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Admission Date: [**2172-8-8**] Discharge Date: [**2172-8-17**]
Date of Birth: [**2172-8-8**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Nevaeh [**Known lastname 10528**] was born at 32
and 2/7 weeks gestation by cesarean birth for a nonreassuring
fetal heart rate. The mother is a 32-year-old gravida 8, para
5, now 6 woman whose prenatal screens are blood type O
positive, antibody negative, rubella immune, RPR nonreactive,
hepatitis surface antigen negative, and group B strep
unknown. This pregnancy was complicated by Insulin dependent
diabetes and chronic hypertension. The mother presented to
[**Name (NI) 86**] hospital on the day of delivery with fetal
deceleration, a good biophysical profile of [**7-14**]. At that time
she was given a dose of betamethasone.
The infant emerged vigorous. Apgars were 8 at 1 minute and 8
at 5 minutes.
The birth weight was 1750 grams, birth length was 44 cm, and
birth head circumference was 30 cm.
PHYSICAL EXAMINATION: The admission physical examination
reveals a vigorous preterm infant, anterior fontanel soft and
flat, nondysmorphic. Neck supple with intact clavicles. Lungs
clear. Mild subcostal retractions. Heart with regular rate
and rhythm. No murmurs. Femoral pulses present. Abdomen soft.
Positive bowel sounds. Normal genitalia. Patent anus. No
sacral or back anomalies. Well perfused. Stable hips and
normal tone and activity.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: She had
some initial transitional respiratory distress which resolved
within few hours of life. She has always remained in room
air. She has had no apnea or bradycardia. On examination her
respirations are comfortable with minimal subcostal
retractions. Lung sounds are clear and equal.
CARDIOVASCULAR: She has remained normotensive throughout her
NICU stay. There was no cardiovascular issues.
FLUIDS, ELECTROLYTES AND NUTRITION: At the time of discharge
her weight is 1620 grams. Enteral feeds were begun on day of
life 1 and were advanced without difficulty to full volume
feedings. She is curently NPO since [**2172-8-16**], with working
diagnosis of Hisrchprung.
GASTROINTESTINAL: She was treated with phototherapy for
hyperbilirubinemia from day of life 3 until day of life 6.
Her repeat bilirubin occurred on day of life 3 and was total
9.8, direct 0.3. Her rebound bilirubin on [**2172-8-15**],
was total 5.3, direct 0.2. Of note one of the infant's
siblings did have Hirschsprung's disease and had a bowel pull
through done at 1-year of age. This infant has had one
spontaneous bowel movement and one with a glycerine
suppository. On [**2172-8-16**], she was kept NPO due to abdominal
distension with multiple KUB showing no pneumatosis, presence of
dilated bowel loop specially the transverse colon.
Brium enema on [**2172-8-17**] showed rectum narrower than sigmoid which
is suggestive of Hirschprung.
HEMATOLOGY: She has had no blood product transfusions during
her NICU stay. At the time of admission her hematocrit was
46.5 and platelets 330,000.
INFECTIOUS DISEASE: She was started on ampicillin and
gentamycin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours and the
blood cultures were negative and the infant was clinically
well. At the time of admission her white count of 9000 with a
differential of 46 poly's and 0 bands. At the time of abdominal
distention, she had sepsis evaluation and showed marked left
shift. She is currently on triple antibitherapy with ampicilli,
gentamicn, and clindamycin. She need LP since the attempt on
[**2172-8-17**] is unsuccessful.
SENSORY: Audiology - Hearing screening has not yet been
performed and is recommended prior to discharge.
PSYCHOSOCIAL: Mom has been involved in the infant's care
throughout her NICU stay.
The infant is transferred to [**Hospital1 1926**] in good condition.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] in [**Hospital1 1474**],
[**State 350**].
CDISCHARGE DIAGNOSIS:
1. Prematurity at 32 and 2/7 weeks gestation.
2. Sepsis ruled out.
3. Status post transitional respiratory distress.
4. Status post hyperbilirubinemia of prematurity.
5. working disagnosis of Hirschprung
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2172-8-16**] 00:45:07
T: [**2172-8-16**] 03:18:25
Job#: [**Job Number 69132**]
|
[
"7742",
"V290"
] |
Admission Date: [**2183-7-18**] Discharge Date: [**2183-8-11**]
Date of Birth: [**2109-8-31**] Sex: M
Service:
CHIEF COMPLAINT: Dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: This is a 73 year old male with
a history of aortic valve replacement in [**2180**], abdominal
aortic aneurysm, hypertension who was transferred from an
outside hospital with one week of dyspnea on exertion,
shortness of breath, fever and violent chills. The patient
denied a history of recent travel, sick exposure, cough,
sputum production, nasal congestion, abdominal pain or skin
infection.
On admission the patient's temperature was 100.8. Three
blood cultures were drawn and he was started on Vancomycin
and Gentamicin. The initial chest x-ray showed negative
pleural effusions or evidence of congestive heart failure.
Transesophageal echocardiogram showed an left ventricular
ejection fraction of 65% with thickened mitral valve with
mild regurgitation, large echodense objects, suggestion of
vegetation, and tricuspid regurgitation. The initial
transesophageal echocardiogram done at [**Hospital6 649**] showed dehiscence of the porcine arteriovenous
graft and a positive abscess. He was admitted for evaluation
and consideration for surgery.
PAST MEDICAL HISTORY: Significant for aortic valve
replacement with porcine valve. The patient unclear reason
for aortic valve replacement, abdominal aortic aneurysm and
hypertension. Hypercholesterolemia, chronic anemia,
infrarenal abdominal aortic aneurysm, and chronic renal
insufficiency.
PAST SURGICAL HISTORY: Aortic valve replacement with porcine
valve.
MEDICATIONS:
1. Lipitor 10 mg p.o. b.i.d.
2. Vitamin B12
3. Lopressor 25 mg b.i.d.
4. Vancomycin started at outside hospital
5. Gentamicin started at the outside hospital
PHYSICAL EXAMINATION: Temperature was 98.4, heartrate 64,
blood pressure 120/70, respiratory rate 20 and saturations
97% on room air. General: He was alert, awake and in no
acute distress, resting comfortably. Head, eyes, ears, nose
and throat: Pupils are equal, round, and reactive to light,
extraocular muscles intact, no lymphadenopathy. Neck was
supple, negative left axis deviation, negative masses,
jugulovenous distension of 14 cm, negative bruits. Trachea
aortic murmur, 2 to 3 tricuspid murmur. Pulmonary clear to
auscultation bilaterally. Abdomen was soft, nontender,
nondistended, positive bowel sounds. Abdominal had no bruits
and no hepatosplenomegaly. Extremities: +2 dorsalis pedis
pulses bilaterally, negative edema. Skin was negative for
dermatitis, ecchymosis, negative splinter hemorrhages or
axillary nodes.
LABORATORY DATA: Initial labs included a white blood cell
count of 6, hemoglobin 11, hematocrit 34.8 and platelets 168.
Chem-7 included sodium 131, potassium 3.3, chloride 102,
carbon dioxide 21, BUN 14, creatinine 1.4, and 98% glucose.
Calcium was 8.6, phosphate was 3.9 and magnesium was 1.8. He
showed dehiscence of the AV.
ALLERGIES: No known drug allergies
HOSPITAL COURSE: After admission the patient was continued
on intravenous Vancomycin and Gentamicin. Infectious Disease
was also consulted. The patient was transferred to the
Coronary Care Unit.
On [**7-21**], the patient was taken to the Operating Room for
an indication of infected aortic valve replacement and
endocarditis. Procedure was a redo sternotomy aortic valve
replacement with homograft 29 mm. The patient tolerated the
procedure well and was sent to the Coronary Intensive Care
Unit. On [**7-22**], Neurology was consulted for an altered
mental status. Their impression was that decreased alertness
could be due to several factors including culture-negative
endocarditis, recent Propofol use and Morphine. [**7-22**],
Infectious Disease reassessed the situation and decided to
continue the intravenous Ceftriaxone, Vancomycin and
Rifampin. On [**7-25**], Renal was consulted for acute renal
failure in which their assessment of the situation was acute
renal failure but there was no indication for dialysis and
that they would follow. The patient continued to course in
the Intensive Care Unit with close monitoring and broad
spectrum antibiotics, including Ceftriaxone, Vancomycin, and
Rifampin. During the course of the Intensive Care Unit stay
Cardiology had recommended placement of a pacemaker. On [**8-1**], the patient was brought back to the Operating Room for
placement of a [**Company 1543**] lead pacemaker. The patient
tolerated the procedure well. Neurology was consulted and
the patient was started on Dilaudid 200 mg. There were no
complications. The patient continued his stay in the
Intensive Care Unit until [**8-5**], at which time he was
transferred to the floor. During the Intensive Care Unit stay
the patient had signs and symptoms of what possibly could
have been a seizure.
On [**8-6**], the patient was assessed for placement of a
percutaneous endoscopic gastrostomy tube due to a 24 hour
caloric count well below [**2182**] calories. On [**8-8**], the
patient was brought back to the Operating Room with placement
of the percutaneous endoscopic gastrostomy tube. The patient
tolerated the procedure well and was discharged back to the
Surgical Floor. Also on [**8-8**], the patient was assessed
for rehabilitation placement.
On [**8-10**], the patient was doing well and tolerating tube
feeds without abdominal pain, nausea or vomiting.
The discharge physical showed vital signs 98.6 temperature,
60 heartrate, 130/70, blood pressure was 105/58, 18
respiratory rate, and 96% on 2 liters. General: He was
alert and oriented in no acute distress. Cardiovascularly,
he was regular rate and rhythm with no murmurs or rubs.
Respiratory rate was clear to auscultation bilaterally.
Abdomen was soft, nontender, nondistended with positive bowel
sounds, positive percutaneous endoscopic gastrostomy
placement. Extremities, negative peripheral edema. Incision
was intact. Physical therapy level was 1 out of 5.
Complications and significant events included acute renal
failure treated without dialysis, pacemaker placement and
percutaneous endoscopic gastrostomy placement.
Discharge laboratory data included a white blood cell count
of 4.7, hemoglobin 10.1, hematocrit 30 on [**8-8**] and a
sodium of 141, potassium 4.0, chloride 109, carbon dioxide of
22, BUN 19 and creatinine of 1.9 and glucose of 94. Dilantin
was 3.5 with a free Dilantin of 1.1 on [**8-9**].
DISCHARGE MEDICATIONS:
1. Hydralazine 50 mg p.o. q. 4 hours
2. Rifampin 600 mg p.o. q.d.
3. Ceftriaxone 2 mg intravenously q. 24
4. Vancomycin 1 gm intravenously q.d.
5. Dilantin 250 mg b.i.d., hold to repeat 30 minutes prior
and 30 minutes after administration of Dilantin
6. Docusate 100 mg p.o. b.i.d.
7. Heparin 5000 units subcutaneous b.i.d.
8. Vitamin C 500 mg p.o. b.i.d.
9. ZnSO4 220 mg p.o. q.d.
10. Amiodarone 400 mg p.o. q.d.
11. Norvasc 10 mg p.o. q.d.
12. Nephrocaps times one p.o. q.d.
13. Nystatin powder to the groin b.i.d. prn
14. UltraCal 80 cc/hr, hold 30 minutes prior and after
administration or administration of Dilantin
15. Ibuprofen 400-600 mg p.o. q. 6 hours
16. Milk of Magnesia 30 ml p.o. prn
17. Tylenol 650 mg p.o. q. 4 hours
PRIMARY DISCHARGE DIAGNOSIS:
1. Status post redo sternotomy and aortic valve replacement
with homograft
SECONDARY DIAGNOSIS:
1. Chronic renal insufficiency
2. Hypertension
3. Hypercholesterolemia
4. Chronic anemia
5. Infrarenal abdominal aortic aneurysm
DISPOSITION: [**Hospital **] hospital, [**Hospital3 672**]
Hospital & Rehabilitation Center. #[**Telephone/Fax (1) 35784**], Fax
[**Telephone/Fax (1) 35785**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] R. 02-358
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2183-8-10**] 19:49
T: [**2183-8-10**] 21:24
JOB#: [**Job Number 35786**]
|
[
"4241",
"42731",
"5849",
"2859"
] |
Admission Date: [**2203-11-3**] Discharge Date: [**2203-11-12**]
Date of Birth: [**2161-11-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath, chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis
EGD with biopsy
History of Present Illness:
41 y/o M w/ h/o HIV/AIDS (HIV dx 83, AIDS 92, last CD4 132, VL
>100K [**10/2203**], RF IVDU), not currently on HAART, previous right
sided bacterial endocarditis with residual 4+ TR, h/o prior MI
in [**2193**], who presents from [**Hospital **] Hospital for emergent
evaluation of pericardial tamponade.
Patient was recently hospitalized at [**Hospital1 18**] for osteomyelitis of
his L-ankle s/p prior fall. Presented to ED with fevers and
ankle pain. Taken to OR by ortho and found to have neg
brefringent crystals c/w gout. Tissue/Bone cultures grew MSSA.
Patient started on cefazolin. F/U MRI could not rule out
osteomyelitis and the patient was discharged to [**Hospital **]
hospital for 6 weeks of IV cefazolin (to end [**2203-12-5**]).
While at [**Hospital1 **], patient had uneventful course until night
prior to admission when he developed low grade temp to 100.2.
The morning of admission patient felt short of breath, lethargic
with some chest pain. Noted to be tachycardic by vitals, and
with decreased O2 sat to 90% on RA -> 96% 2L NC. Chest CT
performed showing massively enlarged cardiac silhouette.
Transfered to [**Hospital1 18**] for emergent pericardiocentesis.
On review of symptoms, 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.
In the ED, T98.8, HR 122, BP 147/87, RR 19, O2 97%. Patient
noted to be uncomfortable, and w/ rub on exam. Pulsus not
performed. Otherwise exam unremarkable. Transferred to cath lab
for emergent peridcardiocentesis.
In cath lab, pericardial pressure 35, RA and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1934**] each
30, RV systolic 55. 1.2 L of sanguinous fluid drained from the
pericardium. Pericardial pressure decreased to 5mm Hg, and RA to
18mm Hg s/p drain. Patient admitted to CCU for further
management.
Past Medical History:
- HIV/AIDS: HIV dignosed in '[**79**], AIDS diagnosed in '[**88**], last CD4
count 132, VL 100K [**2202-7-26**]. Perscribed HAART but pt reports
noncompliance for past 5 months (followed by Dr [**Last Name (STitle) 2219**] at [**Hospital1 2177**]
and NP [**Doctor Last Name **] [**Telephone/Fax (1) 2218**]) -- ONLY FATHER KNOWS DIAGNOSIS.
- Hep C
- Hep B cleared
- Myocardial infarction in [**2193**]
- h/o endocarditits with grade 4 TR - approximately 12 years ago
- Recurrent epididimitis
- h/o IVDU on methadone 80 mg QD (followed at Baycove
[**Telephone/Fax (1) 2217**])
- Asthma
- osteomyelitis (MSSA) on cefazolin
Social History:
Pt was most recently living at [**Hospital1 **]. He has a girlfriend.
[**Name (NI) **] denies tobacco, EtOH, and current drug use/abuse. He is in a
methadone program because of past IVDU.
Family History:
NC
Physical Exam:
ON ADMISSION:
VS: T 99.3, BP 132/72 , HR 105 , RR 20, O2 99% 2l NC
Gen: Caucasion male w/ mild bitemporal wasting resting
comfortably in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple. Unable to appreciate JVD as prominent carotid
pulses b/l.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. +2/6 SEM at LUSB.
Chest: Pericardial drain in place, clean, dry, intact, No
scoliosis or kyphosis. Resp were unlabored, no accessory muscle
use. Sparse basilar crackles right > left.
Abd: +BS, softly distended, non-tender, liver edge palpable
below the costal margin. No abdominial bruits.
Ext: R-AKA. Left ankle in cast, 2+ DP pulse. No c/c/e. No
femoral bruits. +line in L-groin, no bleeding, no hematoma.
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
ON DISCHARGE:
VS: 98.1 117/89 118 20 95% RA
Exam was largely unchanged. Abdomen was mildly distended, not
tender, normoactive bowel sounds. His cardiac exam was
unchanged, the pericardial drain was pulled on day 2 of
admission. Lungs were clear to auscultation bilaterally. Wound
vac was in place, with minimal drainage.
Pertinent Results:
[**2203-11-3**] 05:00PM OTHER BODY FLUID TOT PROT-6.1 GLUCOSE-69
LD(LDH)-650 AMYLASE-56 ALBUMIN-1.9
[**2203-11-3**] 05:00PM OTHER BODY FLUID WBC-2122* HCT-11* POLYS-56*
LYMPHS-27* MONOS-13* EOS-2* METAS-2*
[**2203-11-3**] 03:58PM LACTATE-3.2*
[**2203-11-3**] 03:50PM GLUCOSE-126* UREA N-38* CREAT-1.8*
SODIUM-132* POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-14
[**2203-11-3**] 03:50PM estGFR-Using this
[**2203-11-3**] 03:50PM CK(CPK)-29*
[**2203-11-3**] 03:50PM cTropnT-<0.01
[**2203-11-3**] 03:50PM CK-MB-NotDone
[**2203-11-3**] 03:50PM WBC-6.2 RBC-3.09* HGB-9.2* HCT-28.6* MCV-93
MCH-29.6 MCHC-32.0 RDW-19.5*
[**2203-11-3**] 03:50PM NEUTS-77.3* LYMPHS-17.1* MONOS-5.3 EOS-0.1
BASOS-0.2
[**2203-11-3**] 03:50PM PLT COUNT-295#
[**2203-11-3**] 03:50PM PT-15.1* PTT-38.2* INR(PT)-1.4*
Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS.
.
ECHO ([**2203-11-3**]) Pre-pericardiocentesis: The left atrium is
elongated. The estimated right atrial pressure is >20 mmHg. The
left ventricular cavity is unusually small. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). The right ventricular cavity
is moderately dilated. There is a large circumferential
pericardial effusion. Stranding is visualized within the
pericardial space c/w some organization. There is left atrial
diastolic collapse. There is right ventricular diastolic
collapse, consistent with impaired fillling/tamponade
physiology. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, consistent with
impaired ventricular filling.
Compared with the prior study (images reviewed) of [**2203-10-20**],
large pericardial effusion with echocardiographic signs of
tamponade is new.
.
ECHO ([**2203-11-3**]) Post pericardiocentesis: The left atrium is
elongated. The right atrium is markedly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (LVEF>55%). The right ventricular cavity
is markedly dilated. Right ventricular systolic function is
normal. [Intrinsic right ventricular systolic function is likely
more depressed given the severity of tricuspid regurgitation.]
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. There is no aortic valve
stenosis. The mitral valve leaflets are mildly thickened. There
is partial flail of a tricuspid valve leaflet. The tricuspid
valve leaflets fail to fully coapt. Severe [4+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2203-11-3**],
the residue pericardial effusion is minimal.
.
Cardiac catherization ([**2203-11-3**]):
1. Large circumferential pericardial effusion with tamponade
physiology.
2. Successful pericardiocentesis with drainage of 1500mls of
blood
stained fluid. Patient left cathlab in stable condition
FINAL DIAGNOSIS:
1. Severe pericardial tamponade.
2. Mild primary pulmonary hypertension.
3. Successful pericardiocentesis with drainage of 1500ml of
blood
stained fluid.
.
ECHO ([**2203-11-4**]): The left atrium is mildly dilated. The right
atrium is markedly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral and
tissue Doppler imaging suggests normal diastolic function, and a
normal left ventricular filling pressure (PCWP<12mmHg). The
right ventricular cavity is moderately dilated. Right
ventricular systolic function is borderline normal [intrinsic
function is likely depressed given the severity of tricuspid
regurgitation.]. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The tricuspid valve leaflets are
mildly thickened and appear shortened/remnants that do not fully
coapt. A small echodensity is seen on the right atrial side of
the septal leaflet - ?vegetation ?old vs. partial flail of
leaflet segment. Severe [4+] tricuspid regurgitation is seen.
There is a small (<1cm), circumferential, partially echo filled
pericardial effusion without evidence of hemodynamic compromise.
Compared with the prior study (post-pericardiocentesis, images
reviewed) of [**2203-11-3**], the findings are similar.
.
ECHO ([**2203-11-5**]): The left atrium is mildly dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). The right ventricular cavity is moderately
dilated. Right ventricular systolic function is borderline
normal. The mitral valve appears structurally normal with
trivial mitral regurgitation. The tricuspid valve leaflets are
mildly thickened and appear shortened/remnants and fail to fully
coapt. A small echodensity is again seen on the right atrial
side of the septal leaflet which could be either a vegeateion or
a partial leaflet segment. Severe [4+] tricuspid regurgitation
is seen. There is a small pericardial effusion. The effusion is
echo dense, consistent with blood, inflammation or other
cellular elements. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2203-11-4**],
the pericardial effusion is slightly smaller and may be more
echo dense. The left ventricular cavity size is probably
slightly larger (reflecting better filling). The small
echodensity on the tricuspid leaflet has not changed in size.
.
ECHO ([**2203-11-8**]): The left atrium is mildly dilated. The right
atrium is dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). The
right ventricular cavity is dilated. Right ventricular systolic
function is normal. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets fail to fully coapt.
Severe [4+] tricuspid regurgitation is seen. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2203-11-5**],
pericardial effusion now appears slightly smaller.
.
ECHO ([**2203-11-11**]):
The right atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
systolic function (LVEF>55%). The right ventricular cavity is
moderately dilated. Right ventricular systolic function is
borderline normal. The mitral valve leaflets are structurally
normal. The tricuspid valve leaflets are mildly thickened. The
tricuspid valve leaflets fail to fully coapt. There is a very
small, partially echo filled pericardial effusion.
Compared with the prior study (images reviewed) of [**2203-11-8**],
the findings are similar.
Brief Hospital Course:
41 year old male with HIV/AIDS, previous R-sided endocarditis
and severe TR, presented in cardiac tamponade from
rehabilitation.
CARDIAC TAMPONADE: On admission, he was transferred to the
cardiac catherization lab, where over one liter of fluid was
drained from his pericardial space. The fluid was sent for gram
stain, culture, AFB, [**Doctor First Name **], TB PCR as well as viral studies and
cytology. A pericardial drain was initially left in place, but
given minimal drainage over 24 hours, was pulled prior to his
transfer to the floor. The etiology of the pericardial effusion
is unknown. He was followed by Cardiology on the floor and the
initial plan was for a pericardial window, for both tissue and
to prevent reaccumulation of fluid. The patient refused the
procedure at this time. He will follow up as an outpatient to
re-evaluate for the procedure. The effusion was followed by
serial ECHO while the patient was in the hospital. There was no
evidence of re-accumulation. He is scheduled for an outpatient
ECHO in several weeks to evaluate the pericardial space for
reaccumlation of effusion.
ATRIAL FIBRILLATION/FLUTTER: Per multiple EKGs, the patient
appears to have developed new a fib/flutter. Given his guaiac
positive stools, it is not advisable to start anticoagulation at
this time. The patient is being rate controlled on a low dose
of beta-blocker, which appears to be effective. He will be
followed by outpatient Cardiology.
ANEMIA: The patient had a hematocrit drop during this admission.
His lab studies are consistent with anemia of chronic disease,
however, the patient was found to have guaiac positive stools.
GI was consulted and recommeded colonoscopy and EGD. The
patient was unable to tolerate the prep and thus the colonoscopy
was cancelled. His EGD demonstrated gastritis and thrush. He
was started on fluconazole to treat the thrush. He was also
transfused two units of packed red blood cells with an
appropriate hematocrit response.
HIV/AIDS: The patient had a CD4 count checked during his last
admission, it was found to be 132 with a viral load >100K.
Given his past noncompliance with HAART therapy and the risk of
developing drug resistant HIV, HAART was not restarted. Pt is
willing to restart HARRT, and the plan remains to restart
medications at rehabilitation. Bactrim was continued for PCP
[**Name Initial (PRE) 1102**].
OSTEOMYELITIS: The patient was previously admitted for left
ankle pain. He was followed previously by both the orthopedic
and ID services. Both services continued to follow the patient
on this admission. The patient was continued on 6 weeks of IV
antibiotics (last day of cefazolin [**2203-12-5**]), although the dose
was decreased to 1g q6 because of a low white blood count.
SEVERE TRICUSPID REGURGITATION: Pt with known grade 4 TR and
flail leaflet which he deveoped after acute bacterial
endocarditis roughly 10 years ago. We restarted his lasix and
spironolactone on this admission.
HCV: HCV viral load checked, and found to be 1.5 million. No
further therapy initiated.
ANXIETY: Pt with history of anxiety and on Klonapin at home.
His home regimen was continued.
ESOPHAGEAL CANDIDIASIS: Patient was found to have thrush on EGD.
He was started on a course of fluconazole given his
immunosupressed state. He is being discharged to complete a two
week course of anti-fungal medication.
Medications on Admission:
cefazolin 2g IV q8
methadone 80mg PO qd (confirmed on prior admit)
prednisone 10mg qd
lovenox 40mg SQ
prilosec 20mg PO qd
ASA 81mg PO daily
colace 100mg PO daily
clonazepam 1mg qAM, 1mg qNoon, 2mg qhs prn
sennekot 2 tabs PO BID PRN
morphine sulfate IR 15mg PO q4 PRN
promethazine 12.5mg PO q4h PRN
Discharge Medications:
1. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble
PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q 12 NOON ().
7. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)) as needed for anxiety.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 14 days.
17. 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.
18. Cefazolin 1 gram Recon Soln Sig: One (1) Intravenous every
six (6) hours for until [**2203-12-5**] weeks: please continue until
[**2203-12-5**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnosis:
Cardiac tamponade
GI Bleeding
Atrial flutter
[**Female First Name (un) 564**] esophagitis
Secondary diagnosis:
Pancytopenia
HIV/AIDS
Hepatitis B and C
Endocarditits with flail tricuspic valve
Right heart failure.
Recurrent epididymitis
IVDU on methadone 80 mg QD (followed at Baycove [**Telephone/Fax (1) 2217**])
?Myocardial infarction in [**2193**]
Asthma
LLE medial MSSA foot abscess/osteomyelitis.
Gout
Traumatic Right AKA
PCP
Anxiety and depression.
PPD (+) treated with 6 months INH
Discharge Condition:
Stable without fluid reaccumulation per ECHO
Discharge Instructions:
You were admitted with shortness of breath. You were
found to have fluid around your heart. The fluid was removed
but no specific cause was identified. If you have any chest
pain or shortness of breath, please alert your doctors
[**Name5 (PTitle) 2227**].
You will need weekly labs (specifically CBC, LFTs, BUN, and
Cr) faxed to Dr. [**Known firstname **] [**Last Name (NamePattern1) 1075**] in the Infectious [**Hospital 2228**] clinic at
[**Hospital1 18**] (fax [**Telephone/Fax (1) 432**]).
You have a wound VAC on your ankle to help with healing of the
tissue. This should be changed every 3 days by the nurses at
your facility. You will need to be seen in the [**Hospital 1957**] clinic to
determine how long you will need to have this in place.
If you have any symptoms of worsening foot pain, foot redness,
fevers, chest pain, nausea, vomiting, or any other concerning
symptoms you are to go to the emergency room.
Medication changes:
1. Lasix and spironalactone were restarted during this
admission.
2. You HAART medication was held during this admission. These
can be restarted by your ID doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) **] are at rehab.
3. You are being treated with an antibiotics called cefazolin.
You need to continue this medication until [**2203-12-5**].
Followup Instructions:
Please arrive at ORTHO XRAY (SCC 2) on [**2203-11-15**] at 7:40 AM for
x-ray *(Phone:[**Telephone/Fax (1) 1228**]).
.
Please follow up with your orthopedic doctor, [**Name6 (MD) **] [**Name8 (MD) 2229**], MD on [**2203-11-15**] at 8:00 AM (Phone:[**Telephone/Fax (1) 1228**])
.
Please follow up with [**Known firstname **] [**Name8 (MD) **], MD on [**2203-11-25**] 11:00AM
(Phone:[**Telephone/Fax (1) 457**])
.
You are scheduled for an ECHO on [**2203-11-21**] at 8 AM.
Please come to the [**Hospital Ward Name 23**] building, [**Location (un) 436**] for your
appointment.
Please follow up with Dr. [**Last Name (STitle) 2230**], CT surgery on Monday, [**11-21**] at 1:15 pm. This appointment is at [**Hospital Unit Name 2231**].
You are also scheduled for a Cardiology appointment with Dr.
[**Last Name (STitle) 2232**] on Monday, [**2203-11-28**] at 9:40 AM. This appointment
is in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**].
Please follow up with the gastroenterologists for a colonoscopy.
You can call to schedule the appointment at ([**Telephone/Fax (1) 2233**].
|
[
"42731",
"412",
"49390"
] |
Admission Date: [**2125-9-18**] Discharge Date: [**2125-9-22**]
Date of Birth: [**2052-12-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
72 year old male with history of cholangiocarcinoma is having
fever and worsening mental status changes.
Major Surgical or Invasive Procedure:
[**2125-9-18**]: ERCP with stent placment
[**2125-9-18**]: Central line placement
History of Present Illness:
72 yo male with a history of metastatic cholangiocarcinoma
called from home because he was having increased jaundice,
abdominal pain, fever and confusion. He was advised to go into
the hospital for evaluation. In the ED he was found to have
worsening LFTs and a fever with elevated lactate.
Past Medical History:
Diabetes, peripheral vascular disease,
bilateral hip replacements, and back surgery x6.
Social History:
used to work as school custodian. has 2 daughters and 2 sons.
wife died in [**2108**]. has not smoked for 25 years, and he doesn't
drink.
Family History:
mother had [**Name2 (NI) 499**] ca, s/p colectomy
Physical Exam:
VS: Temp 97.0, BP 118/46, Pulse 62, RR 19, 99% on Cool neb mask,
pain currently 0/10
Gen: alert, oriented, jaundiced male currently doing well on
cool
neb mask
HEENT: sclera icteric, MMM, OP clear
Neck: no lymphadenopathy, no thyromegally
CV: RRR, nl S1S2, no murmers
Lungs: slight crackles at bases
Lymphatics: no axillary or inguinal lymphadenopathy
Abd: mild tenderness in LUQ, no rebound or guarding, positive BS
Ext: 2+ edema below pneumoboots
Neuro: alert and oriented, moving all extremities, sensation
intact.
Pertinent Results:
On Admission: [**2125-9-18**]
WBC-14.8* RBC-3.24* Hgb-10.5* Hct-28.9* MCV-89 MCH-32.5*
MCHC-36.5* RDW-14.2 Plt Ct-357 Neuts-94.3* Bands-0 Lymphs-4.3*
Monos-1.2* Eos-0 Baso-0.2
PT-16.2* PTT-30.0 INR(PT)-1.5*
Glucose-239* UreaN-45* Creat-1.2 Na-128* K-2.7* Cl-88* HCO3-22
AnGap-21*
ALT-67* AST-83* AlkPhos-352* Amylase-50 TotBili-12.2* Lipase-61*
Calcium-8.2* Phos-3.5 Mg-1.9
Albumin-2.6*
CRP-153.6*
Lactate-5.6*
Brief Hospital Course:
Patient having fever and mental status changes at home. In the
ED he was found to have worsening LFTs and a fever with elevated
lactate. He received Vancomycin and Cefepime in the ED.
An ERCP was performed on day of admission ([**2125-9-18**]) which showed
-The common bile duct demonstrated a filling defect in the upper
portion with no filling of the left intrahepatic duct. Per
endoscopy report, a balloon sweep was performed with sludge and
purulent drainage noted.
In addition, a CT of abdomen was performed on [**2125-9-18**], this
showed:
- Stable examination of the abdomen and pelvis without change in
the multiple lobar infiltrative cholangiocarcinoma with
left-sided biliary dilatation and decompression of the right
biliary tree, via a metallic stent, which is unchanged in
position.
-Worsening bibasilar atelectasis.
Due to the apparent cholangitis, he was initially admitted to
the SICU for close observation. He was trasnferred to [**Hospital Ward Name 121**] 10
once the fever defervesced and his blood pressure was more
stable.
He was changed to Meropenem for a 3 day course and then switched
to PO Cipro to discharge home. His blood cultures were no
growth, however his bile culture grew out Pseudomonas. He will
continue on the Cipro at home.
Medications on Admission:
finasteride 5 mg daily, folic acid 1 mg daily, gabapentin 300 mg
at bedtime, oxycodone 5 mg 1 to 2 q.4h., Colace 100 mg b.i.d.,
ursodiol 300 mg t.i.d., Lasix 80 mg daily, potassium chloride 20
mEq daily, metformin 500 mg twice a day, fexofenadine 60 mg
twice a day, Zeloda 1500mg [**Hospital1 **]. (held during hospitalization)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache/pain.
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
cholangitis
Discharge Condition:
good
Discharge Instructions:
please call the transplant office @ [**Telephone/Fax (1) 72722**] for fevers >
101.5, severe nausea, vomitting, pain, change in mental status
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2125-10-1**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-10-1**] 1:10
Please f/u with ERCP / GI team. call ([**Telephone/Fax (1) 2360**] for an
appointment
Completed by:[**2125-9-27**]
|
[
"0389",
"25000"
] |
Admission Date: [**2155-9-3**] Discharge Date: [**2155-9-10**]
Date of Birth: [**2090-5-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Nausea, vomiting and hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 65F with DMI on an insulin pump, HTN p/w nausea vomiting
and SBP to 200s. Pt states that symptoms started the night
before admission with nausea and inability to keep down POs.
sugars at the time was in the 120s. Patient woke up from sleep
the morning of admission with nausea and vomiting
(non-bloody/non-bilious). Blood sugar noted to be 440. Patient
called EMS and on arrival blood sugar 381. She had a similar
presentation just over a year ago and nausea/vomiting attributed
to gastroparesis vs gastritis and esophagitis (seen on EGD). Per
patient and husband, she has been told that she has
gastroparesis [**1-3**] DM.
.
ED: bp 190/72 on arrival. Given anti-emetics and labetalol prn.
BP later 170 systolic. Given pr aspirin. iv fluids given. EKG
without change. 1st set CEs negative. Lack of iv access, so
femoral line attempted x 2 without success (one femoral arterial
stick). Patient was chest pain free. 2 peripheral ivs were
placed. ABG performed: 7.57/25/101.
Past Medical History:
1. Sciatica with h/o laminectomy.
2. DM1 for 36 years, on insulin pump
3. Hypercholesterolemia
4. h/o CP in [**2137**], cardiac cath clean - sx's felt to be ?spasms.
5. HTN
6. Hiatal hernia
7. s/p hysterectomy
Social History:
Married, lives with husband, has 4 children, smokes 10 cig/day,
occassional EtOH, no illicit drug use.
Family History:
Mother MI [**97**]'s
Father MI [**07**]'s
Physical Exam:
Vitals: T: 97.5 P: 72 BP: 132/72 R: 16 SaO2: 98% RA.
General: alert and oriented x 3, NAD
HEENT: NC/AT, PERRL, EOMI without nystagmus, anicteric sclera,
dry mucous membranes, top dentures ill fitting but no OP lesions
Neck: supple, no JVD
Pulmonary: Lungs CTA bilaterally although air movement somewhat
limited
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, nondistended, nontender, no rebound or guarding
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted, skin tanned.
Pertinent Results:
[**2155-9-3**] 12:05PM freeCa-1.09*
[**2155-9-3**] 12:05PM GLUCOSE-260* LACTATE-2.0 NA+-136 K+-4.0
CL--97*
[**2155-9-3**] 12:05PM TYPE-ART PO2-101 PCO2-25* PH-7.57* TOTAL
CO2-24 BASE XS-2
[**2155-9-3**] 01:40PM PT-12.1 PTT-26.5 INR(PT)-1.0
[**2155-9-3**] 01:40PM PLT COUNT-244
[**2155-9-3**] 01:40PM NEUTS-85.0* LYMPHS-10.4* MONOS-3.8 EOS-0.5
BASOS-0.3
[**2155-9-3**] 01:40PM WBC-8.8 RBC-4.37 HGB-14.1 HCT-40.9 MCV-94
MCH-32.2* MCHC-34.4 RDW-13.6
[**2155-9-3**] 01:40PM ALBUMIN-4.4 CALCIUM-10.2 PHOSPHATE-1.5*#
MAGNESIUM-1.9
[**2155-9-3**] 01:40PM CK-MB-NotDone
[**2155-9-3**] 01:40PM ALT(SGPT)-31 AST(SGOT)-34 CK(CPK)-99 ALK
PHOS-102 AMYLASE-46
[**2155-9-3**] 01:40PM estGFR-Using this
[**2155-9-3**] 01:40PM GLUCOSE-227* UREA N-40* CREAT-1.5* SODIUM-135
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-20* ANION GAP-20
[**2155-9-3**] 01:56PM LACTATE-2.4*
[**2155-9-3**] 02:00PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2155-9-3**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2155-9-3**] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2155-9-3**] 02:00PM URINE GR HOLD-HOLD
[**2155-9-3**] 02:00PM URINE HOURS-RANDOM
[**2155-9-3**] 07:20PM PLT COUNT-221
[**2155-9-3**] 07:20PM WBC-8.5 RBC-3.77* HGB-12.4 HCT-37.2 MCV-99*
MCH-32.9* MCHC-33.3 RDW-13.1
[**2155-9-3**] 07:20PM CALCIUM-8.1* PHOSPHATE-3.1# MAGNESIUM-1.6
[**2155-9-3**] 07:20PM CK-MB-5 cTropnT-<0.01
[**2155-9-3**] 07:20PM CK(CPK)-93
[**2155-9-3**] 07:20PM GLUCOSE-222* UREA N-30* CREAT-1.1 SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-19
Brief Hospital Course:
In [**Hospital Unit Name 153**]: pt was kept NPO due to persistent nausea and vomiting.
she was started on iv reglan as well as other antiemetics. her
symptoms are improving but not yet resolved. her blood pressure
was better controlled with a combination of captopril, clonidine
and labetalol iv. will need to further titrate dose as well as
consolidate and switch to po when tolerating. pt's dm was
aggressively managed with iv rehydration and insulin. her gap
has since closed and sugar came down. [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recommendation, her insulin pump's d'ced while she's not able to
tolerate po. she's currently on glargin baseline and sliding
scale. she's to restart insulin pump once tolerating po.
.
#) Nausea/vomiting - felt due to gastroparesis. Improved with
IV antiemetics. Was ultimately controlled with oral reglan. By
discharge, this had resolved.
.
#) HTN - no evidence of end organ damage seen. Initially
treated with IV labetolol, and this was changed to oral
formulation by discharge. Her ace inhibitor was continued.
Clonidine patch was started. BP was well controlled at
discharge.
.
#) DMI - on insulin pump at home. Presented with ketones in
urine and AG = 16 suggestive of mild DKA. Started on IVF
resuscitation and insulin gtt for improved control - gap
resolved and BG controlled. Transitioned to lantus and lispro
(HS and sliding scale) and pump turned off. [**Last Name (un) **] consulted.
Agreed with this plan. Plan to leave pump of indefinately.
.
#) Sciatica - [**Last Name (un) 16604**] and oxycodone held in hospital as pt.
was slightly confused on presentation. This was not restarted,
and she did not experience overt opiate withdrawal. At the time
of discharge, she was not complaining of back pain, so the
opiates were not restarted/continued.
.
Pneumococcal vaccine status confirmed (last [**2152**]); gave
influenza vaccine.
