMB1 stenosis. There was an occluded
small OMB2. The RCA had a 60% diffuse stenosis which was
calcified and leading to a PDA. 2. Resting hemodynamics
demonstrated mildly elevated left sided filling pressures with
mean PCWP 21 mmHg. There is mild pulmonary artery systolic
hypertension with PASP of 42 mmHg. The cardiac index is
preserved at 2.52 L/min/m2 (using an assumed oxygen
consumption). There was moderate aortic stenosis with a
calculated aortic valve area of 1.19 cm2 (based on an assumed
VO2).
FINAL DIAGNOSIS:
1. Severe three vessel coronary artery disease.
2. Moderate to severe mitral regurgitation.
3. Moderate aortic stenosis.
4. Moderate pulmonary artery hypertension.
5. Mildly elevated pulmonary capillary wedge pressure.
CAROTID U/S: Right ICA 60-69% stenosis. A more severe [**Country **]
stenosis cannot be excluded due to the presence of
calcifiedplaque. Left ICA 40-59% stenosis. Right verterbral
artery appears occluded. L vertebral open.
SPIROMETRY: Impression: Severe obstructive ventilatory defect
with a moderate gas exchange defect. There are no prior studies
available for comparison.
TEE: IMPRESSION: Regional left ventricular systolic dysfunction.
Mild to moderate mitral regurgitation. Moderate thickened aortic
valve with significant aortic stenosis present (though not
quantified).
Brief Hospital Course:
85yoM with no primary care for 25+ years presenting from [**Hospital 89271**]
Hospital with posterior/inferior NSTEMI, PNA, and GI bleed.
.
ACTIVE ISSUES
.
# CORONARIES: The patient presented with acute onset dyspnea and
was found to have an NSTEMI with elevated CE's. He was started
on ASA 325, Atorvastatin 80mg, and Metoprolol. He was not
originally started on heparin or plavix given GIB (see below)
and was trasnfused 1U pRBCs to minimize cardiac demand ischemia.
After undergoing a flex sig, a cath was performed and showed
"LAD disease, with ramus occluded, diseased circ, 60% RCA, and
aortic valve area 1.1 without gradient". Given the extent of his
disease, the option of a CABG and valvular repair was offered.
However, cardiac surgery evaluated him and determined that he
would not be a good surgical candidate and should be medically
managed at this point. His valvular disease was not significant
enough to warrant mitral and aortic valve replacements, but
should be monitored. On discharge, he will begin taking the
follow medications for optimal medical management: aspirin 325
mg daily, Atorvastatin (Lipitor) 80mg daily, metoprolol 75mg
daily, and lisinopril 5mg.
.
# PUMP: On admission, he appeared euvolemic without evidence of
volume overload. An ECHO on [**3-26**] showed 3+ MR and severe aortic
stenosis with depressed EF35%. However after medical treatment
and diuresis, a repeat ECHO showed 2+ MR and a TEE confirmed
these findings. He will follow-up with Dr. [**Last Name (STitle) 1911**] as an
outpatient for repeat TTE and management of his heart failure
with the likely initiation of diuretic therapy.
.
# GI Bleed: The patient reported intermittent bloody bowel
movements in the past, BRBPR with stool. Likely lower source,
diverticulosis vs polyp vs AVM. GI was consulted. He was made
NPO and underwent a flexible sigmoidoscopy on [**3-27**] which showed
a polyp and bleeding hemorroids. His polyp was not removed given
the bleeding risk and recent MI and should be followed as an
outpatient with GI for this issue. He required 1 U pRBCs on [**3-27**]
but then stopped bleeding with stable hematocrit. He will need
a colonoscopy as an outpatient. His Plavix was held on
discharge and he should receive his colonoscopy before
restarting this. He will also be continued on omeprazole for
gastric protection while taking ASA.
.
# Community-acquired pneumonia: The patient reported cough and
shortness of breath for the past 2-3 weeks, and underwent CTA at
OSH which showed evidence of b/l PNA, and was given a dose of
Levofloxacin. He denied fevers and b/l lower lobe opacities are
more likely CHF exacerbation in the setting of NSTEMI given
infiltrates are bilateral and patient is not an aspiration risk.
However, given his elevated white count of 21.9, which may be
all or partially due to his NSTEMI and GI bleed, his
Levofloxacin was continued for 5 days.
.
TRANSITIONAL ISSUES
.
# Follow-up care: Mr. [**Known lastname 36413**] will be seeing Dr. [**Last Name (STitle) 1911**]
for outpatient Cardiology appointments. At this point, he will
be assisted in setting up an appointment with a primary care
physician, [**Name10 (NameIs) 1023**] will then be coordinating his care. Since he has
not been watched by the medical system for a while, he should be
encouraged to follow-up closely, given that he is on many new
medications and will new follow-up imaging to monitor his
valvular function.
.
# Health screening: He will likely need routine health
maintenance, most notably a colonoscopy, especially given his GI
bleeding and anemia. Follow-up with a new PCP will be essential
for him to follow his routine health care maintenance.
Medications on Admission:
No home medications
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule,
Delayed Release(E.C.)(s)
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
Please check chem-7 on Friday [**4-6**] with results to Dr.
[**Last Name (STitle) 1911**] at [**Telephone/Fax (1) 11767**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Non ST Elevation myocardial infarction
Aortic Stenosis, valve area 1.2
Moderate Mitral Valve Regurgitation
Acute systolic congestive heart failure
Acute Kidney Injury
Lower GI Bleed
Carotid Stenosis
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack and had a cardiac catheterization that
revealed many blockages in your heart arteries. You have been
started on many medicines to help your heart function better and
recover from the heart attack. You were also found to have
blockages in the arteries in your neck that could lead to a
stroke if these blockages worsen. You had some bleeding from
your rectum that appeared to be due to internal hemorrhoids but
you absolutely need to have a colonoscopy to look at your whole
colon to make sure there are no other areas of bleeding or
polyps. You also were found to have emphysema or COPD due to
your smoking. It is extremely important that you do not start
smoking again. Your kidneys were not working well due to your
heart problems but now have almost returned to [**Location 213**] function.
Your heart is weak after the heart attack and you had some fluid
retention that was treated with diuretics. We are not sending
you home on diuretics now but you need to weigh yourself every
day in the morning and call Dr. [**Last Name (STitle) 1911**] if your weight
increases more than 3 pounds in 1 day or 5 pounds in 3 days.
.
We started you on the following medicines:
1. Start taking aspirin 325 mg daily to prevent another heart
attack
2. STart taking Atorvastatin (Lipitor) to prevent further
blockages in your arteries from cholesterol buildup
3. Start taking metoprolol to prevent another heart attack and
lower your heart rate
4. Start taking Lisinopril to lower your blood pressure and help
your heart pump better.
5. Start taking Omeprazole to protect your stomach from the
aspirin.
.
It is extremely important that you take all of your medicines
and follow up with your doctors.
Followup Instructions:
Department: CVI [**Location (un) **], [**Apartment Address(1) **]
When: WEDNESDAY [**2153-5-9**] at 2:00 PM
With: [**Last Name (un) 1918**] [**Doctor Last Name **] [**Telephone/Fax (1) 11767**]
Building: [**Location (un) 20588**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
**Please call Dr. [**Last Name (STitle) **] office on Monday [**4-9**] to
ask for names of Primary Care Physicians in the area that he
would recommend.**
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"41071",
"486",
"5849",
"5990",
"4280",
"4019",
"V1582",
"41401",
"2859"
] |
Admission Date: [**2128-1-25**] Discharge Date: [**2128-2-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
slow responses, right sided weakness
Major Surgical or Invasive Procedure:
thoracentesis
nasogastric tube placement
History of Present Illness:
86yo right handed man with PMH significant for uncontrolled HTN
and hyperlipidemia who was in his USOH the night of presentation
when he walked to the restroom at 8:30pm. He then sat on the
couch but when his wife called to him to come to dinner, he was
slow to respond, stood but could not walk due to right-sided
weakness and his speech was slurred. She gave him a series of
commands which he performed but his response time was
significantly slowed and she had difficulty understanding his
speech. At this point, she called EMS. He is now transferred
here after CT of the head at OSH showed a 2.5cm x 2.4cm left
thalamic ICH with slight rupture into the ventricle. On
presentation to [**Location (un) 620**], he was hypertensive to 231/88 and he
was given lopressor, to lower his pressure to the current level
of 204/64.
Past Medical History:
anemia, w/u pending - referred by PCP to hematologist. Wife
brought in letter stating the belief that he has a problem with
"red cell production"
HTN x [**3-18**] yrs, often uncontrolled to 200's
hyperlipidemia
GERD
ankylosing spondylitis
L ICA carotid stenosis (complete occlusion)
h/o tuberculosis "in his neck", s/p multidrug treatment x 6mos
no MI, CAD, or stroke
Social History:
Lives with his wife, retired SBO. Quit smoking 8yrs ago after
20ppyr history. No other drug use.
Family History:
brother died of MI at age 70
Physical Exam:
Exam on discharge:
VS 98.5 204/64 16 98% 97
Gen Lying in bed in NAD
CV rrr
Pulm ctab
Abd soft
Ext L foot erythematous and swollen, warm to touch
NEURO
MS Lying in bed with eyes closed. Opens them to voice. Oriented
to hospital and city, states it is [**2128**]. Speech is very
dysarthric (from normal baseline) and slow but fluent and
without
apparent errors. Follows simple commands. Slow response time.
CN Pupils anisocoric (b/l cataracts) - L 1.5mm and R 2mm;
neither
reacts. VFF to confrontation. EOMI including upgaze. Facial
sensation intact. R NLF flat. Smile full. Hearing intact. Palate
rises symmetrically. Shrug [**4-17**]. Tongue midline
Motor normal bulk/tone. +R pronator drift
D B T WE FE FF IP Q H DF PF TE
Coord Decreased FFM/RAMs on right side, esp compared to
non-dominant left side
Reflexes 2+ throughout, except for 1+ at ankles. Toe up on R,
down on L
Sensory intact to all primary modalities throughout, no
extinction to LT
Gait deferred
Pertinent Results:
Admission labs:
CBC: WBC-3.5* RBC-3.28* Hgb-10.0* Hct-28.9* MCV-88 MCH-30.4
MCHC-34.5 RDW-19.0* Plt Ct-124*
Coags: PT-12.1 PTT-31.6 INR(PT)-1.0
Chem10: Glucose-130* UreaN-27* Creat-1.4* Na-133 K-3.9 Cl-102
HCO3-26 Calcium-7.8* Phos-3.8 Mg-2.0
LFTs: ALT-33 AST-38 CK(CPK)-44 AlkPhos-473* TotBili-0.5
Albumin-3.3* Lipase-54 GGT-321*
Cardiac enzymes negative x 3
Other labs:
proBNP-7299*
ABG: Type-ART pO2-100 pCO2-53* pH-7.34* calTCO2-30 Base XS-0
Repeat: Type-ART pO2-103 pCO2-49* pH-7.33* calTCO2-27 Base XS-0
Pleural fluid:
WBC-550* RBC-482* Polys-9* Lymphs-72* Monos-0 Meso-1* Macro-18*
TotProt-1.9 Glucose-127 LD(LDH)-89 Albumin-1.3 Cholest-37
GRAM STAIN-FINAL; FLUID CULTURE-PENDING; ANAEROBIC
CULTURE-PENDING; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PENDING
CXR: Right-sided volume loss and right apical pleural
thickening, unchanged. Increased opacity involving the right
lung may represent scarring versus atelectasis. Comparison with
previous radiographs would help to better assess for long-term
interval change.