Medications on Admission:
albuterol inh prn
?aspirin 325mg daily
calcitriol 0.5mcg po daily
citalopram 40mg daily
Humalog pump
lisinopril 30mg daily
lorazepam 0.5mg daily prn
neurontin 800mg po qam, qpm, 1600mg qhs
[**Year (4 digits) 16604**] 40mg qam and 10mg qhs
oxycodone 5mg po q6hrs prn
ranitidine 300mg po qday
reglan 10mg po qid
zocor 40mg daily
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
2. Gabapentin 400 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
Disp:*120 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety or insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
10. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSAT (every Saturday).
Disp:*4 Patch Weekly(s)* Refills:*2*
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28)
Units, insulin Subcutaneous at bedtime.
Disp:*10 mL* Refills:*2*
14. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale (attached) Units, insulin Subcutaneous QACHS insulin.
Disp:*6 mL* Refills:*2*
15. Syringe Misc Sig: One Hundred (100) syringes, insulin
Miscellaneous as directed.
Disp:*100 syringes, insulin* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperglycemia and hypertensive crisis
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Return to the Emergency Department at [**Hospital1 18**] for:
Lightheadedness, nausea, vomiting, uncontrolled high blood
pressure or blood sugar, headache, changes in vision
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2155-9-15**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2155-10-1**] 10:40
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2155-12-18**] 7:50
|
[
"V5867",
"2720"
] |
Admission Date: [**2152-6-29**] Discharge Date: [**2152-7-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypertensive emergency with AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 96278**] is a [**Age over 90 **] year old female with history of poorly
controlled hypertension (reported baseline SBP of 170),
dementia; admit with HTN emergency and mental status changes.
Patient had emesis x3, blood-tinged with last episode, at [**Hospital1 1501**]
this morning. She was hypertensive to SBP 190-240/70-90 there
without significant improvement after her morning meds.
In the ED, SBP 270/80, HR 76, afebrile. Had emesis x1; NGL done
with some guaiac positive return (coffee ground appearing). NGT
kept in place, 200 cc total returned to suction. GI consulted,
felt likely [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear; would EGD only if continued
hematemesis and BP more stable. BP wise, brought down to goal
~190 with labetalol gtt. EKG with isolated TWI in V6, 1st set
enzymes negative. There was concern for mental status changes
(at baseline "pleasantly confused", per last d/c summary vaguely
oriented to time/place); in ED patient oriented to self and
agitated requiring restraints to keep patient from pulling out
NGT. Had head CT with no brain pathology but concern for
intraocular hemorrhage on initial read. Other workup included
lactate 2.2, CXR and U/A unremarkable.
Past Medical History:
PAST MEDICAL HISTORY
- Hypertension, difficult to control per PCP; baseline
reportedly 170s
- Congestive heart failure, EF unknown
- Borderline DM2
- Chronic kidney disease stage IV (baseline Cre 1.6-1.8)
- Osteoarthritis s/p L THR
- Dementia
- Hypothyroidism, recently started on levothyroxine (last month)
Social History:
Lives at [**Hospital3 2558**]. Power of Attorney is brother [**Name (NI) **]
[**Name (NI) 102210**]. Denies tobacco, EtOH.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 97.8F, BP 151/50 (range 131/46 - 179/63 since arrival
to ICU) P 75, RR 19, 98% SaO2 on 2 L NC
General: NAD, well nourished elderly female
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: supple, no nuchal rigidity, bilateral carotid bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MRG
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated
Skin: no rashes
Neurologic Examination:
Mental Status:
Awake and alert, but poor attention; follows simple commands
only intermittently
Oriented to person but cannot/will not state time or place.
Language: perseverative; to question of name, answered "[**Known firstname 102211**]
[**Last Name (NamePattern1) 102212**]..." and when asked to repeat, "No ifs ands or
buts," said, "No and ifs and ifs and buts and buts and..."
Calculation: not tested
Fund of knowledge: unable to assess
Memory: registration: [**2-7**] items, recall [**2-7**] items at 3 minutes
No evidence of apraxia or neglect
Cranial Nerves:
Blinks to threat. Pupils equally round and reactive to light, 4
to 3 mm bilaterally.
Extraocular movements intact, no nystagmus. Facial sensation
intact bilaterally. Facial movement normal and symmetric.
Hearing intact to finger rub bilaterally. Palate elevates
midline. Tongue protrudes midline, no fasciculations. Trapezii
full strength bilaterally.
Motor:
Normal bulk and tone throughout. No tremor or asterixis.
Able to lift all extremities off the bed but unable to cooperate
with detailed testing. According to nursing staff, she was
pulling at tubes overnight with full strength in both arms.
Sensation: No deficits to light touch and pin-prick.
Reflexes: B T Br Pa Pl
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes were downgoing bilaterally.
Coordination: No intention tremor.
Gait: Unable to assess
Pertinent Results:
ADMISSION LABS:
[**2152-6-29**] 11:51AM BLOOD WBC-15.9*# RBC-5.26 Hgb-14.7 Hct-43.2
MCV-82 MCH-27.9 MCHC-34.0 RDW-13.1 Plt Ct-272
[**2152-6-29**] 11:51AM BLOOD Neuts-94.2* Bands-0 Lymphs-3.9*
Monos-1.2* Eos-0.3 Baso-0.5
[**2152-6-29**] 11:51AM BLOOD Glucose-223* UreaN-26* Creat-1.3* Na-138
K-4.0 Cl-101 HCO3-22 AnGap-19
[**2152-6-29**] 11:51AM BLOOD cTropnT-<0.01
[**2152-6-29**] 11:51AM BLOOD ALT-10 AST-15 CK(CPK)-43 AlkPhos-76
TotBili-0.6
[**2152-6-29**] 08:32PM BLOOD TSH-0.29
[**2152-6-29**] 08:32PM BLOOD Free T4-2.3*
[**2152-6-29**] 12:11PM BLOOD Lactate-2.2*
[**2152-6-29**] 10:17PM BLOOD Lactate-3.8*
[**2152-6-30**] 04:31AM BLOOD Lactate-2.0
NOTABLE DISCHARGE LABS:
Cr 1.2, BUN 19
WBC 14.1
HCT 38.8
INR 1.6
MICROBIOLOGY:
[**6-29**], [**2152-7-2**] Urine Cultures: negative
[**2152-7-7**] Urine Cultures: NGTD
[**2152-7-2**] Urine Legionella: negative
[**6-29**], [**7-2**], [**2152-7-6**] Blood Cultures: negative
[**2152-7-6**] Stool C. diff toxins A & B: negative
CT HEAD W/O CONTRAST Study Date of [**2152-6-29**] 11:56 AM
HISTORY: Altered mental status, systolic blood pressure 200's,
nausea and
vomiting. Rule out intracranial bleed.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT.
CT OF THE HEAD WITHOUT CONTRAST: There is no evidence of masses,
hydrocephalus, shift of normally midline structures, infarction,
or hemorrhage. Bilateral basal ganglia calcifications are seen.
The ventricles and sulci are prominent consistent with
age-related atrophy. Vascular calcifications are seen. Confluent
hypodensities within the periventricular white matter likely
represent chronic microvascular ischemia. The osseous structures
demonstrate hyperostosis frontalis interna. The surrounding soft
tissues are unremarkable. The visualized paranasal sinuses are
clear. Partial opacification of the mastoid air cells
bilaterally is noted. A right scleral band is seen around the
right globe.
IMPRESSION: No intracranial hemorrhage.
CT ABDOMEN W/CONTRAST Study Date of [**2152-6-29**] 2:53 PM
INDICATION: [**Age over 90 **]-year-old female with vomiting and abdominal pain.
COMPARISON: Abdominal radiographs from same day.
TECHNIQUE: MDCT-acquired axial imaging of the abdomen and pelvis
was performed following administration of oral and intravenous
contrast. Multiplanar reformatted images were obtained and
reviewed.
CT ABDOMEN: There is mild dependent bibasilar atelectasis. Liver
is
unremarkable. There is a thin crescent of hyperdensity layering
in the
gallbladder fundus, which may represent a tiny amount of [**Doctor Last Name 5691**]
versus a small focus of adenomyomatosis. Gallbladder is
otherwise unremarkable. Pancreas is atrophic and fatty replaced.
Spleen is unremarkable. Adrenal glands and kidneys are
unremarkable. There is no hydronephrosis. Stomach and
intra-abdominal loops of bowel are unremarkable. Nasogastric
tube is in place, tip in the gastric body. There is a moderate
axial hiatal hernia and a small fat-containing ventral hernia.
There is no free air, free fluid, or abnormal intra- abdominal
lymphadenopathy. There is mild atherosclerotic calcified and
noncalcified plaque throughout the abdominal vasculature.
CT PELVIS: Pelvic loops of large and small bowel are
unremarkable, except to note sigmoid diverticulosis. Evaluation
of the deep pelvic structures is limited by streak artifact from
bilateral hip replacements. There is no definite free pelvic
fluid. There is no abnormal pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: There is no osseous lesion suspicious for
malignancy.
Multilevel degenerative changes in the thoracolumbar spine are
noted, with
moderate dextroconvex thoracolumbar scoliosis.
IMPRESSION:
1. No specific CT finding to explain hematemesis and abdominal
pain.
2. Moderate axial hiatal hernia.
3. Diverticulosis, without evidence of diverticulitis.
4. Small fat-containing ventral hernia.
ECHO [**2152-6-30**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). A mild apical intracavitary gradient is identified.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: hypertrophic, hyperdynamic left ventricle
Chest X-ray, PA and Laterl [**2152-7-2**]:
The lungs are hyperinflated and the diaphragms are flattened,
consistent with COPD. There are low inspiratory volumes.
Allowing for this, there is
probable moderate cardiomegaly and mild unfolding of the aorta.
The ascending aorta is prominent, consistent with chronic
hypertension. There is upper zone re-distribution, but I doubt
overt CHF. There is a small right pleural effusion posteriorly.
There is also minimal blunting of both costophrenic angles. No
focal infiltrate is identified.
Sinus rhythm with supraventricular premature depolarizations.
Marked
lateral ST segment depressions. Compared to the previous tracing
sinus rhythm
is now present with overall reduced ventricular rate and
diminished ischemic
ST segment depression.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 142 96 444/463 86 64 169
ECG - [**2152-7-4**] - Ectopic atrial rhythm with ventricular premature
depolarizations. Inferior myocardial infarction. Short P-R
interval with abnormal P wave axis raising consideration of
ectopic atrial rhythm. Diffuse non-diagnostic repolarization
abnormalities. Compared to the previous tracing of [**2152-7-3**] an
ectopic atrial rhythm is now present with inferior myocardial
infarction pattern.
Shoulder XR [**2152-7-4**] - IMPRESSION: No acute fracture detected
involving the proximal humerus or
shoulder girdle. Possible old healed proximal humeral fracture.
Probable
chronic rotator cuff tear. Superior and anterior subluxation of
humeral head
with respect to glenoid, but no frank dislocation.
CXR [**2152-7-4**] - Lung volumes are low, particularly elevation of
the left lung base, new. Some of this may be due to left lower
lobe atelectasis. Heart size top normal, unchanged. No pulmonary
edema or vascular redistribution to suggest heart failure. No
appreciable pleural effusion. This examination is not designed
for detection of rib fractures which are easily missed.
ECG - [**2152-7-6**] - 7AM - Atrial fibrillation, mean ventricular rate
128. Compared to the previous tracing no major change.Rate
PR QRS QT/QTc P QRS T
128 0.86 312/431 0 -9 -155
Brief Hospital Course:
HYPERTENSION, HYPERTENSIVE EMERGENCY, ALTERED MENTAL STATUS:
Ms. [**Known lastname 96278**] was initially admitted to the MICU after coming from
the ED on a labetolol drip for her hypertension. Once in the
MICU, neurology was consulted for altered mental status,
non-fluent aphasia and possible left-sided neglect. Neurology
ultimately felt her presentation was consistent with transient
worsening of her dementia from relative
hypotension/hypoperfusion in the setting of aggressive blood
pressure reduction. SBP was at one point 110 - 120 while on the
beta-blocker drip. Neurology recommended maintaining SBP within
the 160 - 180 range, which was attained off medicines. After 24
hours of blood pressures in this range, mental status and speech
returned to baseline. She had no residual deficits and was at
her baseline dementia. Head CT showed no evidence of bleed.
Since she recovered to baseline, further MRI studies were not
deemed necessary. At discharge she was conversant, pleasant and
was able to follow multistep commands. She had registration but
significantly impaired recall at 5 minutes, with no improvement
with prompting or lists.
Two days after being called out to the floor from the MICU, her
blood pressure began to increase and she was restarted on
lisinopril 40mg, HCTZ 25m, with PRN hydralazine. On [**2152-7-2**],
she then dropped her systolic BP to the 70's when her rhythm
changed from sinus to atrial fibrillation with RVR. She was
noted to have ST segment depressions in I, II, AVL, V3, V4, V5,
V6 and ST elevation in III, AVR, VI. She did not respond to IV
metoprolol, and as pacer pads were being placed she developed
ventricular fibrillation. She became pulseless for which chest
compressions were initiated and the patient was given 1 shock.
NSR was reattained and patient regained consciousness. Repeat
EKG showed NSR, but continued, however to show lessened ST
changes as above. A right femoral central line placed, heparin
bolus and gtt initiated for a STEMI.
She was transferred to the CCU conversant and, on [**7-3**], was
started on 20 mg LISINOPRIL, 25 mg METOPROLOL [**Hospital1 **], and NORVASC 5
mg daily for a low SBP goal of 160 based on the patient's
longstanding hypertension in the 170's. Her IV heparin was
discontinued, and SC heparin started due to the risk of
bleeding. Her troponins were elevated (max 5.3) and trended
down with medical managment of her ischemia, thought to be [**1-8**]
demand during the afib episodes. She was started on ASA,
continued on beta blocker, ACEI and high dose statin. She was
continued on these medications throughout the hospitalization.
GIbIIa inhibitor was not started due to concern for acute
bleeding.
ATRIAL FIBRILLATION:
Once patient was hemodynamically stable, she was transferred
back to the floor on [**7-4**], where she continued to have episodes
of atrial fibrillation with RVR. She was difficult to controll
with IV beta blockade and responded transiently to cardizem IV.
She was started on cardizem PO 60mg qid, with marginal control
of HR (90s - 100s) with frequent reversions to fibrillation. On
[**7-5**], patient was started on amoiodarone loading dose of 400mg
QD. She converted to sinus rhythm of ~ 50 - 60. She had
occasional reversions to atrial fibrillation on [**7-5**] - [**7-6**],
which were converted to sinus rhythm with 20mg IV doses of
cardizem. Her rhythm was controlled for over 24 hours prior to
discharge. Patient was also noted to have 2 asymptomatic
pauses of 3 - 5 seconds each. She was evaluated by EP and
ordered a 30 day heart monitor to be triggered for HR < 40 or >
100. She has a follow up appointment with Dr. [**Last Name (STitle) **]
regarding atrial fibrillation control and suspected tachy-brady
syndrome.
Because of frequent conversions from atrial fibrillatin to sinus
rhythm, her age and her history of hypertension and diabetes,
patient was deemed a candidate for anticoagulation. She was
started on coumadin 2mg PO daily on [**2152-7-5**], which was increased
subsequently to 4mg PO daily on [**2152-7-6**]. Her INR on [**2152-7-7**] was
1.6. She should have her INR measured daily and warfarin dosing
adjusted to goal of INR 2 - 3.
LEUKOCYTOSIS:
She was noted to have leukocytosis on admission. The workup for
this has remained negative throughout hospitalization, and may
have been a stress response although blood cultures were pending
at discharge (multiple earlier sets were negative). Her urine
cultures, C.diff and legionella were negative. She was afebrile
throughout and was never on antibiotics while in-house.
UPPER GI BLEED:
The day of admission, Ms. [**Known lastname 96278**] has several episodes of emesis
thought to be from GI upset in the setting of the severe
hypertension. The last episode of emesis was coffee-grounds and
guaiac positive. The GI service was consulted and felt this was
due to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear, and she was never scoped. Her
bleeding appeared to resolve as her Hct was stable throughout
the admission and she had no further episodes of emesis. She
was placed on PO protonix. She did test positive for H.Pylori
by EIA, but was not treated due to no signs of acute bleeding
and the risks associated with long term antibiotic treatment in
a geriatric patient.
On [**7-4**] patient was noted to have right sided abdominal pain on
deep palpation. Negative [**Doctor Last Name **], no signs of acute abdomen
were noted on exam. Pt. has a ventral hernia on CT from [**6-29**],
but no other abdominal process to explain the pain. Her lactate
was 1.3. LFTs normalized by [**2152-7-6**]. Pain was well controlled
with APAP. She should be reevaluated with serial abdominal
exams for follow up.
LEFT SHOULDER PAIN:
Left shoulder and chest wall pain were also noted on [**7-4**].
These were reproducible w/ palpation, and with shoulder ROM
manipulation. Patient also had supraspinatus tenderness, no
apprehension sign. Given recent chest compressions when she was
coded, there was concern for fractures. X-ray did not show
fractures of the ribs or shoulder/humerus. Shoulder x-ray
showed probable rotator cuff tear. She was treated by physical
therapy and acetaminophen around the clock.
HYPOTHYROIDISM:
The patient has a history of hypothyroidism and her synthroid
had been recently increased from 50 to 225 mcg in the course of
1 month, and while at [**Hospital1 18**], she has been given 50 mg given
concern for overmedication causing AFib.
CHRONIC KIDNEY DISEASE:
At baseline, patient has CKD with likely etiology being HTN.
Baseline reportedly 1.6-1.8. Cr improved to 1.2 with 250 - 500
NS boluses daily and remained stable stable [**7-4**] - [**7-7**]. Patient
will require renal dosing of medications.
SCLERAL BUCKLE:
Opthalmology also consulted for a possible intraocular
hemorrhage that was seen on CT on admission. Ophthalmology
thought the scleral buckle was secondary to prior repair of
retinal detachment.
CODE STATUS, COMMUNICATION:
The patient is a poor candidate for invasive procedures given
her age and baseline dementia. Her brother, [**Name (NI) **] [**Name (NI) 102210**] is
her health care proxy and her current status is DNR/DNI. He can
be reached at ([**Telephone/Fax (1) 102213**] or [**Telephone/Fax (1) 102214**].
PENDING ISSUES FOR FOLLOW-UP:
1. Patient is on coumadin and will require daily measurements of
PT/INR and adjustment of her coumadin dose to achieve goal INR
of 2 - 3.
2. Patient was started on amiodarone for atrial fibrillation
with rapid ventricular response. She should be continued on
this medication at a dose of 400mg daily for another 10 days,
then on 200mg daily for another 14 days, followed by maintenance
dose. Her liver and kidney function tests should be checked
weekly and electrolytes every other day until stabilized.
3. Heart failure - patient has documented heart failure of
likely diastolic dysfunction. EF ~ 70%. She is on metoprolol
and lisinopril. Her diet is restricted as below and she has no
fluid restriction. Activity level is as per PT recommendations.
Patient should be weighed daily and monitored for symptoms of
heart failure: shortness of breath, leg edema, orthopnea. She
will be follow up by cardiology and primary care physician.
Medications on Admission:
MEDICATIONS AT HOME
Norvasc 5 mg daily (increased yesterday)
Synthroid 225 mcg daily (appears recent increase)
Lisinopril 20 mg daily
Atenolol 50 mg daily
Colace 100 mg [**Hospital1 **]
APAP 650 TID
bisacodyl prn
MOM prn
[**Name2 (NI) **]
senna [**Hospital1 **] prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous ASDIR (AS DIRECTED): As per [**Hospital1 18**] inpatient sliding
scale.
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 10 days: Then can be changed to 200mg daily for
additional 14 days, followed by maintenance dose.
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Q
1700.
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Myocardial infarction, Hypertensive emergency
Secondary: Hypertension, Atrial fibrillation, Diabetes mellitus,
Chronic kidney disease
Discharge Condition:
Hemodynamically stable
At discharge she was conversant, pleasant and was able to follow
multistep commands. She had registration but significantly
impaired recall at 5 minutes, with no improvement with prompting
or lists.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with significantly elevated blood
pressure. As you were treated for this, you had changes in your
mental state. You then developed a new arrhythmia, following
which you had a heart attack. These were thought to be due to
elevated thyroid hormones.
.
You were treated for all these complications and required
intensive care unit management. You were able to recover to
your mental state baseline. Your arrhythmias were finally
controlled with medications (see medication list below).
Finally, because of your arrhythmia (atrial fibrillation) you
were started on a medication (coumadin) to help prevent a
stroke.
You were discharged to your nursing facility in a
hemodynamically stable condition, with your heart rate
controlled.
During your hospitalization, through discussion with your health
care proxy and the medical staff, you resuscitation status was
changed to Do not resuscitate, do not intubate.
Should you experience new chest pain, shorness of breath,
difficulty speaking, dizzyness, palpitations, fever, cough, new
pain or any other symptom concerning to you, please contact your
health care provider at the rehabilitation facility or go to the
nearest emergency room.
Followup Instructions:
Please follow up with the following appointments:
You will be seen at your facility by your primary care doctor:
Dr. [**First Name (STitle) 807**].
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Hospital1 18**], [**Hospital Ward Name 23**] 7, on [**2152-8-4**] at 2pm.
[**Telephone/Fax (1) 102215**].
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2152-7-17**] 9:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2152-8-4**] 2:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"40390",
"4280",
"2449",
"42731",
"25000"
] |
Admission Date: [**2176-2-8**] Discharge Date: [**2176-2-14**]
Date of Birth: [**2098-10-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right upper lobe lung cancer.
Major Surgical or Invasive Procedure:
[**2176-2-8**] Video-assisted thoracic surgery right
upper lobectomy, video-assisted thoracic surgery right lower
lobe superior segmentectomy, mediastinal lymph node
dissection and flexible bronchoscopy.
[**2176-2-9**] Flexible Bronchoscopy
History of Present Illness:
76F who is a former smoker had a history of dry cough for the
past year. She saw her physician and had [**Name Initial (PRE) **] CXR, which showed a
RUL infiltrate. She was treated with antibiotics without
improvement. She then underwent a chest CT [**2175-5-4**], which
demonstrated a 5x3cm spiculated ilfiltrate in the RUL. She was
treated with another course of levo and had a repeat CT scan
[**2175-6-7**]. This scan showed an increase in size in the RUL
consolidation with some new fullness in the R hilum. PET-CT was
done on [**2175-9-9**], revealing intense FDG activity in the R lung
consistent with malignancy. There was also an FDG-avid area in
the proximal descending colon. The patient underwent a flex
bronch [**2175-10-19**], and the brushings and washings were negative. No
lymph nodes were biopsied. She then underwent a CT guided biopsy
of the mass which revealed NSCLC most consistent with poorly
differentiated adenocarcinoma.
Past Medical History:
Cardiomyopathy
Macular degeneration
Detached retina
Spinal Stenosis
Asthma w h/o intubation,
Arthritis
osteoporosis
Open cholecystectomy in the [**2135**].
Cataract extraction bilateral
Social History:
Lives with family. 25 pack-year quit 12 years ago. ETOH
occasional
Family History:
Siblings - sister w pancreas ca, brother w [**Name2 (NI) 500**] cancer
Physical Exam:
VS: T: 98.8 HR 94 SR BP: 108/60 Sats: 96% 3L
General: no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds on right with scattered rhonchi
GI: benign
Extr: warm no edema
Incision: Right VATs site clean dry intact no erythema
Neuro: non-focal
Pertinent Results:
[**2176-2-14**] WBC-9.6 RBC-2.88* Hgb-9.0* Hct-27.5 Plt Ct-433
[**2176-2-13**] WBC-7.5 RBC-3.15* Hgb-9.6* Hct-29.4 Plt Ct-396
[**2176-2-11**] WBC-11.2* RBC-2.95* Hgb-9.2* Hct 30 Plt Ct-290
[**2176-2-9**] WBC-13.5* RBC-3.26* Hgb-10.5* Hct-31.0* Plt Ct-354
[**2176-2-8**] WBC-18.6*# RBC-3.97* Hgb-12.6 Hct-37.6 Plt Ct-413
[**2176-2-8**] WBC-6.9 RBC-3.84* Hgb-11.7* Hct-35.2* Plt Ct-377
[**2176-2-14**] Glucose-110* UreaN-10 Creat-0.8 Na-135 K-4.4 Cl-100
HCO3-27
[**2176-2-13**] Glucose-102* UreaN-9 Creat-0.8 Na-137 K-3.9 Cl-100
HCO3-27
[**2176-2-9**] Glucose-132* UreaN-16 Creat-1.3* Na-137 K-4.1 Cl-104
HCO3-26
[**2176-2-9**] Glucose-192* UreaN-19 Creat-1.9* Na-137 K-4.8 Cl-101
HCO3-26
[**2176-2-8**] Glucose-227* UreaN-17 Creat-1.5* Na-139 K-4.8 Cl-100
HCO3-26
[**2176-2-8**] Glucose-158* UreaN-14 Creat-1.2* Na-140 K-4.2 Cl-105
HCO3-24
[**2176-2-9**] CK(CPK)-245* [**2176-2-9**] CK(CPK)-349*
[**2176-2-14**] Calcium-9.0 Phos-2.9 Mg-1.9
[**2176-2-13**] Calcium-8.8 Phos-2.9 Mg-2.3
[**2176-2-9**] pO2-172* pCO2-64* pH-7.22* calTCO2-28 Base XS--2
NON-REBREA
[**2176-2-10**] Type-ART pO2-111* pCO2-52* pH-7.32* calTCO2-28 Base
XS-0
[**2176-2-10**] Type-ART pO2-102 pCO2-48* pH-7.34* calTCO2-27 Base XS-0
[**2176-2-11**] ART pO2-131* pCO2-37 pH-7.41 calTCO2-24 Base XS-0
CXR:
[**2176-2-13**] FINDINGS: In comparison with the study of [**2-12**], the
postoperative changes are again seen in the right hemithorax.
This includes the mediastinal and tracheal displacement as well
as distortion of the right hilus. The left lung remains
essentially clear except for some atelectatic streaks at the
base. There appears to be a hiatal hernia in the retrocardiac
region on the lateral projection.
[**2176-2-11**] Tiny loculated right apical pneumothorax unchanged,
small to moderate right pleural effusion probably decreasing,
pleural tubes still in place. Mild cardiomegaly stable. Hiatus
hernia noted. Left upper lung clear.
[**2176-2-9**]: In comparison with the study of [**2-8**], right chest tube
again
extends to the apex and descends inferiorly to terminate at the
level of the hemidiaphragm. The small to moderate right apical
pneumothorax is again seen, though quite subtle. Right perihilar
opacity persists, most likely representing a combination of
atelectasis and contusion in this recently postoperative
patient. Left lung remains essentially clear.
Micro: BC x 2 no growth to date, Ucx negative, sputum rare
yeast
Brief Hospital Course:
Mrs. [**Known lastname 25780**] was admitted on [**2176-2-8**] for Video-assisted
thoracic surgery right
upper lobectomy, video-assisted thoracic surgery right lower
lobe superior segmentectomy, mediastinal lymph node dissection
and flexible bronchoscopy. She was extubated in the operating
room and monitored in the PACU prior transfer to the floor.
Overnight she developed respiratory distress and was
re-intubated and transferred to the SICU for respiratory
failure. Aggressive pulmonary toilet, mucolytic nebs were
administered.
Respiratory: Respiratory failure [**2176-2-9**] re-intubated on a
vent, sedated, unable to to protect her airway and manage
secretions. Aggressive pulmonary toilet, mucolytic nebs were
administered. Followed by serial ABGs (see above). On [**2176-2-10**]
she was extubated with oxygen saturations in the 94-98% with
occasional desaturations to low 90's on 50% shovel mask.
Aggressive chest PT was administered her oxygen saturations
improved 94-97% on 4 Liters nasal cannula. She transferred to
the floor on [**2176-2-12**]. Oxygen saturations remained > 93% at rest
on 3Liters of nasal cannula with desaturations to 88% with
acitivity. She required home oxygen to maintain oxygen
saturations > 93%.
Flexible bronchoscopy was performed on [**2176-2-10**] which showed
slight effacement of right middle lobe medial segment.
[**Doctor Last Name 406**] drain: right was removed on [**2176-2-10**]. She was followed by
serial chest films which showed atelectasis and stable right
apical space.
Cardiac: she remained hemodynamically stable in sinus rhythm.
GI: prophylactis PPIs and bowel regime were administered
Nutrition: She tolerated a regular diet.
Speech: Speech and swallow consulted for a weak voice. Vocal
cord paralysis since [**2164**] no signs of aspiration. Continue with
regular diet, thin liquids, medications whole. F/U with voice
therapy as an outpatient.
Renal: ATN with peak CRE 1.9 base 1.1-1.3. She was hydrated
with CRE return to baseline. On [**2176-2-12**] she was gently diuresed
with IV lasix with good Urine output.
On [**2176-2-13**] she restarted her home lasix dose. Electrolytes were
repleted as needed.
Pain: Acute on chronic pain. history of spinal stenosis takes
home oxycodone. She was started with a Dilaudid PCA titrated to
comfort. Once extubated she was converted to PO oxycodone with
good pain control.
Disposition: Physical therapy recommended Short term rehab. She
was discharged [**2176-2-14**] to [**Hospital1 **] in [**Location (un) 701**].
Medications on Admission:
Furosemide 20 mg a day, amlodipine 5 mg a day, Nexium 40 mg a
day, Cymbalta 60 mg a day, Lipitor 10 mg daily, aspirin 81 mg
daily, meclizine 25 mg three times a day as needed, oxycodone
one tablet five times a day, Flovent two puffs
twice a day, albuterol as needed, Actonel 150 mg once a month,
multivitamin one tablet a day, vitamin C 500 mg daily, calcium
plus D 600 mg two tablets per day, vitamin E 400 international
units per day, flaxseed oil 1000 mg, and omega-3 tablets three
times a day, Ocuvite one drop per day.
Discharge Medications:
1. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
10. Meclizine 25 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for vertigo.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Right upper lobe nodule
Cardiomyopathy
Macular degeneration
Detached retina
Spinal Stenosis
Asthma w h/o intubation,
Arthritis
Osteoporosis
Open cholecystectomy in the [**2135**].
Cataract extraction bilateral
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Call Dr.[**Name (NI) 25781**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills
-Increased shortness of breath cough or sputum production
-Chest pain
-Incision develops drainage
-You may shower no tub bathing or swimming for 3 weeks
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2176-2-29**]
2:30
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Chest X-Ray 2:00pm before your appointment on the [**Location (un) 861**]
Radiology Department
Completed by:[**2176-2-16**]
|
[
"5180",
"49390",
"5845"
] |
Admission Date: [**2128-12-29**] Discharge Date: [**2129-1-3**]
Service: MEDICINE
Allergies:
Feldene / Ceftriaxone / Augmentin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo [**Age over 90 **] speaking female with severe Parkinson's, CRI,
recurrent UTI's, diastolic CHF, afib, dementia, ppm for
bradycardia who presented from NH for ? PNA and dehydration,
found to be persistently hypotensive in ED and transferred to
MICU for possible sepsis. History is obtained from daughter, as
patient is noncommuncative currently. Per daughter, patient was
in USOH (baseline includes some eating, drinking, wathcing tv,
looking at pictures, and somewhat verbal to daughter) until
[**Name (NI) 2974**] when appetite declined. Labs sent with nothing revealing.
On Sunday patient stopped eating and began sleeping all of the
time. Tues CXR done which demonstrated possible PNA vs CHF. No
cough, fever. Levofloxacin x 1 given. Sent to ED for possible
PNA and dehydration.
.
Vitals were initially stable in ED until pt became hypotensive
to systolic of 70's. Pancultured and given ceftriaxone (has true
allergy to this), vancomycin 1000mg x 1, flagyl 500 mg x 1, and
dexamethasone 10 mg IV x 1. Central line placed (unable to get
in touch with daughter to get permission for this) and started
on levophed. Also guaic positive in ED.
.
Of note the patient has been admitted in the past ([**2128-7-10**])
for urosepsis treated with Augmentin after patient got AIN s/p
Ceftriaxone, then again in [**2128-8-10**] with change in mental
status & possible urosepsis but cultures negative. Most recent
admission in [**Month (only) 359**] for UTI with possible urosepsis (E. coli in
urine, MSSA in blood, treated with meropenem), PNA,
hypernatremia.
.
ROS: Unable to obtain from patient. Per daughter, afebrile, more
sleepy, no SOB, cough, URI sxs, CP, abd pain, diarrhea,
constipation. Lives in [**Location **] so +sick contacts.
Past Medical History:
#Recurrent urinary tract infections
#Congestive heart failure with a normal EF, 4+ MR. [**First Name (Titles) **] [**Last Name (Titles) 113**]
[**2121**]
#Bipolar disorder
#Parkinson's disease
#Asthma
#OA
#s/p DDD pacer in [**2121**] for bradycardia.
Social History:
Lives [**Hospital3 **]. Daughter is [**First Name5 (NamePattern1) 335**] [**Last Name (NamePattern1) 111445**] who is on
staff at [**Hospital1 18**] as [**Hospital1 595**] interpreter (beeper [**Numeric Identifier 111446**])
Family History:
Non contributory
Physical Exam:
per admitting resident:
Vitals: 97.1, 91, 84/58 (MAP 62), 22, 100% on 2L
HEENT: PERRL, left eye closed, unable to assess EOM, anicteric
sclera, MMM, OP clear
Neck: supple, no LAD, no thyromegaly
Cardiac: RRR, NL S1 and S2, no MRGs
Lungs: crackle at right base, o/w CTAB
Abd: soft, NTND, NABS, no HSM, no rebound or guarding
Ext: contracted, warm, 2+DP
Neuro: unable to fully assess d/t patient
noncompliance/unresponsiveness. CN III intact, will not squeeze
hands or follow commands
Pertinent Results:
Labs:
[**12-29**] INR 7.5 (NH)
Na 158(from 157 day prior) , K 5.7, Cl 121, HCO317, BUN 77, Cr
6.7 (from 6.9 day prior)
.
Studies:
UA: tr leuks, neg nit, [**3-14**] WBC, few bact, tr ket, sm bili
.
CXR:
Dual chamber pacer in place. Left lower lobe with consolidation
and possibly a left pleural effusion.
.
EKG: NSR, LAD, poor R wave progression, Q wave in III and V1,
0.[**Street Address(2) 1755**] depressions in V4-V6.
.
CT Head: Moderate size bilateral occipital lobe low density
zones- consider vertebrobasilar infarction. Involvement of
cortex argues against infection. Hypertensive encephalopathy is
possible, but requires clinical correlation.
.
[**Street Address(2) **] [**2128-11-9**]:
Mild LVF. EF nml (>55%). RV nml. Mild AR. Trivial MR.
.
Brief Hospital Course:
[**Age over 90 **] yo [**Age over 90 **] speaking female with severe Parkinson's, CRI,
recurrent UTI's, diastolic CHF, afib, dementia, ppm for
bradycardia who presented with a possible PNA and dehydration,
found to be persistently hypotensive in emergency department and
transferred to MICU for possible sepsis. Patient had a history
of multiple recent previous admissions. The patient presented
hypotensive and somnolent. She was given IV fluid resuscitation
and broad antbiotic coverage, she also was started on pressors.
Her head CT showed changes consistent with vertebrobasilar
infarction rather than infection.
The patient's condition did not improve with maximal care, and
given her poor prognosis, the family decided to pursue comfort
measures only. The patient passed away in presence of her family
on [**2129-1-3**]
Medications on Admission:
D5 1/2 NS at 80cc/hr
Roxanol 2.5 mg SL Q4H prn
Procrit 2,000 SQ MWF
MVI
Seroquel 25 mg PO BID
Seroquel 12.5 mg PO Q4H prn
Metoprolol 50 mg PO TID
Hydralazine 10 mg PO Q6H
Sinemet 25/100 TID
Oxycodone 2.5 mg PO Q 8H prn
Acet prn
Warfarin 5 mg PO QD
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"0389",
"5849",
"5859",
"486",
"4280",
"99592",
"25000"
] |
Admission Date: [**2170-12-10**] Discharge Date: [**2170-12-14**]
Date of Birth: [**2099-10-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
AVR (25mm mosaic porcine) [**12-10**]
History of Present Illness:
71 yo F who was noted to have a mheart murmur on physical exam.
An echo on [**2170-9-27**] showed AS.
Past Medical History:
AS, Hysterectomy, Appendectomy [**2151**], RT tib/fib fx from MVC,
Anxiety
Social History:
retired
lives with husband
rare etoh
1 ppd tob x 50 years
Family History:
mother deceased from MI in 60s
Physical Exam:
WDWN elderly F in NAD HR70 RR 16
Pertinent Results:
[**2170-12-14**] 07:17AM BLOOD WBC-8.0 RBC-2.98* Hgb-9.7* Hct-28.1*
MCV-94 MCH-32.5* MCHC-34.4 RDW-13.9 Plt Ct-175
[**2170-12-14**] 07:17AM BLOOD Plt Ct-175
[**2170-12-13**] 08:10AM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-138
K-3.7 Cl-100 HCO3-29 AnGap-13
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *70 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Normal LV cavity
size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Mildly dilated
ascending aorta. Focal calcifications in ascending aorta. Simple
atheroma in aortic arch. Focal calcifications in aortic arch.
Mildly dilated descending aorta. Simple atheroma in descending
aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Calcified tips of papillary
muscles. Mild (1+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. Frequent ventricular premature beats. Results were
Conclusions
PRE-BYPASS:
1. No spontaneous echo contrast or thrombus is seen in the body
of the left atrium or left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending aorta is mildly dilated. There are simple
atheroma in the aortic arch. There are focal calcifications in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta.
6. The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (area = 0.8cm2). Trace aortic
regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
POST-BYPASS:
Patient removed from cardiopulmonary bypass on phenylephrine
infusion and atrially paced.
1. There is a bioprosthesis in the aortic position. The valve is
well seated. The leaflets are only poorly seen but do appear to
be working. There appaers to be a trace perivalvular leak seen
in the deep transgastric views. No valvular aortic regurgitation
is seen. The peak gradient across the valve is 17.8mmHg.
2. Biventricular function is maintained; LVEF>55%.
3. The degree of mitral regurgitation has decreased to trace.
4. Aortic contours are intact post-decannulation.
Brief Hospital Course:
Admitted on [**2170-12-10**], taken to the OR and underwent AVR (25mm
mosaic porcine). Post-operatively, she was taken to the CVICU
in stable condition. She was weaned from mechanical ventilation
and extubated. She was started on Lasix & beta blocker, chest
tubes were removed, and was transferred to the telemetry floor
on POD # 1. Early am on POD # 3, she had rapid AFib, and was
treated with increased lopressor, and amiodarone. She
subsequently went in to junctional rhythm, with stable
hemodynamics, and her lopressor & amiodarone were decreased.
Her rhythm has returned to NSR today, and she is ready for
discharge home.
Medications on Admission:
Lorazepam 0.5"
Toprol XL 12.5'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Toprol XL 25 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*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
AS now s/p AVR
Hysterectomy, Appendectomy [**2151**], RT tib/fib fx from MVC, Anxiety
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 incision.
No lifting more than 2 pounds or driving until follow up with
surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 7047**] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2170-12-14**]
|
[
"4241",
"3051"
] |
Admission Date: [**2135-9-27**] Discharge Date: [**2135-10-7**]
Date of Birth: [**2104-8-11**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Fever, tachycardia
Major Surgical or Invasive Procedure:
Temporary hemodialysis catheter placement
Tunnelled hemodialysis catheter placement
[**Last Name (un) 1372**] intestinal tube placement
History of Present Illness:
This is a 31 yo male with biliary atresia s/p liver [**Last Name (un) **]
in [**2110**], s/p small bowel resection [**8-/2135**], recent staph
bacteremia [**12-27**] infected HD line who was transferred from OSH for
fevers and tachycardia. At home, patient complained of two weeks
of fatigue, productive cough, progressive lower extremity edema,
and fevers/chills. At a VNA visit he was noted to be
tachycardic and taken to an OSH.
.
At OSH, he was febrile and noted to be in SVT, which broke with
adenosine. He was started on levofloxacin for suspected LLL PNA
on CXR. This was broadened empirically to vanc/pip-tazo given
concern for SBP, as well. Patient was transferred to [**Hospital1 18**] ICU.
.
In the ICU, all cell lines of his CBC were trending down, hct
drop from 27 to 19, given 2U PRBC with appropriate increase to
26. No clear source of blood loss. He also c/o
myalgias/arthralgias, with multiple sick contacts, so flu swab
was sent. This came back positive, so he was started on
oseltamivir. Diagnostic para was negative for SBP and CXR did
not show PNA, so vanc/pip-tazo were stopped. His vitals have
shown mild tachycardia from the 90s to low 100s, current BP
136/90.
.
Currently, patient c/o fevers, chills, night sweats, myalgias,
arthralgias, dyspnea, cough productive of greenish sputum, and
hematuria. He denies CP, sore throat, n/v/d, abd pain, melena,
hematochezia, dysuria, frequency, urgency.
Past Medical History:
-biliary Atresia s/p liver [**Hospital1 **] at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
-small bowel resection
Social History:
denies any tobacco, EtOH or illict drug use. Lives at home with
parents, engaged. Has one child with a prior girlfriend. Does
not work.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
Vitals - T: 101.1 (current) BP: 136/92 HR: 110 RR: 22 02 sat:
94% 3L
GENERAL: Tachypneic, diaphoretic, mild resp distress, alert and
cooperative
HEENT: NCAT, no scleral icterus, MM dry, no JVD
CARDIAC: +S1/S2, no M/R/G, slightly tachycardic, regular rhythm
LUNG: Rhonchi throughout right lung, exp wheezing on left, good
air mvmt
ABDOMEN: NABS, several abdominal scars, soft, distended, no TTP.
Dependent flank edema.
EXT: 2+ LE edema, WWP.
Pertinent Results:
*** CBC
[**2135-9-27**] WBC-7.8 RBC-2.99* Hgb-9.1* Hct-26.9* MCV-90 MCH-30.3
MCHC-33.8 RDW-16.6* Plt Ct-169#
[**2135-10-7**] WBC-9.6 RBC-3.40* Hgb-9.8* Hct-29.5* MCV-87 MCH-28.9
MCHC-33.2 RDW-16.7* Plt Ct-187
[**2135-9-27**] Neuts-84.2* Lymphs-7.2* Monos-3.4 Eos-4.8* Baso-0.4
[**2135-9-27**] PT-16.0* PTT-35.2* INR(PT)-1.4*
.
*** Chemistries
[**2135-9-27**] Glucose-87 UreaN-23* Creat-2.5* Na-137 K-4.2 Cl-109*
HCO3-21* AnGap-11
[**2135-9-28**] Glucose-105 UreaN-24* Creat-2.5* Na-136 K-4.0 Cl-110*
HCO3-19* AnGap-11
[**2135-9-28**] Glucose-98 UreaN-28* Creat-2.6* Na-136 K-4.1 Cl-110*
HCO3-20* AnGap-10
[**2135-9-29**] Glucose-80 UreaN-30* Creat-2.8* Na-138 K-4.1 Cl-112*
HCO3-20* AnGap-10
[**2135-9-30**] Glucose-78 UreaN-38* Creat-3.6* Na-137 K-3.8 Cl-111*
HCO3-17* AnGap-13
[**2135-10-1**] Glucose-95 UreaN-45* Creat-4.2* Na-137 K-3.8 Cl-110*
HCO3-17* AnGap-14
[**2135-10-2**] Glucose-82 UreaN-52* Creat-5.5*# Na-135 K-3.9 Cl-110*
HCO3-16* AnGap-13
[**2135-10-3**] Glucose-80 UreaN-57* Creat-6.6*# Na-138 K-4.3 Cl-110*
HCO3-15* AnGap-17
[**2135-10-4**] Glucose-83 UreaN-66* Creat-7.6* Na-139 K-4.6 Cl-111*
HCO3-15* AnGap-18
[**2135-10-5**] Glucose-92 UreaN-51* Creat-6.9* Na-140 K-3.8 Cl-108
HCO3-20* AnGap-16
[**2135-10-6**] Glucose-98 UreaN-35* Creat-5.7*# Na-141 K-3.7 Cl-107
HCO3-26 AnGap-12
[**2135-10-7**] Glucose-139* UreaN-22* Creat-4.3*# Na-140 K-3.8 Cl-105
HCO3-28 AnGap-11
.
*** Liver Function Tests:
[**2135-9-27**] ALT-33 AST-79* LD(LDH)-399* CK(CPK)-310* AlkPhos-371*
TotBili-0.4
[**2135-9-28**] ALT-25 AST-63* LD(LDH)-319* CK(CPK)-305* AlkPhos-265*
TotBili-0.6
[**2135-9-28**] LD(LDH)-364*
[**2135-9-29**] ALT-20 AST-62* LD(LDH)-403* AlkPhos-267* TotBili-1.0
[**2135-9-30**] ALT-18 AST-68* LD(LDH)-504* AlkPhos-336* TotBili-0.5
[**2135-9-30**] CK(CPK)-387*
[**2135-10-1**] ALT-15 AST-56* LD(LDH)-442* AlkPhos-329* TotBili-0.6
[**2135-10-2**] ALT-14 AST-56* LD(LDH)-469* AlkPhos-321* TotBili-0.5
[**2135-10-4**] ALT-12 AST-48* AlkPhos-310* TotBili-0.5
[**2135-10-5**] ALT-13 AST-39 AlkPhos-275* TotBili-0.5
[**2135-10-6**] ALT-10 AST-40 AlkPhos-301* TotBili-0.5
[**2135-10-7**] ALT-14 AST-48* AlkPhos-327* TotBili-0.4
[**2135-9-30**] Lipase-119*
.
*** Albumin, Calcium, Phosphorus, Magnesium
[**2135-9-27**] Albumin-1.1* Calcium-6.3* Phos-3.2 Mg-0.8*
[**2135-9-28**] Calcium-6.0* Phos-3.2 Mg-1.4*
[**2135-9-28**] Calcium-6.5* Phos-3.7 Mg-1.8
[**2135-9-29**] Calcium-6.7* Phos-4.3 Mg-1.8
[**2135-9-30**] Albumin-1.5* Calcium-6.8* Phos-4.3 Mg-1.7
[**2135-10-1**] Calcium-7.3* Phos-4.4 Mg-1.7
[**2135-10-2**] Calcium-7.4* Phos-4.4 Mg-1.7
[**2135-10-3**] Calcium-7.3* Phos-4.6* Mg-1.8
[**2135-10-4**] Albumin-1.2* Calcium-7.2* Phos-5.0* Mg-1.9
[**2135-10-5**] Calcium-7.2* Phos-4.4 Mg-1.8
[**2135-10-6**] Albumin-1.1* Calcium-7.0* Phos-4.0 Mg-1.7 Iron-22*
[**2135-10-7**] Calcium-6.9* Phos-3.1 Mg-1.7
.
*** Other Lab Tests:
[**2135-10-6**] calTIBC-55* Ferritn-1367* TRF-42*
[**2135-9-28**] TSH-0.18*
[**2135-9-30**] Free T4-0.48*
[**2135-10-4**] T3-50*
[**2135-10-7**] C3-70* C4-26
[**2135-10-6**] Vanco-21.5*
.
*** Serum tacrolimus level:
[**2135-9-28**] tacroFK-2.2*
[**2135-9-29**] tacroFK-3.5*
[**2135-9-30**] tacroFK-5.5
[**2135-10-1**] tacroFK-11.5
[**2135-10-2**] tacroFK-8.6
[**2135-10-3**] tacroFK-10.2
[**2135-10-4**] tacroFK-8.7
[**2135-10-5**] tacroFK-6.9
[**2135-10-6**] tacroFK-8.8
[**2135-10-7**] tacroFK-5.0
.
*** Urine
[**2135-9-28**] 11:44AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2135-9-28**] 11:44AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2135-9-28**] 11:44AM URINE RBC->50 WBC-[**10-14**]* Bacteri-FEW [**Month/Year (2) **]-MANY
Epi-0
[**2135-9-28**] 11:44AM URINE Hours-RANDOM UreaN-339 Creat-73 Na-58
URINE CULTURE (Final [**2135-9-29**]): NO GROWTH.
.
[**2135-10-2**] 11:10AM URINE Color-Brown Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2135-10-2**] 11:10AM URINE Blood-LG Nitrite-NEG Protein->300
Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-0.2 pH-5.5 Leuks-NEG
[**2135-10-2**] 11:10AM URINE RBC->50 WBC-[**1-27**] Bacteri-MANY [**Month/Day (1) **]-NONE
Epi-[**1-27**]
[**2135-10-2**] 11:10AM URINE Hours-RANDOM UreaN-195 Creat-157 Na-32
K-63
[**2135-10-2**] 11:10AM URINE Osmolal-295
URINE CULTURE (Final [**2135-10-2**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
*** Peritoneal Fluid.
[**2135-9-28**] 08:10AM ASCITES WBC-25* RBC-50* Polys-1* Lymphs-7*
Monos-0 Eos-3* Macroph-89*
GRAM STAIN (Final [**2135-9-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2135-10-1**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2135-10-4**]): NO GROWTH.
Transthoracic Echcardiogram:
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%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
No vegetation identified (but cannot exclude).
.
Abdominal Ultrasound:
INDINGS: Postsurgical anatomy and inability of patient to
cooperate with
breathing instructions limits this examination.
No evidence of focal lesions. Echogenic linear structures are
seen in the
liver, likely due to pneumobilia. Limited views of the pancreas,
due to
overlapping bowel gas. Gallbladder not seen, likely surgically
absent. There
is no intrahepatic biliary duct dilatation.
IVC, right main and left hepatic vein are patent.
The main portal vein and right portal vein are patent and show
normal
hepatopetal flow. Flow was seen in the splenic veins, however,
difficult to
obtain splenic vein waveform. The SMV was not imaged. The left
portal vein
is not definitely identified.
The right hepatic artery, main hepatic artery, are patent with
normal
waveforms. The left hepatic artery was not seen.
Ascites is seen in the left lower quadrant.
IMPRESSION:
1. Main and right portal veins have appropriate flow and
directionality; the
left portal vein difficult to visualize, and unable to assess.
2. Left hepatic artery not clearly visualized; remainder of the
arteries and
veins of the liver appear patent.
3. Gallbladder not seen, likely surgically removed.
4. Trace ascites.
.
Renal U/S:
Both kidneys are echogenic throughout with poor corticomedullary
differentiation. They are of a good size, measuring 11.3 cm
longitudinally on
the left, and 11.7 cm longitudinally on the right. No
hydronephrosis or focal
abnormality is seen in relation to either kidney.
Both main renal veins and main renal arteries are patent. There
are normal
resistive indices on both sides varying from 0.59 to 0.66.
Views of the urinary bladder are unremarkable.
Incidental note is made of a small amount of ascites.
CONCLUSION:. The kidneys are of increased echogenicity
bilaterally with poor
corticomedullary differentiation, in keeping with chronic renal
disease, from
the patient's known post-infectious glomerulonephritis. There is
no
hydronephrosis. There is good perfusion of the kidneys.
Brief Hospital Course:
#. Multifocal Pneumonia. On arrival to the floor, patient had
significant rhonchi bilaterally, and had an oxygen saturation of
94% on 3L of oxygen by nasal cannula. Serial blood cultures
were negative and an echocardiogram demonstrated no vegetations
suggestive of endocarditis. A repeat chest x-ray was obtained
which demonstrated multifocal opacities sugeestive f pneumonia.
He was restarted in IV vancomycin, piperacillin-tazobactam, and
levofloxacin for treatment of multifocal pneumonia in the
setting of influenza, in a immunosupressed patient. Antibiotics
were dosed renally and adjusted to match his changing renal
function. His respiratory symptoms and pulmonary exam improved
with treatment and he was successfully weaned from supplemental
oxygen. Per the recommendation of infectious disease, he was
treated for a total of 8 days of antibiotics with complete
resolution of symptoms.
.
#. H1N1 Influenza. On admission, his influenza swab tested
positive for H1N1 swine like influenza. He was treated with
five days of oseltamivir 150mg PO bid and kept on droplet
precautions. He defervesced on hospital day 4, and droplet
precautions were removed, and droplet precautions were removed
24 hours later, with the completion of antiviral therapy.
.
#. Acute on Chronic Renal Failure. On admission, serum
creatinine was 2.5, which was increased over his baseline of 1.9
at his last discharge. Urinalysis was X, and FeNa was 1.46%.
He was given IV fluid boluses and his creatinine did not
decrease. He later was treated with IV albumin, with no
improvement of his renal function. His serum creatinine
subsequently began to increase to a peak of 7.6, with a
concomitant decrease in urine output. [**Month/Day/Year 1326**] nephrology
was consulted, and a urinalysis, urine chemistries were
repeated. Urinalysis was significant for muddy brown casts, and
acute tubular necrosis was diagnosed. A temporary hemodialysis
catheter was placed on [**2135-10-3**], and hemodialysis was initiated
on [**2135-10-4**]. The temporary catheter was exchanged for a
tunneled catheter on [**2135-10-6**]. By discharge, serum creatinine
had improved to 4.3, but he was still oliguric with under 100cc
of urine output per day. He was relisted for kidney [**Date Range **],
and follow-up will be arranged with [**Date Range **] nephrology.
Infectious disease was consulted regarding infectious causes of
renal failure, and recommended CMV, HIV, BK virus, HBV and HCV
viral load tests, which were pending at the time of discharge.
.
#. Chronic liver disease s/p liver [**Date Range **]. On admission,
patient had a mild transamititis with an ALT and AST of 33 and
79, an elevated alkaline phosphatase of 371, low albumin of 1.1
and an INR of 1.4, all of which were at his baseline. An
ultrasound guided paracentesis was performed, revealing mild
ascites, but paratoneal fluid analysis demonstrated no SBP.
Patient was continued on his home doses of tacrolimus 0.5mg PO
bid and lactulose 30ml PO tid. Daily serum tacrolimus levels
were drawn, and doses were held as his renal function worsened.
On the day of discharge, his serum tacrolimus level had
decreased to 5.0, and he was restarted on tacrolimus 0.5mg
daily. Serum tacro levels will be drawn at [**Date Range 2286**] on [**2135-10-11**]
and faxed to the liver [**Date Range **] center. MELD on discharge was
23. Follow-up was arranged with the liver [**Date Range **] center on
[**2135-10-19**].
.
#. Hyperthyroidism. On admission, serum TSH was low at 0.18.
Free T4 was low at 0.4 and T3 low at 50. This was thought to be
due to sick euthyroid and was on uncertain significance in a
patient with acute illness. Repeat TSH levels are recommended
4-6 weeks after discharge.
Medications on Admission:
OxycoDONE 2.5 mg Q4H:PRN pain
Oseltamivir Phosphate 75 mg PO BID
Sarna Lotion 1 Appl TP TID:PRN itching
DiphenhydrAMINE 25 mg Q6H:PRN itching
Ipratropium Bromide 1 NEB IH Q6H SOB
Ondansetron 4 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/NG Q6H:PRN fevers, pain
Tacrolimus 0.5 mg PO Q12H
Pantoprazole 40 mg PO Q24H
Lactulose 30 mL PO/NG TID
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*1 bottle* Refills:*2*
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1 bottle* Refills:*2*
5. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO once a day.
6. Outpatient Lab Work
Please draw serum tacrolimus level with [**Date Range 2286**] next tuesday
[**2135-10-11**] and fax the result to Dr. [**Last Name (STitle) 497**] at the liver [**Last Name (STitle) **]
center.
Discharge Disposition:
Home With Service
Facility:
vna southeastern [**State **]
Discharge Diagnosis:
Acute on Chronic Renal Failure
H1N1 Influenza
Multifocal Pneumonia
s/p liver [**State **]
Discharge Condition:
Stable, alert and oriented to person, place and time.
Discharge Instructions:
You were admitted for high heart rate and fevers. Laboratory
testing revealed you had H1N1 swine like influenza. A chest
x-ray showed pneumonia. Fluid was taken from your abdomen and
demonstrated no infection. You were treated with antiviral
medications for your flu. You were treated with intravenous
antibiotics for your pneumonia. Your kidney function
deteriorated and hemodialysis was initiated. With hemodialysis,
your laboratory values improved. While here your blood level of
thyroid stimulating hormone (TSH) was low. This is not
surprising in the case of an acute illness, but your primary
doctor may want to recheck you TSH valcue is 4-6 weeks.
Please make the following changes in your medications:
Please CHANGE your dose of tacrolimus to 0.5mg by mouth daily
Please STOP taking lasix
Please START Pantoprazole 40mg by mouth daily
You will require hemodialysis for the forseeable future. Your
first hemodialysis session will be on [**2135-10-8**].
Please adhere to your follow-up appointments. They are important
for managing your long-term health.
.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Please follow up with the following appointments:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2135-10-8**]
7:30
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2135-10-19**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],[**MD Number(3) 13795**]:[**Telephone/Fax (1) 37766**]
Date/Time:[**2135-10-26**] 9:00
Please make an appointment with your primary care doctor within
the next two weeks.
|
[
"49390",
"5849",
"486",
"5119",
"5859"
] |
Admission Date: [**2199-11-18**] Discharge Date: [**2199-12-16**]
Date of Birth: [**2199-11-18**] Sex: M
Service:NEONATOLOGY
HISTORY: [**Known lastname 17766**] is a former 31-week infant born via normal
spontaneous vaginal delivery to a 32-year-old gravida 3, para
[**11-28**] mother. The pregnancy was complicated by premature
prolonged rupture of membranes at 25 weeks of gestation and
the mother was on bedrest for six weeks until delivery. She
well-controlled gestational diabetes mellitus; otherwise was
a healthy woman with no major antenatal issues. Her
pregnancy was complicated by a motor vehicle accident in
[**Month (only) **], however this did not affect the remainder of her
pregnancy course.
Maternal laboratory studies were A+, hepatitis B surface
PERINATAL HISTORY: The mother progressed to spontaneous
vaginal delivery secondary to preterm labor in the setting of
concerns over the possibility of chorioamnionitis. The
infant was born at 31 weeks gestation. The infant emerged
with decreased tone, initially some mild respiratory efforts,
heart rate of 100, but then required some bag mask
ventilation in order to maintain sufficient respiratory
effort. The patient responded well to these attempts and was
taken to the Neonatal Intensive Care Unit for further
management. Apgar scores were 6 at one minute and 8 at five
minutes.
PHYSICAL EXAMINATION: On admission this was a pink,
nondysmorphic infant, blow-by oxygen, well perfused and
saturated. There was a flat anterior fontanel with the
exception of the presence of some alopecia on the right
temporal region. There was no skull defect. The skin was
intact. No other lesions were noted. The clavicles were
intact. The cardiac examination revealed normal S1 and S2
without murmurs. The lungs had fair and equal air entry
bilaterally. The abdomen was benign. There was no
hepatosplenomegaly or organomegaly. There was normal
genitalia in this infant with well-descended left testis,
unable to palpate the right. Hips were normal. The spine
was intact and the neurological examination was nonfocal with
appropriate tone and reflexes for age.
MEASUREMENTS: Birth weight was 1,830 grams (75th
percentile). Length was 42 cm (around the 55th percentile).
Head circumference was 26.8 cm which was then repeated around
29 cm putting him between the 25th and 50th percentile for
gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory:
[**Known lastname 17766**] had some retracting and increased work of breathing
after delivery and was briefly on CPAP and then weaned over
24 hours to room air, and has remained on room air for the
remainder of his hospital stay. He did have some evidence of
respiratory immaturity consistent with gestational age. He
was briefly on caffeine. This was discontinued on the 11th
day of life. He has had minimal apnea since then and has
been free of apnea for over a week prior to discharge.
2. Cardiovascular: The patient has a murmur which was
initially quite loud and now has become softer consistent
with peripheral pulmonic stenosis and confirmed by
echocardiogram. His examination reveals a pink, warm and
well-perfused infant. His last hematocrit was 30 on [**12-7**], and there have been no other concerns from a
cardiovascular standpoint.
3. Fluids, electrolytes and nutrition: His weight today is
2,645 grams. Head circumference is 32 cm. He is taking
50-70 cc of Enfamil 24 calorie or breast milk supplemented to
24 calories ad lib, and he is achieving at least 130 cc per
kg per day of intake on an ad lib basis. Over the last 24
hours he took about 160 cc per kg per day. By himself he is
waking up to feed. He has had no other concerns for fluid
and electrolyte issues.
4. Dermatologic: He does have a sebaceous nevus on his
scalp. He has had a consultation with dermatology for
cosmetic purposes. This area can be surgically removed when
he gets closer toward childhood but it is not any source for
concern at the present time.
5. Neurological: He had normal head ultrasounds early in
life and he needs a 30-day ultrasound which can be scheduled
as an outpatient.
6. [**Last Name (STitle) **]almologic: His most recent examination showed
immature retina but normal vascularization out to zone 3 in
both eyes. He needs a follow up in two weeks with Dr. [**Last Name (STitle) 47288**] [**Last Name (Prefixes) **] at [**Hospital3 1810**].
7. Gastrointestinal: He has some neonatal jaundice with a
peak bilirubin of 9.1 on day of life three. He received
about 3-4 days of phototherapy and has not been on
phototherapy since then. This was discontinued around day of
life six to seven. He has had no other major problems of
feeding intolerance.
8. Infection: He had a seven-day course of antibiotics due
to concerns of maternal chorioamnionitis. Blood and
cerebrospinal fluid remained unremarkable and the antibiotics
were discontinued after seven days. Approximately one week
prior to discharge he had an episode where he had increased
periodic breathing and a concern for possible sepsis and
received a short course of antibiotics. Work-up was also
negative and he has been clinically well since that time with
no other concern for sepsis.
9. [**Last Name (STitle) 47289**]ry:
A. Audiology: A hearing screen was performed with
automated auditory brainstem responses.
B. Ophthalmology: The infant's eyes were examined as
mentioned above and were found to be immature but at zone 3.
Follow up in two weeks should be with Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) **] at
[**Hospital3 1810**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47290**] with [**Hospital **]
Pediatrics, phone #[**Telephone/Fax (1) 47291**]. She has been informed. She
is looking after this baby's older sibling and follow up can
be arranged for tomorrow or the day after.
CARE RECOMMENDATIONS:
1. Feeds at discharge: Enfamil supplemented to 24 calories
per ounce or mother's mild supplemented with Enfamil powder
at 24 calories per ounce given on an ad lib basis.
2. Medications: Fer-In-[**Male First Name (un) **] 0.2 cc daily.
3. Car seat position screening is being done.
4. State newborn screening status: Immunizations received -
the infant is getting Synagis and hepatitis B vaccine.
Immunizations recommended - Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: 1. Born at less than 32
weeks gestation. 2. Born between 32 and 35 weeks with plans
for day care during the RSV season, smoker in the
household or with preschool siblings. 3. With chronic lung
disease. Influenza immunization should be considered
annually in the fall for preterm infants with chronic lung
disease once they reach six months of age. Before this age
the family and other caregivers should be considered for
immunization against influenza to protect the infant.
FOL[**Last Name (STitle) **]P APPOINTMENTS SCHEDULED AND RECOMMENDED:
1. Follow up with Dr. [**Last Name (STitle) 47290**] tomorrow or the day after
discharge.
2. Visiting nurse is to be arranged for two days following
discharge for a weight check.
3. Follow up with dermatology regarding nevus sebaceous on a
p.r.n. basis.
4. Follow up with Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) **] at [**Hospital3 1810**] in
two weeks for repeat eye examination.
5. Follow up this week at [**Hospital3 1810**] as an
outpatient for head ultrasound.
DISCHARGE DIAGNOSES:
1. Former 31-week premature infant now corrected to 35 weeks
gestation.
2. History of mild respiratory distress resolved.
3. History of neonatal jaundice resolved.
4. Sepsis evaluation completed.
5. Nevus sebaceous.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 37234**]
MEDQUIST36
D: [**2199-12-16**] 11:57
T: [**2199-12-16**] 12:08
JOB#: [**Job Number 47292**]
|
[
"7742",
"V290"
] |
Admission Date: [**2197-8-24**] Discharge Date: [**2197-8-31**]
Date of Birth: [**2142-5-31**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Demerol
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
headache, nausea, left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55yo woman with PMH significant for stroke with right
hemiparesis and language difficulties, breast cancer,
hypertension, s/p R CEA who presents as a transfer from an OSH
with headache, nausea, and left hemiparesis. History is limited,
as the OSH reports are brief and do not include old records or
new reports, the patient will only comply with some history and
examination due to pain, and her family cannot be reached
(husband [**Name (NI) **] [**Telephone/Fax (1) 75253**] was called without any answer,
daughter reportedly on the way). The patient reports symptoms of
right sided headache and nausea with vomiting beginning around 3
or 4pm. She says the left sided weakness occurred sometime
around the same time. She presented to [**Hospital 8641**] Hospital, where
she was noted to have "decreased LOC," "L facial," and "L
weakness." A neurology consult was called - notes are "dictated"
but not
provided. A brief neurology note reports left neglect, left
hemiparesis, and old right hypesthesia. She was given morphine
2mg IV x 1, 4mg IV x 1, zofran 4mg x 1, and dilaudid 0.5mg x 1
(2205). She had a head CT, which was reported as "negative" to
the accepting ED attending, though did not come with a report.
She was then transferred to [**Hospital1 18**].
She reports that her prior stroke caused right sided weakness
and numbness of the face, arm, and leg, as well as speech
difficulties (unclear if dysarthria or aphasia). She reports
these have improved or resolved, and that this speech is not as
bad as her prior stroke. She feels her headache is improved
after treatment at [**Location (un) 8641**] (though severely worsened after
movement in the CT scanner). She reports history of migraines,
which are different from this in both severity and diffuseness.
Past Medical History:
hypertension
stroke x 2 as above
s/p right carotid endarterectomy
breast cancer 4yrs ago, s/p surgery and XRT, not active per pt
chronic low back pain
Social History:
married, has at least one daughter. [**Name (NI) **] EtOH, smoked x 1yr, quit
2wks ago by report
Family History:
noncontributory
Physical Exam:
VS: T 98.3, HR 53, BP 165/63, RR 14, SaO2 100%
Gen: appears uncomfortable
HEENT: NCAT, MMM, OP clear
Neck: R scar, but no bruits appreciated
CV: RRR, nl S1, S2, II/VI systolic murmur
Chest: CTAB
Abd: soft, NTND, BS+
Ext: warm and dry
Neurologic examination:
Mental status: Awake and alert, cooperative with exam at first,
but then after CT reports severe headache and will not fully
cooperate. Oriented to name, though slow in saying first name
(says last name when asked name). Says year is "200...4", does
not say month. However, able to tell some history of current
symptoms and past events. Speech is nonfluent with repetition
and naming affected. +dysarthria. No right-left confusion.
Cranial Nerves: Pupils equally round and reactive to light, 5 to
3mm bilaterally. No RAPD. blinks to threat bilaterally, L>R.
Extraocular movements intact bilaterally without nystagmus.
Sensation absent V2-V3 and right V1, feels it slightly in left
V1. Facial asymmetry, with right side of mouth open and left
closed, but right moving more and left not moving much at all;
forehead moves bilaterally. Hearing intact bilaterally. Palate
cannot be visualized. No gag, +cough. When asked to put out
tongue, puts it deviated far left, but able to move it to the
right easily.
Motor: Flaccid left arm and leg, left leg externally rotated. No
observed myoclonus, asterixis, or tremor. RUE and RLE full
strength, LUE and LLE 0/5.
Sensation: Reports decreased sensation on the right, and absent
to noxious (nailbed pressure) on the left.
Reflexes: 2 and symmetric throughout (?R>L). Toe downgoing on
right, mute on left.
Coordination and gait: not tested
Discharge exam:
MS- alert and oriented x3. Speech fluent.
CN- functional left facial droop, disappears with distraction or
complex phonemic speech. PERRL. EOM's full. tongue at midline.
Motor- left hemiparesis resolving. + [**Doctor Last Name 60437**] sign. Protects
face with left arm drop.
Reflexes- normal, symmetric throughout.
Pertinent Results:
[**2197-8-24**] 01:00AM BLOOD WBC-7.1 RBC-4.43 Hgb-14.4 Hct-41.3 MCV-93
MCH-32.4* MCHC-34.8 RDW-14.0 Plt Ct-294
[**2197-8-24**] 01:00AM BLOOD Neuts-78.4* Lymphs-18.5 Monos-3.0 Eos-0.1
Baso-0.1
[**2197-8-26**] 07:50AM BLOOD PT-11.8 PTT-27.0 INR(PT)-1.0
[**2197-8-26**] 07:50AM BLOOD Glucose-67* UreaN-13 Creat-0.8 Na-144
K-4.1 Cl-109* HCO3-26 AnGap-13
[**2197-8-24**] 01:00AM BLOOD ALT-24 AST-27 CK(CPK)-150* AlkPhos-179*
Amylase-51 TotBili-0.5
[**2197-8-24**] 02:07PM BLOOD CK-MB-5 cTropnT-0.05*
[**2197-8-26**] 07:50AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.3
[**2197-8-24**] 02:07PM BLOOD %HbA1c-5.9
[**2197-8-24**] 02:07PM BLOOD Triglyc-120 HDL-38 CHOL/HD-3.1 LDLcalc-56
[**2197-8-24**] 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2197-8-24**] 02:05PM BLOOD FACTOR V LEIDEN-PND
IMAGING:
CT HEAD W/O CONTRAST [**2197-8-26**] 11:37 AM
FINDINGS: A small amount of subarachnoid blood in the left
frontal sulci is resolving. There are no new areas of
subarachnoid hemorrhage. There is no shift of the normally
midline structures or major vascular territorial infarct. There
is no hydrocephalus. Osseous structures and paranasal sinuses
are unchanged.
IMPRESSION:
1. Resolving left frontal subarachnoid hemorrhage.
CT HEAD W/O CONTRAST [**2197-8-24**] 1:28 AM
No prior comparison studies are available. There is a small
amount of subarachnoid blood in left superior frontal sulci
(2:24). There is a second focus of small amount of hemorrhage
overlying a left frontal gyrus (2:19). No mass effect or shift
of normally midline structures. Ventricles and cisterns are
normal in size. No evidence of major vascular territorial
infarct.
Partially visualized is an interrupted tooth projecting into the
left maxillary sinus. The sinus and mastoid air cells are clear.
Bony structures and surrounding soft tissue structures are
unremarkable.
IMPRESSION:
1. Small amount of subarachnoid hemorrhage in the superior left
frontal region.
2. Small amount of acute hemorrhage overlying a left frontal
gyrus, most likely also representing subarachnoid hemorrhage.
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers (images after cough and Valsalva
maneuver are technically uboptimal). Left ventricular wall
thickness, cavity size and egional/global systolic function are
normal (LVEF >55%) No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No cardiac source of embolism identified. Normal
global and
regional biventricular systolic function.
MR HEAD W/O CONTRAST [**2197-8-24**] 5:53 PM
FINDINGS: Small linear foci of T2 and FLAIR prolongation in the
sulci of the left frontal lobe correspond with the known area of
subarachnoid hemorrhage on the CT scan of [**2197-8-24**], and
represent a small amount of chronic subarachnoid blood. No new
areas of hemorrhage are identified. No masses or mass effect are
seen. Ventricles and sulci are normal in configuration.
MR angiography and MR venography were also performed, and show
no aneurysms or vascular malformations.
There is no evidence of infarction.
IMPRESSION: Small amount of linear high T2 signal in the left
frontal lobe corresponding with the known area of subarachnoid
hemorrhage. No aneurysms or other vascular malformation. No
evidence of infarction.
Speech and Swallow Consultation:
Mrs. [**Known lastname **] presented with a moderate oral dysphagia and a mild
to moderate delay in swallow initiation. However once the
pharyngeal swallow was started, it was functional and no residue
was seen. The pt did not aspirate today, but the pyriform
sinuses filled completely before the swallow [**2-3**] swallow delay
and it is therefore recommended she use a chin tuck with the
thin liquids. She was able to manage moist, ground solids, but
did not feel comfortable and is requesting pureed solids at this
time. Pill should be crushed and given with purees.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 4, mild-moderate dysphagia with
consistencies restricted because of retention in the oral
cavity.
RECOMMENDATIONS:
1. Suggest a PO diet of thin liquids and pureed consistency
solids.
2. Use a chin tuck when drinking liquids.
3. No straws.
4. Place solid food on the right side of your mouth.
5. Alternate between bites and sips as needed.
6. All pills crushed with purees or in liquid form.
Brief Hospital Course:
55yo woman with history of stroke (with right
weakness/numbness), R CEA, HTN, breast cancer 4yrs ago, who
presents as a transfer from an OSH with right-sided headache,
nausea, vomiting, dysarthria, and left hemiparesis. On
presentation to this hospital, she was disoriented, with a
nonfluent aphasia including difficulty with repetition,
dysarthria, decreased bilateral facial sensation, an unclear
facial asymmetry, no gag (but cough present), left tongue
protrusion, left hemiparesis, and left hemisensory loss. Head CT
revealed a left parietal subarachnoid hemorrhage.
Her neurologic exam was difficult to localize, as her
examination was not entirely consistent. Is it was odd to have
left sided symptoms and a left sided lesion. MRI/MRA was
obtained to rule out possibility of venous sinus thrombosis or
multiple emboli to explain her symptoms. MRA did not reveal
aneurysm to explain her subarachnoid hemorrhage. Her daily
aspirin therapy was held. She was covered on an insulin sliding
scale for tight glycemic control.
The patient had an acute "thunderclap" headache over the weekend
resulting in repeat CT evaluation. There were no acute changes
by head CT. Her headache was intially treated with dilaudid IV,
then tapered to her chronic dose of methadone.
Further examination and history revealed the patient has
significant psychosocial stressors with history of interpartner
violence/abuse. The patient had an event prior to discharge
consisting of violent shaking movements with her eyes closed and
bilateral arms thrashing. This is strongly suggestive of a
pseudoseizure or behavioral event given 90% of seizures occur
with eyes open and deviation to one side. Furthermore the event
demonstrated complete resolution of her prior left sided
hemiparesis, garnering further support for conversion. A repeat
Head CT was without any changes to suggest new neuropathology.
Her prior subarachnoid hemorrhage seen on admission has nearly
completely resorbed. Further physical therapy will greatly
benefit her expected continued recovery for her deficits. She
will follow up with Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 877**] in the neurology
department at [**Hospital1 18**] once discharged from rehab.
Medications on Admission:
methadone 20mg qid prn pain
lipitor 40mg daily
ASA 81mg daily
plavix 75mg daily
doxycycline 100mg [**Hospital1 **] (for acne)
lunesta 3mg qhs
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. Methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Insulin Regular Human 100 unit/mL Solution Sig: dose per
sliding scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 17921**] Center - [**Location (un) 5450**], NH
Discharge Diagnosis:
Left Frontal Subarachnoid Hemorrhage
Conversion Disorder
Discharge Condition:
Stable. Resolving left hemiparesis- antigravity at discharge.
Resolving left facial droop. Positive [**Doctor Last Name 60437**] Sign. Protects
face with left arm drop.
Discharge Instructions:
You were admitted and found to have a subarachnoid hemorrhage
and left sided weakness. The bleeding in your brain was small
and stable by repeat CT scans. You should expect your deficits
to resolve very rapidly.
Please contiue to take all medications as prescribed.
Call your doctor or 911 if you experience any symptoms of chest
pain, shortness of breath, new weakness, numbness or tingling.
Followup Instructions:
Please seek the guidance of a psychiatrist or other mental
health professional for further support with your life stresses.
Please call [**Telephone/Fax (1) 2574**] to schedule a follow up appointment
with Dr. [**Last Name (STitle) 877**] and Dr. [**First Name (STitle) **] on the Neurology service at
[**Hospital1 18**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"4019"
] |
Admission Date: [**2157-1-10**] Discharge Date: [**2157-2-1**]
Date of Birth: [**2090-12-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2157-1-24**] Aortic valve replacement (23mm St. [**Male First Name (un) 923**] mechanical) and
coronary artery bypass grafting x3 (LIMA-LAD, SVG-OM1-OM2)
[**2157-1-24**]
Left heart catheterization, coronary angiography [**1-18**]
History of Present Illness:
Mr. [**Known lastname 33733**] is a 66 year old gentleman who was admitted with a
non-healing ulcer on his heel. He subsequently underwent a
right below the knee amputation ([**8-30**]) with a prolonged
post-operative course. He was readmitted now with CHF and
catheterization was done to demonstrate left main and diffuse
three vessel disease. Echocardiography has demonstrated
critical AS as well. he was referred for surgical evaluation for
AVR/CABG.
Past Medical History:
insulin dependent diabetes mellitus
coronary artery disease -s/p MI
chroinc systolic CHF
atrial fibrillation
polyarthritis rheumatica,predisone dependent
peripheral vascular disease
s/p right BKA
s/p AICD implant
Social History:
Pt and wife live at home in [**Name (NI) 8117**], [**Name (NI) **]. Pt retired in [**11-28**]
from
his work as a manager in auto sales. He states he hopes to
return to his previous work part-time in the future. He has a
close family.
ETOH:denies
Tobacco: former use
Family History:
N/C
Physical Exam:
Admission:
VS: 96.2 68 137/67 18 99RA
Gen: NAD, pleasant
HEENT: EOMI, pupils reactive to light, R pupil slightly larger
than the left
CV: irreg irreg, no m/g/r
Pulm: CTA in upper fields b/l, crackles in bases
Abd: +BS, nt/nd, obese
Ext: R BKA; L foot digits [**12-26**] with dry gangrene on distal joints
top part of toes, similar ulcer on right heal.
Pulses
Rad Fem [**Doctor Last Name **] PT DP
R P P dop
L P P dop dop dop
Pertinent Results:
TTE (Complete) Done [**2157-1-12**] at 9:32:13 AM FINAL
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (LVEF = 20 %). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricle has moderate
global free wall hypokinesis. There is severe aortic valve
stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Carotid U/S - [**2157-1-18**]
IMPRESSION:
1. Antegrade flow in both vertebral arteries.
2. Occluded left ICA.
Cardiac Cath - [**2157-1-20**]
FINAL DIAGNOSIS:
1. Moderate left main and diffuse three vessel coronary artery
disease.
2. Moderate to severe aortic stenosis.
3. Low cardiac output/index.
4. Left ventricular systolic and diastolic dysfunction.
5. Severe pulmonary hypertension.
[**2157-1-31**] 04:03AM BLOOD WBC-13.3* RBC-2.86* Hgb-8.5*
[**Known lastname **],[**Known firstname **] [**Initial (NamePattern1) **] [**Known lastname **]. [**Age over 90 95331**] M 66 [**2090-12-8**]
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2157-2-1**] 10:52 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2157-2-1**] 10:52 AM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip #
[**Clip Number (Radiology) 95332**]
Reason: r/o cva
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with ? L visual field cut.