Loculated left-sided pleural effusion. Increased air space
opacity involving the left mid and lower lung is less
conspicuous than seen previously. Diagnostic considerations
include asymmetric pulmonary edema and pneumonia.
Chest CT: Small right and moderate left pleural effusions,
probably not transudate, greater and maybe loculated in the left
side.
Peripheral consolidation in the right upper lobe, largely
scarring, but peribronchial thickening in the lower lobes, could
be chronic or subacute infection.
Fusiform aneurysmal dilatation of the suprarrenal abdominal
aorta.
Head CT [**1-25**]: The left thalamic hemorrhage is similar in size,
measuring 2.6 x 2.4 cm. There is interval increase in a small
amount of intraventricular hemorrhage. There is no new mass
effect, hydrocephalus, or major vascular territorial infarction.
Slight bulge of normally midline structures to the right is
noted. Surrounding osseous and soft tissue structures are again
noted. Mucosal thickening is seen in the sphenoid sinus.
Repeat [**1-27**]: The left thalamic hemorrhage has decreased in size.
There has been an increase in the amount of intraventricular
blood. Otherwise, no change.
L LENI: No evidence of intraluminal thrombus.
Abd u/s: 1. Normal gallbladder and no biliary ductal dilatation.
2. No hydronephrosis.
ECHO: The left atrium is mildly dilated. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated athe sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is moderate pulmonary artery systolic hypertension. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade.
Brief Hospital Course:
Impression: 86yo man with PMH significant for HTN presents with
dysarthria and subtle right-sided weakness, along with delayed
response time cognitively, and was found to have left thalamic
bleed with slight extension into the ventricle, likely secondary
to hypertension. His hospital course was complicated by multiple
medical problems as detailed below. He was eventually
transferred to the MICU for hypercarbic respiratory failure,
made DNR/DNI and expired.
Hospital course:
1. hemorrhage - He was initially admitted to the stroke service
for management. His blood pressure was difficult to control (see
below). His exam remained unchanged with severe dysarthria,
slight right hemiparesis, and waxing and [**Doctor Last Name 688**] mental status
most likely secondary to metabolic encephalopathy (see medical
problems listed below).
2. hypertension - His blood pressure remained poorly controlled
initially: metoprolol was initiated but was ineffective.
Hydralazine was added and was initially successful at
controlling the blood pressure, but his blood pressure increased
again when the metoprolol was weaned. ACE inhibitor was not
started due to mild acute renal failure. His HCTZ was continued.
3. respiratory difficulties - Due to his bulbar weakness, the
patient was unable to clear his secretions. He was treated with
aggressive chest PT and deep suction (which was difficult due to
deviated trachea). A CXR on admission showed a loculated pleural
effusion on the left, which was not seen on previous x-rays. The
pulmonary service was consulted, and performed a diagnostic
thoracentesis, which was consistent with a transudative
effusion. ECHO was performed, which showed... Diuresis was
started. For wheezing, he was treated with albuterol and
atrovent. A chest CT showed emphysematous changes. He continued
to decline and developed hypercarbic respiratory failure
requiring transfer to the MICU. He was made comfort care and
expired.
4. elevated alkaline phos - His alk phos remained elevated
during his hospitalization. This may be secondary to his
ankylosing spondylitis, but was rather high for this
explanation. GGT was elevated, but abdominal ultrasound was
negative.
5. ?cellulitis - He was initially treated for concern for L foot
cellulitis with cefazolin. However, suspicion remained low and
the antibiotics were discontinued without effect. LENI was
negative.
6. renal failure - He was noted to have rising creatinine and
BUN during the beginning of his hospital stay, with low UOP at
times. FeNa was 0.22% and urine eosinophils were negative, no
hydronephrosis on abdominal ultrasound. He was initially treated
with IVF, and when UOP picked up and renal function stabilized,
diuresis was started.
7. FEN - He failed his speech and swallow. An NGT was placed by
IR on [**1-26**], and tube feeds started [**1-28**].
8. Code Status - Pt was made DNR/DNI by his family after
worsening neurologic deficits manifested in the setting of
respiratory failure. He expired at 11:45 pm on [**2128-2-3**].
Medications on Admission:
toprol
lipitor
protonix
iron sulfate
isosorbide
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure.
Stroke.
Renal failure.
Discharge Condition:
Expired.
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"5849",
"51881",
"5119",
"4019",
"2720",
"53081",
"2859"
] |
Admission Date: [**2174-2-8**] Discharge Date: [**2174-2-21**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Dizziness, vomiting, fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC:[**CC Contact Info 86781**]
HPI: 89 year old right handed man with type 2 diabetes mellitus,
peripheral vascular disease, atrial fibrillation, CAD, HLD, who
presented to [**Hospital **] after a fall. He was transferred
from [**Hospital **] this afternoon for surgical management of
his C2 fracture.
The history was recounted by his daughter-in-law [**Name (NI) **] [**Name (NI) 61454**]
(who is also his HCP). Mr [**Known lastname 68659**] had his supper last night, and
mentioned to his wife [**Name (NI) 440**] that he was not feeling well. His
wife
thought that he looked pale. He then vomited all of his food
that
he had just eaten, and complained of the room spinning to his
wife. [**Name (NI) **] did not complain of a headache, or any pain. His wife
helped him on to the couch, and she noticed that he was rigid,
and he was slouching to the right on the chair. She had to call
his caregiver [**Name (NI) **], to help him sit up. The caregiver thought
that he had a viral illness, and gave him a bath and put him to
bed.
The next morning, he woke up around 5 am. His wife had her back
turned when he fell, but he fell approximately 24 inches out of
the bed. She activated his medical alert button and he was taken
to [**Hospital3 17163**].
According to [**Doctor First Name 440**] and [**Doctor First Name **], Mr [**Known lastname 68659**] had become confused over a
period of 2 months. At the OSH a CT Cspine was done which showed
a C2 dens body fracture, and a CT Head showed no acute changes.
He is on Coumadin and at the OSH he was given 2 units of FFP and
10units of Vitamin K. His was 1.3 at the OSH, but instead due to
an attempt to reverse him given his status of taking Coumadin.
He was transferred to [**Hospital1 18**] for further management of his C2
fracture. When he was assessed by the neurosurgical team, and
they heard the history of the prior night, they suggested a
repeat head CT.
ROS: unobtainable from the patient. According to his wife, he
had
no tinnitus, no change in his speech, no facial droop, memory
impairment for several months, and symptoms described above. He
had no chest pain, palpitations, dyspnea, fever, new GI or GU
symptoms.
Past Medical History:
Type 2 diabetes mellitus
CAD
HLD
Peripheral vascular disease
A-Fib on Coumadin
Urinary incontinence after prostate surgery (?)
Social History:
Lives with his wife, who is his second wife of 22 years. He used
to smoke cigars, but his pack history is unknown. He drinks an
occasional beer. He never used recreational drugs. He uses a
rollator frame to walk. He has been incontinent of urine since
his prostate surgery.
PCP: [**Name10 (NameIs) **] [**Last Name (STitle) **] [**Last Name (NamePattern4) 69075**]-[**Last Name (un) **], [**Hospital **] Medical, [**University/College **]
Family History:
Mother and father died in their 60s, father died of an
MI. Unclear what his mother died of. The family are originally
from [**Country 6257**].
HCP [**Telephone/Fax (1) 86782**] ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 61454**])
Physical Exam:
O: T:97 BP: 165/85 HR:68 R:20 O2Sats:98%
Gen: cachectic, leaning to the left, he has a poor fitting hard
collar on obscuring the lower portion of his face.
HEENT: abrasion and ecchymosis on right frontal/pariteal region
His oral mucosae are dry.
Skin: R shin erythema noted
Peripheral pulses: no posterior tibial or dorsalis pedis
bilaterally, rest of the pulses are present. Feet are cold.
CVS: irregularly irregular heart sounds, with an ESM in the
aortic area [**1-29**], with radiation to the carotids.
Resp: fine crackles bilaterally
GI: soft, non-tender, no organomegaly, and normal bowel sounds.
Mental status
He is awake, oriented to self. Does not know the date or year.
He
is able to identify his wife but not his daughter-in-law. His
primary language is English, but he seemed to understand his
family speaking in Portuguese better than in English.
Cranial nerves
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Shuts his eyes to fundoscopic exam. Blinks to
threat
bilaterally, does not follow commands for extraocular movements.
His neck is immobilised so dolls head not attempted. Corneal
reflexes are in tact bilaterally. Facial symmetry is obscured
by
his hard collar. He is hard of hearing bilaterally. He has a gag
reflex, and his tongue is midline.
Motor: He has Geggenhalten bilaterally. He has marked wasting of
his legs L>R. He moves all extremities spontaneously strength
could not formally be assessed, but his legs are weaker than his
arms.
Sensation: he is too inattentive to do a reliable sensory exam
His reflexes are difficult to illicit throughout.
Toes are mute bilaterally
Rectal exam normal sphincter control (done by neurosurgery),
stool guaiac was negative.
Pertinent Results:
[**2174-2-8**] 03:00PM BLOOD WBC-9.9 RBC-3.76* Hgb-12.6* Hct-37.4*
MCV-100* MCH-33.6* MCHC-33.7 RDW-13.6 Plt Ct-230
[**2174-2-8**] 03:00PM BLOOD PT-14.9* PTT-24.0 INR(PT)-1.3*
[**2174-2-8**] 03:00PM BLOOD Glucose-278* UreaN-27* Creat-0.9 Na-142
K-3.9 Cl-101 HCO3-26 AnGap-19
[**2174-2-8**] 11:19PM BLOOD ALT-38 AST-30 CK(CPK)-103 AlkPhos-112
[**2174-2-8**] 03:00PM BLOOD cTropnT-0.01
[**2174-2-8**] 11:19PM BLOOD Calcium-9.1 Phos-3.2 Mg-1.7 Cholest-153
[**2174-2-10**] 01:34AM BLOOD %HbA1c-PND
[**2174-2-8**] 11:19PM BLOOD Triglyc-79 HDL-65 CHOL/HD-2.4 LDLcalc-72
[**2174-2-10**] 01:34AM BLOOD Osmolal-320*
[**2174-2-8**] 11:19PM BLOOD TSH-1.6
[**2174-2-8**] 11:19PM BLOOD Digoxin-0.6*
CT head [**2174-2-8**]
1. Right cerebellar hypodensity consistent with acute/subacute
infarct, more
conspicuous than on the prior exam. No intracranial hemorrhage.