REASON FOR THIS EXAMINATION:
r/o cva
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: DBH TUE [**2157-2-1**] 3:14 PM
PFI: 1. Left posterior temporal lesion likely old ischemia.
2. Left internal carotid artery completely occluded at its
origin.
Preliminary Report !! PFI !!
PFI: 1. Left posterior temporal lesion likely old ischemia.
2. Left internal carotid artery completely occluded at its
origin.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
PFI entered: TUE [**2157-2-1**] 3:14 PM
Imaging Lab
Hct-26.4* MCV-92 MCH-29.6 MCHC-32.1 RDW-16.8* Plt Ct-336
[**2157-1-31**] 04:03AM BLOOD Glucose-51* UreaN-21* Creat-0.8 Na-136
K-4.0 Cl-101 HCO3-33* AnGap-6*
Brief Hospital Course:
Mr [**Known lastname 33733**] is a 66 year old male with known severe PVD, DM,
severe AS, CHF, who was admitted with LLE gangrene. He
underwent a right below the knee amputation. During this
admission the patient developed acute CHF and ARF. He was found
to have severe AS and multivessel CAD and on [**2157-1-24**] he underwent
an aortic valve replacement (#23mm St.[**Male First Name (un) 923**] Mechanical) and
coronary artery bypass grafting times three
(Lima->LAD/SVG->OM1-OM2sequential). Please refer to Dr. [**Doctor Last Name 95333**] operative report for further details. He
tolerated the procedure well and was transferred in critical but
stable condition to the surgical intensive care unit. He awoke
neurologically intact, pressors were weaned and he was extubated
on post-operative day one. Mr.[**Known lastname 33733**] was placed on stress dose
steroids for his polymyalgia rheumatica and was seen in
consultation by [**Last Name (un) **] for elevated blood sugars. He required
aggressive diuresis with a lasix drip. Electrophysiology
interrogated his internal pacemaker and his epicardial wires
were removed. Coumadin and heparin were started for the
mechanical aortic valve and atrial fibrillation. On POD#4
Mr.[**Known lastname 33733**] was transferred to the surgical step down floor. The
lasix drip was weaned to off. [**1-30**] Mr.[**Known lastname 33733**] complained of poor
visual focus in the mornings. An Ophthalmology consult was done
and he was found to have a normal exam. Neurology was also
consulted and felt it was likely due to fluctuating blood
sugars. [**2-1**] a Head CTA was done which confirmed a previous
ischemic event. No new changes.Neurology cleared Mr.[**Known lastname 33733**] for
discharge to rehab. He also experienced diarrhea toward the end
of his stay and tested positive for clostridium difficile. He
was placed on flagyl. The steroid taper was completed and he
was placed on his home maintenance dose of hydrocortisone. By
post operative day #8, [**2-1**] he was ready for transfer to a rehab
facility for increase in strength, endurance and daily
activities.All follow up appointments were advised.
Medications on Admission:
#. Warfarin stopped on [**2157-1-7**], unclear reason
#. Carvedilol 12.5'
#. Spironolactone 12.5'
#. Captopril 12.5"
#. Rosuvastatin 5'
#. Furosmide 80'
#. Digoxin 0.125mg QOD
#. K-DUR 20'
#. Magnesium oxide
#. Hydrocortisone 10' for PMR,
#. Insulin glargine 32 QHS
#. Novolog SS
#. Citalopram 20'
#. Pantoprazole 40"
#. Oxycodone
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
16. Warfarin 1 mg Tablet Sig: 7.5 Tablets PO DAILY (Daily):
titrate for an INR goal of 2.5-3.5 for an aortic mechanical
valve.
17. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous at bedtime.
Disp:*qs units* Refills:*2*
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
Subcutaneous four times a day: per sliding scale.
19. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days: dc on [**2-8**].
22. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
x 1 week.
23. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
24. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
s/p aortic valve replacement & coronary artery bypass grafts
coronary artery disease
peripheral vascular disease
Acute on chronic heart failure- LVEF 20%
Severe Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation
history of perpherial vascular disease with left foot gangrenous
changes,s/p rt. BKA
s/p AICD [**11/2156**] ([**Company 2267**])
insulin dependent diabetes mellitus
atrial fibrillatiion
h/o polymyalgia rheumatica- prednisone dependent
clostridium difficile colitis
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 100.5
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for one month and off all narcotics
No lifting more than 10 pounds for 10 weeks
take all medications as directed
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] ([**Telephone/Fax (1) 14585**] for left lower extremity
vasculature in 1 month.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 95334**] PCP ([**Telephone/Fax (1) 95335**] in [**12-24**] weeks.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14715**] Cardiology([**Telephone/Fax (1) 95336**] in [**12-24**] weeks.
Dr. [**Last Name (STitle) **] Cardiac Surgeon([**Telephone/Fax (1) 11763**] in [**3-28**] weeks.
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2157-2-1**]
|
[
"4241",
"5849",
"2761",
"4280",
"41401",
"42731",
"4240",
"2724",
"2859",
"412",
"V4582",
"V5867"
] |
Admission Date: [**2119-1-25**] Discharge Date: [**2119-1-27**]
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old woman who
fell out of bed at rehabilitation and struck the left side of
her head. No loss of consciousness. She complains of a
left-sided headache with left shoulder pain.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Cerebrovascular accident (times three); no residual
deficits.
3. Hernia.
4. Hypothyroidism.
5. Depression.
6. Seizure disorder.
7. Hard of hearing.
8. Odontoid fracture in [**2114**].
ALLERGIES: The patient is allergic to AMOXICILLIN.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
normal sinus rhythm in the 60s, blood pressure was 236/50,
respiratory rate was 17. The patient was awake and alert.
She appeared in no acute distress. The lungs were clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. The abdomen was soft,
nontender, and nondistended. Extremities were warm and dry.
Back and neck were nontender. Neurologically, the patient
followed commands. Pupils were equal, round, and reactive to
light and accommodation. Extraocular movements were intact.
Left periorbital ecchymosis and swelling were noted.
Strength was full with no deficits.
RADIOLOGY/IMAGING: A head computed tomography revealed right
temporoparietal subarachnoid hemorrhage with no shift.
A computed tomography of the cervical spine revealed odontoid
fracture (type 2) with 4-mm to 8-mm displacement; similar to
findings reported in [**2114**].
Shoulder films showed no fracture or dislocation.
HOSPITAL COURSE: The patient was admitted for blood pressure
control with conservative management. The patient was placed
in a hard collar. There were no complications throughout her
stay.
MEDICATIONS ON DISCHARGE: (Medications at the time of
discharge included)
1. Docusate 100 mg p.o. b.i.d.
2. Senna one tablet p.o. q.d.
3. Venlafaxine 25 mg p.o. b.i.d.
4. Phenytoin 150 mg p.o. b.i.d.
5. Levothyroxine 100 mcg p.o. q.d.
6. Pantoprazole 40 mg p.o. q.24h.
7. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed.
DISCHARGE DISPOSITION: The patient was discharged back to
rehabilitation.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 1327**] in two
weeks.
2. The patient was to be discharged with an Aspen collar.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2119-1-27**] 09:03
T: [**2119-1-27**] 09:04
JOB#: [**Job Number 43955**]
|
[
"4019",
"2449",
"311"
] |
Admission Date: [**2196-1-28**] Discharge Date: [**2196-2-3**]
Date of Birth: [**2143-6-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
Mr. [**Known lastname 10794**] is a 52yo male with a past medical history of
non-ischemic cardiomyopathy (LVEF 30%-35%), insulin-dependent
diabetes mellitus, hepatitis C infection, HTN, HLD,
schizophrenia and depression who is presenting in acute
respiratory distress after recent admission to the MICU/Gen med
([**Date range (1) 63644**]) for similar presentation. The patient reports that he
was smoking crack cocaine earlier 2 days ago began to have chest
pain and progressive shortness of breath over the past 2 days.
He also reports worsening of productive cough (white sputum)
which has been present since his discharge from the hospital on
[**1-21**]. He says that he felt that he never truly returned to his
baseline after his last hospitalization. He says that he has had
worsening orthopnea, with use of 3 pillows instead of his usual
2 last night. He denies edema, PND. He denies fevers/chills or
other URI sx, chest pain/pressure, pleuritic pain. He has had a
VNA and reports that his weight has decreased from 183 to 180,
he has avoided salt in his diet and he has been fully compliant
with this medications. He does think that the crack that he
smoked 2 days ago had "less baking soda in it." The patient also
does have a past medical history of MRSA pna requiring
tracheostomy.
.
He also had admission from [**2112-12-8**] in which he was intubated
and CT showed multifocal pneumonia. Because the radiographic
evidence of this pneumonia cleared quickly within 2 weeks, it
was felt that this was crack lung as opposed to infectious. He
was treated with broad spectrum abx and his respiratory status
returned to baseline. During his admission [**Date range (1) 63644**], the patient
was felt to have crack lung/hypersensitivity pneumonitis given
parenchymal abnormality seen on chest CT, he was treated with
one dose of methylprednisone 125mg but had hyperglycemia
requiring insulin gtt and was thus not treated with steroids. He
did not receive antibiotics. There may have been a component of
CHF during this presentation and the patient was treated with
lasix gtt during this prior admission.
.
In the ED, initial VS were: RR 40s, O2 Sat: 75% on NRB. The
patient received nitro gtt, was placed on BiPap with dramatic
improvement. The patient was also treated with levofloxacin and
vancomycin. He received lasix 40mg IV x1, aspirin and tylenol
1000mg po. Blood cultures were obtained.
.
On arrival to the MICU, the patient is still tachypneic but
completing full sentences. He is alert, oriented and does not
appear in acute distress.
.
Review of systems:
(+) Per HPI. Endorses headaches. Endorses diarrhea which
resolved 2 days ago.
(-) Denies fever, chills, night sweats, recent weight gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. CARDIAC RISK FACTORS: Type II Diabetes, Hyperlipidemia, HTN
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
- Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 20%, LVD
6.4cm, mild RV dilation, borderline function, 1+ MR)
- hepatitis C antibody positive
- MRSA pneumonia (requiring trach)
- COPD
- Substance abuse (cocaine)
- Tobacco abuse
- schizophrenia
Social History:
- history of multiple incarcerations (>6 months in [**2193**])
- lives with sister
- walks w/ cane due to right sided foot drop
- Tobacco history: current smoker, 1 cig per day
- ETOH: denies
- Illicit drugs: crack cocaine three days ago
Family History:
- Father: pacemaker, deceased
Physical Exam:
ADMISSION EXAM:
.
Vitals: T: 98.6 BP: 98/61 P:95 R: 31 18 O2: 100% CPAP with FiO2
100% and PEEP of 5
General: Alert, oriented, no acute distress with CPAP on
HEENT: Sclera anicteric, MMM, poor dentition, EOMI, PERRL
Neck: supple, JVP not able to be assessed, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Lungs: diffuse dry crackles, no wheezes. Air movement
throughout. No use of accessory muscles with CPAP in place.
Abdomen: soft, minimal diffuse tenderness, mild distended, bowel
sounds present, obese
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: 98.8 98.7 115/68 100 20 94% 1L NC BG: 77-239 mg/dL
I/Os: 1300 | 1000 + BRP (-0.5L LOS)
GENERAL: Appears in no acute distress. Alert and interactive.
Able to speak in full sentences.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD just above clavicle at
90-degrees.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Faint breath sounds bilaterally with inspiratory crackles
at bases; rhonchi in upper airways bilaterally. No wheezing.
Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; no peripheral edema, 2+ peripheral
pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
Pertinent Results:
ADMISSION LABS:
.
[**2196-1-28**] 09:30PM BLOOD WBC-13.6* RBC-4.20* Hgb-11.1* Hct-35.4*
MCV-84 MCH-26.4* MCHC-31.4 RDW-15.3 Plt Ct-333
[**2196-1-28**] 09:30PM BLOOD Neuts-74.1* Lymphs-18.8 Monos-2.5
Eos-4.2* Baso-0.4
[**2196-1-28**] 09:55PM BLOOD PT-11.4 PTT-35.1 INR(PT)-1.1
[**2196-1-28**] 09:30PM BLOOD Glucose-127* UreaN-12 Creat-0.9 Na-144
K-4.0 Cl-108 HCO3-26 AnGap-14
[**2196-1-29**] 03:06AM BLOOD ALT-19 AST-23 LD(LDH)-360* CK(CPK)-98
AlkPhos-65 TotBili-0.4
[**2196-1-29**] 03:06AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.9 Mg-1.4*
[**2196-1-28**] 09:30PM BLOOD ASA-NEG Ethanol-17* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-1-28**] 09:31PM BLOOD Lactate-2.2*
[**2196-1-28**] 10:35PM BLOOD Lactate-1.2
[**2196-1-29**] 05:07AM URINE cocaine-POS
.
DISCHARGE LABS:
.
[**2196-2-1**] 07:25AM BLOOD WBC-6.4 RBC-3.55* Hgb-9.2* Hct-30.1*
MCV-85 MCH-26.0* MCHC-30.7* RDW-15.1 Plt Ct-335
[**2196-1-29**] 03:06AM BLOOD PT-12.6* PTT-32.4 INR(PT)-1.2*
[**2196-2-3**] 06:55AM BLOOD Glucose-112* UreaN-9 Creat-0.8 Na-143
K-4.3 Cl-108 HCO3-29 AnGap-10
[**2196-2-3**] 06:55AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8
.
MICROBIOLOGY DATA:
[**2196-1-28**] Blood culture (x 2) - pending
[**2196-1-29**] MRSA screen - negative
[**2196-1-29**] Urine legionella - negative
.
IMAGING:
[**2196-1-30**] CHEST (PORTABLE AP) - In addition to a severe
infiltrative abnormality, with probable confluence in the lung
bases, there are many small discrete nodular opacities, which
have grown appreciably since [**1-28**], probably entirely new
since [**1-18**]. Pattern strongly suggests widespread
infection, possibly septic emboli. Heart is moderately enlarged,
unchanged. At least small bilateral pleural
effusions are presumed.
Brief Hospital Course:
IMPRESSION: 52M with a PMH significant for non-ischemic
cardiomyopathy (LVEF 30%-35%), insulin-dependent diabetes
mellitus, hepatitis C infection, HTN, HLD, schizophrenia and
depression with recent hospitalization for crack lung, who
presented with acute hypoxic respiratory distress found to have
bilaterally diffuse airspace opacification with suspected
component of CHF exacerbation, in the setting of recent illicit
substance use.
.
# DIFFUSE, BILATERAL LUNG OPACIFICATION AND ACUTE RESPIRATORY
DECOMPENSATION - Consistent with his prior hospitalizations, Mr.
[**Known lastname 10794**] was admitted with acute hypoxic respiratory failure
requiring NIPPV in the setting of recent crack cocaine use,
attributed to acute crack inhalation lung injury. In [**Month (only) 1096**]
[**2194**], he presented with a picture concerning for multifocal
pneumonia, although his rapid resolution of symptoms without
antibiotics was more consistent with hypersensitivity
pneumonitis or crack lung. Three days preceding admission, he
notes crack cocaine use. He was admitted to the MICU for
respiratory monitoring and required a period of BiPAP use with
improvement with symptomatic treatment, namely nebulizers and
agressive respiratory therapy. He was not intubated during this
admission. While he received a single dose of IV Vancomycin in
the ED, these were discontinued, and steroids were deferred
given his similar presentation with rapid improvement in the
past despite minimal intervention. His admitting CXR showed
bilateral opacifications, despite a normal WBC and no fevers. A
chest CT on prior admission showed marked diffuse bilateral
airspace opacities, ground-glass in appearance, with confluent
consolidation -- but subsequent CXRs noted rapid improvement
despite limited therapy, supporting a crack lung or
hypersensitivity etiology. Over several days, his supplemental
oxygen was weaned and he ambulated 100 feet without
destaurations, maintaining his oxygen saturations in the 92-94%
range on room air (which is his baseline). He had no cough or
respiratory symptoms and he resumed all of his home medications.
.
# INSULIN-DEPENDENT DIABETES MELLITUS - Patient previously
managed with Lantus dosing (taking 40 units at home) -
intermittently checks his glucose at home, has been under the
200 mg/dL range per the patient. Last HbA1c 7.4% in 11/[**2194**]. No
evidence of retinopathy, renal failure (baseline creatinine
0.9-1.1) or neuropathy. We titrated his Lantus to 50 units SC at
nighttime for tighter glucose control.
.
# NON-ISCHEMIC CARDIOMYOPATHY / CHRONIC SYSTOLIC HEART FAILURE -
Patient with known moderate global left ventricular hypokinesis
(LVEF = 30-35%), LVD 6.4-cm, mild RV dilation, borderline
function, 1+ MR on 2D-Echo from 12/[**2194**]. His respiratory
decompensation was attributed to a pulmonary source
predominantly. He was tolerating his home PO Lasix, and returned
to room air with adequate oxygen saturations prior to discharge.
We continued his Lisinopril 10 mg PO daily, Metoprolol succinate
XL 100 mg PO daily, maintained his home dose of Furosemide 40 mg
PO daily and kept him on a fluid restriction of 1500 mL daily.
He was monitored with daily weights, monitored I/Os, and his
goal for diuresis was 0.5-1L daily.
.
# HYPERTENSION - Managed as an outpatient with ACEI,
beta-blocker. Discharged on home regimen without changes.
.
# HYPERLIPIDEMIA - We continued Atorvastatin 20 mg PO QHS.
.
# SUBSTANCE, TOBACCO ABUSE HISTORY - He has multiple prior
episodes of relapse with resulting hospitalizations; patient
notes mostly crack-cocaine use (2-3 days prior to admission) in
lieu of alcohol use. Lives with sister who is supportive and is
a probation officer. We offered him a nicotine patch for tobacco
use and provided smoking cessation counseling. Social work
consultation was provided and motivational support was offered;
he may benefit from outpatient addiction program assistance,
which he is strongly considering. He does not qualify for dual
diagnosis admission since his psychiatric illness is
compensated.
.
# HEPATITIS C INFECTION - He has a history of positive HCV
antibody documented in [**2188**]. No evidence of sequelae of chronic
liver disease. Liver synthetic function appears maintained (plt
424, albumin 2.8). LFTs: AST 29 and ALT 13 with T-bili 0.4 from
prior lab studies. HIV negative, AMA and smooth negative in
[**2190**]. Abdominal U/S in [**2189**] was normal. HCV viral load
20,101,696 IU/mL in 11/[**2194**]. Will need follow-up as outpatient
for AFP, serial ultrasounds, candidacy for possible anti-viral
therapy
(likely poor candidate) given his hepatitis C infection.
.
TRANSITION OF CARE ISSUES:
1. Social work consultation was provided and motivational
support was offered; he may benefit from outpatient addiction
program assistance given his substance abuse history.
2. Has outpatient follow-up with primary care physician and
Pulmonology scheduled.
3. Will need follow-up as outpatient for AFP, serial
ultrasounds, candidacy for possible anti-viral therapy (likely
poor candidate) given his hepatitis C infection.
4. Will also need outpatient PFTs and Pulmonology follow-up to
evaluate for other underlying lung disease.
Medications on Admission:
1. 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.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. insulin lispro 100 unit/mL Solution Sig: [**12-21**] units
Subcutaneous per sliding scale.
6. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
7. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. sertraline 50 mg Tablet Sig: 0.5 Tablet PO once a day.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
14. codeine sulfate 30 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for pain.
15. Seroquel 100 mg Tablet Sig: 0.5-1 Tablet PO at bedtime.
Discharge Medications:
1. 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.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Novolog 100 unit/mL Solution Sig: [**12-21**] units Subcutaneous once
a day: per insulin sliding scale.
6. Lantus 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
7. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. codeine sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. quetiapine 100 mg Tablet Sig: 0.5-1 Tablet PO HS (at
bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnoses:
1. Acute pulmonary syndrome (presumably related to crack-cocaine
use)
2. Acute on chronic exacerbation of non-ischemic cardiomyopathy
.
Secondary Diagnoses:
1. History of polysubstance abuse
2. Insulin-dependent diabetes mellitus
3. Hypertension
4. Hyperlipidemia
5. Positive Hepatitis C antibody
6. Chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of
your acute respiratory issues. You were first admitted to the
medical intensive care unit given concern for worsening heart
failure in the setting of your illicit substance use, but this
resolved with supportive therapy. You should AVOID ALL ILLICIT
SUBSTANCE USE in the future and take all necessary steps to
obtain motivational assistance and substance abuse program
assistance to promote healthy living.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED: NONE
.
* Upon admission, we CHANGED:
We CHANGED: Lantus from 40 to 50 units subcutaneously in the
evenings for better glucose control
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2196-2-11**] at 9:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2196-2-11**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PFT
When: THURSDAY [**2196-2-11**] at 9:30 AM
** Please contact our registration department at [**Telephone/Fax (1) 10676**] to
update your information.**
.
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: FRIDAY [**2196-2-12**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63642**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
|
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"4019",
"2724"
] |
Admission Date: [**2200-10-24**] Discharge Date: [**2200-11-11**]
Date of Birth: [**2119-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Vicodin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath, exertional dyspnea
Major Surgical or Invasive Procedure:
[**2200-10-27**] Mitral Valve Replacement (33mm St. [**Male First Name (un) 923**] tissue)/
Coronary artery bypass grafts x 4 (LIMA-LAD, SVG-OM, SVG-Dg,
SVG-PDA)
[**2200-10-24**] Left and right heart catheterization, coronary
angiography
History of Present Illness:
80M with history of coaornary disease who was in usual health
until two weeks ago when he noted progressively worsening
dyspnea and orthopnea. His symptoms progressively worsened and
he presented to [**Hospital3 3583**] on [**10-23**] and was found to be in
heart failre with a BNP of 2351 and a borderline troponin of
0.15. An ECHO was performed and showed LVEF of 25%. He was
diuresed with IV lasix and was oxygenating well on 2L NC but
still had dyspnea. Of note, the patient's last stress test was
in [**2199**] and was unremarkable with preserved LVEF. He received
metformin and lovenox on morning of transfer and was not given
plavix. He was transferred to [**Hospital1 18**] for catheterization.
At cath, he was found to have severe three vessel coronary
artery disease, moderate to severely elevated right and left
sided filling pressures and depressed cardiac index and
ejection fraction with diffusely hypokinetic left ventricle.
He was referred for surgical revascularization.
Past Medical History:
osteoporosis
spinal stenosis
hx of asbestos exposure
kidney stones- s/p lithotripsy colon polyps
hyperlipidemia
glaucoma
peripheral vascular disease.
diverticulosis
colonic polyps
Hypertension
diabetes
Social History:
Quit smoking 44 years ago, previously had a 15 pack-year
history. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father died of CVA. No other known FH of CVD.
Pertinent Results:
[**2200-10-24**] Cardiac Cath:
1. Coronary angiography of this right dominant system revealed
severe, calcific three vessel coronary artery disease. The LMCA
did not have focal stenoses. The LAD had a 90% stenosis in the
mid-vessel. The proximal portion of the major diagonal branch
had a 70% stenosis. The LCx had a 99% stenosis at the origin,
with left to left collaterals. The RCA was totally occluded
proximally, with left to right collaterals.
2. Resting hemodynamics revealed moderate to severely elevated
right and left sided filling pressures (RVEDP 19 mm Hg, LVEDP 25
mm Hg, respectively). The PCWP mean was elevated at 28 mm Hg.
There was moderate pulmonary artery hypertension (PASP 59 mm
Hg). The systemic arterial blood pressure was low-normal (SBP
105 mm Hg). The cardiac index was depressed at 1.7 L/min/m2. The
systemic and pulmonary vascular resistances were mildly elevated
at 1697 dynes-sec/cm5 and 315 dynes-sec/cm5, respectively.
3. Left ventriculography demonstrated a dilated left ventricle
with global, severe hypokinesis to akinesis, with estimated
ejection fraction of 25%. There was moderate to severe mitral
regurgitation.
[**2200-10-25**] ECHO:
The left atrium is dilated. The right atrium is markedly
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is moderate to
severe regional left ventricular systolic dysfunction with
inferior/inferolateral and inferoseptal akinesis. Overall left
ventricular systolic function is moderately depressed (LVEF= 30
%). [Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] with
borderline normal free wall function. 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. An eccentric, medially directed jet of at
least moderate (2+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname **] was found to have triple vessel disease on
catheterization, with right heart pressure elevated and mitral
regurgitation. He was taken to the operating room on [**10-27**] where
coronary bypass grafting and mitral valve replacement were
performed. See operative note for details. He weaned from
bypass on Milrinone,epinephrine and neosynephrine.
Postoperatively he was relatively stable and was extubated on
[**Name (NI) 80108**]. His epinephrine was weaned and discontinued as was his
neosynephrine by POD 2. The Milrinone was then slowly weaned
and he remained stable.
He was gently diuresed, however, he became hypotensive each time
he received a Lasix bolus. A Lasix drip was instituted with a
good diuresis and stable blood pressure. Consult was obtained
from the CHF service-- we appreciate their recommendations. The
patient was transitioned from the lasix gtt to bolus treatment,
which he tolerated well.
He made good progress with physical therapy before discharge.
By the time of discharge, the patient was ambulating with
assistance, the pain was controlled with oral analgesics, and
the woundf was healing. He was discharged on POD 15 to The
Rehab of [**Location (un) **] and Islands for further recovery.
Medications on Admission:
Prilosec 20 qd
Altace 10 qd
Metformin 1000 qam, 500 qpm
Crestor 10 qd
ASA 81
MVI
Ca Vit D
Actonel 35 qFriday
Lasix
Timolol 0.5% to L eye [**Hospital1 **]
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Captopril 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
5. Furosemide 10 mg/mL Solution Sig: Four (4) Injection [**Hospital1 **] (2
times a day).
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day).
12. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
17. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
congestive heart failure
coronary artery disease
Diabetes Mellitus
Dyslipidemia
Hypertension
peripheral vascular disease
h/o nephrolithiasis
chronic anemia
spinal stenosis
glaucoma
osteoporosis
diverticulosis
colonic polyps
Discharge Condition:
good
Discharge Instructions:
No lifting more than 10 pounds for 10 weeks
no driving for 4 weeks and off all narcotics
report any temperature greater than 100.5
report any redness or drainage from incisions
shower daily, no baths or swimming
take all medications as directed
no lotions, powders or creams to incisions
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 58201**] in 2 weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] in [**3-2**] weeks
Completed by:[**2200-11-11**]
|
[
"2761",
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"4019",
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"5859"
] |
Admission Date: [**2145-8-17**] Discharge Date: [**2145-8-19**]
Date of Birth: [**2099-9-7**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2145-8-18**], placement of 2 drug-eluting
stents to LAD, and 1 drug-eluting stent to the RCA.
History of Present Illness:
Mr. [**Known lastname 6164**] is a 45 yo male w/o known CAD with an aspirin allergy
who presented to his PCP yesterday for 2 weeks of intermittent
chest pain. His PCP did an ECG that showed ST depressions in
V1-V5 and he was sent to the ED at [**Hospital3 **]. By time he arrived
at the ED, his pain had resolved. No medications were given at
that time. He had one episode of chest pain overnight which
also resolved without treatment. He was transferred to [**Hospital1 18**]
for aspirin desensitization and cardiac catheterization.
He describes his chest pain as a pressure in the upper chest
("like someone is standing on me") that lasts about 3-5 minutes
and resolves on its own. His initial episode was two weeks ago
during light activity (walking around). His next episode was a
few days later and he began having chest pain episodes more
often (up to about 3 per day) and having pain at rest. He
states that during one episode a few days ago, he had a cough
that was productive for slightly blood-tinged saliva. Yesterday
morning he went to work and his friends convinced him to call
his PCP.
At [**Hospital3 **] Hospital, he was given 5000 units SC heparin, 70mg
SC Lovenox, and Plavix 300mg po. 1st set of enzymes was CPK
236, CKMB 3.2, Troponin I 0.06 (indeterminate per their lab).
2nd set CPK 200, CKMB 2.8, Troponin I 0.08 (also indeterminate).
Third set 180, 2.5, and 0.04 (also indeterminate). He also had
a normal CXR and CT that showed emphysematous changes but no
evidence of PE.
He has a very strong family history for premature CAD with his
sister having a MI at age 42 and his father having multiple [**Name (NI) 5290**]
beginning in his 50's.
On review of systems, he denies any fever, chills, headaches,
weakness, numbness, nausea, vomiting, diarrhea, constipation, or
hematuria. He endorses one episode of left side pain at the OSH
due to "sitting in one place too long" that resolved with 2mg IV
morphine. All of the other review of systems were negative.
Past Medical History:
Herniated disc in back
Emphysema - diagnosed after he had an episode of pneumonia,
reports his exercise tolerance is high and he can "walk forever
and run with my kids"
Social History:
Lives in [**Location 2498**], MA with his wife and son (age 13). Previously
smoked cigarettes extensively (2-3ppd for 30 years), quit 1.5
years ago, now continues to smoke some cigars (states he will
completely quit after this hospitalization). Denies EtOH or
illicit drug use. Works as an iron worker.
Family History:
He has a very strong family history for premature CAD with his
sister having a MI at age 42 and his father having multiple [**Name (NI) 5290**]
beginning in his 50's.
Physical Exam:
VS: T=98.3 BP=143/79 HR=65 RR=14 O2 sat=97% RA
GENERAL: Well-appearing male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma. No LAD,
no thyromegaly
NECK: Supple with no JVD.
CARDIAC: PMI located in 5th intercostal space at midclavicular
line. RRR, 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. BS+
EXTREMITIES: No clubbing/cyanosis/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:
ADMISSION LABS:
15.9
11.8>---<304
47.5
141 107 13
-----------< 92
4.1 24 0.8
PT 12.2 PTT 53.1 INR 1.0
CK 125
CK-MB 3
Trop T <0.01
Notable OSH labs: WBC 13.5 with normal diff, Cr 1.0, BUN 11
Tot Chol 180 LDL 116 HDL 47 Trig 85, Normal LFT's
EKG:
[**8-16**] at OSH: NSR, very slight ST elevations in V1-V2, T wave
inversions in V4-V5, ST depression V4-V5
[**8-17**] at OSH: NSR, T waves slightly normalized in V4-V5,
continued ST depression in V4-V5
[**8-17**]: NSR, no ST elevations but T wave inversion V4
[**8-18**] 4:45am: NSR, Marked ST elevation in leads V1-V4
[**8-18**] 4:55am: NSR, Resolution of ST elevations, T wave inversions
V1-V4
[**8-19**]: NSR, Continued T wave inversions in precordial leads c/w
[**Last Name (un) 46104**] T waves
CT Chest at OSH: No CT evidence of pulmonary thromboembolism.
Emphysematous changes.
Cardiac cath [**2145-8-18**]:
Coronary angiography in this right dominant system demonstrates
two vessel disease. The LMCA had no angiographically apparent
disease. The LAD had an 80% stenosis in the mid-portion of the
vessel. The D1 had a 70% stenosis at the origin. The Cx had
minor luminal irregularities on angiography. The RCA had a 70%
stenosis in the mid portion of the vessel. Patient received two
Endeavor 3.0 drug-eluting stents to the LAD and an Endeavor 3.5
drug-eluting stent to the RCA.
TTE [**2145-8-18**]: 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 a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
INPATIENT LABS:
[**2145-8-19**] 04:25AM BLOOD WBC-14.1* RBC-4.84 Hgb-15.7 Hct-45.8
MCV-95 MCH-32.4* MCHC-34.3 RDW-13.0 Plt Ct-285
[**2145-8-19**] 04:25AM BLOOD PT-11.5 PTT-36.0* INR(PT)-1.0
[**2145-8-19**] 04:25AM BLOOD Glucose-112* UreaN-12 Creat-0.9 Na-137
K-4.8 Cl-104 HCO3-23 AnGap-15
[**2145-8-18**] 01:55AM BLOOD CK(CPK)-104
[**2145-8-18**] 05:00PM BLOOD CK(CPK)-76
[**2145-8-18**] 01:55AM BLOOD CK-MB-3 cTropnT-<0.01
[**2145-8-19**] 04:25AM BLOOD CK(CPK)-66
[**2145-8-18**] 01:55AM BLOOD PT-12.4 PTT-125.3* INR(PT)-1.0
[**2145-8-19**] 04:25AM BLOOD PT-11.5 PTT-36.0* INR(PT)-1.0
Brief Hospital Course:
# CORONARY ARTERY DISEASE: Patient was admitted for two weeks
of intermittent escalating chest pain. On admission, he was
chest pain free and had ECG changes concerning for ACS (T waves
inversions and ST depressions in precordial leads). It was felt
that his symptoms were consistent with unstable angina and he
was scheduled for cardiac catheterization the next morning. He
was started on a heparin gtt, metoprolol 12.5mg po bid,
atorvastatin 80mg po daily. His PTT was at goal approximately 8
hours after initiating heparin.
Early the morning after admission, the patient experienced
an episode of chest pain. An ECG was obtained which showed ST
elevation in leads V1-V4. His pain resolved with administration
of SL nitro x 3 and morphine. He was then started on
integrillin gtt, nitro gtt, and given Plavix 75mg. Later that
morning, he was taken for cardiac catheterization and found to
have 70% stenosis of the LAD and 80% stenosis of the RCA. He
received 2 DES to the LAD and 1 DES to the RCA. He had no
complications during the procedure. After the procedure, he was
chest pain free and remained chest pain free throughout his
admission. A follow-up TTE showed normal heart function.
His cardiac markers remained negative throughout his
admission, and his chest pain and ST elevations had resolved
quickly with SL nitro and morphine. Therefore, it was felt that
the patient's chest pain was best attributable to coronary
vasospasm. Therefore, his medications were switched to
isosorbide mononitrate 30mg po daily and amlodipine 5mg po daily
to prevent coronary vasospasm. His metoprolol was discontinued,
and atorvastatin 80mg was changed to simvastatin 20mg po daily.
Since he received 3 drug-eluting stents, he will need to
continue Plavix 75mg po daily for at least one year, and aspirin
indefinitely.
# ASPIRIN DESENSITIZATION: Patient had an allergy to aspirin on
admission, and had previously had angioedema and hives with
aspirin therapy. Therefore, an aspirin desensitization protocol
was instituted and the patient was desensitized without
complications.
# BACK PAIN: Patient has a history of herniated disc in his
back, and complained of some back pain during admission. He was
managed with prn oxycodone-acetaminophen for the back pain as an
inpatient, but takes Darvocet and Soma at home. He was
discharged with PCP [**Name9 (PRE) 702**] for further prescriptions of pain
medication.
Patient requested he be a FULL CODE during his admission.
Medications on Admission:
Carisoprodol 350 mg Tablet One Tablet(s) po daily prn for back
pain
Propoxyphene N-Acetaminophen [Darvocet-N 100] 100 mg-650 mg
Tablet [**2-5**] Tablet(s) by mouth three times a day prn for back
pain
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual As directed: Take one tablet if you develop chest
pressure. If pain fails to resolve completely, may repeat every
5 minutes, maximum 3 doses. If you take this medication, call
your physician [**Name Initial (PRE) 2227**].
Disp:*10 tablets* Refills:*2*
7. Carisoprodol 350 mg Tablet One Tablet(s) po daily prn for
back pain
8. Propoxyphene N-Acetaminophen [Darvocet-N 100] 100 mg-650 mg
Tablet [**2-5**] Tablet(s) by mouth three times a day prn for back
pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Coronary artery disease, coronary artery vasospasm,
status-post stenting to coronary arteries
Secondary: Chronic back pain, emphysema
Discharge Condition:
Hemodynamically stable, afebrile and without chest discomfort.
Discharge Instructions:
You were admitted with chest pain that had begun about 2 weeks
prior. You also had an aspirin allergy. You were evaluated and
found to have narrowing in the arteries that supply your heart.
These were treated with stents to keep them open. You also
underwent aspirin desensitization. You have been started on
several new medications. You MUST take these medications every
day to keep your heart healthy, your stents open and to prevent
new development of aspirin allergy. You especially need to take
your Plavix and Aspirin every day for one year, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s.
Please take all medications as prescribed.
- Start Clopidogrel 75 mg daily
- Start Simvastatin 20 mg daily
- Start Aspirin 325 mg daily
- Start Isosorbide Mononitrate 30 mg daily
- Start Amlodipine 5 mg daily
You need to have repeat lab tests in 6 weeks. These labs should
include liver function tests and a cholesterol panel.
Please keep all outpatient appointments.
Given your recent procedure, you must not lift objects greater
than 10 pounds (lbs) for the next 7 days. No driving for 2 days
after discharge.
Seek medical advice immediately if you notice recurrent chest
pain, chest pressure, shortness of breath out of proportion to
exercise, difficulty breathing at rest, lower extremity
swelling, fever, chills, recurrent bleeding or pain from your
groin or any other symptom that is concerning to you.
Followup Instructions:
You have follow-up scheduled with your primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 17918**] on Monday, [**2145-8-23**] at 3:45 pm.
Cardiology: Wednesday [**9-15**] at 11:30am. Address: 15 [**Doctor Last Name **]
Bros Way and [**Street Address(2) 82898**], [**Location **]. Phone:
[**Telephone/Fax (1) 8725**]
You need to have repeat lab tests in 6 weeks. These labs should
include liver function tests and a cholesterol panel. Please
discuss these lab tests and all your new medications with Dr.
[**Last Name (STitle) 17918**] at this appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"41401"
] |
Admission Date: [**2154-6-13**] Discharge Date: [**2154-6-15**]
Date of Birth: [**2100-4-27**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12657**]
Chief Complaint:
CSF leak, AD otorrhea
Major Surgical or Invasive Procedure:
[**2154-6-13**] repair of CSF leak
History of Present Illness:
54 yo M with chronic CSF leak
Past Medical History:
HTN, CAD s/p NSTEMI, and stents x 2
Social History:
+tobacco, +etoh
Physical Exam:
Afebrile VSS
AD dressing changed. Would flat, no otorrhea
Facial function intact and symmetric
Pertinent Results:
[**2154-6-14**] 02:00AM BLOOD WBC-13.0* RBC-4.44* Hgb-13.4* Hct-37.6*
MCV-85 MCH-30.2 MCHC-35.6* RDW-13.8 Plt Ct-291
[**2154-6-14**] 02:00AM BLOOD Plt Ct-291
[**2154-6-14**] 02:00AM BLOOD Glucose-247* UreaN-14 Creat-0.8 Na-139
K-4.2 Cl-105 HCO3-23 AnGap-15
[**2154-6-14**] 02:00AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.9
Brief Hospital Course:
Initially monitored in ICU setting. Vitals remained stable.
ECG was normal. Transferred to floor on POD 1. Ambulated and
tolerated PO's. No clear fluid drainage or swelling of incision
site. Received IV ceftriaxone while an inpatient. Lovenox held
for 48 hours, and restarted on POD 2.
Medications on Admission:
Metoprolol, Aspirin, Valsartan, ativan, lovenox, omeprazole,
zocor
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain. Tablet(s)
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate Oral
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Lovenox 1.5 mg/kg SC QD
8. Keflex 500 mg Po QID x 7 days
Discharge Disposition:
Home
Discharge Diagnosis:
CSF leak
Discharge Condition:
Good
Discharge Instructions:
Light activity, no straining or bending over. Call the office
if develop neck stiffness, light bothering eyes, or high fevers.
Followup Instructions:
Dr. [**Last Name (STitle) 3878**], 1 week-call office to schedule
Completed by:[**2154-6-15**]
|
[
"41401",
"4019",
"412",
"V4582",
"3051"
] |
Admission Date: [**2150-12-26**] Discharge Date: [**2151-1-7**]
Service: NEUROSURGERY
Allergies:
Cosopt / Lisinopril
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Left arm weakness
Major Surgical or Invasive Procedure:
[**12-26**] Right Burr Holes and SDH evacuation
[**12-30**] Placement of Subdural Drain
History of Present Illness:
88yo woman s/p mechanical [**2150**]. She sustained an
acute SDH at that time as well as a fractured him. She had
prolonged hospital course and was just discharged to rehab on
[**12-23**]. Pt returns from rehab today with complaint of worsening
left sided weakness and lethargy.
Past Medical History:
-CAD
-HTN
-NIDDM
-b/l cataract surgery
-cholecystectomy
-polyp removal from uterus
- hip ORIF
Social History:
No ETOH
No tobacco
lives with husband who is hospitalized, children very involved
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
O: T:98.1 BP: 162/68 HR:72 R 18 O2Sats97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL 4-3mm EOMs- unable to look left past
midline bilaterally.
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech slow
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally.
III, IV, VI: Extraocular movements are limited to the left
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. full strengths on right
UE and LE. Left neglect but able to lift UE and LE antigravity.
Sensation: Intact to light touch
DISCHARGE EXAM:
As above - A&0 x 2
Pertinent Results:
[**12-26**] CT head: IMPRESSION:
1. Interval decrease in density but increase in size of the
right hemispheric subdural collection which may represent
subdural hygroma, now with increased mass effect on the right
hemisphere and increased midline shift to the left, as above,
now 13 mm.
2. Evolving small left parietal subdural hematoma, not
increased.
[**12-26**] CT head: IMPRESSION:
1. Stable evolving right hemispheric subdural collection with
stable mass
effect on the right hemisphere and 11 mm shift of normally
midline structures to the left, previously 13 mm shift.
2. Stable left parietal subdural hematoma.
3. Interval burr hole evacuation with intracranial foci of
pneumocephalus;
largest focus along the right frontal hemisphere, other
scattered foci in the right cerebral hemisphere.
[**12-27**] CT head: IMPRESSION:
1. Stable large right subdural hematoma with chronic and acute
components
with stable mass effect on the right hemisphere. 13 mm leftward
shift of
midline structures is also stable.
2. Stable left parietal subdural hematoma measuring up to 4 mm
in maximum
thickness. No new areas of acute hemorrhage.
[**12-29**] CT Head:
1. Large right subdural hematoma, increased in size due to
increased
nondependent fluid, with a new septation. Expected evolution of
dependent
blood within this colleciton, without evidence of new
hemorrhage.
2. Increased leftward midline shift. Increased prominence of the
left
temporal [**Doctor Last Name 534**], consistent with increased trapping of the left
lateral
ventricle due to compression of the third ventricle.
3. Persistent right uncal herniation.
[**12-30**]/ CT HEad:
Interval evacuation of large right subdural collection, much of
which is now replaced by moderate pneumocephalus anteriorly,
with mild
improvement of leftward shift but similar configuration of mass
effect on the right frontal lobe, which may not be immediately
relieved. Right transcranial catheter with tip in the right
frontal region. No new focal hemorrhage.
[**1-1**] CT head:
1. Subdural catheter with tip in the right frontal subdural
collection.
2. Right frontoparietal subdural hemorrhage, smaller in size but
still 11 mm in greatest thickness.
3. Improvement in pneumocephalus which is now bifrontal.
4. Improvement in shift of normally midline structures from 12
to 6 mm.
5. Resolution of right uncal herniation
[**1-6**] R Knee XRay
No previous images. Generalized demineralization of the bony
elements. No evidence of acute fracture or dislocation or joint
effusion.
There is some meniscal calcification, especially in the lateral
aspect. Some vascular calcification is noted posteriorly
Brief Hospital Course:
Patient was admitted from the Emergency Department to the
Neurosurgical service and taken to the operating room for burr
holes (2) and evacuation of subdural hematoma. Surgery was
without complication and the patient tolerated it well. She was
extubated and transferred to the PACU where she remained
overnight. Post operative head CT revealed stable post op
changes. Left neglect was improving compared to preop.
On POD#1 she was transferred to the floor. She was started on
cipro for a UTI. Pt remained lethargic and was not taking PO's,
therefore IVF was continued.
On POD#2 her exam was again stable, but she remained lethargic.
Speech and Swallow were consulted to eval whether PO intake was
safe. PT and OT were consulted for assistance with discharge
planning.
On POD#3 pt continued to be lethargic and mental status was
declined in comparison to immediate post op. A head CT was
obtained which revealed resolving pneumocephalus but expanding
fluid collection. CXR was obtained which revealed pleural
effusion. She was started on lasix.
ON POD#4 MS [**First Name (Titles) **] [**Last Name (Titles) 1506**] therefore a dobhoff was placed. KUB
confirmed placement in the proximal duodenum. It was decided
that the SDH needed to be drained therefore she was taken to the
operating room. In the OR the subdural collection was drained
and a subdural drain was placed. She remained intubated and was
trasnferred to the PACU where she remained overnight. On [**12-31**]
she was still intubated but interacting on exam slightly more
than she was pre-operatively. Her hematocrit was 22 so she
recieved a unit of red cells. On [**1-1**] she had a CT which was
improved and as a result she was extubated and tolerated it well
while on nasal cannula. She was trasnferred to the floor and
tube feeds were started on [**1-1**] as well and she remained stable
there into [**1-2**]. On [**1-2**] she was stable however developed
hypertension and decreased urine output. She was placed on
antihypertensive medications in addition to her prior agents and
bolused fluid and her UOP improved. On [**1-3**] she had a CXR which
showed pulmonary venous congestion and she was given lasix. Her
BNO was found to be elevated and the team had difficulty
controllign her blood pressures. At this time her subdural
drain was also pulled. The medicine team was consulted to
comment on her hypertension and fluid overload and they felt
althoguh she had a history of CHF she was not currently in it.
Recommendations were made and carried out with improvement in
her medical status. On [**1-4**] her exam continued to improve, her
blood pressure was under control, and she was progressing
towards discharge to rehab.
She pulled her NG Tube on [**1-5**], however, a PO diet was initiated
and she did quite well. 3 days of calorie counts were obtained
by nutrition, who determined that she adequately met her calorie
requirements with oral intake. She complained of R knee pain on
[**1-6**], and an XRay revealed no acute fracture but a small
effusion. She was OOB with PT and standing with assistance.
She was discharged to rehab on [**2151-1-7**].
Medications on Admission:
tylenol
tums 500"
colace
flonase "
keppra 500"
metformin 500"
metoprolol 75 "'
timolol "
vit d 1000
senna
miconazole "
Discharge Medications:
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 DAILY (Daily).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
7. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
9. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
13. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] @ [**Hospital1 189**]
Discharge Diagnosis:
Subdural Hematoma s/p evacuation
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, do not
resume taking these until cleared by your surgeon.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2151-1-7**]
|
[
"5990",
"41401",
"4019",
"25000"
] |
Admission Date: [**2100-12-28**] Discharge Date: [**2101-1-6**]
Date of Birth: [**2039-6-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 61 year old man
with known three vessel coronary artery disease and
congestive heart failure with an ejection fraction of 25 to
30% who had a planned coronary artery bypass grafting
scheduled for the morning of admission when he was noted to
be acutely short of breath while undressing in the
Preoperative Holding Area. States this is more severe than
his usual and did not resolve with rest. He had no
associated chest pain. He received 40 mg of intravenous
Lasix, Captopril, Lopressor and was started on Nitroglycerin
drip. He subsequently diuresed 1100 cc and had symptomatic
improvement. Over that day he was weaned off of his
Nitroglycerin drip and was seen to have improvement in his
symptoms. He had noted one month history of increasing
dyspnea on exertion and orthopnea and had been admitted to
[**Hospital 882**] Hospital in early [**Month (only) 1096**] with similar symptoms.
An echocardiogram at that time revealed an ejection fraction
of 40% with global hypokinesis and a catheterization
reportedly showed three vessel disease for which he was then
transferred to the [**Hospital6 256**] on
[**2100-12-2**]. His initial workup showed troponin of .56
and a chest x-ray with bilateral effusion and a left upper
lobe infiltrate. He was started on beta blocker, ACE
inhibitor and heparin and received Levaquin for a urinary
tract infection plus a possible pneumonia. Due to his
infection, his coronary artery bypass graft was subsequently
deferred at that time and since he had a history of stable
angina he was discharged to home at that time to return for
elective surgery.
PAST MEDICAL HISTORY: Coronary artery disease, congestive
heart failure with an ejection fraction of 25 to 30% by
echocardiogram on [**2100-12-1**], borderline hypertension,
recent urinary tract infection on last admission and recent
pneumonia on last admission.
SOCIAL HISTORY: He was born in [**Country 4754**] and now lives in
[**Location 2312**]. He is not married and has no children. His
tobacco history reveals he smoked 1 1/2 packs per day for 15
years and quit 25 years ago. He does drink occasional
alcohol and does not use intravenous drugs.
ALLERGIES: No known drug allergies.
MEDICATIONS: His medications at home include Captopril 12.5
mg p.o. b.i.d., Lopressor 15 mg p.o. t.i.d., Aspirin 325 mg
p.o. q.d., Zocor 20 mg p.o. q.d.
REVIEW OF SYSTEMS: Significant for positive dyspnea on
exertion, positive orthopnea, positive dry cough, no fevers
or chills or urinary frequency and no dysuria.
PHYSICAL EXAMINATION: On physical examination he is a
pleasant well nourished, well developed male in no apparent
distress. His vital signs showed a temperature of 97,
heart rate 91, blood pressure 114/62, respirations 22, and
oxygen saturations of 92% on 76% face mask. His head, eyes,
ears, nose and throat showed pupils equal, round and reactive
to light, extraocular movements intact, and oropharynx is
clear. His neck has jugulovenous pressure to about 9 to 10
cm. He has no bruits. Carotid pulses are 2+ bilaterally.
His lungs are clear to auscultation bilaterally and heart is
regular rate and rhythm with a normal S1 and S2 with no
murmur, rub or gallop. His abdomen is soft, nontender,
nondistended with positive bowel sounds. His extremities
showed 2+ pitting edema to the mid calf with 2+ dorsalis
pedis and 2+ posterior tibialis pulses. His neurological
examination shows him to be alert and oriented and grossly
intact.
LABORATORY DATA: His laboratory data on admission include a
white count of 19.1, hematocrit 45.5%, platelet count of
368,000 and sodium of 41, potassium 3.1, chloride 106, carbon
dioxide 22, BUN 16, creatinine 1.1 and blood glucose is 186.
His electrocardiogram showed sinus tachycardia at 119
beats/minute with T wave inversions in V5 and V6 which were
old and [**Street Address(2) 4793**] depressions in V1. His chest x-ray showed
low lung volumes, positive for mild congestive heart failure
and positive for bilateral effusions.
HOSPITAL COURSE: The patient was then admitted and brought
to the Coronary Care Unit where he was diuresed, treated and
stabilized. He was then later that date transferred to the
floor where he continued to be diuresed. On the evening of
admission he was noted to have a brief run of nonsustained
ventricular tachycardia consisting of five beats during which
he was stable and asymptomatic. His enzymes were checked
over the day and his troponin peaked at .21. On [**2100-12-30**], he had transthoracic cardiac echocardiogram which
showed 1 to 2+ mitral regurgitation which was unchanged from
previous echocardiogram and an ejection fraction of about
25%. Later that night he was noted to have a ten beat run
and nonsustained ventricular tachycardia during which he was
asymptomatic with stable vital signs. On [**12-31**], he was
thought to be stable and he was brought to the Operating Room
for coronary artery bypass grafting times four with the left
internal mammary artery to the left anterior descending
coronary artery, saphenous vein graft to the obtuse marginal
sequential to the ramus and a saphenous vein graft to the
right coronary artery. This surgery was performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The surgery was performed under general
endotracheal anesthesia with a cardiopulmonary bypass time of
123 minutes and a cross-clamp time of 91 minutes. The
patient was transferred to the Surgical Intensive Care Unit
in stable but critical condition on Levophed, Milrinone and
Propofol drips. He pulled from anesthesia well, followed
commands and was extubated later that evening. He also was
started on an insulin drip for blood sugars greater than 120.
By postoperative day #1, his Milrinone was weaned off and he
was started on Amiodarone drip for brief runs of nonsustained
ventricular tachycardia. By postoperative day #2, he
continued on his Amiodarone drip to help prevent further
ectopy and required Levophed for blood pressure support. He
had his chest tubes discontinued without incident on
postoperative day #3 and was transfused 1 unit of packed red
blood cells on this date. On postoperative day #3 he was
transferred from the Unit to the Surgical Floor and was
started on cardiac rehabilitation physical therapy. Chest
x-ray performed on postoperative day #4 showed mild to
moderate left pleural effusion. He continued with diuresis
and repeat chest x-ray on postoperative day #5 showed slight
improvement in this effusion and it was felt that the patient
was ready to be discharged to home with the [**Hospital6 1587**] services.
His discharge examination revealed vital signs stable with a
temperature of 98.8, heart rate 78, blood pressure 100/67,
respirations 20 and oxygen saturations 93% on room air. His
lungs were clear to auscultation. His heart was regular rate
and rhythm. His abdomen was soft, nontender, nondistended
with positive bowel sounds. His incisions are clean, dry and
intact.
His discharge laboratory data included white count of 12.6,
hematocrit 27.7%, platelet count of 273,000, sodium 137,
potassium 4.0, chloride 101, carbon dioxide 30, BUN 17,
creatinine 1.1 and blood glucose of 93.
DISCHARGE DISPOSITION/CONDITION: He will be discharged to
home with [**Hospital6 407**] services in good
condition.
DISCHARGE MEDICATIONS:
Lipitor 10 mg p.o. q.d.
Aspirin enteric coated 325 mg p.o. q.d.
Colace 100 mg p.o. b.i.d. prn.
Isordil 30 mg p.o. q.d., this is due to poor targets for
bypass grafts.
Plavix 75 mg p.o. q.d., also due to poor targets for his
bypass graft.
Amiodarone 400 mg p.o. b.i.d. times seven days and then 400
mg p.o. q.d. times seven days and then 1 tablet p.o. q.d. and
the need for this medication is to be reassessed by the
patient's cardiologist in one month's time.
Amantadine Hydrochloride 10 cc p.o. b.i.d. for four days as
the patient was exposed to a patient who tested positive for
influenza.
Lasix 60 mg p.o. t.i.d. times seven days, then 60 mg p.o.
b.i.d. times five days.
Potassium chloride 20 mEq p.o. b.i.d. times 12 days.
Percocet 1 to 2 tablets p.o. q. 4 hours prn pain.
FOLLOW UP: The patient should follow up with Dr. [**Last Name (STitle) 53443**] in
one to two weeks, with his cardiologist in two to three weeks
and with Dr. [**Last Name (STitle) **] in four weeks.
PRIMARY PROCEDURE: Coronary artery bypass grafting times
four with left internal mammary artery to the left anterior
descending coronary artery, saphenous vein graft to the
obtuse marginal with a sequential graft to the ramus and a
saphenous vein graft to the right coronary artery.
PRIMARY DIAGNOSIS:
Coronary artery disease.
Congestive heart failure.
Hypertension.
Pneumonia.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 31272**]
MEDQUIST36
D: [**2101-1-6**] 16:13
T: [**2101-1-6**] 18:51
JOB#: [**Job Number 53444**]
|
[
"41401",
"4280",
"486",
"4019"
] |
Admission Date: [**2158-1-3**] Discharge Date: [**2158-1-8**]
Date of Birth: [**2096-5-3**] Sex: M
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Insulins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Dyspnea, LE edema
Major Surgical or Invasive Procedure:
Cardiac catheterization- no intervention
History of Present Illness:
61 year old primarily Italian speaking male with known coronary
artery disease (s/p 3 vessel CABG in [**5-25**], and multiple PCI's on
both native and grafts), status-post re-PCI of SVG=>D2 in-stent
restenosis via Cypher DES on 12/[**2156**]. Also, has history of PVD,
HTN, DM, HLP, smoking history. Recently admitted
[**11/2157**]/6/[**2157**] for acute decompensated heart failure in the
setting of a non-ST elevation myocardial infarction. Peak CK
2200, and troponin T 5.21 (baseline Cr 1.5), with troponin on
discharge 3.21. Patient had post-procedure echocardiogram on
[**2157-12-27**], which demonstrated no new MR with LV ejection fraction
35% (depressed from [**5-29**] EF 45%).
Since discharge on [**2157-12-30**], he has had intermittent dyspnea at
home, unclear if this was exertional or rest, which has been
increasing over the past 2 days. Associated with this SOB is
chest heaviness, no other symptoms (including no fevers, chills,
nausea, vomiting, diaphoresis, palpitations, ligtheadedness,
syncope, worsening LE edema).
He presented to [**Hospital 8050**] hospital on [**1-3**] in heart failure, and
was given 80 mg 80 IV lasix, morphine. He was started on heparin
drip for elevated cardiac enzymes (though decreaed since last
admission at [**Hospital1 18**]), and transferred to [**Hospital1 18**] for invasive
management. Here, heparin drip was discontinued (as cardiac
enzymes were decreased from prior) and he was given another 80
mg IV lasix and placed on nitroglycerin drip transiently for
pulmonary edema. Chest x-ray here was consistent with heart
failure. He was chest pain free on admission.
Past Medical History:
1. DMII - on humalog
2. HTN
3. hyperchol
4. CAD:
- [**2146**] - first IMI c/b VT, stent to an 80% RCA lesion.
- [**2152**] - CABG: SVG -> OM, SVG-> D1 & SVG-> D2
- [**2153**] - PTCA to SVG->D1 in [**5-26**], PTCA w/ brachy therapy to
SVG->D2 in [**10-26**]
- [**5-29**] - PTCA to SVG-D1 with 4 Cypher DES
- [**4-28**] - PTCA showed LAD had a 80% distal lesion. The LCX was
totally
occluded proximally. Distal LAD stented.
- [**11-28**] - stenting of the ISR of SVG to the D2
.
5. Severe symptomatic PVD s/p mult peripheral stents
- [**2155**] - 3 left SFA Dynalink stents to the left superficial
femoral artery
- [**4-28**] - Successful Atherectomy to the right EIA, CFA and SFA
- [**5-/2157**] - Successful atherectomy of the [**Female First Name (un) 7195**] and CFA.
Atherectomy of the LSFA complicated by distal embolization to
the AT and PT
- [**9-28**] - Successful atherectomy of the right SFA and CFA.
Successful stenting of the right EIA. Successful stenting of the
left CIA and EIA.
5. Systolic dysfunction: TEE in [**5-29**] showed no masses,
vegatatation. TTE in [**5-29**] showed EF 45%, Mild global LV
hypokinesis, trivial MR
6. Depression
7. AFib
8. Nephropathy
9. Hematuria
10. GERD
11. chronic LBP
12. colon polyps
13. PUD
Social History:
Married, speaks Italian, + smoker, quit two years ago but
restarted recently approximately 2 cigarettes per day (120 pk-yr
history). Denies alcohol or other drug use
Family History:
No family history of CAD
Physical Exam:
Admit PE:
vitals- T 99.4, BP 104/52, HR 85, RR 24, 97% on 2L o2; Wt 94 kg
gen- lying in bed, 45 degrees, 2 pillows, NAD
heent- EOMI. OP CLEAR. PERRLA.
neck- diffuse jvp at 8cms
pulm- bibasilar rales. upper lung fields clear. no wheezes
cv- RRR. normal s1/s2. +s3. no murmurs
abd- obese. nt/nd. NABS
ext- no edema
neuro- alert and oriented x 3. speaks limited english. motor fn
[**4-28**] UE/LE.
Pertinent Results:
DATA: EKG- sinus at 92 bpm, QRS axis 70, normal intervals; ST
depression V4 2mm; V5 1mm; V6 1mm -> new compared to prior
.
Labs: Na 141, K 4.5 (from 5.5) , Cl 103, Co2 24, BUN 68, Creat
1.9 (from 2.0) Ca 8.4, Mag 2.0, WBC 11.0, Hct 28.8, Plt 226
.
[**2158-1-4**] 7:30 am CK 165 Trop 2.33
[**2158-1-4**] 7:40 pm CK 210 Trop 2.42
[**2158-1-5**] 07:15AM CK(CPK)-143 CK-MB-3
.
Max CK 2225 ([**2157-12-26**]), Max Trop 5.21 ([**2157-12-25**])
[**2158-1-3**] pBNP: [**Numeric Identifier 47373**]
.
CXR [**2157-1-3**]: Small bilateral pleural effusions with prominence
of the pulmonary vasculature, consistent with mild pulmonary
edema. Scattered bibasilar atelectasis is noted
.
Cardiac Catheterization:
PROCEDURE DATE: [**2158-1-5**]
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease. Congestive heart failure. Dyspnea.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease with occluded
SVG-OM and
SVG-D.
2. Severe biventricular diastolic dysfunction.
3. Preserved cardiac output / index.
COMMENTS: 1. Selective coronary angiography demonstrated native
three vessel coronary artery disease in this right dominant
circulation.
The LMCA was without angiographically apprarent flow limiting
disease.
The LAD had moderate diffuse disease in the proximal and mid
vessel
without flow limitation. The diagonal branches were not
visualized. The
LCX was a small vessel with a mid-segment occlusion. The OM
branches
were not visualized. The RCA was a dominant vessel with a
proximal total
occlusion.
2. Graft angiography demonstrated that the SVG-D2 was occluded
distally
at the previously placed stent. The SVG-OM was occluded
proximally.
3. Right and left heart catheterization demonstrated elevated
right and
left sided filling pressures (RVEDP=15mmHG, mean PCWP=35mmHg,
LVEDP=35mmHg). Severe pulmonary arterial hypertension was
present.
Cardiac output and index were 4.5 L/min and 2.2/ L/min/m2
respectively. No transaortic gradient seen from catheter
pullback from
LV to ascending aorta.
4. Left ventriculography was not performed to reduce contrast
volume
Brief Hospital Course:
61 y/o M w/ h/o CAD, CABG, CHF, CRI, PAF p/w CHF exacerbation
.
1. CHF: Unclear precipitator, although he had a recent
pneumonia. His cardiac enzymes were elevated but down-trending
from previous admission. Unlear whether dietary indiscretion or
medical noncompliance were an issue, as patient did not know
what mediacations he [**Last Name (un) **] on. He came in with dyspnea and LE
edema. Had cardiac catheterization showing elevated right and
left sided pressures with PCWP of 35. His cardiomyopathy is
ischemic judging by wall motion abnormalities and his EF is 35%
by echo this admission. He did not have any intervention. He was
transfered to the CCU for tailored diuresis, where he diuresed
well with IV lasix. He self removed his femoral pressure
monitoring line, but not before two readings of PCWP around 20
were recorded. He diuresed over 2800 cc in two days in the CCU
and was transferred back to the floor for continued diuresis.
His IV lasix was changed to PO and he continued to diurese
appropriately. He was dicharged without LE edma, crackles, or
SOB.
.
2. CRI: He has elevated Cr in the past. His Cr was Cr 2.0 on
admission and 1.7 on discharge. It is thought to be due to CHF
on CRI, but there could be some component of dye induced
nephropathy. He will need his Cr checked on his next office
visit to see if he is trending down.
.
3. CXR infiltrate: He had recently completed course of levoflox
for PNA. During his stay he had no fever or productive cough to
support pneumonia. He did have a mild leukocytosis but it was
down trending. Suspected to be atelectasis vs delayed
radiographic resolution of pna. he did not receive antibiotics.
.
4. Hyperkalemia: In setting of renal insufficiency. He was given
Kayexalate and Insulin and it normalized.
.
5. DM insulin dependent: He was continued on his home insulin
regimen of 50 units of 75/25 qam and qpm. He recieved RISS for
breakthrough coverage and was given a diabetic diet.
.
6. CAD: He was chest pain free throughout his admission. He was
treated with aspirin, plavix, toprol and imdur.
.
7. AFib: He has a history of afib but has not been in it for his
last two admissions. He presented without anticoagulation,
though it is not clear why. He does carry a diagnosis of PUD and
colonic polys, but it is unclear if these are the reasons he is
not anticoagulated. We will defer to outpatient cardiologist,
Dr. [**First Name (STitle) **], and PCP as he was not anticoagulated prior to
admission and this diagnosis is old.
Medications on Admission:
Clopidogrel 75 mg qday
Aspirin 325 mg qday
Valsartan 80 mg qday
Alprazolam 0.5 mg po qhs prn
Furosemide 40 mg po bid
Levofloxacin 250 mg po qday to continue until [**2158-1-3**]
Isosorbide Mononitrate 120 qday
Nitroglycerin 0.3 mg Tablet, Sublingual prn
Pantoprazole 40 mg qday
Toprol XL 200 mg qday
Lipitor 80 mg qday
Insulin Lisp & Lisp Prot (Hum) 75-25 unit/mL 80 units sc twice a
day.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
10. Insulin Lisp & Lisp Prot (Hum) 75-25 unit/mL Suspension Sig:
as outlined below Subcutaneous twice a day: 80 units SC BID as
previously taking.
11. Outpatient Lab Work
Please have a "Chem 7" drawn within the week, and have results
sent to Dr. [**Last Name (STitle) **] at ph [**Telephone/Fax (1) 1144**] or fax [**Telephone/Fax (1) 6443**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CHF
CAD
Acute Renal Failure
Discharge Condition:
stable.
Discharge Instructions:
Please call your doctor if you have worsening shortness of
breath or leg swelling. Please come directly to the emergency
room if you have any concerning chest pain.
Please take all your medications as prescribed. Please weigh
yourself daily. If your weight increases by three pounds, please
call your doctor.
Followup Instructions:
In addition to the appointments below, please follow-up with
your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1144**] within the month. Follow-up
with Dr. [**First Name (STitle) **] as scheduled.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2158-1-13**]
9:30
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2158-2-7**]
3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2158-2-7**] 4:30
Completed by:[**2158-1-11**]
|
[
"4280",
"41401",
"42731",
"5849",
"2767",
"25000",
"4019",
"53081",
"2724",
"412",
"V5867"
] |
Admission Date: [**2147-12-27**] Discharge Date: [**2148-1-1**]
Date of Birth: [**2081-2-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
[**2147-12-29**] ERCP performed, stent placed, stones extracted
[**2147-12-28**] Perc drain placed
History of Present Illness:
This is a 66 year-old male with a distant history of a Bilroth
II procedure and recently diagnosed cholelithiasis who presents
with acute cholecystitis and possible choledocholithiasis who is
being transferred from [**Hospital6 19155**] for ERCP.
Frequent upper abdominal pains recently. Recent ER visit with US
showing cholelithiasis and thickened GB wall with slight dilated
CBD and dilated PD. LFTs showed t bili of 3.1 with direct 1.4
but no fever, chills, jaundice or bloody stools prior to
admission at OSH. At OSH had fevers and chills and brief
diarrhea but no nasuea or vomiting. Last bowel movement he
recalls was last Saturday (5 days ago). He thinks he has passed
small amounts of flatus but he is not sure.
.
Admitted [**12-23**] to OSH. LFTs trended down and he was scheduled for
cholecystectomy. Laparoscopic cholecystectomy performed [**2146-12-26**]
which was "challenging with empyema of the gallbladder
encountered with both acute and chronic cholecystitis".
Intraoperative cholangiogram performed which showed markedly
dilated CBD and intrahepatic duct with 6-7 2-3mm gallstones in
the distal CBD which did not flush. Duct ligated and gallbladder
removed.
.
Post operatively he developed wheezing and a CXR showed probably
RLL infiltrate c/w possible aspiration PNA. He was started on
DuoNebs with good affect. Overnight he became more confused and
had worsening abdominal pain which they treated with Demoral
without good affect but which responded to ativan. The next
morning (the morning of transfer) a CXR showed ongoing RLL
infiltrate with possible cephalization and so he was diuresed
with almost 2L output.
.
On arrival in the [**Hospital Unit Name 153**] he was in visible discomfort, tachypneic,
and complaining of RUQ pain which was worth with deep breathing.
VSS and as noted below.
.
ROS:
(+) +RUQ pain worse with inspiration, +R shoulder pain, +mild
SOB x2 days, +mild cough x 2 days, +diarrhea (brief, nonbloody,
resolved, last episode ~5 days ago), +no bowel movement x5 days
(-) The patient denies any nausea, vomiting, current diarrhea,
melena, hematochezia, chest pain, orthopnea, PND, lower
extremity edema, dysuria.
Past Medical History:
Cholelithiasis
DMII
HTN
h/o Billroth II surgery [**66**] years ago
hyperlipidemia
Social History:
Retired, lives with wife, former [**Name2 (NI) 1818**], no alcohol in 40 years,
no illicits
Family History:
Non-contributory
Physical Exam:
On Admission
Vitals: T 99.2 BP 149/79 HR 105 RR 26 O2Sat 94/6L
GEN: well-nourished, mild respiratory distress
HEENT: EOMI, PERRL, dry MM
NECK: unable to appreciate any JVD
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: diffuse wheeze anteriorly, crackles at right lower base
ABD: distended, tense, +RUQ tenderness, no rebound or guarding,
chole drain draining yellow fluid, hypoactive bowel sounds
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. Moves all 4
extremities.
SKIN: jaundiced, no cyanosis
Pertinent Results:
[**2147-12-31**] 08:10AM BLOOD WBC-8.0 RBC-4.06* Hgb-13.2* Hct-37.3*
MCV-92 MCH-32.6* MCHC-35.5* RDW-12.9 Plt Ct-401
[**2147-12-27**] 04:49PM BLOOD WBC-11.5* RBC-4.46* Hgb-14.4 Hct-41.8
MCV-94 MCH-32.2* MCHC-34.3 RDW-12.8 Plt Ct-299
[**2147-12-31**] 08:10AM BLOOD Glucose-91 UreaN-9 Creat-0.5 Na-137 K-4.6
Cl-99 HCO3-30 AnGap-13
[**2147-12-27**] 04:49PM BLOOD Glucose-200* UreaN-11 Creat-0.7 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
[**2147-12-31**] 08:10AM BLOOD ALT-46* AST-33 AlkPhos-114 TotBili-1.8*
[**2147-12-27**] 04:49PM BLOOD ALT-75* AST-34 AlkPhos-135* TotBili-2.7*
.
Micro:
[**2147-12-28**] 5:00 pm FLUID,OTHER
Source: fluid collection around the liver.
GRAM STAIN (Final [**2147-12-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
Blood cx: NGTD
.
Urine cx: No growth
.
MRSA SCREEN (Final [**2147-12-30**]): No MRSA isolated.
Imaging:
CT Abd-Pelvis
IMPRESSION:
1. Heterogeneous predominantly fluid collection in the
gallbladder fossa
measuring 9.3 x 5 x 6.9 cm. The JP drain has displaced and is no
longer
draining this collection.
2. Subcapsular hepatic fluid.
3. Small bilateral pleural effusions with compressive
atelectasis.
4. Possible high-density material seen in the distal CBD
consistent with
stones. Recommended correlation with ERCP.
5. Calcification of the aorta and coronary arteries.
.
TTE
IMPRESSION: Normal global and regional biventricular systolic
function. Probable mild diastolic dysfunction. Mild mitral
regurgitation. Trivial pericardial effusion without echo
evidence of tamponade.
.
CXR [**12-30**]
CHEST RADIOGRAPH
INDICATION: Status post ERCP. Evaluation for interval changes.
COMPARISON: [**2147-12-28**].
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Minimal interstitial pulmonary edema, associated with a
minimal right
pleural effusion and a mild degree of left and right basal areas
of
atelectasis. Unchanged size of the cardiac silhouette. No newly
appeared
focal parenchymal opacities suggesting pneumonia.
Brief Hospital Course:
The patient was initially admitted to the medicine service on
[**2147-12-27**]. He underwent a CT scan that showed a 9x5cm biloma and
perihepatic fluid c/w bile leak. He was started on broad
spectrum atbx with vanc/zosyn. On [**12-28**], the patient underwent
percutaneous drainage of his biloma and drain was left in place.
His lab values were improving and his LFTs began to trend down.
On [**12-29**], patient underwent ERCP with sphincterotomy and
extraction of stones from the CBD. A pancreatic stent was
placed. The patient tolerated the procedure well. The patient's
diet was then changed to clears, and advanced as tolerated to
regular diet. The patient was transferred to the floor on HD 4.
His pain was much improved and he was tolerating regular diet.
His foley was dc'd on HD4, and patient voided without problem.
His [**Name2 (NI) **] continued to trend down and all cultures were negative.
He was transitioned to po pain meds, and restarted on his home
medications as well. Vanc/zosyn were discontinued and patient
was switched to unasyn on [**2147-12-30**]. He will be sent home with 3
days of augmentin to complete a 1wk course of atbx. On day of
discharge, patient's JP drain was removed, but new pigtail drain
was left in place. Of note, the patient did have increased work
of breathing upon admission with SOB/dyspnea. Crackles and
diffuse wheeze were heard in the RLL and CXR showed some
consolidation in that area. Patient was started on nebulizer
treatments and adequate pain control was started to minimize
splinting. ECHO was performed to rule out heart failure, and
this study was normal. Patient's breathing continued to improve
during his stay, and he was saturating well on RA at time of
discharge with no complaints of dyspnea.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Home Medications:
Alprazolam 0.5mg Q8H
Simvastatin 10mg daily
Lisinopril 10mg daily
Metformin 1000mg [**Hospital1 **]
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
3. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
4. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **] [**Hospital1 **]
Discharge Diagnosis:
Bile leak s/p lap chole, CBD stones
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down 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.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-16**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
You will be contact[**Name (NI) **] by the by the ERCP department regarding
followup.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2148-1-26**] 10:45
Completed by:[**2148-1-1**]
|
[
"5070",
"25000",
"2859",
"4019",
"3051"
] |
Admission Date: [**2189-5-20**] Discharge Date: [**2189-5-30**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4854**]
Chief Complaint:
fever, hypotension, afib with RVR
Major Surgical or Invasive Procedure:
redo LUE AV fistula & replacement R SCV tunneled HD
History of Present Illness:
56 yo male, h/o ESRD [**2-5**] anti-GBM disease, on HD, DM2, HTN, p/w
fevers s/p HD session. Pt was reportedly dialyzed today; HD was
almost completed but had to be stopped early secondary to
clotting in the fistula. Pt/wife stated that he had felt unwell
since dialysis session on Monday (2 days prior to admission).
At this time, he was having some bilateral shaking of his arms.
He also reports some pain in his right shoulder, above the site
of his HD catheter. He states that this was worse with
movement. He had 1 episode of loose stools 1 day PTA. He
denies any URI symptoms, no CP/SOB/abdominal pain. After HD
session on day of admission, he felt unwell/lethargic at home.
He had some more episodes of shaking/rigors. He took a nap, and
after awaking from this, had a fever to 104. At this time, his
wife brought him to the [**Name (NI) **].
.
On presentation to the ED, he was febrile to 103.9; HR was
initially in the 90s with SBP=130. He subsequently went into
afib with a ventricular response 150-170s, with SBPs as low as
40-50. In the ED, he received 3 L NS (CVP from [**9-18**]; max). He
was seen by renal who felt that this was likely septic shock,
recommended vanco/gent. Renal stated that HD catheter (right
SC) should be used for fluids/pressors/abx (pt has history of
difficult access, ?saving femoral sites for future HD
catheters). As his SBP did not significantly improve with IVF,
he was started on dopa gtt with some improvement in SBP but
?exacerbation of tachycardia. Bedside TTE showed no pericardial
effusion or signs of tamponade. He was reportedly mentating
well throughout ED course. Other ED events include treatment of
hyperkalemia (7.1 to 4.6) with bicarb, D50. On presentation to
the ICU, he remained hypotensive, in afib with RVR, was
mentating adequately. He had no specific complaints but did
state that he was having pain in right shoulder at site of HD
catheter.
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-7**]
2. DM2: dx [**2177**]
3. HTN
4. Chronic low back pain [**2-5**] herniated discs
5. CHF
6. Peripheral neuropathy
7. Anemia
8. h/o nephrolithiasis
9. s/p cervical laminectomy; ?osteo in past
10. h/o depression
11. h/o MSSA bacteremia ([**3-9**]-infected HD catheter), E. coli
bacteremia
12. s/p L AV graft: [**7-7**]
13. h/o [**12-7**] of L4-5 diskitis, osteo, epidural abscess
Social History:
Lives w/ wife, son, daughter-in-law, and three grandchildren in
[**Name (NI) 86**] area, has been unemployed [**2-5**] disability, smokes tobacco
1 ppd x45 years, past alcohol, no recreational drug use.
Family History:
1. DM
2. Renal failure
Physical Exam:
Gen: pleasant male, sitting in bed, A&Ox3 ("[**Hospital3 **],"
"[**2189**]," "[**5-20**]," "[**Last Name (un) 2450**]")
HEENT: PERRL, OP clear
Lungs: CTA bilat, no w/r/r
CV: tachy s1/s2, no m/r/g appreciated
ABd: soft, nt/nd, nabs
Extr: no c/c/e, DP 1+ bilat
Skin: with right SC HD catheter; some tenderness superior to
this area, some firm areas around site
Pertinent Results:
[**2189-5-20**] 04:50PM BLOOD WBC-12.2*# RBC-3.86*# Hgb-11.5*#
Hct-35.9*# MCV-93 MCH-29.7 MCHC-31.9 RDW-18.4*
[**2189-5-22**] 04:08AM BLOOD WBC-7.9 RBC-2.98* Hgb-8.6* Hct-27.9*
MCV-94 MCH-28.8 MCHC-30.8* RDW-18.6* Plt Ct-275
[**2189-5-25**] 06:00AM BLOOD WBC-5.2 RBC-2.52* Hgb-7.3* Hct-23.6*
MCV-94 MCH-28.8 MCHC-30.8* RDW-18.9* Plt Ct-353
[**2189-5-29**] 04:55AM BLOOD WBC-7.1 RBC-3.13* Hgb-8.9* Hct-28.6*
MCV-92 MCH-28.4 MCHC-31.1 RDW-18.6* Plt Ct-550*
[**2189-5-20**] 04:50PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-3 Eos-0
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2189-5-20**] 11:20PM BLOOD PT-16.6* PTT-33.4 INR(PT)-1.5*
[**2189-5-24**] 12:00AM BLOOD PT-19.3* PTT-42.1* INR(PT)-1.8*
[**2189-5-29**] 12:41PM BLOOD PT-14.2* PTT-48.9* INR(PT)-1.3*
[**2189-5-20**] 04:50PM BLOOD Glucose-109* UreaN-31* Creat-9.6* Na-131*
K-7.1* Cl-93* HCO3-21* AnGap-24*
[**2189-5-22**] 04:08AM BLOOD Glucose-74 UreaN-40* Creat-9.3* Na-138
K-4.6 Cl-101 HCO3-22 AnGap-20
[**2189-5-24**] 05:58PM BLOOD Glucose-113* UreaN-26* Creat-6.4*# Na-137
K-4.2 Cl-100 HCO3-23 AnGap-18
[**2189-5-28**] 06:05AM BLOOD Glucose-62* UreaN-8 Creat-4.7* Na-143
K-4.1 Cl-105 HCO3-28 AnGap-14
[**2189-5-29**] 12:41PM BLOOD Glucose-71 UreaN-12 Creat-6.6* Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
[**2189-5-21**] 03:34AM BLOOD ALT-4 AST-12 LD(LDH)-176 CK(CPK)-271*
AlkPhos-101 Amylase-25 TotBili-0.4
[**2189-5-20**] 04:50PM BLOOD CK-MB-2 cTropnT-0.39*
[**2189-5-20**] 11:20PM BLOOD CK-MB-3 cTropnT-0.37*
[**2189-5-21**] 03:34AM BLOOD CK-MB-2 cTropnT-0.34*
[**2189-5-20**] 11:20PM BLOOD Calcium-7.9* Phos-5.2* Mg-1.5*
[**2189-5-22**] 04:08AM BLOOD Calcium-7.9* Phos-5.4* Mg-2.3
[**2189-5-29**] 12:41PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8
[**2189-5-28**] 06:05AM BLOOD TSH-5.9*
[**2189-5-28**] 06:05AM BLOOD Free T4-1.0
[**2189-5-21**] 03:34AM BLOOD Genta-1.5* Vanco-10.9*
[**2189-5-26**] 04:00AM BLOOD Vanco-19.9*
[**2189-5-29**] 03:45PM BLOOD Vanco-17.1*
Time Taken Not Noted Log-In Date/Time: [**2189-5-20**] 10:19 pm
BLOOD CULTURE
**FINAL REPORT [**2189-5-23**]**
AEROBIC BOTTLE (Final [**2189-5-23**]):
REPORTED BY PHONE TO [**Doctor Last Name **] [**Doctor Last Name **] AT 11:55AM ON [**2189-5-21**]
- CC6D.