2. Paranasal sinus disease, likely due to ongoing inflammation.
3. Right frontal scalp soft tissue swelling and hematoma.
CT c-spine [**2174-2-8**]
1. Transverse fracture through the base of the dens (Type 2),
although the
presence of sclerosis and degenerative changes of the fracture
fragments as
well as calcification of large posterior pannus suggests a more
chronic
nature. However, there is mild prevertebral soft tissue swelling
at this
level, measuring up to 7 mm.
2. Prominent posterior pannus at the level of C1-2, resulting in
marked canal
stenosis and deformity of the thecal sac. Additional thecal sac
deformity
results from degenerative changes between C3 and C7, most severe
at C6-C7. If
neurological symptoms are referable to these levels, MRI is
recommended for
further evaluation of the spinal cord.
3. Bilateral pleural effusions with interstitial pulmonary
edema.
4. Multilevel bilateral neural foraminal narrowing.
CT head [**2174-2-9**]
PFI: Right cerebellar hemisphere infarct with short-interval
increase of
edema, now with partial effacement of fourth ventricle and
ambient cisterns on
the right, compatible with slight upward transtentorial
herniation on the
right. No evidence of midline shift or tonsillar herniation. No
new vascular
territory infarct. No hemorrhagic transformation. Of note, a
right frontal
subgaleal hematoma appears increased in size and density since
the day prior.
Please correlate clinically.
CT head [**2174-2-10**]
No significant interval change.
Discharge labs:
139 | 100 | 28
---------------< 239
4.1 | 29 | 0.7
11.1
9.1 >------< 346
33.8
Brief Hospital Course:
Mr. [**Known lastname 68659**] is an 89 year old right handed man with type 2
diabetes mellitus, peripheral vascular disease, atrial
fibrillation on Coumadin with a subtherapeutic INR, CAD, HLD,
who presented to [**Hospital **] after a fall. He was
transferred
from [**Hospital **] this afternoon for surgical management of
his C2 fracture. Prior to transfer, he was given FFP and vitamin
K despite INR 1.3 at time of presentation. Prior to his fall,
the patient had vomiting and vertigo which was concerning for a
posterior circulation event. His memory has been gradually
becoming impaired over a period of 2 months.
.
Hospital course by problem;
.
Neurology; The patient was found to have a large right
cerebellar hypodensity on CT head consistent with stroke. It
was thought this was most likely cardioembolic in the setting of
subtherapeutic INR. Clinically, it appeared that the stroke
preceeded his fall and subsequent dens fracture. He was
admitted to the neurology ICU for q1h neurochecks. His coumadin
was resumed without a bridge and blood pressure was allowed to
autoregulate. He was continued on his home statin (LDL was 72),
and fingersticks covered with regular insulin sliding scale.
HbA1c was 7.9%. A repeat CT head was worrisome for partial
effacement of fourth ventricle and ambient cisterns on the
right, compatible with slight upward transtentorial herniation
on the right. He was started on mannitol at 1g/kg x1 then
0.5g/kg q6h. This was discontinued after serum osmolality
increased to 320. Mannitol was not given after that. The
patient's HCP, [**Name (NI) **] [**Name (NI) 61454**], confirmed the patient's DNR/DNI
status and wish against any surgical intervention if his
clinical situation worsened. Vessel imaging and echocardiogram
were not performed as it was unlikely that these studies would
change management. Exam on discharge was notable for
occasionally opening of eyes to voice, although he is not
following commands. Occasional mumbling, but no understandable
speech. Will have slight spontaneous movement of hands,
inconsistent retraction from pinch in upper extremities, none
observed in lower extremities.
The patient was found to have a type-2 dens fracture on CT
C-spine, likely from his fall out of bed. He was followed by
the neurosurgery service who recommended that he continue using
the cervical collar at all times for his C2 fracture. He can
follow up with Dr. [**Last Name (STitle) 739**] at [**Telephone/Fax (1) **] in 6 weeks
([**3-24**]) with a CT scan of the cervical spine with reconstruction.
.
ID; The patient had a T max of 101.5 [**2-9**] PM and mild
leukocytosis with WBC 11.2. A CXR showed a question of LLL
atelectasis vs. pneumonia. Blood cultures have been negative.
Urine cultures grew enterococcus, resistent to tetracycline, but
otherwise pan-sensitive, and on [**2-10**] he was started on Levoquin
and Clindamycin planned for a 10-day course. On [**2-14**] he spiked
a temperature of 101.4 and antibiotics were switched to Zosyn.
He continued to have temperature > 101 and vancomycin was added
[**2-15**] although stopped on [**2-16**]. He is being treated for presumed
aspiration pneumonia with Zosyn, which should continue through
[**2-23**]. He has been afebrile since [**2-16**]. Thus far, blood and
sputum cultures have been negative.
.
Respiratory; The patient continued to exhibit increased work of
breathing and an ABG on [**2-14**] was 7.52/39/81. He was transferred
to the intensive care unit. He remained on nasal cannula
overnight until 5 AM when he desaturated on 6L NC and a repeat
ABG was 7.49/44/55. He was started on humidified O2 at 15L/min.
His DNI status was confirmed with his HCP. BIPAP was
considered but this has been deferred for now. He has been
doing well on 40-50% humidified face mask, with intermittent
suctioning.
.
CV; The patient was continued on a beta-blocker and digoxin for
rate control and monitored on telemetry. Coumadin was initially
resumed with no bridge due to the size of the cerebellar infarct
and concern for hemorrhagic transformation with aggressive early
anticoagulation. Based on the increasing size of infarct,
Coumadin was discontinued, and he was instead placed on full
dose aspirin. He has a follow-up appointment scheduled with Dr.
[**Last Name (STitle) **] in Neurology on [**3-25**] - Phone [**Telephone/Fax (1) 44**] and the
possibility of switching back to Coumadin can be readdressed at
that time.
.
Abd/GI; The patient had a Dobhoff placed [**2-9**] for tube feeds.
Swallowing ability can be reassessed if mental status improves
further. A PEG was discussed, however given his overall tenuous
status, he was not considered a good candidate for placement at
this time. This can be readdressed if his condition improves.
.
Goals of care; The patient was transferred back to the step-down
unit on [**2-15**]. Multiple discussions have been had with the
patient's HCP and other family members in regards to goals of
care. Uniform agreement has been had in the patient's DNR/DNI
and no surgeries, however there has been some debate within the
family in regards to PEG tube. As per the HCP, the family does
not wish to make the patient CMO at this time but would not want
any aggressive measures to be done to prolong his life.
Medications on Admission:
- Coumadin 2 mg on Monday & Wednesday, and on 4 mg on all other
days
- Colace:
- Omeprazole:
- Meformin: 1000mg [**Hospital1 **]
- Metoprolol: 50mg [**Hospital1 **]
- Digoxin: 0.125mg QOD
- Potassium supplements: 10 meq qday
- Lasix: 40mg qday
- Lipitor: 10 mg Qday
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) tablet PO BID
(2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection ASDIR (AS DIRECTED): please follow attached sliding
scale.
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 gram Intravenous Q8H (every 8 hours) for 3 days.
12. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for
3 doses.
13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehabilitation hospital
Discharge Diagnosis:
Primary: Cerebellar stroke
Secondary: Atrial fibrillation
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Lethargic
Activity Status: Bedbound
Pupils equal and reactive. Will occasionally open eyes in
response to stimuli. Mumbles but has not produced decipherable
speech. Minimal response to painful stimuli in lower
extremities. Occasional slight spontaneous movement in hands.
Discharge Instructions:
You were admitted following a fall, with symptoms of dizziness.
You were found to have a very large cerebellar stroke. You also
have a cervical fracture which is being managed conservatively
with a hard C-collar
Medication changes:
-Stop taking Coumadin, switch to full-dose aspirin
If you notice any of the concerning symptoms listed below,
please call your doctor or come to the emergency department for
further evaluation.
Followup Instructions:
Neurology: Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2174-3-25**] 2:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"5070",
"42731",
"25000",
"41401",
"V5861",
"V5867"
] |
Unit No: [**Numeric Identifier 107381**]
Admission Date: [**2181-9-25**] Discharge Date: [**2181-10-4**]
Date of Birth: Sex:
Service:
REASON FOR ADMISSION: Living related kidney transplant.
PROCEDURE PERFORMED: Renal transplant ultrasound and MR
contrast of the kidney.
HISTORY OF PRESENT ILLNESS: [**Known firstname 7232**] [**Known lastname 106665**] is a 69 year-old,
African-American female with end stage renal disease who has
been on [**Known lastname 2286**] for a long time. She underwent a
pretransplant evaluation and was found to be a suitable
candidate for organ transplantation. Her nephew presented as
a potential live donor and underwent evaluation and completed
his work-up.
HOSPITAL COURSE: On [**2181-9-25**], she underwent a left sided live
donor renal transplant. The kidney was somewhat slow to
reperfuse, taking about 20 to 25 minutes before it completely
pinked up but did not make urine in the operating room. Her
postoperative course was complicated by delayed graft
function, slow graft function, although she did not require
[**Date Range 2286**]. She did not make much urine. She underwent
ultrasound of the transplanted kidney on [**2181-9-25**], the day
after surgery, that demonstrated a normal flow and somewhat
reduced arterial wave forms. Ultrasound was repeated on
postoperative day number 3 which was also performed and
demonstrated a very small fluid collection around the kidney
but the resistive indices remained low. She completed her
induction immunosuppression which included 4 doses of
thymoglobulin and steroid injection, in conjunction with
Prograf and CellCept maintenance therapy. Steroids were
discontinued on postoperative day number 5. On [**2181-10-2**], she
underwent a MRA due to continued poor renal function. The MRA
demonstrated a 5 x 9 cm perinephric fluid collection. She
also demonstrated mild stenosis in the left common iliac and
no evidence of anastomotic stenoses in the renal artery. Ms.
[**Known lastname 106665**] was started on a liquid diet after surgery, which was
advanced over 3 days to a regular diet. She had no other
hospitalized complications. She eventually began making more
substantial quantities of urine 2 days prior to discharge and
was discharged home on [**2181-10-4**] with follow-up instructions
with the transplant office.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern4) 3433**]
MEDQUIST36
D: [**2181-12-12**] 15:18:12
T: [**2181-12-12**] 15:39:03
Job#: [**Job Number 107382**]
|
[
"40391",
"2720",
"41401",
"53081",
"3051"
] |
Admission Date: [**2181-6-30**] Discharge Date: [**2181-7-26**]
Date of Birth: [**2120-4-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
ICH, SAH, depressed skull fracture s/p trauma
Major Surgical or Invasive Procedure:
1. 1.5 craniotomy for repair.
2. Elevation of displaced depressed skull fracture.
3. Reconstruction of displaced orbital rim.
4. Reconstruction of orbital roof and posterior wall.
5. Exenteration of frontal sinus with obliteration, packing and
sealing.
6. Ethmoidal sinus repair with packing and sealing.
7. Duraplasty.
8. Plastic cranioplasty.
History of Present Illness:
Pt is a 61 yo with unknown PMH who is admitted after being
hit by a [**Doctor Last Name **] while riding a bike without a helmet. He was
reportedly conscious, but confused at the scene. He went to an
OSH where he was following commands intermittently and answering
questions inappropriately. He was agitated and disoriented. He
was eventually intubated and transferred here after CT scans
showed multiple facial and skull fractures, a left frontal
depressed skull fracture, multiple IPHs and diffuse SAH, and
multiple spinal fractures. He was given triple antibiotics,
pepcid, and started on propofol. He also got morphine and
ativan.
Here, he was initially paralyzed, but when this wore off, he was
agitated and moving all extremities. He was also following
midline commands.
Past Medical History:
unknown
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
Exam upon admission:
Mental Status:Intubated and agitated, but opens eyes to command
off propofol.
HEENT:Depressed skull over left frontal lobe. No laceration
here.
No CSF leak seen currently. Left eye swollen shut and
proptotic.
CN:
Pupils: On right 3 to 2.5. Left swollen shut.
Nasal Tickle:
Gag/Cough:Present on tube.
Corneal Reflex:Present on right. None on left.
OCRs:Unable due to collar.
Motor:Moves all exts equally and strongly.
Toes:Mute bilaterally
Respiration:Pt is overbreathing ventilator.
Pertinent Results:
CT C spine [**6-29**]:
1. Right occipital condyle fracture and one-half vertebral body
posterior subluxation of the condyle on the C1 vertebral body.
2. Mild anterior widening of the C3/4 and C4/5 disc interspaces.
Ligamentous injury is suspected.
3. ? Fracture through the anterior inferior C7 vertebral body.
CTA [**6-29**]:
No evidence of carotid injury identified on CT angiography. No
evidence of dissection. No evidence of occlusion. Extensive
fractures and intracranial changes as on the previous CT head.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**6-29**]:
1. Depressed left frontal and parietal bone fractures with 14 mm
depression of the fracture fragments and extension through the
left frontal sinus, ethmoid air cells and sphenoid sinus on the
right. The fracture line extends through the right cavernous
carotid canal and CTA should be performed for further
evaluation.
2. Comminuted nasal bone fracture.
3. Right maxillary sinus fracture.
4. Right occipital condyle fracture. Please see CT C-spine
report for full characterization as well as description of
posterior subluxation of the occipital condyles on C1.
5. Extensive intraparenchymal, extraaxial and subarachnoid
hemorrhage is best described on CT head scan performed on the
same day.
[**6-29**] Head CT
1. Diffuse subarachnoid hemorrhage.
2. Left frontal, parietal and temporal subdural hematoma.
Subdural hematoma layers over the tentorium.
3. Left frontal extra-axial hemorrhage and intraparenchymal
hemorrhage and hemorrhagic contusions.
4. Right subfalcine herniation.
5. Depressed left frontal skull fracture with 14-mm depression
of the fracture fragments. Fracture line extends through the
right cavernous carotid canal. CTA is recommended to exclude
carotid injury. Other fractures are best described on CT
sinus/maxillofacial scan performed on the same day.
Brief Hospital Course:
Mr. [**Name13 (STitle) 42915**] was transferred from an OSH to [**Hospital1 18**] ER for
evaluation and treatment for a L depressed skull fracture, SAH,
and C1 occiput subluxation. The pt arrived in the ED intubated
and unresponsive. Neurosurgery as well as plastic surgery, ENT
and trauma were consulted for further care. An ICP monitor
(bolt) was placed in the ICU on admission, and ICPs were
monitored. He was started on vancomycin, gentamicin, and flagyl
for empirical coverage; he was also loaded and continued on
Dilantin for seizure prophylaxis. The patient was monitored
with serial CTs and neurological examinations. The patient was
kept in a hard collar; though no vessel dissection was noted,
and there was no acute surgical issue concerning the neck, it
was determined that further assessment would be made once acute
concerns had been resolved. The patient was taken to the trauma
ICU from the ER. The patient was prepared for surgical repair,
to go to the operating room on the 6th. On the fourth of
[**Month (only) 216**], the CT showed no change in SAH as well as the left
frontal contusion. There was an interval decrease of the acute
left frontal and parietal SDH, as well as significant decrease
of the subfalcine herniation. The patient went to the operating
room on the sixth for a craniotomy, elevation of dispaced
depressed skull fracture, reconstrution of a displaced orbital
rim, orbital roof and posterior wall, and exenteration of the
frontal sinus with obliteration, packing and sealing, ethmoidal
sinus repair with packing and sealing, duraplasty, and plastic
cranioplasty. The post operative CT was improved.
.
The patient was evaluated by physical and occupational therapy
as well as speech and swallow post-operatively.
.
Starting [**7-3**], the dexamethasone was weaned, the patient was in
stable condition. On [**7-5**], the patient was extubated, and doing
well post-extubation. The patient continued to require a sitter
for disorientation and inappropriate behavior. As the patient
had very poor oral intake, a Dobhoff tube was placed on [**7-7**],
which was pulled out twice by the patient. There was a question
of a pneumomediastinum (read as present, but immediately
resolved by one radiologist, and as never having been present by
another) following Dobhoff tube placement, though the patient
remained stable with no complaints. Repeat chest x-rays were
read as normal. Speech and swallow were later consulted for
evaluation recommending a regular diet of thin liquids and
regular solids. The patient was encouraged to eat, and his PO
intake increased. Endocrinology had also been consulted for
evaluation of hypernatremia, who felt that both the adrenal and
thyroid axis were intact, and that diabetes insipidus was not
the etiology; the patient's sodium was closely monitored, and it
normalized slowly not warranting further intervention.
.
On [**7-10**], the patient was transitioned to Keppra for seizure
prophylaxis, and his diet was changed to a regular one. The
patient was closely monitored, and received a chest x-ray to
evaluate for possible pneumomediastinum with the change in diet,
and questionable history of a pneumomediastinum. The patient
remained stable, though with waxing and [**Doctor Last Name 688**] orientation, and
no sign of pneumomediastinum.
.
The 14th and [**7-11**], the patient was possibly leaking
CSF [**Last Name (un) 834**] his nares. Nasal drippings were sent for laboratory
examination, confirming a CSF leak. The patient then went to
the operating room on [**7-12**] for lumbar drain placement for the
CSF leak; the patient was started on vancomycin for prophylaxis,
and tolerated the procedure well. The drain was removed on
[**7-15**], w/o renewed nasal CSF leakage.
Opthalmology was consulted for evaluation of the patient's
visual fields post-operatively.
.
The patient's family was also in discussion with the
neurosurgical team, social work, and case management regarding
disposition, as the patient had not been covered by insurance
for further rehabilitation as an out patient.
.
Multiple attempts were made over the coarse of [**7-11**] to
have the patient placed for rehabilitation, with an emphasis on
cognition. However, the patient required sitters to prevent him
from taking off the collar. With redirection or distraction he
was generally easily kept in line, and he probably does not need
full time one-on-one supervision once he is in a more active and
social environment such as rehab. He did frequently remove
collar despite all attempts to keep in place.
.
Throughout his stay on the floor, other than the cognitive
issues (impulsivity, no encoding in short term memory,
recalcitrant behavior probaly secondary to desinhibition,
disorientation in time), his general neurological exam was
stable, with PERRL, full eye movements (perhaps limited
mechanical restriction of the L eye), symmetric facial motor and
sensory systems, straight tongue protrusion, no motor deficits
nor pronator drift, intact sensory systems to touch, symmetric
reflexes with downgoing toes.
.
Psychiatry evaluated pt and felt significance of injuries
prevented pt from holding information and placed him at risk for
potentially self-neglectful and harmful behavior.
DIAGNOSES:
Neuro:
I - BRAIN: Diffuse subarachnoid hemorrhage. Left frontal,
parietal and temporal subdural hematoma. Subdural hematoma
layers over the tentorium. Left frontal extra-axial hemorrhage
and intraparenchymal hemorrhagic contusions.
II - SKULL/FACE : Depressed left frontal skull fracture with
14-mm depression, s/p repair. Comminuted nasal bone fracture.
Right maxillary sinus fracture
III - SPINE: Right occipital condyle fracture and one-half
vertebral body posterior subluxation of the condyle on the C1
vertebral body. Mild anterior widening of the C3/4 and C4/5 disc
interspaces. Questionable fracture through the anterior inferior
C7 vertebral body.
IV - Post-traumatic cognitive dysfunction, as outlined above
Endocrine:
Transient hypernatremia directly post-traumatic, likely related
to high doses of mannitol.
GI:
Questionable transient pneumomediastinum, unable to objectify,
no clinical consequences with negative F/U studies.
Medications on Admission:
unknown
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Comminuted displaced depressed frontal skull fracture with
orbital blow out
2. Frontal sinus fracture
3. Ethmoid sinus fracture
4. Frontal lobe contusions
5. c1 SUBLUXATION
6. C7 fracture
5. Left sided dural tear
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
YOU MUST WEAR CERVICAL COLLAR AT ALL TIMES.
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? 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 IF YOU EXPERIENCE ANY OF THE FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN [**5-4**] WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN and c-spine WITHOUT
CONTRAST
You will need to follow up at the endocrinology clinic (please
call ([**Telephone/Fax (1) 33582**] to make an appointment) in [**Month (only) **].
Completed by:[**2181-7-26**]
|
[
"2760"
] |
Admission Date: [**2185-7-29**] Discharge Date: [**2185-8-4**]
Date of Birth: [**2124-8-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Visual field deficit
Major Surgical or Invasive Procedure:
Right subfrontal craniotomy for tumor resection
History of Present Illness:
60-year-old female who was recently seen in Brain [**Hospital 341**] Clinic,
with progressive visual loss and was found to have a growing
tuberculum sella meningioma. She was electively admitted on [**7-29**]
for resection of said mass.
Past Medical History:
Hypercholestrolemia
Social History:
from [**Country 4812**] and now lives in the U.S. with her daughter. She
has 7 children.
Family History:
non-contributory
Physical Exam:
On Discharge:
Oriented x 3 with interpreter.
Right eye has little sight but patient does she "shadows."
Left pupil is reactive to light. Right pupil is small but
unreactive.
Face symmetric, tongue midline.