STAPH AUREUS COAG +.
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.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2189-5-23**]):
STAPH AUREUS COAG +.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
Time Taken Not Noted Log-In Date/Time: [**2189-5-20**] 10:20 pm
BLOOD CULTURE
**FINAL REPORT [**2189-5-23**]**
AEROBIC BOTTLE (Final [**2189-5-23**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 103963**] [**2189-5-20**].
ANAEROBIC BOTTLE (Final [**2189-5-23**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 103963**] [**2189-5-20**].
[**2189-5-22**] 1:00 pm CATHETER TIP-IV RIGHT TUNNELLED DIALYSIS.
**FINAL REPORT [**2189-5-25**]**
WOUND CULTURE (Final [**2189-5-25**]):
STAPH AUREUS COAG +. >15 colonies.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
[**2189-5-23**] 5:33 pm BLOOD CULTURE
**FINAL REPORT [**2189-5-29**]**
AEROBIC BOTTLE (Final [**2189-5-29**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2189-5-29**]): NO GROWTH.
Cardiology Report ECG Study Date of [**2189-5-20**] 4:40:10 PM
Atrial fibrillation with rapid ventricular response
Ventricular premature complex
Indeterminate QRS axis
Late precordial QRS transition
Prominent/modestly peaked T waves - possible hyperkalemia
Consider also chronic pulmonary disease
Clinical correlation is suggested
Since previous tracing of [**2189-4-6**], findings as outlined now
present
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
147 0 80 258/342.57 0 90 10
[**First Name3 (LF) 706**] Final Report
US EXTREMITY NONVASCULAR LEFT [**2189-5-23**] 2:32 PM
US EXTREMITY NONVASCULAR LEFT
Reason: rule out fluid collection around LUE graft
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with tunneled HD catheter in R SC, ESRD, with L
AV graft
REASON FOR THIS EXAMINATION:
rule out fluid collection around LUE graft
INDICATION: 56-year-old man with tunneled hemodialysis catheter
in right subclavian vein, end-stage renal disease and left AV
graft. Evaluate for fluid collection surrounding the left upper
extremity graft.
LEFT UPPER EXTREMITY ULTRASOUND: The patient's left upper
extremity arteriovenous graft is again seen, without evidence of
intraluminal flow, and multiple internal echos suggesting
thrombosis. No fluid collections are seen surrounding the graft.
The fat, muscle, and fascial planes are preserved.
IMPRESSION:
1. No fluid collections surrounding the patient's left upper
extremity AV graft.
2. Graft thrombosis.
[**Hospital 706**] Final Report
MR L SPINE SCAN [**2189-5-23**] 8:02 AM
MR L SPINE SCAN; -52 REDUCED SERVICES
Reason: epidural abscess? discitis?
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with h/o discitis and increasing pain
REASON FOR THIS EXAMINATION:
epidural abscess? discitis?
EXAM: MRI of the lumbar spine.
CLINICAL INFORMATION: Patient with history of discitis and
increasing pain. Rule out epidural abscess.
TECHNIQUE: T2 sagittal images were acquired. The examination is
limited as patient was unable to continue.
FINDINGS: Compared to the previous MRI of [**2188-1-24**], again noted
is endplate changes at L4-5 level with anterior displacement of
L4 over L5 secondary to spondylolisthesis. Since the previous
study, the high-grade narrowing of the spinal canal has resolved
which could be secondary to laminectomy at this level. No
evidence of spinal stenosis seen at other levels. Bilateral
severe narrowing of the neural foramina is noted. Disc bulging
is seen at L5-S1 level as before.
IMPRESSION: Limited study demonstrating chronic changes of
discitis and osteomyelitis at L4-5 level. For better assessment
a repeat study with gadolinium is recommended if clinically
indicated.
Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Left
ventricular
systolic function is hyperdynamic (EF 70-80%). No masses or
thrombi are seen
in the left ventricle. There is no ventricular septal defect.
Right
ventricular chamber size and free wall motion are normal. The
aortic root is
moderately dilated. The number of aortic valve leaflets cannot
be determined.
The aortic valve leaflets are mildly thickened; there is focal
thickening of
the right cusp that could represent a vegetation. There is no
aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2187-11-19**], the aortic and tricuspid valve abnormalities are new, and
are highly
suggestive of endocarditis.
Cardiology Report ECG Study Date of [**2189-5-23**] 4:29:46 PM
Baseline artifact. Sinus rhythm. First degree A-V block.
Non-diagnostic poor
R wave progression. Compared to the previous tracing of [**2189-5-21**]
sinus rhythm
has replaced atrial fibrillation. Clinical correlation is
suggested.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 204 96 428/459.57 31 27 17
[**Last Name (NamePattern1) 706**] Final Report
CHEST (SINGLE VIEW) [**2189-5-29**] 12:50 PM
CHEST (SINGLE VIEW); CHEST FLUORO WITHOUT RADIOLOGI
Reason: H/O RENAL FIALURE, NOW INSERTIUON OF CATHETER FOR
DIALYSIS
CHEST 7:49 a.m. [**5-29**]:
HISTORY: Catheter insertion for dialysis.
IMPRESSION: A single frontal spot film of the chest centered
over the right lower lobe was provided for documentation of a
fluoroscopic guided procedure without a radiologist in
attendance. It shows a dual channel central venous line, tip
projecting over the right atrium.
Brief Hospital Course:
# MRSA Bacteremia and sepsis: Patient presented to the ED with
fevers/chills after partial HD session on [**5-20**] (stopped early
due to fistula clotting), he was admitted to the MICU in afib
with RVR and subsequent hypotension, found to have sepsis, MRSA
bacteremia. He responded to fluids and pressors, and vancomycin
and gentamicin. His subclavian line was changed over a wire and
the catheter tip also grew out MRSA. He was loaded on amio for
afib with good result (PR increased to 212 after amio started).
TTE showed no pericardial effusion or evidence of tamponade, but
was concerning for endocarditis given valve thickening. A TEE
was attempted but was unsuccessful due to inability to pass the
U/S scope. He was weaned from pressors on [**5-23**] but remained in
the MICU for until [**5-25**] for CVVH. He remained hemodynamically
stable, restarted hemodialysis without difficulty. All
surveillance blood cultures had no growth. For further ID work
up patient will need an outpatient MRI with gadolinium (to
further assess chronic changes of discitis and osteomyelitis at
L4-5) and TEE for more accurate assessment of endocarditis.
Patient will continue vancomycin for 6 weeks and will follow up
in the [**Hospital **] clinic on [**6-15**] at 2pm
.
# ESRD: Patient was continued on CVVH while in the MICU via a
new subclavian line changed over wire. He was transitioned back
to HD without difficulty once out of the MICU. ID recommended
removing the line altogether and resiting it to L subclavian.
However given L subclavian is a future site for dialysis access
via fistulas in his L arm. ON [**5-29**] LUE AV fistula was redone by
transplant surgery & replacement R SCV tunneled HD was placed.
.
# Afib with RVR: Patient was loaded on IV amiodarone while in
the MICU and then continued on PO amiodarone 400 po bid x 14
days. He will need oupatient follow up of his TFTs, LFTs, and
PFTs by his PCP. [**Name10 (NameIs) **] will need to restart anticoagulation once
cleared by surgery, that no further procedures are required.
.
# Chronic Pain: Patient was continued on methadone, oxycodone,
and neurontin per home regimen
.
# Anemia: Remained stable at baseline 26-30, attributed to ACD
and ESRD. Continued Epo and transfusions as needed with
dialysis.
.
# HTN: BP remained stable after MICU stay. Continued PO
amiodarone and BB. Consider restarting amlodipine and
lisinopril as BP allows as outpatient.
.
# CAD: Pt's elevated troponins attributed to end stage renal
disease. He was continued on BB and aspirin.
.
# Diabetes - Continued diabetic diet, SSI with FS QID.
.
# Depression - Continued paxil, remeron, and seroquel.
Medications on Admission:
Meds at home:
Oxycodone PRN
Colace
Amlodipine 10 mg
Paxil 20 mg
Protonix 40 mg
Seroquel 25 mg
Remeron 30 mg
Neurontin 200 mg QHD
Lisinopril 40 mg (recently held)
Methadone 10 mg q4h
Lopressor 100 mg TID, recently decreased to 50 mg TID
Coumadin 5 mg
Sevalemer 400 mg TID
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
6. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for back or surgical pain.
Disp:*30 Tablet(s)* Refills:*0*
16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
DIALYSIS for 5 weeks: TO BE DOSED AND GIVEN AT DIALYSIS.
Disp:*0 0* Refills:*0*
17. Outpatient Lab Work
PATIENT NEEDS CBC DRAWN ONCE A WEEK
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
HD catheter sepsis
Discharge Condition:
good
Discharge Instructions:
please seek medical attention if you experience fevere > 101.5,
severe nausea, vomitting, pain
please take medications as instructed
no driving while taking narcotic pain meds
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-6-4**]
9:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. Date/Time:[**2189-6-12**] 11:30
INFECTIOUS DISEASE CLINIC [**6-15**] AT 2PM
[**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**] MD, [**MD Number(3) 4858**]
Completed by:[**2189-5-31**]
|
[
"78552",
"99592",
"42731",
"2767",
"40391",
"4280",
"311"
] |
Admission Date: [**2109-8-21**] Discharge Date: [**2109-8-23**]
Date of Birth: [**2049-8-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy [**2109-8-22**]
History of Present Illness:
The patient is a 59M with minimal past medical history who
underwent colonscopy yesterday ([**First Name4 (NamePattern1) 12536**] [**Last Name (NamePattern1) **]) with removal of
2 polyps on right side of the colon now with BRBPR. Tolerated
the procedure well without bleeding. After no issues, went to
work the next day and then had 2 episodes of BRBPR. Initially
associated with mild abdominal cramping but this subsequently
resolved. Denies syncope, dizziness, palpitations.
.
Went to [**Hospital3 **]where VS: 98.2 112 163/103, found to
have HCT of 38.6 (baseline 41). Dark maroon, guiaic positive
stool on rectal. Continued to have episodes of bloody stools +
clots but he felt were improving. Got 1L NS.
.
In the [**Hospital1 18**] ED, initial vs were 98.7 106 140/98 16 100. Rectal
revealed bright red blood. HCT of 30.7 down from 38.6 at OSH
(baseline of 41). Typed and crossed for 2U. 2 large bore IV for
access. Talked w/ GI plan to start Golytely prep tonight for
scope tomorrow. Got 1L of fluid. vitals on transfer: 98.6 98
114/85 98%RA.
.
On the floor, no complaints. With colonoscopy prep had episode
of bloody bowel movement. Ambulating to commode without sx.
Past Medical History:
Borderline hypertension
Social History:
- married, 2 children, 5 grandchildren
- works as maintenance supervisor
- tobacco abuse, trying to quit
- minimal ETOH
Family History:
- no family history of colon or prostate cancer
Physical Exam:
Vitals: 110 137/88 18 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: S1, S2 Regular rate and rhythm, 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:
Lab Results:
[**2109-8-21**] 09:10PM BLOOD WBC-7.4 RBC-3.05* Hgb-10.8* Hct-30.7*
MCV-101* MCH-35.2* MCHC-35.0 RDW-13.3 Plt Ct-219
[**2109-8-21**] 09:10PM BLOOD Neuts-83.7* Lymphs-11.9* Monos-3.1
Eos-0.9 Baso-0.4
[**2109-8-21**] 09:10PM BLOOD PT-12.9 PTT-26.7 INR(PT)-1.1
[**2109-8-21**] 09:10PM BLOOD Glucose-124* UreaN-10 Creat-0.7 Na-137
K-4.4 Cl-104 HCO3-23 AnGap-14
[**2109-8-22**] 02:33AM BLOOD WBC-6.2 RBC-2.53* Hgb-8.9* Hct-25.9*
MCV-102* MCH-35.1* MCHC-34.3 RDW-13.1 Plt Ct-228
[**2109-8-22**] 07:26AM BLOOD Hct-25.9*
[**2109-8-22**] 10:54AM BLOOD Hct-37.5*#
[**2109-8-22**] 04:07PM BLOOD Hct-35.9*
[**2109-8-22**] 10:08PM BLOOD Hct-35.9*
[**2109-8-23**] 04:07AM BLOOD WBC-4.6 RBC-3.59*# Hgb-11.9*# Hct-34.2*
MCV-95# MCH-33.3* MCHC-34.9 RDW-15.6* Plt Ct-145*
[**2109-8-23**] 02:27PM BLOOD Hct-35.6*
.
CXR [**2109-8-22**]:
Relatively large lung volumes without marked diaphragmatic
depression. Moderately air-filled colonic segments seen in the
right upper
quadrant. No evidence of free subdiaphragmatic air. No focal
parenchymal
opacity suggesting pneumonia. Normal size of the cardiac
silhouette without evidence of pulmonary edema.
.
Colonoscopy [**2109-8-22**]:
At the distal post-polypectomy site there was an overlying
eschar suggestive of recent bleeding. There was no visible
vessel to clip. There was no active bleeding. There were two
sigmoid polyps. The procedure was aborted secondary to
hemodynamic instability (BP dropped to the 60s and he required
IVF boluses). The patient was interactive during this time.
Impression: At the distal post-polypectomy site there was an
overlying eschar suggestive of recent bleeding. There was no
visible vessel to clip. There was no active bleeding. There were
two sigmoid polyps. The procedure was aborted secondary to
hemodynamic instability (BP dropped to the 60s and he required
IVF boluses). The patient was interactive during this time.
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
The patient was admitted to the MICU for active bleeding. He
required a total of 5 units of PRBCs for his bleeding and
anemia. He underwent coloscopy by GI who saw the site of
polypectomy but no active bleeding. During the procedure, he
had an episode of hypotension with systolic blood pressures in
the 60s, and then developed a brief rash which resolved over the
next couple of hours. This may have been due to the Fentanyl
and Versed that he received for the colonoscopy. He received
normal saline boluses and blood for his hypotension and this
resolved. His hematocrit remained stable. Follow-up will be
arranged with a colorectal surgeon (Dr. [**Last Name (STitle) 85321**] for removal of
the remaining polyps and he will be called with this
appointment. He stayed in the ICU until his hematocrit was
stable and then was discharged. He was told to go emergently to
an ER if he started to bleed again.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Lower GI bleed after colonoscopy
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 bleeding after a
colonoscopy. You underwent repeat colonoscopy which looked at
the site of bleeding but you were no longer actively bleeding.
You received blood transfusions and were monitored closely in
the intensive care unit. You still have polyps which were not
completely removed from the colon and you need to see a
colorectal surgeon to address this. The gastroenterology
doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 138**] [**Name5 (PTitle) **] to set this up. If you do not here from
them in 1 week, you should call Dr. [**Last Name (STitle) 85321**] (colorectal surgeon)
to schedule an appointment to remove the remaining polyps. His
office number is [**Telephone/Fax (1) 2296**].
No medications were added or changed.
You should follow-up with your primary care doctor in 1 week for
repeat blood counts.
If you have any further episodes of bleeding from your rectum,
dark or black stools, lightheadedness, weakness, dizziness or
other symptoms that concern you, you should go to an emergency
room immediately.
Followup Instructions:
Please see your primary care doctor in 1 week to check your
hematocrit.
You will be contact to schedule surgery to remove the remaining
polyps. If you do not here from the surgeon in 1 week, you
should call Dr. [**Last Name (STitle) 85321**] (colorectal surgeon) to schedule an
appointment to remove the remaining polyps. His office number
is [**Telephone/Fax (1) 2296**].
|
[
"2851",
"4019",
"3051",
"42789"
] |
Admission Date: [**2129-2-19**] Discharge Date: [**2129-2-23**]
Date of Birth: [**2051-4-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Left arm pain
Major Surgical or Invasive Procedure:
placement of intraaortic balloon pump
[**2129-2-20**] cardiac catheterization with 2 Cypher overlapping stents
to the left circumflex artery and second obtuse marginal artery
History of Present Illness:
The patient is a 77 year old Spanish-only speaking female with a
history of CAD s/p MI in [**March 2125**] s/p CABG (LIMA->LAD,
SVG->OM1, SVG->D1, SVG->rPDA) complicated by sternal wound
infection with subsequent debridement, chronic rest angina, DMII
and HTN who presented to [**Hospital3 417**] Hospital on [**2129-2-19**] with
the chief complaint of worsening left arm pain at rest. The
history was obtained by the patient's daughter [**Name (NI) 26681**] as the
patient does not speak English
The patient described to her daughter's a history of daily
angina that occurs with rest that is substernal in origin and
radiates to her left arm. She did have a prior MI but cannot
recall her symptoms at the time as she was unconscious. In the
past week, she described increasing shortness of breath with
intermittent left arm pain. On Friday [**2129-2-18**], she described more
intense left arm pain at rest that was associated with shortness
of breath and mild chest tightness that resolved spontaneously
(the patient does not have nitro at home). On Saturday morning
[**2129-2-19**], the patient again experienced left arm pain and
substernal chest pain that lasted for hours. She still complains
of some chest pain upon transfer on a nitro gtt.
At [**Hospital3 417**] hospital, she went into vfib arrest and was
shocked once with 200 joules and was given a push of 150 mg
amiodarone IV with SBP 187/119. She was then placed on an
amiodarone gtt and nitro gtt. By report, she was went into
torsades at [**Hospital3 417**] and was given magnesium 2 gm IV x 1.
Before being transported to [**Hospital1 18**], the patient then again had a
vfib arrest and was shocked once again with 200 joules into
sinus rhythm. Her troponin and CK at [**Hospital3 **] was negative.
She arrived to the CCU with some chest pain on nitro and
persistent left arm pain. Her EKG showed old TWI in I and avL
and new [**Street Address(2) 4793**] depressions in V2-V3.
At baseline, the patient sleeps with her head elevated but notes
no increased peripheral edema or weight gain. Her daughters say
she has been compliant with all her medications.
Past Medical History:
DMII
CAD s/p MI 4'[**24**] with CABG
HTN
Social History:
The patient lives alone.
Family History:
Noncontributory.
Physical Exam:
P=60 BP=142/58 RR=22 97% on 10 liters NRB
Gen - NAD, Spanish-speaking
Heart - RRR, no M/R/G
Lungs - CTAB (anteriorly)
Abdomen - soft, NT, ND + BS
Ext - no C/C/E, + 2 d. pedis, left arm pain reproducible with
palpation
Pertinent Results:
[**2129-2-19**] 09:00PM GLUCOSE-279* UREA N-31* CREAT-1.1 SODIUM-138
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
[**2129-2-19**] 09:00PM ALT(SGPT)-22 AST(SGOT)-44* LD(LDH)-217
CK(CPK)-306* ALK PHOS-78 AMYLASE-98 TOT BILI-0.5
[**2129-2-19**] 09:00PM LIPASE-24
[**2129-2-19**] 09:00PM CK-MB-25* MB INDX-8.2* cTropnT-0.15*
[**2129-2-19**] 09:00PM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-3.6
MAGNESIUM-2.7*
[**2129-2-19**] 09:00PM WBC-13.2*# RBC-4.39 HGB-13.7# HCT-38.9 MCV-89
MCH-31.2 MCHC-35.2* RDW-12.7
[**2129-2-19**] 09:00PM PLT COUNT-254
[**2129-2-19**] 09:00PM PT-15.5* PTT-130.1* INR(PT)-1.5
CHEST (PORTABLE AP) [**2129-2-22**] 7:14 AM
IMPRESSION:
Interval improvement in the magnitude of bilateral lower lobes
partial atelectasis with some residual right lower lobe partial
atelectasis present. Mild degree of segmental atelectasis in the
posterior segment of the left lower lobe.
ECHO Study Date of [**2129-2-21**]
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional
left ventricular wall motion is normal. There is no left
ventricular outflow
obstruction at rest or with Valsalva. Right ventricular chamber
size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
The pulmonary
artery systolic pressure could not be determined. There is no
pericardial
effusion.
C.CATH Study Date of [**2129-2-20**]
COMMENTS: 1. Selective coronary angiography of this right
dominant
system revealed mutli vessel disease. The LMCA contained mild
disease.
The LAD was totally occluded after the first diagonal branch.
The
distal LAD filled well from the LIMA. The LCX had severe,
diffuse
disease throughout. OM1 had a totally occlusion but filled via
a patent
SVG. OM2 was a large vessel witha n 80% proximal stenosis
before
bifurcating into two large poles. The RCA was diffusely
diseased up to
50% in the PDA and 60% is the RPL.
2. Graft angiography revealed an occluded SVG-PDA, a patient
SVG-OM-D1,
and a patent LIMA-LAD.
3. Limited resting hemodynamics revealed a normal central
aortic
pressure of 111/39.
4. Successful PTCA and stenting of the LCX into OM2 with 2
overlapping
2.5 x 28 mm Cypher DES. The LCX portion of the proximal stent
was
dilated to 3.0 mm. Final angiography revealed no residual
stenosis, no
apparent dissection, and normal flow (see PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Occluded SVG-PDA
3. Patent SVG-OM-D1 and LIMA-LAD
4. Successful placement of 2 drug-eluting stents in the LCX and
OM2.
ECG Study Date of [**2129-2-21**] 8:10:40 AM
Sinus rhythm
Left anterior fascicular block
Diffuse ST-T wave abnormalities with prolonged Q-Tc interval -
Clinical correlation is suggested for possible metavolic/drug
effect and/or
ischemia
Since previous tracing of, [**2129-2-20**], further ST-T wave changes
present
Brief Hospital Course:
The patient is a 77 year old Spanish-speaking female with a
history of DMII, HTN, CAD s/p CABG '[**24**] (LIMA->LAD, SVG->OM1, D1,
rPDA) who presents with persistent left arm and chest pain not
relieved by nitro gtt with [**Street Address(2) 4793**] depressions in V2-V3 with old
TWI in I and avL.
1. CAD
- The patient was continued on a nitro drip, heparin drip,
statin and aspirin, holding her beta-blocker initially given her
history of ?bradycardia in ambulance.
- Her EKG initially showed mild ST depressions anteriorly with
no ST elevations, acute ischemic changes and her left shoulder
pain was reproducible on exam. However her polymorphic VT may
have been precipitated by an acute coronary syndrome and her
unstable angina. Her first troponin was negative. Her case was
reviewed and it was decided to maintain medical management
overnight. During this time, the patient's peak troponin hit
near 6 up from 0.15 on admission and her peak CK was 1570 up
from 306.
- She was taken to the cath lab the following day where she was
found to have an occluded SVG->PDA, patent SVG->OM1,D1 and
patent LIMA->LAD. The OM2 had a proximal 80% stenosis which was
subsequently stented into the LCX via 2 overlapping Cypher
stents. Her left arm pain resolved post-procedure and was felt
to be her likely anginal equivalent.
- She was ultimately titrated up to Lisinopril 10 mg and
Metoprolol 25 mg [**Hospital1 **] and maintained thereafter on plavix in
addition to her regimen above.
- Lastly, the patient had an echocardiogram which showed an EF
of 60% with no gross wall motion abnormalities.
2. HTN
- Her HR was originally 55 without beta-blockade. We were able
to successfully titrate up to Lisinopril 10 mg and Metoprolol 25
mg [**Hospital1 **] without difficulty.
3. DMII
- The patient does take insulin at home in the am ?NPH 45 units
and metformin 1 gm [**Hospital1 **]. For now, we initially held her metformin
as she went to cath. This was restarted prior to discharge. The
patient was not instructed to follow up with [**Last Name (un) **] as she does
not get her medical care in this area.
4. Polymorphic VT
- The patient was loaded on amiodarone 150 mg IV at the outside
hospital. We continued the patient on an amiodarone gtt at 1 mg
prior to cath. After her intervention, she experienced no more
significant arrhythmias.
- EP was consulted and agreed that her polymorphic VT was most
likely secondary to ischemia. She was discontinued from
amiodarone and secondary to her good EF, did not require further
intervention.
Medications on Admission:
Lasix 20 mg PO BID
Lescol 40 mg PO QD
Metformin 1 gm [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*9*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Metformin HCl 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
good
Discharge Instructions:
Please return to the ER or call 911 if you experience any more
chest or left arm pain.
You MUST take Plavix every day for 9 months along with your
aspirin. Failure to do so may result in another heart attack or
even death.
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**], to
schedule an appointment in [**12-19**] weeks. At this time, you should
discuss which local cardiologist you may follow up with after
your heart attack. You will need to see a cardiologist in 4
weeks.
|
[
"41401",
"412",
"25000"
] |
Admission Date: [**2184-5-12**] Discharge Date: [**2184-5-18**]
Date of Birth: [**2127-1-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Progressive angina
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 1 [**2184-5-14**].
History of Present Illness:
This is a 57 yo male pt with history CABGs in [**2160**] and [**2172**] and
multiple stents since. He reports recent increase in anginal
symptoms with minimal exertion. Referred for cath showing known
3VD with patent RIMA to PDA, LCX (known) 100% with SVG to OM 90%
stenosis.
Past Medical History:
IWMI.
CAD/multiple PCIs.
OA.
Hiatal hernia.
Right rotator cuff tear.
S/P CABG [**2160**].
S/P CABG with RIMA to PDA, SVG to Ramus.
Social History:
Lives in [**Location **] with wife and 20 year old son. Does not work
-- disabled. Tob: quit 27 years ago -- 30 pack year history.
ETOH: 1 drink per week.
Family History:
Mother deceased with MI in 70s.
Pertinent Results:
[**2184-5-16**] 03:22AM BLOOD WBC-16.1* RBC-3.15* Hgb-10.1* Hct-28.4*
MCV-90 MCH-32.2* MCHC-35.7* RDW-13.2 Plt Ct-117*
[**2184-5-16**] 03:22AM BLOOD Plt Ct-117*
[**2184-5-16**] 11:57PM BLOOD Glucose-137* UreaN-24* Creat-1.1 Na-128*
K-4.2 Cl-98 HCO3-26 AnGap-8
[**2184-5-16**] 11:57PM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname 2643**] was admitted on [**2184-5-12**] for cardiac cath showing known
3 VD with occluded SVG to OM and 100% occluded LCx. Referred
for 1 one vessel CABG s/p multiple previous attempts at failed
stents.
On [**2184-5-14**] he proceeded to the OR and underwent a CABG x 1 with
LIMA to the ramus with Dr. [**Last Name (STitle) **]. He was successfully weened
and extubated on his operative day and was transferred pou of
the CSRU on POD 2.
On PODs two and three he experienced some bursts of afib and SVT
to the 140s, broken with IV diltiazem and increase in PO
lopressor. Patie3nt has experienced no further episodes of SVT.
On POD four he was cleared by the physical therapy team and it
was decided that he was safe for discharge home.
Medications on Admission:
Aspirin 325 daily.
Nexium 40 daily.
Lopressor 50 [**Hospital1 **].
Plavix 75 daily.
Folic acid 1 daily.
Zetia 10 daily.
Lopid 600 [**Hospital1 **].
Lisinopril 10 daily.
Hytrin 2 daily.
Nitro patch 0.1 mg/hour -- three patches during daytime hours.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO q6h PRN.
Disp:*120 Tablet(s)* Refills:*0*
6. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO q6h PRN as
needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Coronary artery disease.
Discharge Condition:
Stable.
Discharge Instructions:
Shower daily nad [**Last Name (un) 24097**] incisions with soap and water -- rinse
well. Do not apply any creams, lotions, powders, or lotions.
No swimming or tub bathing.
No lifting greater than 10 pounds.
Schedule follow-up appointments as scheduled.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks.
Follow-up with Dr. [**Last Name (STitle) **] in [**4-2**] weeke.
Follow-up with Dr. [**Last Name (STitle) 11493**] in [**2-1**] weeks.
Completed by:[**2184-5-18**]
|
[
"41401",
"42731",
"42789"
] |
Admission Date: [**2104-2-3**] Discharge Date: [**2104-2-11**]
Date of Birth: [**2104-2-3**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Doctor First Name **] is a 1195 gram, 28 and 2/7
weeks, twin number one, admitted secondary to prematurity and
respiratory distress. She was born to a 35 year-old, Gravida
I, Para 0 to 2, white female, with prenatal screens
remarkable for A positive, antibody negative, RPR
nonreactive, Rubella immune, hepatitis B surface antigen
negative, GBS unknown. Mother did have a history of [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 4585**] and cervical dysplasia with previous laser therapy.
This was an in-[**Last Name (un) 5153**] fertilization pregnancy with di/di
twins. Ultrasound with Twin A with intra-cardiac echogenic
focus, nuchal translucency, no amniocentesis was done. She
was admitted at 25 weeks with cervical shortening and was
beta complete. Good interval growth. On magnesium sulfate
since about 26 weeks with expectant management. On day of
delivery, she progressed to advanced cervical dilatation with
bulging bag of membranes. A Cesarean section was performed
under spinal anesthesia. Rupture of membranes was at the
time of delivery. This twin was vertex, given facial CPAP.
Apgars were 7 at one minute and 8 at five minutes of life.
The patient was brought to the Neonatal Intensive Care Unit
with blow-by oxygen.
PHYSICAL EXAMINATION: On examination on admission, in
general, this is a premature infant, orally intubated, pink
and retracting. Temperature of 97.5. Pulse of 155,
respiratory rate of 40, blood pressure 53/26 with a mean of
35. Oxygen saturation of 91 percent. Weight 1195 grams
which was the 50th to 75th percentile, length of 35.5 cm,
which was 50th to 75th percentile, head circumference of 27
cm which was the 50th to 75th percentile. Anterior fontanel
is soft and flat. She is non dysmorphic. Orally intubated
with good aeration, although there were some coarse breath
sounds. No murmur noted. Normal pulses. She had a soft
abdomen with three vessel cord. No hepatosplenomegaly.
Normal female genitalia and a patent anus. No hip click. No
sacral dimple. Tone was normal for age.
HOSPITAL COURSE:
1. Cardiovascular: Patient developed a murmur on day of life
number four and was treated with Indomethacin. The
patient has had no murmur since completing a course of
Indomethacin and has been hemodynamically stable.
2. Respiratory: The patient was initially intubated. She was
weaned to CPAP on day of life number two and weaned to
room air on day of life four. She has 3 to 4 apnea or
bradycardia episodes related to apnea of prematurity every 24
hours. She is currently on caffeine.
3. FEN: The patient was initially n.p.o. on total fluids of
80 cc per kg per day. She was started on trophic feeds
and then made n.p.o. again when a PDA was noted and she
was started on Indocin. She restarted feeds on day of
life number six and is currently on 30 cc/kg per day and
working up 10 cc per kg per day, twice a day. Total
fluids are at 150 cc/kg per day with the remainder being
P.N. She currently has a UVC in for access.
4. Gastrointestinal: The patient was started on phototherapy
on day of life number two for a bilirubin of 5.9 over 0.3.
Next bilirubin of 7.2 over 0.4. Phototherapy was
discontinued on day of life number 8 with a bilirubin of
4.0 over 0.3 with a rebound plan for tomorrow.
5. Infectious disease: The patient was started on Ampicillin
and Gentamycin for a planned 48 hour rule-out. CBC was
obtained which was benign. Blood culture was no growth
and, therefore, after 48 hours, Ampicillin and Gentamycin
were discontinued.
6. Hematology: The patient had a normal hematocrit
throughout her stay. Hematocrit on day of life 7 was 43.
7. Neuro: The patient had a normal head ultrasound on day of
life number five. Plan is for repeat head ultrasound
tomorrow.
CONDITION ON DISCHARGE: Good.
CARE RECOMMENDATIONS:
1. Feeds to continue to go up by 10 cc per kg twice a day of
breast milk, total fluids of 150 cc per kg per day.
2. Medications: The patient is currently on caffeine for
apnea of prematurity.
3. Immunizations: None have been given as of yet.
DISCHARGE DIAGNOSES:
1. Prematurity at 28 and 2/7 weeks.
2. Twin gestation.
3. PDA, status post Indomethacin.
4. Hyperbilirubinemia status post phototherapy.
5. Rule out sepsis, status post 48 hour antibiotics.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 58671**]
MEDQUIST36
D: [**2104-2-11**] 17:08:17
T: [**2104-2-11**] 17:47:26
Job#: [**Job Number 60443**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2108-6-29**] Discharge Date: [**2108-7-3**]
Date of Birth: [**2049-3-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Atenolol / Metoprolol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2108-6-29**] Coronary bypass grafting x 5: Left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein single graft from aorta to first obtuse marginal
coronary; reverse saphenous vein single graft from aorta to the
second obtuse marginal coronary artery; as well as reverse
saphenous vein double sequential graft from aorta to the
posterior descending coronary artery and posterior left
ventricular coronary artery
History of Present Illness:
59 year old male in [**2106-2-11**] underwent a coronary CT as
part of a research protocol which revealed a significant Left
Circumflex stenosis. Follow up stress testing did not reveal any
perfusion defects. On [**2106-2-16**] he underwent cardiac
catheterization where he was found to have an 80% OM2. The RCA
was patent and the LAD had a 50% stenosis in the proximal
portion. An attempt to open the OM2 was made, although was
unsuccessful as the lesion was calcified.
The patient reports that about two months ago he developed new
onset angina. He describes mid and upper left sided chest
tightness associated with pain in the neck and left arm. This
only occurs with exertion, ie. Two flights of stairs. In
addition, he has noticed new dyspnea on exertion. These symptoms
typically resolve with rest or SL nitroglycerin. Recent stress
testing has revealed inferoseptal and posteroseptal ischemia. He
was referred for cardiac catheterization. Cardiac catherization
revealed multivessel coronary artery disease.
Past Medical History:
Coronary artery disease s/p failed OM2 PCI in [**2106**]
HIV
Trigeminal neuritis
[**2104**] resection of basal cell cancer
Asthma/seasonal allergies
Hepatitis
Anxiety
Depression
Tonsillectomy
resection of pilonidal cyst
Social History:
Lives with: partner
Occupation: unemployed dental ceramist
ETOH: 2 glasses of wine per week
+tobacco [**5-17**] cigs/day x 43 yr
Family History:
Father died of an MI at age 74 + MI
Physical Exam:
Pulse:67 Resp: 12, O2 sat: 100%
B/P 144/
Height: 5'[**10**] in Weight:162Lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit none Right: 2+ Left:2+
Pertinent Results:
[**2108-6-29**] Echo: The left atrium and right atrium are normal in
cavity size. No spontaneous echo contrast is seen in the left
atrial appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/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 for the patient's body
size. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. There is no pericardial effusion.
Post Bypass: Patient is in sinus rhythm on phenylepherine
infusion. Preserved biventricular function, LVEF >55%. Mitral
regurgitation is now [**1-13**]+. Aortic contours are intact. Remaining
exam is unchanged. All findings discussed with surgeons at the
time of the exam.
[**7-2**] CXR: In comparison with the study of [**6-29**], the various
monitoring and support devices have been removed. Specifically,
there is no evidence of pneumothorax. There has been an increase
in opacification at the left base with silhouetting of the
hemidiaphragm, consistent with atelectasis and pleural effusion.
Less prominent atelectatic changes seen at the right base. The
upper lungs remain clear.
[**2108-6-29**] 04:50PM BLOOD WBC-13.6*# RBC-2.59* Hgb-10.2* Hct-28.7*
MCV-111* MCH-39.5* MCHC-35.5* RDW-14.1 Plt Ct-153
[**2108-7-2**] 06:00AM BLOOD WBC-10.5 RBC-2.62* Hgb-10.0* Hct-29.6*
MCV-113* MCH-38.0* MCHC-33.7 RDW-14.1 Plt Ct-130*
[**2108-6-29**] 04:50PM BLOOD PT-16.4* PTT-30.6 INR(PT)-1.5*
[**2108-6-29**] 06:47PM BLOOD PT-14.4* PTT-32.8 INR(PT)-1.2*
[**2108-6-29**] 06:47PM BLOOD UreaN-10 Creat-0.9 Cl-108 HCO3-25
[**2108-7-2**] 06:00AM BLOOD Glucose-112* UreaN-10 Creat-1.3* Na-136
K-4.8 Cl-105 HCO3-26 AnGap-10
[**2108-7-3**] 06:00AM BLOOD UreaN-11 Creat-1.1 K-4.2
[**2108-7-1**] 05:01AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.4
Brief Hospital Course:
Mr. [**Known lastname 9624**] was a same day admit and brought to the operating
room on [**6-29**] where he underwent a coronary artery bypass graft
surgery. See operative report for further details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. In the first twenty four hours he was
weaned from sedation, awoke neurologically intact, and extubated
without complications. He continued to progress but remained in
the intensive care unit on Neo-Synephrine for blood pressure
management. He was eventually weaned off and transferred to the
telemetry floor on post operative day two. Chest tubes and
epicardial pacing wires were removed per protocol. Physical
therapy worked with him on strength and mobility. He continued
to progress well and was ready for discharge with VNA services
and the appropriate follow-up appointments on post operative day
four.
Medications on Admission:
Trizivir 300mg-150mg-300mg one tablet twice a day
Bupropion HCL 75mg two tablets every morning, one tablet every
evening
Pravastatin 10mg daily
Viread 300mg daily
Trazodone 150mg daily at bedtime
Aspirin 325mg daily
Coenzyme Q10 200mg daily
Flaxseed Oil daily
Efudex 5% cream as needed
Hydrocortisone 2.5% cream as needed
Anusol Suppository as needed
Nitroglycerin .3mg SL prn
Discharge Medications:
1. Trizivir 300-150-300 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
2. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. 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:*1*
5. Viread 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) as needed for q AM: 150 mg in am and 75 mg in pm .
Disp:*60 Tablet(s)* Refills:*0*
7. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): 150 mg in am and 75 mg in pm .
Disp:*30 Tablet(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for PAIN.
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 5
HIV
Trigeminal neuritis
[**2104**] resection of basal cell cancer
Asthma/seasonal allergies
Hepatitis A
Anxiety
Depression
s/p Tonsillectomy
s/p Resection of Plonidal cyst
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 9625**] in 1 week ([**Telephone/Fax (1) 798**]) please call for appointment
Dr [**Last Name (STitle) **] in [**2-14**] weeks - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2108-7-3**]
|
[
"41401",
"2724",
"4019",
"3051"
] |
Admission Date: [**2195-12-13**] Discharge Date: [**2195-12-20**]
Date of Birth: [**2123-1-12**] Sex: F
Service: SURGERY
Allergies:
Codeine / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72 yo F presents BIBA from OSH s/p fall down [**1-3**] steps. X-rays
at OSH showed posterior left rib fractures, and a left clavicle
fracture. No LOC. Tetanus given 1 week ago. At OSH, glucose
450, WBC 16.3, ceftriaxone x1 dose, 10 units of insulin.
Past Medical History:
1. IDDM
2. s/p AAA repair
3. ureteral stent with atrophic R kidney
4. s/p TAH/BSO
Social History:
lives at home with her husband, [**Name (NI) **] [**Name (NI) 28211**], [**Telephone/Fax (1) 76452**].
Family History:
non-contributory
Physical Exam:
on admission:
101.4 F (rectal) 110 140/90 24 97%
General: NAD, appears mildly confused
Eyes: 3-->2 bilaterally
ENT: airway patent
Neck: c-collar in place, trachea midline
Respiratory: CTAB
CV: nl rate, regular rhythm
Chest: left amteropr cjest wa;; temder to palpation
GI: soft, NTND, guaiac negative, good rectal tone
Foley in place, no gross blood
Spine: non-tender
Neuro: A&O x2, following commands, MAEW
Pertinent Results:
admission labs:
[**2195-12-13**] 04:51PM GLUCOSE-241* LACTATE-2.5* NA+-143 K+-4.3
CL--104 TCO2-24
[**2195-12-13**] 04:15PM CK(CPK)-483* AMYLASE-19
[**2195-12-13**] 04:15PM CK-MB-7 cTropnT-<0.01
[**2195-12-13**] 04:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2195-12-13**] 04:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2195-12-13**] 04:15PM WBC-16.4* RBC-4.30 HGB-12.7 HCT-36.5 MCV-85
MCH-29.6 MCHC-34.8 RDW-17.5*
[**2195-12-13**] 04:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2195-12-13**] 04:15PM URINE RBC-[**10-20**]* WBC-[**10-20**]* BACTERIA-FEW
YEAST-MOD EPI-0-2
pertinent imaging:
[**12-13**] CT head (OSH): large left hematoma soft tissue. No SAH or
SDH, no fracture, sinuses clear, no acute intracranial process.
[**12-13**]: CT chest: L lateral ribs 3->6 rib fx's. posterior [**1-4**] rib
fx's
[**12-13**]: CT c-spine: degenerative changes, no fx or dislocation
[**12-13**]: CT torso: neg for acute intra-abdominal process, s/p AAA
repair. R adrenal mass 3.6x1.8cm c/w adenoma. R ureteral stent
with atrophic R kidney. s/p TAH/BSO.
[**12-14**]: CXR: As compared to [**2195-12-13**], slight left
suprabasal
atelectasis has developed. Small left-sided pleural effusion,
no
pneumothorax. Rib fractures and clavicular fracture are
unchanged.
[**12-17**]: CXR: (prelim) Moderate left pleural effusion, slightly
increased. Adjacent L retrocardiac opacity likely represents
atelectasis but coexisting infxn is not excluded. No definite
pneumonia.
Brief Hospital Course:
Upon arrival to the [**Hospital1 18**] ED, a trauma basic was called. The
patient had multiple radiographic studies, as detailed above.
The patient was admitted to the TICU, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
attending. Her pain was controlled with dilaudid, and she was
placed on insulin sliding scale for her high glucose. She was
additionally started on ciprofloxacin for her UTI. Her
pulmonary function was closely monitored because of her multiple
rib fractures. Incentive spirometry was encouraged. She was
seen by the inpatient geriatrics service, and the physical
therapy and occupational therapy services. It was felt that she
would be best served in a rehab facility upon discharge. The
Acute Pain Service was contact[**Name (NI) **] regarding placement of an
epidural, and an epidural was placed on HD 3. The patient was
transferred to the floor, and continued to work with physical
therapy. She tolerated a regular home diet, and continued on
her home medications. The patient continued to improve, and her
epidural was removed on HD 6.
She was placed on an insulin sliding scale in addition to her
home oral diabetic medications, and this was titrated as needed
for improved blood sugar control. She will continue her diabetic
medications and insulin sliding scale at her Rehab facility. On
HD 6, a Foley was placed for urinary retention, and 1250 cc were
emptied. Her Foley was d/c'd the next day, and she failed a
voiding trial, so it was replaced. It was then d/c'd, and she
was voiding, though incontinent at times. She was bladder
scanned for only 66cc - negative for overflow incontinence.
Early in her hospital course, the urology service was consulted
regarding her UTI given her stent and renal issues - per their
recommendations, the stent was left in place ,and she completed
her 7 day course of ciprofloxacin for complicated UTI on HD 7.
Medications on Admission:
advair
oxycontin
albuterol/ventolin HFA 90 mcg
lorazepam 1 [**Hospital1 **]
buproprion (wellbutrin xl) 150 qhs
trazodone 300 qhs
gemfibrozil 600
glyburide 5 [**Hospital1 **]
ibuprofen 800 [**Hospital1 **]
atenolol 100
premarin 0.625
lipitor 40 mg
effexor 150 mg
detrol 4 mg qhs
aspirin 325 mg qd
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain: Hold for sedation or RR <12.
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for breakthrough pain: Hold for sedation or RR
<12.
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
17. Insulin Sliding Scale
Please keep patient on a tight Humalog insulin sliding scale.
Titrate as needed to keep blood sugars between 120 and 140 if
possible.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
1.s/p fall
2. Left lateral ribs 3->6 rib fractures. Posterior [**1-4**] rib
fractures
Discharge Condition:
stable
Discharge Instructions:
You have been admitted to [**Hospital1 69**]
after a fall. You have been cared for by the trauma team. The
acute pain service has also followed you.
.
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.
* Redness around your wounds or drainage from your wounds.
* 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.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in trauma clinic in [**12-2**] weeks.
Please call [**Telephone/Fax (1) 6429**] to make an appointment.
Please call your primary care physician to schedule an
appointment in 1 week for monitoring of blood sugar management.
Please call your Urologist to schedule an appointment for 1 week
for f/u of complicated UTI and renal f/u.
|
[
"5990",
"25000",
"V5867"
] |
Admission Date: [**2134-7-13**] Discharge Date: [**2134-7-16**]
Date of Birth: [**2071-4-28**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Dicloxacillin / Levofloxacin
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Chronic, cough, fever
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
Ms. [**Known lastname 52**] is a 63 year-old female with Burkitt's lymphoma
(last chemo [**2134-4-29**]) with recent parainfluenza pneumonia who
presented on transfer with sepsis.
Over past three weeks has had cough. Seen by Dr. [**Last Name (STitle) **] on
[**6-29**] and felt to be consistent with postviral irritative
bronchitis; at that time had had no fever. She was given a
brief course of steroids followed by inhaled steroids.
Then presented to an OSH with continued cough and fever to 103.
Found to have a RLL and RML PNA on CXR and was given 2 L NS and
azithromycin/ceftriaxone and transferred to [**Hospital1 18**] as she
receives all of her oncologic care here. Enroute in the
ambulance, she developed hypotension.
In the [**Hospital1 18**] ED, initial vitals included P 106 BP 78/45. She
was fluid resusicated with 5 L NS, however remained hypotensive
with SBPs in the 80's-90's. She was treated with vancomycin and
cefepime and admitted to the ICU. A CTA was done which showed
no PE, but did show opacification in the RML concerning for
infection.
ROS:
(+) fever per HPI
(+) 60 point weight loss since [**Doctor Last Name 11579**] diagnosis
(+) alopecia with chemo
(-) chest pain, palpatations
(+) cough per HPI
(-) abdominal pain, diarrhea, constipation
(-) rash
(+) right shoulder pain
(-) dysuria, frequency, hematuria
(-) weakness
Past Medical History:
ONCOLOGIC HISTORY:
1. Burkitt's lymphoma
- Diagnosed in [**2133-11-27**], s/p multiple chemo regimens.
- Most recent cycle (IVAC) was on [**2134-4-29**] with complications of
admission for profound neutropenia, fever, parainfluenza
infection, and bacteremia.
2. Hypothyroidism.
3. Hyperlipidemia.
4. Hx of Pseudomonas bacteremia.
5. Hx of Coag-neg staph bacteremia.
6. Hx of Enterobacter bacteremia.
7. Hx of Parainfluenza and pneumonia
Social History:
Her husband has COPD and has required frequent hospitalizations.
One of her sons and daughter-in-law live downstairs with their
three children. She worked as a system analysis at NHIC, but is
currently retired. Denies tobacco or alcohol use.
Family History:
There is no family history of lymphoma or other malignancies
within the family. Her sister has a history of cirrhosis. Her
brother has diabetes and anterograde amnesia.
Physical Exam:
Vitals -
General - well appearing, sitting in a chair at the bedside
HEENT - no icterus; no pallor; no thrush
CV - regular; split S2; no murmurs
pulm - bilateral crackles without clear focus; no wheeze
abd - soft; non-tender; lower abdominal scar from prior
c-section
ext - warm; 1+ edema
neuro - alert; in good spirits; able to provide clear history
Pertinent Results:
WBC: 6.6 -> 6.1; 36% bands
at discharge, WBC 2.3
HCT: 32 -> 28 -> 30.2
PLT: 129 -> 103
INR: 1.5
Cr: 0.4
Lactate: 1.2
LDH: 175
ALT: 62
AST: 53
Alb: 3.4
UA: negative
[**7-13**] CXR: IMPRESSION:
1. Right perihilar opacification is new since [**2134-6-17**] and
may represent early infectious process versus nodule. Correlate
clinically. Recommend follow up imaging post treatment or
dedicated CT chest for further evaluation.
2. Right-sided pleural effusion is resolved compared to the
prior chest x-ray.
3. Minimal right basilar atelectasis is noted.
[**7-13**] CTPA:IMPRESSION:
1. No evidence of pulmonary embolism.
2. Focal nodular opacity in the right middle lobe measuring up
to 2.4 cm in cross-section with surrounding ground-glass halo,
new from prior study from three weeks ago, likely represents
pneumonia.
3. Tree-in-[**Male First Name (un) 239**] micronodularity in the lower lobes most likely
related to
aspiration or pneumonia. Please note the presence of mild
bronchial wall
thickening in the lower lobes and right middle lobe could also
indicate
chronic aspiration, though airways disease/bronchitis is also
considered.
Brief Hospital Course:
1. Pneumonia / Septic shock: Presented with fever and
hypotension and imaging showing infiltrate. Bronchoscopy with
BAL showed 1+ GNR, 1+ GPR and yeast. Initially treated with
vancomycin and cefepime with marked improvement. After 48+
hours afebrile and stable, transitioned to oral regimen. Given
no GPC on BAL, did not cover staph auerus (MRSA). Given allergy
to levofloxacin, oral options were more limited; as there had
been improvement without coverage for atypicals, switched to
cefpodoxime alone. Plan was for 14 days total with follow-up
three days post-discharge.
2. Burkitt's lymphoma: Felt to be in remission; WBC trended
down during stay with resolved bandemia; LDH was normal.
Medications on Admission:
Levothyroxine 100 mcg Tablet po daily
Acyclovir 400 mg Tablet po q8h
Clonazepam 0.5 mg Tablet po tid prn
Oxycodone 5 mg Tablet po q4h prn
Lidocaine patch prn shoulder pain
Pyridoxine 50 mg Tablet po daily
Sennosides 8.6 mg Tablet 1-2 Tablets [**Hospital1 **] prn
Docusate Sodium 100 mg Capsule po bid
Vancomycin 125 mg PO QID
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for prn shoulder pain.
6. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Sennosides 8.6 mg Capsule Sig: [**11-28**] Capsules PO twice a day as
needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
10. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Health care associated pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with pneumonia. Please be sure to complete a
course of antibiotics, as prescrubed.
If you experience ANY fevers/chills, shortness of breath,
worsening fatigue or have any concerns, please seek medical
attention right away.
Followup Instructions:
Department: HEMATOLOGY/[**Month/Day (2) 3242**]
When: MONDAY [**2134-7-19**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Last Name (NamePattern1) 280**] [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"0389",
"78552",
"486",
"99592",
"2449"
] |
Admission Date: [**2170-8-7**] Discharge Date: [**2170-8-16**]
Date of Birth: [**2112-2-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
VF arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Placement of ICD
History of Present Illness:
Mr. [**Known lastname 79807**] is a 58 year-old man who suffered a VF arrest while
jogging in a park in [**Location (un) 745**]. There were other joggers nearby
during the arrest who administered immediate CPR. At the time
of EMS arrival, he was noted to be in VF arrest (9:43 AM); he
received a shock at 200 J and was given amiodorone 300 mg; at
that time he was found to be in asystole and CPR was continued.
A pulse was first noted at 9:49 AM; he was in sinus rhythm. He
was intubated and cooled with ice packs in the field.
.
In the ED, he was found to be hypotensive and was given IVF
without response; he was started on neosynephrine and given ASA
325. He was cooled to 35 degrees C and sedated on versed and
fentanyl. He received vecuronium as muscle paralytic to prevent
shivering.
.
His ECG in the ED showed sinus bradycardia to 52 with normal
axis and LVH by voltage criteria; there were TWI in leads I and
aVL, V1-V2, a right bundaloid pattern, and a prolonged QTc to
500.
Past Medical History:
# AORTIC INSUFFICIENCY for many years. He is followed by Dr.
[**Last Name (STitle) 32963**] in cardiology at [**Hospital1 112**]. Valve replacement was
recommended in the past and he has been considering this. OSH
TTE shows 2+ AI. For several months, he has had chest pressure
and dyspnea sensation while running and has been concerned about
cardiac trouble since then.
.
# GASTROESOPHAGEAL REFLUX DISEASE
Social History:
Nonsmoker, rare EtOH, no drug use. Married with 2 children.
Residence in [**Location (un) 745**]. Jogs for exercise on average 4-5x/wk for
total 20 mi/wk. Works in marketing for [**Company 22916**]; job requires
frequent travel.
Family History:
Family history significant for mother with CAD and MI age 64,
father with CAD with CABG in 70s, sister with MI at age 62.
Physical Exam:
PHYSICAL EXAM AT ADMISSION:
Vitals: T94.8, HR 57, 117/59, R16, 100% on AC 0.5, 550 x 14,
PEEP 5
General: Intubated, sedated.
HEENT: NC/AT. Pupils 2 mm, minimally responsive, equal. Sclera
anicteric. MMM, ETT and NGT in place.
Neck: Supple, no adenopathy, no JVP elevation appreciated.
Chest: CTA bilat on vent
Heart: RRR, S1 S2, soft SM at apex, ?diastolic murmur at RUSB
Abdomen: +BS soft NT/ND
Extrem: +shivering, no edema, 2+ distal pulses bilaterally.
Neuro: Sedated. No spontaneous movement or response to pain
(?[**12-30**] residual paralytics).
..
PHYSICAL EXAM AT DISCHARGE:
Tm 99.1, BP 132/74, HR 68, RR 20, 95% on RA
He is alert and oriented, in no acute distress. Memory,
cognition, judgment, language and other neurological function is
back to baseline from before cardiac arrest. Heart exam shows
RRR. [**2-1**] blowing diastolic murmur is heard loudest at base.
Dressing is in place over left upper chest at site of ICD
placement. Non-erythematous, non-edematous, appropriately
tender. There is mild tenderness to palpation over precordium
where he received chest compressions. Lungs are clear. Abdomen
is non-tender and non-distended. There is no lower extremity
edema.
Pertinent Results:
LABS FROM ADMISSION:
.
[**2170-8-7**] 10:02PM GLUCOSE-114* UREA N-14 CREAT-0.8 SODIUM-140
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-28 ANION GAP-11
[**2170-8-7**] 10:02PM CK(CPK)-553*
[**2170-8-7**] 10:02PM CK-MB-22* MB INDX-4.0 cTropnT-0.19*
[**2170-8-7**] 10:02PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.0
[**2170-8-7**] 06:09PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2170-8-7**] 06:09PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.050*
[**2170-8-7**] 06:09PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2170-8-7**] 06:09PM URINE RBC-18* WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2170-8-7**] 02:10PM WBC-17.8*# RBC-4.75 HGB-14.8 HCT-43.0 MCV-90
MCH-31.2 MCHC-34.5 RDW-13.0
[**2170-8-7**] 10:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-8-7**] 10:15AM PT-14.3* PTT-32.3 INR(PT)-1.2*
..
EKG: sinus bradycardia to 52, normal axis, LVH by voltage
criteria, TWI in I and aVL, V1-V2, right bundaloid pattern,
prolonged QTc at 500
..
CORONARY CATHETERIZATION ([**2170-8-7**]):
1. Selective coronary angiography of this right-dominant system
demonstrated single-vessel coronary artery disease. The LMCA,
LCX, and
RCA were all without angiographically-apparent flow-limiting
stenoses.
The LAD had a proximal 80% stenosis that improved to 30% after
direct
intracoronary infusion of nitroglycerine.
2. Aortography demonstrated severe aortic regurgitation and
mild
dilatation of the ascending aorta without evidence of
dissection.
FINAL DIAGNOSIS:
1. Single-vessel coronary artery disease.
2. Aortic regurgitation.
..
TTE ([**2170-8-7**]):
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. There is normal
regional and global biventricular systolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve is bicuspid.
The aortic valve leaflets are mildly thickened. The study is
inadequate to exclude significant aortic valve stenosis. Severe
(4+) aortic regurgitation is seen. The aortic regurgitation jet
is eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mildly thickened bicuspid aortic valve with severe
eccentric aortic regurgitation directed toward the anterior
mitral leaflet. Mild symmetric left ventricular hypertrophy with
dilated left ventricular and preserved regional/global systolic
function. Moderately dilated aortic root. Borderline pulmonary
hypertension.
.
TEE ([**2170-8-9**]):
No mass/thrombus is seen in the left atrium or left atrial
appendage. No mass or thrombus is seen in the right atrium or
right atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The ascending aorta is mildly dilated. The aortic valve has
three leaflets but is functionally bileaflet. Leaflets are
thickened and deformed. No masses or vegetations are seen on the
aortic valve. An eccentric jet of moderate to severe (3+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Trivial mitral regurgitation is seen.
IMPRESSION: No vegetations seen. Functionally bicuspid aortic
valve with thickened leaflets and eccentric, moderate to severe
aortic regurgitation. Mildly dilated thoracic aorta.
..
CT HEAD ([**2170-8-7**]):
FINDINGS: There is no intra-axial or extra-axial hemorrhage,
mass effect, shift of normally midline structures, or
hydrocephalus. [**Doctor Last Name **]-white matter differentiation is preserved.
Ventricles, sulci and basal cisterns are unremarkable.
Structures within the posterior fossa are unremarkable. No
suspicious lytic or blastic osseous lesion is identified. There
is scattered opacification of ethmoid air cells, and thickening
of the posterior aspect of the left maxillary sinus. Visualized
paranasal sinuses and mastoid air cells are otherwise well
aerated.
IMPRESSION: No acute intracranial abnormality identified.
..
CXR ([**2170-8-14**]):
FINDINGS: There is a single chamber pacer/AICD in place with
lead terminating in the region of the right ventricle. There is
no pneumothorax.
There is significant interval increase in right lung base
opacity. This
appears to be progressive since [**2170-8-9**]. There is
blunting of the right costophrenic angle. These findings likely
represent a right pleural effusion and given the chronicity of
findings adjacent right lung base pneumonia. The left lung is
unchanged from past studies. There is a large cardiac
silhouette, and mediastinal contours are unremarkable.
IMPRESSION:
1. Interval progression of right lung base opacity, likely
pneumonia.
2. Interval placement of single chamber pacer/AICD with lead in
good
position.
Brief Hospital Course:
In summary, this is a 58 year-old man presenting s/p ventricular
fibrillation arrest, now intubated, sedated and paralyzed on
cooling protocol, back in normal sinus rhythm. The period
between onset of cardiac arrest and restoration of sinus pulse
was approximately 6 minutes, per EMS report.
..
# RHYTHM / VF ARREST:
Shortly after presentation to the emergency room he went to the
cath lab where there was evidence of coronary vasospasm of the
LAD; there were no fixed lesions requiring stenting, only a 30%
fixed stenosis of the LAD (see full catheterization report
above). Urine toxicology was negative. Echo showed severe
aortic regurgitation and mild symmetric LVH with preserved
global systolic function. He was started on a nitro drip for
vasospasm and afterload reduction in the setting of known AI.
He was cooled per neuroprotective protocol post cardiac arrest
and maintained in a hypothermic state for 24 hours. He was
sedated throughout with Fentanyl and midazolam and paralyzed
with vecuronium to minimize shivering.
.
Twenty-four hours after beginning cooling, his core body
temperature was slowly warmed. He became increasingly agitated
overnight and on the morning of HD 2, his sedation was weaned
and he was extubated. Telemetry showed no further episodes of
ventricular dysrhythmia. The presumed cause for his VF arrest
is coronary artery vasospasm. It is unclear at this time
whether the (exertional) anginal-type symptoms he describes in
the weeks leading up to this event are also due to vasospasm.
.
During the hospital course, his nitro drip was switched over to
long acting nitro and calcium channel blocker. An ICD was
placed several days prior to discharge. He will have follow-up
with his cardiologist at [**Hospital1 112**] as well as follow-up in the [**Hospital **]
clinic at [**Hospital1 18**].
..
# PUMP / VALVES:
An echocardiogram performed in the ED showed normal EF with
severe AI and moderate LV dilation. Although he was initially
hypotensive in the ED requiring neosynephrine he became
hypertensive in cath lab and his pressor was discontinued. As
above, there was no significant coronary artery disease and no
regional wall motion abnormalities. A repeat TTE performed two
days after admission showed normal LV function with EF of >55%
and an aortic valve with three leaflets but functionally
bileaflet; AR was 3+. It is unclear at this time whether his
aortic insufficiency is at all related to his VF arrest.
.
As above, he was continued on afterload reducing agents. He
will follow-up at [**Hospital1 112**] with Dr. [**Last Name (STitle) 32963**]. Aortic valve
replacement is being considered.
..
# ISCHEMIA / CAD:
As above, coronary angiography showed a 30% fixed stenosis of
his proximal LAD. LCx and RCA were unremarkable. The LAD
coronary vasospasm that likely caused his cardiac arrest was
treated with Imdur and amlodipine. We continued his home dose
of aspirin 81 mg qday.
.
# RESPIRATORY STATUS / PNEUMONIA:
He was intubated in the field secondary to his cardiac arrest
and continued on ventilation throughout the cooling and
rewarming period. On HD 2, sedation was weaned and he was
extubated on the morning of HD 3.
.
The night before extubation, he spiked a fever. Differential at
that time included VAP, aspiration pna, pulmonary embolus, and
endocarditis (given his known valvular disease). [**12-1**] blood
cultures grew gram positive cocci (later speciated as coag neg
staph), and he was started empirically on IV vanco. A
tranesophageal echo was done while he was still intubated that
was negative for valvular vegetations. CXR came back showing
bibasilar consolidations c/w aspiration pna. We started him
empirically on Zosyn and continued the vanco. When blood
culture speciation returned and he began tolerating PO, IV vanco
and Zosyn were stopped and he was started on levo and flagyl to
complete a seven day course of antibiotics.
.
Unfortunately, on day 7 of his antibiotic course he spiked a
low-grade fever to 100.6, then on day 8 to 101.1. Repeat CXR,
PA and lateral, showed worsening RLL pneumonia. Blood and urine
cultures were negative. Infectious disease consultation
recommended increasing dose of levo to 750 QDAY. We made this
change and decided to treat for an additional 7 days for
presumptive hospital acquired pneiumonia. He had no more fever
over the next 24 hours. O2 sats were excellent on RA and there
was no cough or sputum production. He is discharged with five
days of PO levo remaining to complete a seven day course.
..
# PLEURITIC CHEST PAIN / STATUS POST CHEST COMPRESSIONS:
Chest pain was treated with IV morphine, switched over to
oxycodone post-extubation. This was suppplemented by a lidocaine
patch. At time of discharge, he is taking vicodin, lidocaine
patch, and NSAIDs with adequate pain control. Narcotic-related
constipation is treated with senna and docusate.
..
# MENTAL STATUS:
There was concern after extubation that he may have memory
deficits s/p arrest. CT-head was ordered at admission and
negative for acute intracranial process. Over the course of the
hospitalization, he became increasingly alert and oriented. His
MS at time of discharge is fully recovered and back to baseline
pre-arrest.
..
# ANEMIA:
During hospital course, he had hematocrit in mid twenties that
rose to 30 at time of discharge. Kidney function was normal;
iron studies WNL and hemolysis labs negative. Unclear why this
otherwise healthy man who runs 20 mi/wk should have anemia,
other than possibly d/t marrow suppression in the setting of
acute illness. This will need follow-up as outpatient.
..
# After extubation, he was started on a regular diet. DVT
prophylaxis with subcutaneous heparin. GI ulcer prophylaxis
with an H2 blocker while intubated which was stopped after
extubation. Code status was full throughout.
Medications on Admission:
# ASA 325 mg daily
# MVI
# Vitamin C 1000 mg daily
# Vitamin D 400 mg daily
# Licorice enzyme supplements
# Free amino acids
# DHEA supplement
# EPA/DHA (Opti-EPA) supplement
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*1*
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical every twenty-four(24)
hours: Please apply for 12 hours then 12 hours off. .
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PRIMARY DIAGNOSES
VF arrest with ICD placement
Coronary vasospasm
..
SECONDARY DIAGNOSIS
Aspiration pneumonia
Aortic insufficiency
Discharge Condition:
Vital signs stable. Afebrile.
Discharge Instructions:
You had a cardiac arrhythmia called ventricular fibrillation
while you were jogging. It was thought that you had some
coronary spasm in the artery that feeds blood to the heart. You
also may need to have aortic valve surgery in the next few
months.
.
You had an internal defibrillator placed that will shock your
heart out of an abnormal rhythm. You need to be seen in the
device clinic in 1 week to check this ICD and be followed by a
cardiologist that specializes in heart rhythms such as Dr.
[**Last Name (STitle) **] or similar doctor [**First Name (Titles) **] [**Last Name (Titles) 112**]. Your ICD has not been
tested, this needs to be done in about 2 months.
.
Also, you had a pneumonia for which we prescribed an antibiotic
called levofloxacin (Levaquin). Take this medication for 5 more
days, and call your doctor right away if you have any chills,
fevers, or cough.
.
You have also been given information for an interventional
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who you know from your hospital
stay and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2689**] who you may choose as your primary care
provider.
.
No lifting more than 5 pounds for 6 weeks. No lifting your left
arm over your head or tucking in your shirt 6-8 weeks. No shower
for one week, you may take a bath but the dressing/incision
should remain dry.
.
Please call your cardiologist if you experience any swelling,
redness, fevers, increasing chest pain, trouble breathing or if
you have any shocks from the ICD firing.
.
Please call [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) 69336**], [**MD Number(3) 79808**] have any questions
about this discharge. [**Telephone/Fax (1) 79809**].
.
If you want a copy of your medical records, please contact
Information Resources on the ground floor of the [**Hospital Ward Name 23**] center
at ([**Telephone/Fax (1) 39110**].
Followup Instructions:
Device clinic: [**Hospital Ward Name 23**] clinical center on [**Hospital Ward Name **], [**Location (un) **].
Tuesday, [**8-21**] at 9am.
.
Cardiology:
Dr. [**Last Name (STitle) 13179**] within next 2 weeks.
Electrophysiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**]
DFT testing needs to be done in approx 2 months
.
Primary Care:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2689**] Phone: [**Telephone/Fax (1) 250**] for an appt in [**1-30**] weeks.
Completed by:[**2170-8-16**]
|
[
"5070",
"486",
"4241",
"53081",
"2859"
] |
Unit No: [**Numeric Identifier 61567**]
Admission Date: [**2165-5-14**]
Discharge Date: [**2165-5-20**]
Date of Birth: [**2165-5-14**]
Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 1692**]-[**Known lastname **] is the 4.165 kg product of
a 39-4/7 week gestation born to a 34 year old G2 P1, now 2
mother. Prenatal [**Name2 (NI) **] include blood type A positive, antibody
negative, hepatitis surface antigen negative, RPR
nonreactive, Rubella immune and GBS negative. The pregnancy
was reportedly unremarkable. The antepartum period was
notable for ruptured membranes 2 hours prior to delivery, no
maternal fever, no other identified sepsis risk factors for
sepsis and no intrapartum antibiotic prophylaxis. The infant
was born vaginally with Apgar of 8 and 9.
PHYSICAL EXAM ON ADMISSION: Weight was 4.165 kg,
intermittent respiratory distress with tachypnea, flaring and
grunting increased with activity. Skin was warm, dry, no
rash. Fontanelle was soft and flat. Palate was intact.
Coarse, moderately aerated breath sounds. Intermittent
grunting, flaring, retracting. Regular rate and rhythm, no
murmurs. Soft, no hepatosplenomegaly, no masses, active bowel
sounds. Normal external male genitalia. Femoral pulses are
2+. Patent anus. Brisk capillary refill. Interactive with
exam. Vigorous intact Moro grasp and suck.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
infant continued to be tachypneic. Chest x-ray demonstrated
fluid in the fissure. The infant remained in room air
throughout hospital course and the tachypnea resolved around
day 2 of life.
Cardiovascular: No issues.
Fluids and Electrolytes: Birth weight was 4.165. Discharge
weight was 4.060. The infant is ad lib feeding breast milk or
Similac 20 calorie, taking in adequate amounts.
GI/GU: Peak bilirubin was 7.6/0.2 on day of life 3 and did
not require any intervention.
Hematology: Hematocrit on admission was 50.3 and he did not
require any blood products during admission.
Infectious Disease: A CBC and blood culture was obtained on
admission. CBC was benign, but with persistence of tachypnea,
ampicillin and gentamicin were started. Repeat chest x-ray on
day of life 1 was concerning or suggestive of pneumonia. At
that time, decision was made to treat infant for 7 days of
antibiotics. A lumbar puncture was performed and was within
normal limits. Infant has been appropriate for gestational
age.
Sensory: Audiology - hearing has been performed with
automated auditory brainstem responses and the infant passed
both ears.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To the newborn nursery.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], telephone
number [**Telephone/Fax (1) 61251**].
CARE RECOMMENDATIONS: Continue ad lib feeding of breast milk
or Similac 20 calorie.
DISCHARGE MEDICATIONS: Continue ampicillin and gentamicin
for a total of 7 days.
Car seat position screening is not applicable. State newborn
screens were sent as per protocol and had been within normal
limits. The infant received hepatitis B vaccine on [**2165-5-16**].
DISCHARGE DIAGNOSIS: Pneumonia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2165-5-20**] 21:13:55
T: [**2165-5-20**] 21:51:26
Job#: [**Job Number 61568**]
|
[
"V053"
] |
Admission Date: [**2201-3-28**] Discharge Date: [**2201-3-31**]
Service: MEDICINE
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Hypothermia, hypotension, bradycardia
Major Surgical or Invasive Procedure:
central venous catheter placement
History of Present Illness:
[**Age over 90 **] yo female with PMH of afib on coumadin, htn, and dementia,
was found at home yesterday [**3-28**] being brady to 40s and
hypothermic 86.7F and hypotensive 60/dop in field. Patient was
given atropine and external paced by EMS. She was brought to ED,
and admitted to MICU. Within an hour after MICU admission, she
was normothermic on Bair hugger and with warmed IVF, and off
pressors (levophed). HR improved as well.
.
She had garbled speech in the ED, code stroke was called.
Neurology recommended MRI and felt her symptoms were likely
unrelated to an acute stroke. Garbled speech is her baseline.
It appears that patient has been having increasing agitation at
home recently, and was started on seroquel and had a recent
fall. CTA of brain was negative.
.
Patient was given vanc/zosyn in the ED, which were continued
overnight last night in the MICU, and discontinued this morning.
Infectious workup is negative so far. Thyroid function was
normal, and tox screen was negative. She was found to have INR
of 12, got 10 of IV vitamin K. On transfer to medicine floor,
her BP, HR and body temperature all returned normal.
.
On arrival to the medicine floor, pt was very drowsy. Her eyes
were closed despite sternal rubs, but she does withdraw to
painful stimuli. She is not requiring oxygen, and her vital
signs are stable. She moaned and grimaced when her abdomen was
palpated.
Past Medical History:
- Alzheimer and [**Last Name (un) 309**] Body Dementia (Dr. [**First Name (STitle) **] neurologist)
Hypertension
- Atrial fibrillation, on coumadin
- Urinary incontinence - detrusor instability
- Diastolic CHF
- Degenerative joint disease/osteoarthritis
- Right hip fracture
- Bilateral knee replacements
- Ventral hernia
- Depression/post-traumatic stress disorder
- Left sided carotid bruit
- Cervical spondylosis, spinal stenosis
Social History:
Lives alone with home health care aide who visits. Recent fall
on [**3-19**] and prior pneumonia in [**Month (only) 404**] caused decline in her
ADLs - unable to feed self anymore and unsteady on feet,
requiring assistance to getting to her walker. Since her fall,
patient has become increasingly agitated and incoherent; was
recently started on Seroquel.
Family History:
Diabetes, arthritis
Physical Exam:
Vitals - T:98.5 BP:107/57 HR:50-68 RR:16 02 sat:100% on room air
GENERAL: not responsive to commands, eyes closed despite sternal
rubs. moans to pain stimuli.
HEENT: RIJ in place. Eyes closed. when opened, PERRL. No LAD.
CARDIAC: bradycardic, irregularly irregular, normal s1, s2, no
m/r/g
LUNG: clear from anterior
ABDOMEN: normoactive BS, soft, nondistended. Pt moans and
grimaces when abdomen was palpated.
EXT: No LE edema, no cyanosis, no clubbing.
NEURO: Not responsive to commands. PERRL. moans to pain
stimuli. moves all 4 extremities.
DERM: No skin rash.
On discharge:
Pt opens eyes, awake able to make requests. Able to follow some
commands.
Abdomen no longer tender.
Otherwise exam unchanged.
Pertinent Results:
[**2201-3-28**]
WBC-4.6 RBC-3.47* Hgb-9.9* Hct-30.7* MCV-88 MCH-28.5 MCHC-32.3
RDW-16.1* Plt Ct-104*
Glucose-124* UreaN-64* Creat-2.0* Na-147* K-4.4 Cl-107 HCO3-30
AnGap-14
ALT-69* AST-55* LD(LDH)-679* CK(CPK)-81 AlkPhos-70 TotBili-0.2
Lipase-66*
cTropnT-0.02*
Calcium-8.8 Phos-4.3 Mg-2.5
Hapto-143
TSH-4.2 T4-7.0 T3-73*
Lactate-2.0
FIBRINOGE-507*
PT-97.1* PTT-88.7* INR(PT)-12.0*
[**2201-3-30**]
WBC-6.5 RBC-3.19* Hgb-8.9* Hct-28.1* Plt Ct-94*
PT-17.5* PTT-38.9* INR(PT)-1.6*
Glucose-88 UreaN-29* Creat-1.4* Na-147* K-3.5 Cl-116* HCO3-26
AnGap-9
ALT-55* AST-46* CK(CPK)-64 AlkPhos-56 TotBili-0.3
Calcium-8.4 Phos-2.5* Mg-2.2
FDP-0-10
CT Brain Perfusion/ CTA Neck:
1. No acute hemorrhage or evidence of acute territorial
infarction, with no evidence of asymmetric perfusion.
2. Central and cortical involutional changes as expected for the
patient's
age of [**Age over 90 **] years.
3. Approximately 40% narrowing of the left internal carotid
artery origin by NASCET criteria. The remaining intra- and
extra-cranial arterial vasculature demonstrates no evidence of
flow-limiting stenosis.
4. Infundibulum at the junction of the A1 segment of the right
ACA and the
ACom vessel.
5. Chronic microvascular ischemic white matter disease.
CXR: Cardiomegaly, mild central congestion. Left basilar
atelectasis.
Limited exam.
CT Head: No evidence of hemorrhage or infarction. No evidence
of change
since a head CT of [**2201-3-28**].
Brief Hospital Course:
[**Age over 90 **] yof w hypertension, atrial fib, Alzheimer's and [**Last Name (un) 309**] Body
dementia who hypothermia, hypotension, bradycardia, and AMS.
.
#AMS - Ddx includes poor cerebral perfusion, oversedating
medications (seroquel), infection on underlying dementia. There
was no evidence of infection and no history of any toxin
ingestion. CTA of the head/neck could not explain her
somnolence. She is having some episodes of improvement at time
of discharge when she was she was alert and able to make
requests.
.
# Hypothermia: Resolved. Working differential includes sespis,
neurogenic hypothermia, ingestion. Less likely is adrenal
insufficiency, thiamine deficiency, hypoglycemia,
hypothyroidism. No evidence of infection. Monitoring on
telemetry was unremarkable.
.
# Coagulopathy: Patient presented with INR 12.0, which corrected
by time of discharge. Her PT/PTT also elevated also elevated.
She was given 10mg IV vitamin K. Thorough evaluation of
coagulation abnormalities was not evaluated further given pt's
overall poor prognosis as it was unlikley to change managemnet.
Pt's family expressly does not want pt to receive blood
transfusion.
# Hypotension: Resolved after rewarming. No evidence after
broad workup for infection, as stated above.
.
# Bradycardia: Resolved. Patient received atropine received in
the field. Her heart rate normalized, although she generally
remains slow. HR drops to high 30s during sleep and she
otherwise asymptomatic. Pt not to be paced if becomes
bradycardic, may receive atropine if necessary.
# Hypernatremia: Pt was hypernatremic on admission, improved
with free water boluses.
.
# Acute renal failure: improving with IVF. Likely pre-renal (on
lasix as outpt). Pt was discharged with prn lasix for signs of
volume overload such as increasing oxygen requirement,
respiratory distress, or lower extremity edema.
# Abd discomfort: Pt presented with abdominal discomfort. KUB
shows non obstructive gas pattern, but consistent with
constipation. She was initiated on a bowel regimen.
.
# Thrombocytopenia: Since hospitalization plt count 80-90s. DIC
workup in ICU negative. Platelets remained low but stable.
.
# Atrial fibrillation: Pt is afib with slow ventricular response
on tele. Coumadin was discontinued on this admission due to
high maintenance required with this medication. This is
consistent with the overall plan to focus on comfort care.
.
# Alzheimer and [**Last Name (un) 309**] Body Dementia: Pt was admitted on Aricept
which was discontinued to reduce unnecessary medications.
.
# Hypertension: Pt's blood pressure was low on admission. All
BP meds were held. They were discontinued prior to discharge to
reduce medications that are not directed towards comfort care.
.
# Diastolic CHF: Compensated currently. Cardiac medications
minimized to prn lasix.
.
# Degenerative joint disease/osteoarthritis: Tylenol and
Mortrin prn for pain control.
# Goals of care: Pt is DNR/DNI, with the understanding that pt
does not want advancement of care. Treatment should be focused
on comfort based care. Family would not want rehospitalization
without communication with health care proxy.