Facial sensation symmetric.
No drift.
Full strength and sensation throughout all extremities.
Incision clean, dry, and intact.
Pertinent Results:
Labs on Admission:
[**2185-7-29**] 03:33PM BLOOD WBC-13.2*# RBC-4.24 Hgb-12.3 Hct-36.4
MCV-86 MCH-29.0 MCHC-33.8 RDW-14.5 Plt Ct-234#
[**2185-7-29**] 03:33PM BLOOD PT-12.5 PTT-19.2* INR(PT)-1.1
[**2185-7-29**] 03:33PM BLOOD Glucose-208* UreaN-7 Creat-0.8 Na-146*
K-3.9 Cl-112* HCO3-25 AnGap-13
[**2185-7-29**] 03:33PM BLOOD Calcium-8.7 Phos-5.3* Mg-2.0
Imaging:
MRI Head [**7-29**]:
LIMITED MRI OF THE BRAIN WITH CONTRAST:
There has been no significant interval change in the size or
appearance of the previously described enhancing mass along the
planum sphenoidale with dural tail, consistent with a
meningioma, which has suprasellar and intrasellar extension,
measuring approximately 23 x 35 mm on sagittal images with prior
measurement in [**2184**] of approximately 22 x 30 mm. Mass effect on
the chiasm and pre- chiasmatic optic nerves is stable. No
obvious vascular invasion is identified. No other abnormal
enhancing lesions are noted within the brain parenchyma.
Estimated tumor volume is approximately 8.96 cm3, slightly
increased from [**2184**] exam where it measured 7.3 cm3.
IMPRESSION:
Slight interval growth from [**2184**] of large planum sphenoidale
meningioma with stable adjacent mass effect.
CT Head [**7-30**]:
FINDINGS: Patient is status post right frontal subcraniotomy.
There has been interval removal of a suprasellar mass as seen on
most recent prior MRI. There is a 1.0 x 1.6 cm focus of high
attenuation located in the right frontal lobe (2A:7) that likely
represents focal intraparenchymal hemorrhage, not significantly
changed when compared to prior exam. High-attenuation material
tracking along the right frontal lobe convexity is unchanged.
There has been interval decrease in extensive pneumocephalus.
The [**Doctor Last Name 352**]-white matter differentiation is preserved. There is no
evidence of acute infarction or change in ventricular size and
configuration. There is no evidence of hydrocephalus. No new
hemorrhage is identified. The visualized paranasal sinuses are
clear.
IMPRESSION:
1. No significant change in right frontal intraparenchymal
hemorrhage and
right frontal hyperdensity seen layering along the dura.
2. Interval decrease in expected pneumocephalus
MRI Head [**7-30**]:
FINDINGS: Since the previous study, the patient has undergone
resection of
tuberculum sella and subfrontal meningioma. There is a right
frontal
craniotomy seen with a subdural collection in this region as
seen on the
recent CT. Small amount of blood products are seen in the
inferior frontal
region on the right secondary to the surgery. There is no
hydrocephalus or
midline shift is seen. No acute infarct seen on diffusion
images. Following gadolinium administration, no residual nodular
area of enhancement seen in the region of tuberculum sella or
the inferior frontal region. The suprasellar lesion seen on the
previous study has been resected. Difference in the signal
intensity of the intraorbital optic nerves is seen with the
right side being slightly had intense on T2-weighted images.
Slight hyperintensity of the right intraorbital or intracranial
optic nerve is also seen on diffusion images. It is unclear
whether this is secondary to edema or ischemia in the optic
nerve. Clinical correlation recommended.
IMPRESSION: Postoperative changes with resection of the
subfrontal tumor
without residual enhancing mass lesion identified. Slight
increased signal of the right optic nerve is seen on the T2 and
diffusion images. This could be secondary to edema from mass
effect. However, clinical correlation recommended. No acute
territorial infarct seen.
Brief Hospital Course:
Mrs. [**Known lastname 51216**] was admitted for an elective craniotomy for
resection of a supersellar meningeoma on [**2185-7-29**]. Her operative
course was uncomplicated and post- operatively the patient was
transferred directly to the intensive care unit. She was
monitored with close neurological observation she was found to
have decreased vision in the right eye with possible light
recognition. MRI showed postoperative changes with resection of
the subfrontal tumor without residual enhancing mass lesion
identified. Slight increased signal of the right optic nerve is
seen on the T2 and diffusion images, no infarct was seen. An
opthamology consult was obtained they felt there was little
change from pre-op and vision prognosis was uncertain. On [**8-1**]
she was transferred to neurological floor she was neurologically
intact except for her vision. She was evaluated by physical
therapy and occupational therapy and they recommended a second
day of therapy while in the hospital. Upon re-evaluation on [**8-4**]
she had improved significantly and they felt she was safe to be
discharged with home services. The patient was given one dose of
Na tablet due to Na of 130. She was neurologically much improved
compared to the prior few days. She was discharged on [**8-4**] with
services. Her family will be available to assist her at home as
well.
Medications on Admission:
ZOCOR 20MG DAILY
VITAMEN C 500MG TID (NON-COMPLIANT)
VITAMEN D 400UNITS DAILY
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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: No driving while on this medication.
Disp:*50 Tablet(s)* Refills:*0*
8. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 doses: On [**8-5**] take 3mg [**Hospital1 **] x 3 days. On [**8-8**] take
2mg [**Hospital1 **] x 3 days. On [**8-11**] take 1mg [**Hospital1 **] x 3 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Supersellar meningioma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair only after sutures have been removed.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
??????Make sure to continue to use your incentive spirometer while at
home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????New onset of tremors or seizures.
??????Any confusion or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**7-29**] days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2185-8-22**]
@4pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your acute hospitalization.
You will also need formal visual field testing in approximately
8 weeks. Please call ([**Telephone/Fax (1) 5120**] to schedule this
appointment.
Completed by:[**2185-8-4**]
|
[
"2760",
"4019",
"2720"
] |
Admission Date: [**2152-9-25**] Discharge Date: [**2152-9-28**]
Date of Birth: [**2074-10-20**] Sex: F
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Trauma
Major Surgical or Invasive Procedure:
IR embolization of internal iliac branches x2, unsuccesful
interventional neuroradiology treatment of ICA thrombosis.
History of Present Illness:
77F admitted with pelvic fractures, hemodynamically unstable
after being struck by a motor vehicle. Transferred from OSH for
further management
Past Medical History:
Breast cancer, GERD, HTN
Brief Hospital Course:
Pt admitted to SICU. She was doing well on HD 1 when she became
unresponsive. She was found to have a R ICA thrombosis with
minimal collateral flow from the MCA. Neurosurgery was unable to
dislodge the thrombus endovascularly. After discussion with the
patient's family, she was made DNR/DNI, then comfort measures
only, and she expired on [**2152-9-28**].
Discharge Disposition:
Expired
Discharge Diagnosis:
Stroke.
Discharge Condition:
Expired
|
[
"53081",
"4019"
] |
Admission Date: [**2128-9-14**] Discharge Date: [**2128-9-21**]
Date of Birth: [**2070-5-11**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
PAD
Major Surgical or Invasive Procedure:
Aortobifemoral bypass with a 14 x 7 Dacron graft, right
profundoplasty and lysis of adhesions
History of Present Illness:
This 58-year-old lady has severe peripheral
vascular disease. She has previously had a left femoral-
popliteal bypass that was made by me. She has also had
bilateral iliac angioplasty and stenting. She has continued
to smoke and developed re-stenosis in her iliac arteries. She
was studied a couple of weeks ago and found to have extremely
narrowed and diseased iliac vessels on the left and occluded
external iliac artery on the right and a slightly aneurysmal
severely diseased infrarenal aorta. Because of this
combination of problems we decided to do an aortobifemoral
graft. She also has bilateral significant renal artery
stenosis
Past Medical History:
PMH: Hypertension, Hyperlipidemia, Borderline Diabetes (diet
controlled), PVD, CAD, s/p MI in [**2107**], Prior CVA ([**2124**] or [**2125**])
-occasional residual memory issues
PSH: Bilateral common iliac artery stenting, [**2126-3-1**] Left
fem-[**Doctor Last Name **] bypass, [**2112**]: Coronary stenting at the [**Hospital3 2358**],
Cholecystectomy, Hysterectomy, Tonsillectomy
Social History:
smoker
drinker
Family History:
n/c
Physical Exam:
a/o x3
nad
crackles at bases
rrr
abd benign
inc c/d/i
RLE dop pt
[**Name (NI) **] palp dp/pt
Pertinent Results:
[**2128-9-21**] 05:21AM BLOOD
WBC-9.3 RBC-3.37* Hgb-10.7* Hct-31.2* MCV-93 MCH-31.7 MCHC-34.2
RDW-14.0 Plt Ct-184
[**2128-9-20**] 02:19AM BLOOD
PT-12.4 PTT-26.3 INR(PT)-1.1
[**2128-9-21**] 05:21AM BLOOD
Glucose-92 UreaN-19 Creat-1.1 Na-133 K-3.4 Cl-100 HCO3-29
AnGap-7*
[**2128-9-21**] 05:21AM BLOOD
Calcium-8.1* Phos-3.8 Mg-2.2
[**2128-9-17**] 5:46 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2128-9-17**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH OROPHARYNGEAL FLORA.
CHEST (PORTABLE AP)
INDICATION: Status post line change.
A single AP view of the chest is obtained, AP upright portable
at 13:40 hours, and is compared with the prior study of [**2128-9-16**].
Patient has had placement of a right-sided IJ line with its tip
projecting over the right atrium on the current examination.
Small bilateral effusions are present, more marked on the left
side with bibasilar atelectasis.
IMPRESSION:
Bilateral pleural effusions, more marked on the left side.
Bibasilar atelectasis, more marked on the left side. Right IJ
line with tip likely in the right atrium.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.2 cm
Left Ventricle - Fractional Shortening: 0.42 >= 0.29
Aorta - Ascending: *3.5 cm <= 3.4 cm
Findings
58 years old female for infrarenal AAA. Has H/O MI and CHF in
the past. Depressed LV systolic function with an EF 40-45%.
There is apical hypokinesia and Basal portion of lateral wall
akinesia. Cardiac output before the clamp with continuity
equation is 3-3.5l/min. Prolong MPI 0.6. Vp before the clamp
48cm/sec. After the clamp it decreased to 20cm/sec and after the
clamp came off it stayed 40cm/sec. E/E' ratio [**9-24**]. No valvular
abnormalities.
LEFT ATRIUM: Normal LA size. All four pulmonary veins identified
and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mildly depressed LVEF. Transmitral
Doppler E>A and TDI E/e' <8 suggesting normal diastolic
function, and normal LV filling pressure (PCWP<12mmHg).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Mildly dilated descending aorta. Focal
calcifications in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
Conclusions
The left atrium is normal in size. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45 %). The
calculated myocardial performance index was 0.65 (MPI .
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. There are simple atheroma in the ascending
aorta. The descending thoracic aorta is mildly dilated. The
aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen.
Brief Hospital Course:
Mrs. [**Known lastname 44356**],[**Known firstname **] was admitted on [**2128-9-14**] with severe b/l
claudication. She agreed to have an elective surgery.
Pre-operatively, she was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preperations were
made.
It was decided that she would undergo a Aortobifemoral bypass
with a 14 x 7
Dacron graft, right profundoplasty and lysis of adhesions..
.
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring.
She was then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care. When stable she was
delined. Her diet was advanced. A PT consult was obtained. When
she was stabalized from the acute setting of post operative
care, she was transfered to floor status
In the VICU she was SOB / Inhalers were started. Pt worked with
PT. On DC her 02 SATS
were back to baseline.
On the floor, she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any incidents. She was discharged homw with VNA services
Medications on Admission:
[**Last Name (un) 1724**]: lopressor 50 ", Plavix 75, asa 81, simvastatin 80, MVI,
Lisiopril 20, Hctz 25, Nitroquick 0.4
Discharge Medications:
1. Medications
lopressor 50 ", Plavix 75, asa 81, simvastatin 80, MVI,
Lisiopril 20, Hctz 25, Nitroquick 0.4
2. Aspirin Sig: One (1) PO once a day.
3. Simvastatin Sig: One (1) PO once a day.
4. Lisinopril Sig: One (1) PO once a day.
5. Hydrochlorothiazide Sig: One (1) PO once a day.
6. Oxycodone Sig: [**12-16**] PO every six (6) hours as needed: prn.
Disp:*20 * Refills:*0*
7. Metoprolol Sig: One (1) PO three times a day.
8. multivitiamin Sig: One (1) once a day.
9. nitro quick Sig: One (1) three times a day: prn / if you
experience chest pain please call your PCP or come to the Er
immediatly.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Aortoiliac occlusive disease.
Hypertension, Hyperlipidemia, Borderline Diabetes (diet
controlled), PVD, CAD, s/p MI in [**2107**], Prior CVA ([**2124**] or [**2125**])
-occasional residual memory issues
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-17**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 3121**], schedule an
appointment for one week
Completed by:[**2128-9-21**]
|
[
"4019",
"2724",
"41401",
"412",
"V4582"
] |
Admission Date: [**2140-3-3**] Discharge Date: [**2140-3-29**]
Date of Birth: [**2088-1-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
acute renal failure
Major Surgical or Invasive Procedure:
Hemodialysis
Removal of hemodialysis catheter
History of Present Illness:
In brief, pt is a 52 year old male with PMH of DM2, obesity,
obstructive sleep apnea, HLD, CAD s/p previous stent at [**Hospital1 3278**]
for possible MI, HTN, and neuropathy who is transferred from
[**Hospital3 **] for further management of rhabdomyolysis with
acute renal failure, severe metabolic acidosis, and
thrombocytopenia.
.
On [**2140-2-29**], at the outside hospital, he underwent an elective
lithotripsy of a right staghorn calculus, during which he was
held in the prone position for 8 hours. He eventually had to
have a percutaneous nephrostomy for stone removal. He had
metabolic acidosis postoperatively and evidence of high lactic
acid, and CK's >15,000 (assay not read higher than this) with
subsequent development of acute renal failure over the next [**12-31**]
days (Cr 0.79-->1.9-->6). He had a pH of 7.18 per anesthesia
records which was treated with a bicarbonate drip. He had an ABG
of 7.4/32/107 on transfer. He was also hyperkalemic to 5.0,
requiring frequent doses of kayaxelate. Of note, he was
hemodynamically stable during his stay without significant
respiratory distress or need for pressors. However, he did have
some runs of Vtach when turned, but responsive to metoprolol. He
was placed on noninvasive ventilation twice during his stay,
once for OSA and otherwise to attempt hyperventilation in
treatment of his metabolic acidosis. He has been oliguric with
dark urine. He also had a PICC line placed [**3-1**]. A nephrology
consult at the OSH thought that he would need hemodialysis, and
he was thus transferred here. His percutaneous nephrostomy tube
eventually dislodged requiring placement of a nephroureteral
stent through existing tract. Drainage was adequate per OSH
report, though the tube was clamped on transfer for unclear
reasons.
.
Course at OSH also c/b thrombocytopenia postoperatively with
platelet counts from 252 preop to 172 immediately postop to 29
morning prior to transfer to 56 after transfusion of 1 unit
platelets. The patient received 1 dose of enoxaparin on [**2140-3-1**].
His platelet was 56 after 1 trasnfusion. Labs on discharge were
significant for an ABG of 7.4/32/107.
.
In the MICU, his renal function has continued to worsen, with
increasing oliguria. Renal has been following, and no urgent
need for HD as of yet. PT has had significant lab abormalities
with AG 20, HCO3 14 today. Pt has been getting IVF and bicarb
per renal recs. Etiology of ARF attributed to rhabdo vs. ATN [**12-30**]
hypotension possibly during surgery, though noted at OSH to be
HD stable with no need for pressors. CK has been improving from
52,000 to 19,000 today. Urology has evaluated given nephrostomy
tube, and recomend keeping tube to gravity. He has also been
noted to have significant transaminitis, which has been
improving, but Tbili rising. Pt has also been hyponatremic.
Pt has also been having leg weakness, left>right since his
surgery at the OSH. Pt states that it hasn't gotten better or
worse. He describes it as a "numbness" but denies tingling. He
was evaluated at the OSH by neurology there, and had considered
CT and spine films, but were not done. Renal has recommended MRI
for possible dissection to explain weakness, LFT abnormalities.
This has not yet been pursued. Pt's thrombocytopenia has been
improving to 70 today. HIT Ab negative. PT has been on
pneumoboots and off heparin since admission. Unclear etiology
thus far.
did not get CT or L-spine films yesterday, exam here with
weakness L>R, but more impressive for decreased sensation rather
than weakness
.
Pt states that he mostly is very tired now. He also has pain in
his mid-lower back that he says has been there since surgery. He
says the numbness and weakness in his left leg as been unchanged
sicne admission. Vital signs prior to transfer were Temp 95.6 HR
78 BP 123/46 HR 78 RR 14 99%RA.
.
.
Review of systems: Positive as above.
Otherwise, denies fever, chills, night sweats. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Pt is unsure how much if any
urine he is making.
Past Medical History:
-Hypertension
-hyperlipidemia
-chronic kidney disease
-obesity
-OSA - does not tolerate CPAP
-diabetes mellitus type II
-CAD s/p stent placement at [**Hospital1 3278**]
-diverticulitis s/p surgical excision
-neuropathy
-right staghorn calculus
Social History:
- Tobacco: 1 pack per week for 16 years, quit 16 years ago
- Alcohol: none
- Illicits: none
Works as a courier. Married with 2 daughters.
Family History:
adopted without knowledge of family history
Physical Exam:
ADMISSION:
Vitals: 96.2 133/74 81 25 96%2LNC BG 145
General: Obese, Alert, oriented, looks fatigued, but NAD
HEENT: icteric sclera, EOMI, dry MM, oropharynx clear, swelling
an yellowing of left lateral aspect of tongue
Neck: supple, difficult to appreciate JVP given body habitus
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: Obes, soft, +BS, non-tender, non-distended
GU: foley in place, minimal urine in bag
Ext: warm, 1+ pitting edema to midshin bilaterally
Neuro: A&Ox3, EOMI, decreased sensation to light touch over left
shin and knee, left foot, pt minimally moving left leg, states
unable to move his left toes, distal strength 5/5 on right
DISCHARGE:
98.7 98.6 130/68 84 18 97%RA
24H 1800 PO / 4850 UOP
8H 380 PO / 1400 UOP
General: Obese, A&Ox3, NAD, eager for discharge
HEENT: EOMI, MMM, L tongue lesion appears well-healing without
drainage, stigmata of recent oozing but no active bleeding;
parotid firm, decreased size, non-erythematous, non-fluctuant,
no interior oozing, no TTP
Neck: supple, difficult to detect JVP 2/2 habitus
Lungs: good BS bilaterally anteriorly and posterolaterally. no
wheeze. no crackles.
CV: Distant sounds [**12-30**] habitus, RRR, nl S1 + S2, no m/r/g
Abdomen: Obese, soft, +BS, no referring pain, some diffuse
abdominal TTP but no r/g, no peritoneal signs. No RUQ pain to
palpation.
Ext: warm, bilat 1+ pitting edema, soft, NT. No asterixis. Faint
BUE tremor, improving.
Neuro: no sensory deficit across abd; [**3-31**] bilat hip and plantar
flexion strength, but unable to dorsiflex or extend L foot > R
foot. UE [**3-31**] bilat.
Pertinent Results:
ADMISSION LABS:
[**2140-3-3**] 09:26PM BLOOD WBC-7.8 RBC-3.43* Hgb-11.8* Hct-30.8*
MCV-90 MCH-34.4* MCHC-38.4* RDW-13.4 Plt Ct-67*
[**2140-3-3**] 09:26PM BLOOD Neuts-81.3* Lymphs-12.2* Monos-5.6
Eos-0.4 Baso-0.5
[**2140-3-4**] 04:01AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
[**2140-3-3**] 09:26PM BLOOD PT-13.3 PTT-23.0 INR(PT)-1.1
[**2140-3-7**] 01:00PM BLOOD Fibrino-1036*
[**2140-3-5**] 01:23AM BLOOD Ret Aut-2.0
[**2140-3-4**] 04:01AM BLOOD Ret Aut-2.3
[**2140-3-3**] 09:26PM BLOOD Glucose-162* UreaN-80* Creat-7.9* Na-131*
K-3.2* Cl-93* HCO3-20* AnGap-21*
[**2140-3-3**] 09:26PM BLOOD ALT-3437* AST-4532* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-196* TotBili-3.4* DirBili-2.7* IndBili-0.7
[**2140-3-4**] 04:01AM BLOOD Lipase-75*
[**2140-3-3**] 09:26PM BLOOD Albumin-2.7* Calcium-6.7* Phos-8.5*
Mg-1.9
[**2140-3-4**] 04:01AM BLOOD Hapto-<5*
[**2140-3-7**] 05:56AM BLOOD Hapto-16*
[**2140-3-8**] 04:28AM BLOOD calTIBC-139* Ferritn-5535* TRF-107*
[**2140-3-8**] 04:28AM BLOOD TSH-3.0
[**2140-3-8**] 04:28AM BLOOD T4-4.4*
[**2140-3-7**] 01:40PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2140-3-7**] 01:40PM BLOOD HCV Ab-NEGATIVE
[**2140-3-3**] 08:43PM BLOOD Type-ART pO2-79* pCO2-33* pH-7.42
calTCO2-22 Base XS--1
[**2140-3-6**] 08:56PM BLOOD Type-ART pO2-89 pCO2-30* pH-7.25*
calTCO2-14* Base XS--12 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2140-3-3**] 08:43PM BLOOD Lactate-1.4
[**2140-3-6**] 08:56PM BLOOD Glucose-125* Lactate-1.2 Na-126* K-4.1
Cl-98*
[**2140-3-3**] 08:43PM BLOOD Hgb-11.3* calcHCT-34
[**2140-3-3**] 08:43PM BLOOD freeCa-0.89*
.
.
DISCHARGE LABS:
Na 138 | Cl 101 | BUN 75 < Glu 95
K 5.0 | HCO3 27 | Cr 7.1
Ca: 9.5 Mg: 2.0 P: 6.0
WBC 6.3 > Hgb 8.0 / Hct 23.8 < Plt 433
.
STUDIES:
.
Images:
CXR [**2140-3-3**]: The left PICC line tip is at the level of the
cavoatrial junction/proximal right atrium and might be pulled
back for approximately 1 cm to secure its position in the low
SVC/cavoatrial junction. Heart size is normal. Mediastinum is
normal. Lungs are essentially clear except for right basal
opacity most likely representing atelectasis, but infectious
process is another possibility.
.
CXR [**2140-3-5**]:
The left PICC line tip is at the level of cavoatrial
junction/proximal right atrium. Cardiomediastinal silhouette is
stable. The right basal opacity is unchanged. No interval
development of interstitial edema or new consolidations has been
demonstrated.
Overall, no significant change noted since the prior study.
Continued attention to the right lower lung is recommended to
exclude the possibility of developing infectious process in this
location.
.
CTAP [**2140-3-5**]:
IMPRESSION:
1. No retroperitoneal hematoma.
2. Heterogeneously fatty liver.
3. Moderately distended gallbladder.
4. Large bowel dilatation extending to what appears to be a
surgical site within the deep pelvis, though evaluation of
surgical anatomy is limited without oral contrast or surgical
operative notes. Decompressed bowel distal to this anastomotic
site is suggestive of a partial or early large bowel
obstruction.
5. Bilateral perinephric stranding with well-positioned
right-sided
nephroureteral stent. Residual calculi noted in the right
kidney, largest measuring 1.1 cm.
6. Nonobstructing small bowel herniation through left abdominal
wall likely related to prior surgery.
7. Significant soft tissue stranding, likely representing
post-surgical change, is noted in the left-sided subcutaneous
tissue overlying the abdomen.
.
RUQ U/S [**2140-3-6**]:
IMPRESSION: Limited examination; however, no overt hepatic
venous or portal venous thrombus is seen. Normal directional
flow is demonstrated.
.
EKG [**2140-3-9**]: Normal sinus rhythm. Poor R wave progression in
leads V1-V3. Slight non-specific T wave changes. Consider
electrolyte abnormality. The poor R wave progression may be a
normal variant but consider prior anterior wall infarction. No
previous tracing available for comparison.
.
CXR [**2140-3-10**]: NG tube tip is out of view below the diaphragm.
Right IJ catheter tip remains in the right atrium. Left PICC tip
is in the mid SVC. There are low lung volumes. There is no
pneumothorax or large pleural effusions. Aside from bibasilar
atelectasis, the lungs are clear.
.
RUQ U/S [**2140-3-13**]: : Study limited by technique. The liver appears
echogenic, compatible with known history of cirrhosis. Trace
perihepatic fluid is noted. Portal vein appears patent. The
common bile duct measures 0.4 cm. The gallbladder appears normal
without evidence of gallstones. The limited visualization of the
head and body of the pancreas appears unremarkable. The tail is
not clearly visualized.
IMPRESSION:
1. Limited examination with echogenic liver, consistent with
known cirrhosis. Trace perihepatic fluid.
2. Partially visualized pancreas appears unremarkable.
.
EKG [**2140-3-14**]: Normal sinus rhythm. Poor R wave progression in
leads V1-V3. Non-specific ST-T wave abnormalities. Compared to
the previous tracing of [**2140-3-9**] no diagnostic change.
.
Renal U/S [**2140-3-15**]: The right kidney measures 14.0 cm. The left
kidney measures 14.5 cm. There is no hydronephrosis,
hydroureter, or evidence of residual renal calculi. The right
percutaneous nephrostomy tube is vaguely evident. Small amount
of perihepatic ascites is noted, but there is no perirenal
fluid. The bladder is not visualized, secondary to patient's
body habitus and bowel gas obscuration.
IMPRESSION: No hydroureteronephrosis. No residual renal stone
noted. Small perihepatic ascites.
.
MRI Thoracolumbar [**2140-3-16**]:
THORACIC SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of the thoracic spine were acquired.
FINDINGS: In the mid thoracic region at T7-8 a central disc
herniation identified moderately narrowing the spinal canal
indenting the spinal cord. At T8-9 there is a small central
disc herniation seen with mild narrowing of the spinal canal and
indentation on the spinal cord. Mild degenerative changes are
seen at other levels. There is no evidence of abnormal signal in
the thoracic spinal cord. In the visualized lower cervical
region at C7-T1 level there is a disc herniation or protrusion
identified on sagittal images which narrows the spinal canal and
indents the spinal cord. There is suspicion for increased signal
within the spinal cord at this level.
IMPRESSION:
1. Spinal canal narrowing in the lower cervical upper thoracic
region with indentation on the spinal cord by disc protrusion
seen on the sagittal images. Increased signal is also suspected
in the spinal cord at this level on the sagittal images. A
focussed study of the cervical spine would be helpful for
further assessment.
2. Disc protrusions at T7-8 and T8-9 levels indenting the spinal
cord with moderate spinal stenosis at T7-8 and mild spinal
stenosis at T8-9 levels. No abnormal signal in the thoracic
spinal cord. 3. Subtle increased signal within the posterior
muscles on the right side in the thoracic region could be due to
edema.
.
LUMBAR SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of the lumbar spine acquired.
FINDINGS: From T12-L1 to L3-4 no abnormalities are seen. At L4-5
disc bulging and a disc protrusion seen in the midline extending
to the left with moderate narrowing of the left subarticular
recess. At L5-S1 level no abnormalities are seen. Increased
signal is seen in both erector spinae muscles in the lumbar
region which could indicate edema. Soft tissue edema is also
seen in the subcutaneous fat in the lumbar region. Diffuse
decreased signal is visualized in the bony structures which
could be secondary to anemia or renal dysfunction. Clinical
correlation recommended.
IMPRESSION: Small disc protrusion at L4-5 level with moderate
narrowing of the left subarticular recess. No intraspinal fluid
collection or thecal sac compression. Increased signal within
the erector spinae muscles and soft tissues could indicate
edema.
.
Renal U/S [**2140-3-19**]: Transabdominal son[**Name (NI) 493**] images are limited
by body habitus but demonstrate normal-appearing kidneys without
hydronephrosis or stones. The left kidney measures 14.1 cm. The
right kidney measures 13.8 cm.
IMPRESSION: Normal renal ultrasound.
.
MICRO:
URINE CULTURE (Final [**2140-3-5**]): NO GROWTH.
MRSA SCREEN (Final [**2140-3-6**]): No MRSA isolated.
Blood Culture, Routine (Final [**2140-3-14**]): NO GROWTH.
URINE CULTURE (Final [**2140-3-10**]): YEAST. >100,000
ORGANISMS/ML.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final 04/13-15/11):
feces negative x3
URINE CULTURE (Final [**2140-3-11**]): NO GROWTH
LEFT PICC CATHETER TIP (Final [**2140-3-13**]): No significant
growth.
WOUND CULTURE (Final [**2140-3-15**]):
SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH. PAN-SENSITIVE
URINE CULTURE (Final [**2140-3-18**]): YEAST. 10,000-100,000
ORGANISMS/ML.
URINE CULTURE (Final [**2140-3-22**]): NO GROWTH.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2140-3-22**]): Feces
negative
OVA + PARASITES (Final [**2140-3-25**]): NO OVA AND PARASITES SEEN.
Brief Hospital Course:
Mr [**Known lastname 1968**] is a 52yo M with h/o HTN, HLD, CAD, DM2, and right
staghorn calculus who developed a likely rhadomyolysis-induced
acute renal failure following operative removal of his
nephrolith at [**Hospital3 **], transferred here with
nephroureteral stent. His hospital course at [**Hospital1 18**] was
complicated by worsening renal failure, thrombocytopenia and
transaminitis. He was transferred to the MICU for altered mental
status in setting of renal failure and needing to initiate
hemodialysis. He was called out from the MICU [**3-12**]. He was on
intermittent hemodialysis, but his renal function improved and
he has not needed hemodialysis since [**3-18**]. The hemodialysis
catheter was pulled [**3-24**]. Additionally, he has had left leg
weakness and numbness since the surgery at [**Hospital3 **]. He
has had no evidence of retroperitoneal bleed, but MRI showed
stenosis and disc herniation that may explain some of the pain
and sensory level findings. He may also have a lumbar plexopathy
from extended prone positioning or cord infarct due to
intraoperative ischemia from positioning. He was also treated
for parotitis. Below is a summary of each of his medical issues
in further detail.
.
*) RIGHT STAGHORN CALCULUS S/P OPERATIVE RETRIEVAL:
Laser lithotripsy was unsuccessful and pt had right percutaneous
nephrostomy and retrieval with later right percutaneous
nephroureteral stent placement after dislodged perc tube. [**3-15**]
renal ultrasound showed no residual stones and no hydronephrosis
bilaterally. Perc nephroureteral stent clamped [**3-17**] AM, UOP not
decreased, [**3-18**] subsequent renal ultrasound with no
hydronephrosis. However, urology recommends leaving tube open to
gravity/bag drainage until patient is seen in followup with his
urologist. Per urology, stent may be in place for 2-3 months
without problems. [**Name (NI) **] has been on allopurinol every other day for
stones, and has had pain control with PO oxycodone. Pain may
have a neuropathic component as below.
.
*) ACUTE KIDNEY INJURY with ANION GAP METABOLIC ACIDOSIS,
causing TOXIC METABOLIC ENCEPHALOPATHY:
Likely due to rhabdomyolysis after prolonged surgery while on
statin and gemfibrozil, causing acute tubular necrosis. Urine
sediment with not many muddy brown casts. His BUN/Cr continued
to rise despite downtrend in CK's initially, and despite much IV
resuscitation. He became increasingly oliguric and IV fluids
were discontinued. This all led to profound anion gap metabolic
acidosis and uremia causing a toxic metabolic encephalopathy. He
was transferred to the MICU and hemodialysis was initiated; the
AMGA and encephalopathy improved. In the workup for HD, his PPD
was negative; hepatitis panel was done and he received HBV
vaccine [**3-22**]. He received intermittent hemodialysis and his
renal function continued to improve. He made progressively more
urine and his BUN/Cr began to trend down spontaneously. He was
last dialyzed on [**2140-3-18**] and the dialysis catheter was removed
[**2140-3-25**]. At the time of discharge he had 5 consecutive days of
downward-trending BUN/Cr. He failed Foley removal twice and was
unable to urinate, so his Foley catheter remains in place. He
will continue on sevelamer until his followup with nephrology as
an outpatient. He will require daily Chem-10 to monitor renal
function and phosphorus.
.
*) DIARRHEA:
Patient has had multiple watery bowel movements since admission.
Negative c.diff [**3-11**], [**3-22**]. Flexiseal placed on admission,
discontinued [**3-21**]. His stool consistency and frequency has been
improving on loperamide prn.
.
*) LOWER EXTREMITY NUMBNESS/WEAKNESS and GENERALIZED PAIN
DIFFUSELY:
He has baseline neuropathy but notes numbness and weakness of
the lower extremity L>R since his surgery. Possible peripheral
nerve damage due to positioning at time of surgery but op notes
are unrevealing. He had no evidence of compartment syndrome or
retroperitoneal bleed either clinically or radiologically. Per
the neurology team, these symptoms are most likely due to cord
infarct/injury vs lumbar plexopathy L>R from surgical
positioning. He is is likely without risk of further injury and
is likely to improve slowly with neuropathic pain meds and
mobilization. MRI showed stenosis and disc herniation; however,
patient is largely asymptomatic from it and is without back
pain. Spine consultants recommended no surgical intervention
given that MRI findings are not likely to be clinically
significant. His pain was controlled on oxycodone and
gabapentin, renally dosed. Physical therapy followed him while
inpatient and he underwent EMG on [**3-28**] prior to discharge. He
will require aggressive physical and occupational therapy while
at rehab. He will need to follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] of
neurology 1-2 weeks after he is discharged from rehab.
.
*) PAROTITIS/TONGUE LACERATION:
He presented with a left-sided tongue laceration, presumably
from biting the tongue during surgery. This was stable and
well-healing although [**3-26**] it had a small, self-limited episode
of bleeding. It has not continued to bleed. For parotitis
diagnosed [**3-12**] he was started on Vancomycin and Unasyn, which
was narrowed to Unasyn and then Augmentin given cultures
negative for MRSA. He received a total of 10 days of
antibiotics. He is to continue warm packs as needed and [**Doctor Last Name **]
wedges three times daily with all meals to stimulate salivary
flow to the left parotid gland.
.
*) ANEMIA:
He has a normocytic anemia. His hematocrit was stable at ~30 for
several days since admission, and then following his onset of
renal failure it drifted downward and stabilized at 22-24 since
[**2140-3-13**]. He has had no evidence of bleeding and it is felt that
the anemia is most likely dilutional given volume overload from
acute renal failure; he is now autodiuresing.
.
*) RHABDOMYOLYSIS:
Initial elevated creatinine kinases to 52,000 (now normalized),
oliguria, dark urine, and acute renal failure were consistent
with acute rhabdomyolysis, possibly due to extended prone
position in the setting of morbid obesity while taking statin
and gemfibrozil. CK's were elevated on admission and trended to
normal. His statin and gemfibrozil continue to be held until his
renal failure completely resolves.
.
*) TROPONIN ELEVATION:
The patient complained of chest pressure [**3-14**] AM; it was in fact
epigastric abdominal pain at his prior baseline, no chest
pressure or pain. His troponin was borderline but his baseline
was unknown. His ECG was unchanged. His troponins were trended
and were overall stable, with a mild rise acceptable in the
setting of acute renal failure, rhabdo, and severe metabolic
derangement. He had no further chest pain so troponins were not
rechecked.
.
*) THROMBOCYTOPENIA:
He had a rather precipitous platelet drop at [**Hospital3 **]
from a pre-op 252 to a nadir of 29 prior to a platelet
transfusion at [**Hospital3 **]. HIT antibody came back negative.
Etiology of thrombocytopenia is still unclear; platelets trended
upward and have normalized since [**2140-3-8**].
.
*) ELEVATED TRANSAMINASES:
Most likely due to shock liver in setting of hypotension at
[**Hospital3 **]; continued to trend down and have normalized
since [**2140-3-19**]. His lipase was also elevated but trended down as
well.
.
*) DIABETES MELLITUS TYPE II:
His home metformin was held while he was inpatient; he was
placed on a lispro insulin sliding scale with evening glargine
dosing increased to 12 units at discharge. His blood sugars were
acceptable on this regimen.
.
*) HYPERTENSION:
His home metoprolol tartrate (50mg [**Hospital1 **]) was increased to TID on
[**2140-3-26**] given upward-trending BPs. This was transitioned to
metoprolol succinate 150mg daily upon discharge.
.
*) CORONARY ARTERY DISEASE/HYPERLIPIDEMIA:
He is s/p stent at [**Hospital1 3278**] for possible MI. He is not on aspirin
at home so this was started [**3-15**]. He was continued on home
metoprolol. His statin/gemfibrozil were held due to rhabdo and
may be restarted once his renal failure resolves.
.
*) OBSTRUCTIVE SLEEP APNEA:
Patient has not tolerated CPAP previously. O2 sats were normal
even at night.
.
*) Prophylaxis: pneumoboots and ASA
*) CONSULTS WHILE INPATIENT: Nephrology, Neurology, Spine,
Nutrition, PT, Social [**Name (NI) **]
*) Communication: Patient, wife [**Name (NI) 5321**] [**Telephone/Fax (1) 90071**]
TRANSITION OF CARE:
- Patient is full code
- Patient has EMG study results pending from [**2140-3-28**]; he will
follow up with neurology 1-2 weeks after discharge from rehab
(appointment will need to be scheduled)
- Patient will follow up with urology for nephroureteral stent
removal within 1-2 weeks after discharge from rehab (appointment
will need to be scheduled)
- Patient will follow up with nephrology on [**2140-5-11**] (appointment
scheduled with Dr. [**Last Name (STitle) 118**]/Dr. [**Last Name (STitle) **] per discharge planning)
- Patient will require weekly CBC for monitoring of anemia and
daily chem-10 until creatinine, phosphate stable
Medications on Admission:
Home meds:
gabapentin 100mg cap TID
gemfibrozil 600mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
toprol XL 100mg daily
pravastatin 80mg qhs
.
On transfer from OSH:
Metoprolol 50mg PO BID
Sodium bicarb at 3 oz/L of IV D5W infusing at 150cc/hr
Insulin at 10U qHS plus sliding scale insulin
hydromorphine 0.5-1mg IV q3hrs PRN pain
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. insulin lispro 100 unit/mL Solution Sig: Two (2)
Subcutaneous ASDIR (AS DIRECTED): 2 units for FS of > 150,
increase by 2 units for every 50 over 150.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
8. lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for for mouth pain: swish and
spit.
9. Outpatient Lab Work
Daily Chem 10.
Weekly CBC
10. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
11. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for loose stool.
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
14. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime: Or according to your doctor's
recommendation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Acute Kidney failure
Acute tubular necrosis
Rhabdomyolysis
.
Secondary:
Parotitis
Spinal stenosis
Disc herniation
Neuropathic pain
Left leg weakness
Type 2 diabetes
Hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr [**Known lastname 1968**],
It was a pleasure to care for you at [**Hospital1 827**]. You were hospitalized with acute renal failure
caused by rhabdomyolysis following your surgery from an outside
hospital. You were initiated on hemodialysis with slow recovery
of your kidney function and have not needed dialysis since [**3-18**]. Certain medications were stopped due to this issue. Please
follow up as indicated for restarting these. You were evaluated
by Renal and Urology specialists regarding the
nephroureterostomy stent you have in place. We tried twice to
remove your bladder catheter and both times you were unable to
void. To avoid damage to your bladder we have left the catheter
in place.
You briefly received tube feeds while hospitalized but were able
to tolerate a regular diet eventually. You had a rectal tube for
diarrhea, and this was eventually removed. There was no noted
infection in your stool.
You have completed a course of antibiotics for an infection in
your left parotid gland. You should continue to have [**Doctor Last Name **]
wedges with all meals to stimulate saliva flow.
You were evaluated by Neurology and Spine specialists regarding
left leg weakness and numbness and pain on your abdominal skin.
Although an MRI showed some herniation and stenosis of your
spine, it was determined that surgery was not necessary, and
that these findings do not necessarily correlate with your
symptoms. Your neuropathic pain improved with Neurontin, and
your weakness is improving with physical therapy and
mobilization. You had a nerve conduction study prior to
discharge and these results can be followed up as an outpatient.
Your medications were changed in the following ways:
STARTED baby aspirin for history of cardiovascular disease
STARTED allopurinol every other day - ask your primary care
physician how long to continue this
STARTED insulin sliding scale - follow up with your primary care
physician about blood sugar control
STARTED insulin glargine (Lantus) before bedtime
STARTED nephrocaps
STARTED sevelamer carbonate
STARTED heparin shots - while you are unable to get out of bed
STARTED lidocaine swish and spit for Parotitis
INCREASED metoprolol from 100mg to 150mg daily
INCREASED gabapentin - follow up dosing based on renal function
STOPPED gemfibrozil - follow up with physician about when to
restart
STOPPED metformin - follow up with physician about when to
restart
STOPPED pravastatin - follow up with physician about when to
restart
CHANGED percocet to oxycodone - attempt to wean yourself off
this medication
Continue the rest of your medications as prescribed.
Do not drive or operate heavy machinery while taking narcotics
or Neurontin (gabapentin).
You will need to follow up with your primary physician to follow
up your hospitalizations and medications.
You will need to follow up with your urologist to determine when
your nephroureterostomy stent should be removed.
You will need to follow up with the neurologist within 1-2 weeks
of being discharged from rehab.
Followup Instructions:
See your primary care physician within one week to follow up
your hospitalizations.
Follow up with your urologist within 1-2 weeks of being
discharged from rehab. If you wish to transfer your urologic
care to [**Hospital1 18**], you may call ([**Telephone/Fax (1) 8791**] to schedule this
appointment with Dr [**Last Name (STitle) 3748**] instead. If you are going to transfer
care to Dr [**Last Name (STitle) 3748**] please bring your [**Hospital3 **] urologic
records with you.
Follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] of neurology within 1-2 weeks of
being discharged from rehab. Please call ([**Telephone/Fax (1) 5088**] to
schedule this appointment.
You are to continue with daily lab draws to monitor your kidney
function and weekly lab draws to monitor your blood count.
Department: WEST [**Hospital 2002**] CLINIC (NEPHROLOGY)
When: WEDNESDAY [**2140-5-11**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**] (with Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **])
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2140-3-29**]
|
[
"5845",
"2762",
"2761",
"2875",
"40390",
"5859",
"2859",
"41401",
"V4582"
] |
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