# Code: DNR/DNI
# Communication:
Daughter [**Name (NI) **] HCP [**Telephone/Fax (1) 96812**]
Son [**Name (NI) 18330**]: [**Telephone/Fax (1) 96813**]
[**Name2 (NI) **]-Daughter [**Name (NI) **]: [**Telephone/Fax (1) 96814**]
Medications on Admission:
* Coumadin 2.5mg Sat/Sun/Tues/Th, 5mg M/W/F
* Alendronate 35 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
* Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
* Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
* Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
* Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime))
* Detrol LA 2 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
* Trandolapril 4 mg Tablet Sig: One (1) Tablet PO twice a day.
* Multivitamin DAILY
* Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day)
* Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day
* Zinc Sulfate 220mg daily
* Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath.
* Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed
for agitation.
6. Motrin 400 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain.
7. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day as
needed for volume overload: please base on symptoms, physical
exam, and daily weights.
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) unit Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] healthcare
Discharge Diagnosis:
Primary:
hypothermia
hypotension
bradycardia
[**Last Name (un) **] body dementia
Secondary:
- Alzheimer and [**Last Name (un) 309**] Body Dementia (Dr. [**First Name (STitle) **] neurologist)
Hypertension
- Atrial fibrillation, on coumadin
- Urinary incontinence - detrusor instability
- Diastolic CHF
- Degenerative joint disease/osteoarthritis
- Right hip fracture
- Bilateral knee replacements
- Ventral hernia
- Depression/post-traumatic stress disorder
- Left sided carotid bruit
- Cervical spondylosis, spinal stenosis
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Lethargic but arousable
Discharge Instructions:
You were seen at [**Hospital1 18**] for low temperature. You were also noted
to have low blood pressure, and slow heart rate. No reason for
these was found, but you improved spontaneously. Your mental
status was initially quite poor, though improved on the day of
your discharge. Because of your recent worsening, your family
made a decision to focus on comfort.
You are going to a skilled nursing facility.
Followup Instructions:
please schedule an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] at [**Telephone/Fax (1) 250**]
in the next 2-3 weeks.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2201-4-27**] 10:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2201-7-22**] 10:50
Completed by:[**2201-4-1**]
|
[
"42789",
"5849",
"2760",
"4280",
"311",
"42731",
"V5861",
"4019",
"2875"
] |
Admission Date: [**2147-12-18**] Discharge Date: [**2147-12-29**]
Date of Birth: [**2094-1-28**] Sex: F
Service: MEDICINE
Allergies:
Oxaliplatin / Iodine Containing Agents Classifier /
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
nausea and emesis
Major Surgical or Invasive Procedure:
Bilateral Nephrostomy Tube Placement [**2147-12-19**]
History of Present Illness:
53 yo f with hx of metastatic colon CA, Spanish speaking, who
presented with n/v/d and was sent to ER for evaluation from her
oncologist. She has not been eating or drinking for last 5 days
due to n/v after returning from a trip to [**Country 7192**]. She has
been having abdominal pain, but does not like to take her
narcotics.
.
On the floor (interview not with interpreter at this time, so
limited) pt complains of pain in her abdomen, worse with
sitting. Some right sided chest dicomfort. States she has had
swelling her LLE for about 1 month, but no pain in her leg. She
is not currently having nausea, but had some this AM. She
reports urinating today with no pain, but a small amount of
blood.
.
VS on arrival were 97.4 101 181/104 18. Pt was found to have ARF
with Cr from 0.8 to 6.7 and hyperkalemic to 7.2. She has a known
mass compressing left ureter and now with a new compression of
the right ureter on CT scan. Urology was consulted and
recommended IR to place a percut nephrostomy tube. Pt was tx
with D50 and insulin, and kayexalate 30. Hypoglycemia ensued
after tx and she was given a [**11-26**] amp D50 with improvment of BS
to 105. K down to 5.5. IVF x 2 liters were given. Pt also had a
neg head CT. Right sided CP, negative LENI, concern for PE, pt
not anticoagulated in ER. No CTA due to Cr. PNA present on CT.
She was given ceft and azithro. VS at trasfer HR-106, SBP-142
16, 100% RA, BS 105.
.
Past Medical History:
- adenocarcinoma of distal sigmoid colon [**1-1**], s/p sigmoid
colectomy by Dr. [**Last Name (STitle) 1120**] on [**2144-2-17**]. T3 lesion measuring 7 cm x
6 cm x 4 cm,
low-grade, [**2-4**] lymph nodes were involved with cancer
- completed adjuvant chemotherapy with FOLFOX in 10/[**2143**]. CEA
continued to slowly rise from 7 in [**12/2145**] to 9.5 in [**2-/2146**]
to 18 in 08/[**2145**]. CT imaging demonstrated new left
hydronephrosis with a 10.4 cm prevertebral mass at the point of
the ureteral obstruction. PET scan in [**7-/2146**] confirmed disease
recurrence near the sigmoid anastomosis causing the ureteral
obstruction. She additionally had evidence of metastatic
disease to the mesentery and mesenteric nodes. She underwent
percutaneous nephrostomy tube placement on [**2146-12-8**]. [**Known firstname **]
completed two cycles of FOLFIRI and on CT [**2147-4-14**]
she had disease progression involving the known omental
metastases and innumerable pulmonary metastasis.
- admission for PE [**2147-4-17**] for inpatient anticoagulation.
- [**2147-6-20**]: Discussion for participation to a clinical trial
with Cisplatin / V1 inhibitor
- [**2147-7-21**]: left sided nephrostomy tube replacement
- [**7-/2147**]: nephrostomy tube removal
- [**2147-8-23**]: Start on Capecitabine
- Left hydronephrosis with 2.4 cm prevertebral mass at the point
of apparent ureteral obstruction in pelvis. Failed ureter stent
.
Social History:
She is married. She has two children. She used to work as a
cleaning person. She does not presently smoke cigarettes but did
smoke about two cigarettes per day for 20 years and quit three
yrs ago just prior to her surgery. She does not drink alcohol
Family History:
There is no family history of breast, ovarian or colon cancer.
Her mother died at age 75 of hypertension and cardiovascular
disease. Her father died at age 82 of a hemorrhagic stroke.
She has two brothers and five sisters. Two of those had uterine
cancer at the age of 49 and 40.
Physical Exam:
ON ADMISSION
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM,
RESP: CTA b/l with good air movement throughout
CV: tachy, S1 and S2 wnl, no m/r/g
ABD: distend, firm, tender to palpation, +BS
BACK: mild CVA tenderness
EXT: no c/c, 1+ pitting edema in LLE
SKIN: no rashes/no jaundice
NEURO: Moving all extremites, able to ambulate to commode.
.
ON DISCHARGE
Vitals 98.7 140/86 105 16 98%RA
I/O: R nephrostomy 500o/n, 950cc day prior, bathroom unrecorded
GEN: NAD, AOx3
HEENT: MMM, OP clear
CV: tachy, RR, nl S1S2 no MRG
PULM: CTA b/l
ABS: BS+, mildly tender to palpation, multiple masses palpated
throughout abdomen
BACK: Nephrostomies are c/d/i
EXT: 2+ DP/PT/radial pulses, no c/c/e
Pertinent Results:
Blood Counts
[**2147-12-18**] 11:23AM BLOOD WBC-11.2* RBC-3.73* Hgb-9.5* Hct-29.4*
MCV-79* MCH-25.5* MCHC-32.4 RDW-17.1* Plt Ct-424
[**2147-12-20**] 04:08AM BLOOD WBC-20.0* RBC-3.13* Hgb-8.1* Hct-24.9*
MCV-80* MCH-25.8* MCHC-32.4 RDW-17.9* Plt Ct-380
[**2147-12-26**] 05:25AM BLOOD WBC-12.4* RBC-3.64* Hgb-9.5* Hct-29.5*
MCV-81* MCH-26.2* MCHC-32.3 RDW-16.6* Plt Ct-415
.
Coags
[**2147-12-24**] 06:30AM BLOOD PT-13.2 PTT-24.0 INR(PT)-1.1
.
Chemistry
[**2147-12-18**] 11:23AM BLOOD UreaN-63* Creat-6.8*# Na-133 K-7.2*
Cl-95* HCO3-26 AnGap-19
[**2147-12-22**] 05:23PM BLOOD Glucose-114* UreaN-20 Creat-2.3* Na-144
K-2.5* Cl-106 HCO3-27 AnGap-14
[**2147-12-25**] 02:30PM BLOOD Glucose-94 UreaN-17 Creat-1.1 Na-137
K-3.9 Cl-102 HCO3-26 AnGap-13
[**2147-12-26**] 05:25AM BLOOD Glucose-95 UreaN-19 Creat-1.3* Na-135
K-4.1 Cl-101 HCO3-25 AnGap-13
.
Imaging
[**2147-12-18**] CXR
1. New small right pleural effusion, with right lower lobe
atelectasis or
consolidation.
2. Diffuse pulmonary nodular metastases.
.
[**2147-12-19**] CT Abd
1. Right lower lobe pneumonia and trace effusion.
2. Apparent increase in size and number of metastatic pulmonary
nodules at
the lung bases.
3. New heterogeneously hypodense liver. This could represent
fatty
infiltration, but congestive edema and/or diffuse metastases are
not excluded.
4. New mild-to-moderate right hydronephrosis, with incompletely
visualized transition point in mid right ureter, suggestive of
obstruction by peritoneal metastasis.
5. Chronic left moderate-to-severe hydronephrosis and atrophy,
secondary to obstruction by left L5 paravertebral mass.
6. Multiple prominent fluid-filled small bowel loops, suggestive
of ileus or partial obstruction secondary to increasing
mesenteric adhesions.
7. Diffuse omental and peritoneal implants.
8. Cholelithiasis.
9. Fibroid uterus.
.
[**2147-12-22**] Nephrostomy Tubes Placement
Bilateral ureteric stenoses, more prominent on the left side.
Satisfactory placement of bilateral nephroureteric stents (8
French x 24 cm). Patient would require routine stent change in
three months.
Brief Hospital Course:
HOSPITAL COURSE
53yo female with w metastatic colon cancer admitted with acute
ureteral obstruction secondary to metastasis, now status-post
bilateral percutaneous nephrostomy tube placement, hospital
course complicated by pyelonephritis and community acquired
pneumonia, treated with antibiotics, made comfort measures only,
discharged to home with hospice care
.
ACTIVE
# Acute Kidney Injury: Patient was admitted with a creatinine of
7.2 secondary to obstructive uropathy from compression by
peritoneal metastases. Patient underwent placement of bilateral
percutaneous nephrostomy tubes by IR [**2147-12-19**], and
nephrouretheral stents on [**2147-12-22**], after which the patient's
Cr trended down to 1.3. The patient had good UOP from right
urostomy, but poor output from L nephrostomy tube (<100cc/day)
which was thought to be secondary to known chronic
hydronephrosis. Urine cultures from L nephrostomy tube grew
MSSA, prompting antibiotic treatment with 5d augmentin and 14d
doxycycline. After 1wk abx, repeat culture was negative and the
L tube was capped. The R tube was not capped, given continued
high output from the R nephrostomy tube, thought to be secondary
to known compression of the bladder by peritoneal metastases.
.
# Community Acquired Pneumonia: Admission CXR demonstrated RLL
consolidation, for which the patient received 5d augmentin, 14d
doxycycline. At discharge patient was given script for
remainder of doxy course.
.
# Metastatic Colon Cancer: Primary issue during hospitalization
became pain [**12-27**] multiple metastases. Given poor prognosis,
patient decided to be made comfort measures only. With
palliative input, pain regimen of dilaudid and fentanyl patch
was started. Patient was discharged home with hospice care.
.
TRANSITIONAL
1. Code status: Patient was DNR/DNI for the duration of this
admission, and was converted to comfort measures only several
days prior to discharge
2. Pending: No labs pending at time of discharge
3. Transition of Care: Patient was scheduled for follow-up with
Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **] for [**1-22**]. Instructions for
nephrostomy tube maintenance were sent home with patient. IR
requested follow-up visit in 6-12weeks, decision regarding
scheduling necessity was deferred to outpatient oncologist.
Patient was discharged home with hospice care.
Medications on Admission:
-Docusate Sodium 100 mg PO BID
-Ondansetron 4 mg IV Q8H:PRN nausea
-Fentanyl Patch 25 mcg/hr TP Q72H
-Oxycodone SR (OxyconTIN) 30 mg PO Q12H
-Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
-Senna 1 TAB PO/NG [**Hospital1 **]:PRN constiapation
-HYDROmorphone (Dilaudid) 0.5 -1 mg IV Q2H:PRN pain
-Heparin 5000 UNIT SC TID
Discharge Medications:
1. Hospital Bed
Semi-electric hospital bed
Patient has a medical condition, which requires positioning of
the body, which is not feasible in an ordinary bed to alleviate
pain
Diagnosis: Peritoneal Carcinomatosis (ICD-9 158.8 Malignant
neoplasm of specified parts of peritoneum)
2. Bedside Comode
Patient is confined to a single room
Dx: ICD 9 code 158.8
3. Normal Saline Flush 0.9 % Syringe Sig: Two (2) flush
Injection once a day: for nephrostomy tube flushes.
Disp:*60 flushes* Refills:*3*
4. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
5. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*90 Tablet(s)* Refills:*2*
7. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 4 days.
Disp:*8 Capsule(s)* Refills:*0*
8. hydromorphone 4 mg Tablet Sig: 1.5 Tablets PO every 2 hours
as needed for pain.
Disp:*500 Tablet(s)* Refills:*0*
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
10. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
11. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
insomnia.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
12. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
13. Reglan 10 mg Tablet Sig: One (1) Tablet PO QID with meals
and before bed.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY
Metastatic Colon Cancer
SECONDARY
Acute Kidney Injury Secondary to Obstruction status-post
Bilateral Nephrostomy Tube Placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname **]:
.
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for treatment of kidney
failure. This was caused by tumors blocking your urine from
leaving your kidneys. You had nephrostomy tubes placed to drain
the urine, and then had stents placed to help prevent blockage
of your kidneys. You are now stable and being discharged home
to be with your family. You will have visiting nurses to help
care for you.
.
During this hospitalization, you decided to focus on treating
your pain, so WE STOPPED ALL PREVIOUS MEDICATIONS, and started
the following medications:
- Colace for constipation
- Senna for constipation
- Fentanyl for pain
- Dilaudid for pain
- Compazine for nausea
- Zofran for nausea
- Reglan for nausea
- Ativan for sleep
- Olanzapine for sleep
- Doxycycline (for 4 days) for infection
.
Please see below for your recommended follow-up appointments
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2148-1-22**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
[
"486",
"5849",
"2760",
"2767",
"2859",
"V1582"
] |
Admission Date: [**2112-3-14**] Discharge Date: [**2112-3-31**]
Date of Birth: [**2057-8-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
lightheadedness, chest discomfort
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting (CABGx3)[**3-16**]
History of Present Illness:
54 yoM w/ a h/o CAD s/p stent->LAD in [**2102**], htn, hyperlipidemia,
and strong family history of CAD who p/w 48 hours of
lightheadedness and chest discomfort. Given these symptoms, his
wife brought him to [**Name (NI) 2079**] [**Name (NI) **]. At [**Name (NI) 2079**], ECG showed TW
inversions in ant leads and bradycardia in the 40s. Cardiac
enzyme were elevated w/ trop 0.29, CK 725, MB 71. Transfer was
arranged to [**Hospital1 18**] for potential cath.
Past Medical History:
Dyslipidemia, Hypertension, Percutaneous coronary intervention,
in [**2102**] w/ stent to LAD at [**Hospital6 **].
Social History:
Denies any tobacco, EtOH or illicit drug use. Works as a nurse
for an insurance company for the last year.
Family History:
His father and brother both died of MIs at age 48.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 97.3, BP 100/57, HR 60, RR 25, O2 95% on 2LNC
Gen: middle aged male in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. no pallor or cyanosis of
the oral mucosa.
Neck: Supple no JVd
CV: RR, normal S1, S2. No S4, no S3.
Chest:CTA
Abd: +BS, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without
bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Discharge
VST 99 HR 84 BP 124/70 RR 20 02sat 94%RA
Gen NAD
Neuro A&Ox3, nonfocal exam
CV RRR no M/R/G
Pulm CTA-bilat
Abdm soft, NT/+BS
Ext warm palpable pulses. Trace edema-bilat
Pertinent Results:
ADMISSION LABS:
[**2112-3-14**] 08:35PM BLOOD WBC-10.2 RBC-4.44* Hgb-14.6 Hct-41.5
MCV-93 MCH-32.8* MCHC-35.1* RDW-13.0 Plt Ct-227
[**2112-3-14**] 08:35PM BLOOD Neuts-76.2* Lymphs-17.1* Monos-5.6
Eos-0.7 Baso-0.4
[**2112-3-14**] 08:35PM BLOOD PT-14.3* PTT-137.7* INR(PT)-1.2*
[**2112-3-14**] 08:35PM BLOOD Plt Ct-227
[**2112-3-14**] 08:35PM BLOOD Glucose-109* UreaN-15 Creat-1.0 Na-143
K-5.0 Cl-110* HCO3-22 AnGap-16
[**2112-3-14**] 08:35PM BLOOD CK(CPK)-1145*
[**2112-3-14**] 08:35PM BLOOD CK-MB-147* MB Indx-12.8*
[**2112-3-14**] 08:35PM BLOOD cTropnT-0.84*
[**2112-3-15**] 03:54AM BLOOD Calcium-7.2* Phos-3.9 Mg-1.7 Cholest-92
[**2112-3-15**] 03:54AM BLOOD Triglyc-48 HDL-31 CHOL/HD-3.0 LDLcalc-51
[**2112-3-15**] 09:35AM BLOOD Type-ART pO2-80* pCO2-30* pH-7.46*
calTCO2-22 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
CXR: No acute cardiopulmonary process
[**2112-3-15**] TTE:
The left ventricular cavity is mildly dilated. LV systolic
function appears depressed with inferior, inferolateral and
apical hypokinesis/?akinesis (however views suboptimal;
estimated ejection fraction ?35-40). Right ventricular chamber
size is normal. with normal free wall contractility. The aortic
valve leaflets are mildly thickened. The aortic valve is not
well seen. There is no aortic valve stenosis. No aortic
regurgitation is seen. No mitral regurgitation is seen. There is
no pericardial effusion.
[**2112-3-15**] Cardiac Catheterization:
1. Coronary angiography of this right dominant system revealed
3 vessel
coronary artery disease. The LMCA had a 60% distal ulcerated
lesion.
The LAD had a widely patent previously placed stent. The origin
of the
LCx had an 80% stenosis. The proximal RCA was 90% stenosed,
with a 100%
distal RCA occlusion and left to right collaterals.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures, with RVEDP and LVEDP of 20 and 27 mm Hg,
respectively. Mean
PCWP was elevated at 19 mm Hg. Systemic arterial pressures were
low
with aortic systolic pressure of 92 mm Hg and mean arterial
pressure of
64 mm Hg. Cardiac index was 3.07 l/min/m2.
3. Left ventriculography revealed no mitral regurgitation and a
large
area of anteroapical and inferoapical dyskinesis. Estimated
left ventricular ejection fraction was 35%.
4. 40 cc IABP was placed in the setting of extensive myocardial
infarction, hypotension, and impending CABG.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2112-3-27**] 1:30 PM
CHEST (PORTABLE AP)
Reason: ?pneumonia
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with altered mental status, wbc 14.4 (?
infiltrate)
REASON FOR THIS EXAMINATION:
?pneumonia
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Elevated white blood count and altered mental
status.
Comparison is made with prior study [**2112-3-22**].
Mild cardiomegaly is accentuated by low lung volumes, unchanged
from prior study. The patient has been extubated. There is no
pneumothorax. The right lung is clear. There is a small left
pleural effusion. Ill-defined opacity in the left base is
persistent, could be atelectasis or pneumonia. Patient is post
median sternotomy and CABG.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
MC [**Last Name (LF) **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 100119**]
(Complete) Done [**2112-3-16**] at 12:08:58 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2057-8-27**]
Age (years): 54 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG with IABP
ICD-9 Codes: 410.92, 440.0, 424.0, 424.2
Test Information
Date/Time: [**2112-3-16**] at 12:08 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2008AW4-: Machine: B-[**Numeric Identifier **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - LVOT diam: 2.4 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. All four pulmonary veins identified and
enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV cavity size. Mild-moderate
regional LV systolic dysfunction. Moderately depressed LVEF.
RIGHT VENTRICLE: Focal apical hypokinesis of RV free wall.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Simple
atheroma in aortic arch. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. The patient appears to be in sinus rhythm. Results were
Conclusions
PRE CPB 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. The left ventricular cavity size is
normal. There is mild to moderate regional left ventricular
systolic dysfunction with apical severe hypokinesis/akinesis. No
apical thrombus is seen. Overall left ventricular systolic
function is mildly to moderately depressed (LVEF= 40 %). The
right ventricle displays normal mid and basal function with mild
to moderate focal hypokinesis of the apical free wall. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion. An intra-aortic balloon pump is seen in
the descending aorta with its tip 2 cm below the distal aortic
arch.
POST-CPB The focal wall abnormalities noted in the pre-bypass
study are unchanged. The mitral regurgitation may be slightly
improved. No other significant changes.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2112-3-16**] 15:29
[**2112-3-29**] 06:30AM BLOOD WBC-14.8* RBC-3.45* Hgb-10.5* Hct-30.3*
MCV-88 MCH-30.4 MCHC-34.6 RDW-14.4 Plt Ct-846*
[**2112-3-29**] 06:30AM BLOOD Plt Ct-846*
[**2112-3-27**] 03:10AM BLOOD PT-15.8* PTT-22.9 INR(PT)-1.4*
[**2112-3-29**] 06:30AM BLOOD Glucose-102 UreaN-22* Creat-0.8 Na-137
K-4.0 Cl-103 HCO3-22 AnGap-16
Brief Hospital Course:
Admitted as transfer from [**Hospital6 33**] with acute MI on
[**3-14**]. Brought to cath lab on [**3-15**] found to have left main and
2VD/EF 35%. Intra Aortic Ballon Pump placed at that time. CT
surgery consulted and patient brought to operating room on [**3-16**]
for coronary artery bypass grafts. Patient tolerated the surgery
well and [**Hospital 19692**] transferred to the cardiac surgery ICU in stable
condition. He remained intubated and hemodynamically stable on
the day of surgery. On POD1 the IABP was weaned and removed,
after which his sedation was stopped. An attempt to wean from
ventilator was unsuccessful. On POD2 he was again weaned and
extubated however required reintubation because of agitation.
Neurology and psychiatry were consulted. The patient had ahead
CT that was negative as well as an MRI and Lumbar puncture that
were also negative. Over the next several days his neuro status
cleared and he was successfully extubated. He did remain
delerious for several additional days but was ultimately
transferred to the stepdown floor on POD 12. The patient also
experienced a Gout flare during this time, rheumatology was
consulted and he was started on Colchicine and Indocin. Over the
next several days he continued to make slow progress in his ADL
and ambulation and on POD 15 it was decided he was stable and
ready for discharge to [**Hospital 38**] Rehab. He will followup with Dr
[**Last Name (STitle) **] in 4 weeks
Medications on Admission:
atenolol 50 mg daily
lisinopril 20 mg daily
lipitor 10 mg daily
aspirin 325 mg daily
niacin 500 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) as needed.
10. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
s/p CABGx3(LIMA-LAD, SVG-OM, SVG-RCA)[**3-16**]. Post-op delerium
PMH: CAD s/p MI-stent LAD w/IABP, HTN, ^chol, Piloneal cyst
removal,Tonsillectomy
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
wound check in 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks
Dr [**First Name (STitle) 5936**] in [**4-12**] weeks
Completed by:[**2112-3-31**]
|
[
"41071",
"41401",
"4019",
"2720"
] |
Unit No: [**Numeric Identifier 76206**]
Admission Date: [**2105-11-25**]
Discharge Date: [**2105-11-27**]
Date of Birth: [**2105-11-25**]
Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname **] is twin #2, born at 2315 gm, the
product of a 36-1/7 week pregnancy, born to a 35-year-old G1,
P0, now 2 mother, with prenatal screen, blood type O+,
antibody negative, RPR nonreactive, rubella immune, HBSAG
negative, GBS unknown. This pregnancy was complicated by twin-
to-twin transfusion with this twin being the recipient twin.
There was oligohydramnios in Twin A. Mom has a history of
depression. Labor was otherwise uncomplicated. There was no
fever. Rupture of membranes was at delivery with clear fluid
and no increased fetal heart rate. This infant was born by C-
section because of oligohydramnios. This infant emerged
active, vigorous, and crying, was dried, bulb suctioned, and
was given blow-by O2 in the delivery room. He was noted to be
persistently cyanotic and transported to the NICU on oxygen.
Apgar scores were 8 and 5 at 1 and 5 minutes. Weight at birth
was 2315 gm, which is 25th percentile. Head circumference was
32.5 cm, which is 25th-50th percentile. Length 46 cm, which
was 25th to 50th percentile.
PHYSICAL EXAMINATION: HEENT: Normocephalic. Anterior
fontanelle open and flat. Intact red reflex bilaterally.
Lungs clear and equal with slight retraction. CV: Regular
rate and rhythm. No murmur. Femoral pulses 2+ bilaterally.
Abdomen: Soft with active bowel sounds. No masses or
distention. GU: Normal male with testes descended
bilaterally. Spine midline, no sacral dimple. Hips stable.
Clavicles intact. Anus patent. Neurological: Good tone. Moves
all extremities equally and well. Extremities warm and well
perfused, pink with good capillary refill. Reflexes intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: The infant has remained on room air since
admission to the NICU and had brief transitional
grunting, flaring, and retracting which resolved on the
newborn day.
2. Cardiovascular: The infant has maintained cardiovascular
stability while in the NICU, and is ruddy and well
perfused with normal heart rates and blood pressures,
and no murmur present.
3. Fluid, electrolytes, and nutrition: The infant was
started on IV fluids on admission to the NICU due to
transitional respiratory issues. The D-stick initially
was 46. A follow up 2 hour later was 34. Due to the D-
stick of 34 and the hypoglycemia, the infant was started
on VI fluids at that time and given a D10W bolus. D-
sticks have been stable since. The infant was started on
enteral feedings on day 1 of IV fluids. There were 2
borderline ACD sticks. The ACD sticks were resolved and
within normal limits prior to the infant being
transferred to the newborn nursery. The infant is
presently ad lib p.o. feeding, Enfamil 20 calories per
ounce, or breastfeeding. Most recent weight is 2315 gm
on [**2105-11-26**]. No electrolytes have been measured
on this baby.
4. GU: bilirubin was done on [**2105-11-27**]. Result is
12.6
5. Hematology: No blood typing has been done on this
infant. Hematocrit at birth was 57 with a platelet count
of 186,000. No further hematocrits or platelets have
been measured.
6. Infectious disease: The CBC and blood culture were
screened on to the NICU due to the transitional
respiratory distress. The CBC was benign with no left
shift. Blood cultures remains to date. The infant was
not started on any antibiotic therapy.
7. Neurologic: The infant has maintained a neurologic exam
for gestational age.
8. Sensory: Audiology, a hearing screen will need to be
performed with automated auditory brainstem responses
prior to discharge from the hospital. It has not been
done thus far.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to the newborn nursery.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 2429**] [**Name (STitle) 4135**]
CARE RECOMMENDATIONS: Ad lib p.o. feedings of Enfamil 20
calories per ounce or breastfeeding.
MEDICATIONS: None.
IRON AND VITAMIN D SUPPLEMENTATION:
1. Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age.
2. All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 International units,
which may be provided as multivitamin preparation daily
until 12 months' corrected age.
Car seat position screening is recommended prior to discharge
from the hospital due to gestational age of 36-1/7 weeks at
birth.
IMMUNIZATIONS RECEIVED: The infant has not received any
immunizations thus far.
IMMUNIZATIONS RECOMMENDED:
1. Synergis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria: (1) Born at less than 32 weeks'
gestation; (2) Born between 32 and 35 weeks with 2 of
the following: Either day care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school siblings; (3) Chronic lung
disease; or (4) Hemodynamically significant congenital
heart defect.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
3. This infant has not received the Rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following discharge
from the hospital if they are clinically stable and at
least 6 weeks but fewer than 12 weeks of age.
Follow-up appointment is recommended with the pediatrician
after discharge from the hospital.
DISCHARGE DIAGNOSES:
1. Prematurity, born at 36-1/2 weeks gestation.
2. Twin gestation.
3. Twin-to-twin transfusion syndrome.
4. Sepsis ruled out.
5. Transitional respiratory distress, resolved.
6. Hypoglycemia, resolved.
[**First Name8 (NamePattern2) 73452**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 73453**]
Dictated By:[**First Name3 (LF) 76207**]
MEDQUIST36
D: [**2105-11-26**] 20:05:05
T: [**2105-11-26**] 20:52:19
Job#: [**Job Number 29568**]
|
[
"V290"
] |
Admission Date: [**2115-11-17**] Discharge Date: [**2115-11-24**]
Date of Birth: [**2073-6-1**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Latex
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
GIB, hematemesis
Major Surgical or Invasive Procedure:
EGD with esophageal varices sclerosis
History of Present Illness:
42 year old female with h/o cholangiocarcinoma dx in [**2112**] s/p
resection, with recent CT showing met cholangiocarcinoma in
9/[**2115**]. Pt was recently admitted for fever due to cholangitis on
[**11-8**] and had chemo (CDDP and Gemcitabine) on Monday, [**11-11**].
Since chemo pt has intermittent nausea adequately controlled by
zofran and compazine. Pt was doing well till night of admission
when she developed nausea/ vomitting and sizable amount of
hemoptysis and clots. Has low grade fever since chemo but
otherwise ROS was neg for shaking chills, chest pain, SOB,
coughing, constipation, diarrhea, tarry stools, abd pain. Pt
has reported gaining 30lbs since [**9-21**] due to ascites.
In ED: vitals: T98.8 P98 BP136/68 R29 Sat 98% RAPt had NG lavage
which evantually cleared up, also was transfused 1U PRBC, GI
consult called, also got zofran and iv protonix.
Past Medical History:
1. Ca Hx-Klatskin tumor originally diagnosed [**9-/2112**] after
presenting with painless jaundice. [**2112-10-21**] pt underwent ex. lap
with en bloc resection of L liver lobe, biliary tree, and portal
vein. Reconstructed portal vein followed by Roux-en-Y
hepaticojejunostomy. Per notes, pathology demonstrated biliary
ductal adenocarcinoma
(T3N0M0) stage [**Doctor First Name **]. Since presentation, patient had multiple
episodes of cholangitis([**8-27**] in past 3 years with last on
[**11-8**]), always short lived and treated with antimicrobial
therapy. She has been on
ciprofloxacin proph for about 1 year. Followed with yearly
abdominal CT without radiographic progression. CAT scan was
performed on [**2115-10-11**] at [**Hospital3 2358**], which revealed that she
had a recurrence of the tumor with occlusion of her portal vein
occluding bile ducts, hepatic artery nearly completely occluded,
and much ascites and was started on diuretics. She was was seen
at [**Hospital1 18**] heme/on clinic [**10-30**] and had repeat CT scan which
revealed metastatic
cholangiocarcinoma with mets to the ovaries, with tremendous
increase in metastatic disease. There was there was obstructive
uropathy on the right side, as well as questionable gastric
outlet obstruction and peritoneal carcinomatosis.
2. cholecystectomy at age 25
3. MVA-multiple orthopedic procedures
4. Strabismus
Social History:
She is a nurse [**First Name (Titles) **] [**Hospital6 204**]. She
denies any alcohol, drugs or tobacco. She lives in [**Hospital1 487**] with
her mom. She is single, no children.
Family History:
Her maternal grandmother had breast cancer in
her 80s and her dad's grandmother had stomach cancer and died in
her 50s. On her mom's side is an extensive family cardiac
history.
Physical Exam:
VITAL: afebrile, 96, 108/51, O2sat99%RA
GENERAL: pleasant female in no apparent distress, jaundiced
skin.
HEENT: sclera icteric, OP clear, EOMI, PERRL.
NECK: Supple.
NODES: No supraclavicular, submandibular, axillary or inguinal
lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate, s1 s2 .
ABDOMEN: soft and distended, but no actual tenderness. Guaiac
neg by ED
BACK: No CVA tenderness.
EXTREMITIES: No clubbing, cyanosis, but +edema.
Pertinent Results:
[**2115-11-17**] 01:30AM GLUCOSE-112* UREA N-14 CREAT-0.8 SODIUM-133
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17
[**2115-11-17**] 01:30AM ALT(SGPT)-149* AST(SGOT)-83* ALK PHOS-663*
AMYLASE-37 TOT BILI-8.2*
[**2115-11-17**] 01:30AM LIPASE-42
[**2115-11-17**] 01:30AM IRON-52
[**2115-11-17**] 01:30AM calTIBC-230* FERRITIN-197* TRF-177*
[**2115-11-17**] 01:30AM WBC-3.0* RBC-2.25* HGB-7.2* HCT-20.9* MCV-93
MCH-31.8 MCHC-34.3 RDW-14.7
[**2115-11-17**] 01:30AM NEUTS-79.7* BANDS-0 LYMPHS-13.3* MONOS-4.6
EOS-2.2 BASOS-0.2
[**2115-11-17**] 01:30AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2115-11-17**] 01:30AM PLT COUNT-88*
[**2115-11-17**] 01:30AM PT-13.4 PTT-25.9 INR(PT)-1.1
[**2115-11-17**] 01:30AM RET AUT-0.3*
[**2115-11-17**] 01:30AM URINE COLOR-Amber APPEAR-SlHazy SP [**Last Name (un) 155**]-1.025
[**2115-11-17**] 01:30AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-LG UROBILNGN-0.2 PH-5.5 LEUK-NEG
[**2115-11-17**] 01:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-[**3-22**] RENAL EPI-0-2
[**2115-11-17**] 01:30AM URINE HYALINE-0-2
CT abd on [**2115-11-7**] showed: 1. Recurrent cholangiocarcinoma, with
intrahepatic bile duct dilatation and gastric outlet
obstruction; exact extent of disease is unclear, but likely
extensive. No evidence of portal hypertension is seen. 2. Large,
cystic, multiseptated mass arising from the adnexa, worrisome
for second primary malignancy.
3. Ascites, and intraperitoneal carcinomatosis, which can arise
from either of the two processes described above. 4. Hiatal
hernia.
[**2115-11-24**] 07:30AM BLOOD WBC-2.2* RBC-3.09* Hgb-9.6* Hct-28.7*
MCV-93 MCH-31.2 MCHC-33.6 RDW-17.0* Plt Ct-89*
[**2115-11-21**] 06:00AM BLOOD Neuts-89.7* Bands-0 Lymphs-6.9* Monos-2.6
Eos-0.2 Baso-0.7
[**2115-11-24**] 07:30AM BLOOD PT-15.2* PTT-29.7 INR(PT)-1.5
[**2115-11-24**] 07:30AM BLOOD Glucose-117* UreaN-11 Creat-0.9 Na-135
K-3.5 Cl-97 HCO3-28 AnGap-14
[**2115-11-24**] 07:30AM BLOOD AlkPhos-431* TotBili-7.8*
[**2115-11-24**] 07:30AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9
[**2115-11-17**] 01:30AM BLOOD calTIBC-230* Ferritn-197* TRF-177*
Brief Hospital Course:
1) GI - In the [**Name (NI) **] pt had Hct of 20 and bloody NG lavage which
did not clear. She was transfused 1U PRBC, GI consult called,
also got zofran and iv protonix and admitted to the [**Hospital Unit Name 153**]. On
arrival to unit pt had EGD which revealed grade III esophageal
varices with signs of old bleeding. She was started on
octreotide and nadolol to control portal htn. Pt was stable
and had appropriate Hct bump to 25 after 2U PRBC's.
She also had climbing bilirubin and low grade temp and was
started on Zosyn for suspected biliary obstruction and ascending
cholangitis coverage. She was rescoped on [**11-18**] and varices were
sclerosed(no banding due to latex allergy) and diuretics of
lasix and aldactone were readded for ascites since BP stable.
[**11-19**] she was transfused another 3U PRBC's with hct bump to 31.9
and antibiotic coverage broadend to Unasyn, Ceftriaxone, Flagyl
because she continued to spike, and for SBP prophylaxis.
Preprocedure of PTC on [**11-20**] she was transfused 1 unit PRBC's, 2
platelets and 2U FFP and procedure went without complication.
ON transfer to the floor she remained hemodynamically stable
with stable Hct and declining bilirubin. She remained afebrile
so on [**11-23**] antibiotic regimen was weaned to only levofloxacin.
Liver teams recommended to repeat EGD with non latex banding in
[**7-27**] days. She also went home on naldolol 20mg qd for portal
htn, and her home doses of diuretics to control her ascites.
2. US finding- Pt was incidentally found to have R
hydronephrosis and a R adenexal mass on her US. The
hydronephrosis was likely caused by blockage by her tumor.
Given her disease prognosis and the fact that her other kidney
is functioning well, no intervention was done. Also the
adenexal mass may represent a second primary maligancy. This
was seen on a prior CT scan and her [**Date Range 5564**] is aware. Again
given the patient's poor disease prognosis, there was no
intervention made at this time.
Medications on Admission:
MEDICATIONS: She is on Lasix 40 mg p.o. b.i.d., Aldactone 25 mg
p.o. b.i.d., Prilosec 20 mg p.o. daily, ciprofloxacin 250 mg
p.o.
daily, this is for prophylaxis for cholangitis and iron.
Discharge Medications:
1. 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:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
6. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO four
times a day: Swish and swallow.
Disp:*qs mL* Refills:*2*
8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please have CBC and alkaline phosphatase and total bilirubin
checked on Monday [**11-25**]
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital1 487**]
Discharge Diagnosis:
Cholangiocarcinoma
Biliary obstruction
Grade III esophageal varices
Discharge Condition:
Stable.
Discharge Instructions:
Call your primary care doctor, [**Hospital1 5564**], or return to the
Emergency Room if you have increasing nausea, vomiting, leg
swelling, confusion, or pain.
Followup Instructions:
Please follow up at all scheduled appointments including
Wednesday in [**Hospital **] clinic. Call the [**Hospital **] clinic on Monday to confirm
your appointment: [**Telephone/Fax (1) 53981**]. Ask to speak with [**Month (only) 116**] [**Doctor Last Name **], PA.
Call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 5564**] for follow up
appointments. You will have a banding procedure in 9 days.
Please call the [**Hospital **] clinic and arrange to see Dr. [**Last Name (STitle) 2161**] for an
appointment: [**Telephone/Fax (1) 1954**].
|
[
"2851",
"2875"
] |
Admission Date: [**2111-2-5**] Discharge Date: [**2111-2-7**]
Date of Birth: [**2090-7-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
20 yo female with 16 year history of insulin dependent DM, on
insulin pump; also recently dx with autoimmune hepatitis,
admitted for DKA w/ glucose in 400's. Had N/V since yesterday,
progressed to inability to keep any fluids down. No F/C. Denies
abdominal pain, diarrhea, no cough, no CP, no SOB. No URI
symptoms, has been in USH up until yesterday. No known sick
contacts, not living in dorms anymore. Patient denies any
changed in pattern of diet, no adjustments in her insulin
dosing. No weight loss, no recent polyuria, polydipsia. Denies
any dysuria. Is currently sexually active, LMP [**2111-1-14**]. Usually
follows with endocrinologist in western Mass. Feels much
improved since admission, now tolerating small sips of fluids/
ice.
.
In ED, patient received 5 L NS, insulin gtt @ 6U/hr; then
changed over to 1/2 NS w/ D5 once sugars decreased, gap closed.
UA positive for ketones/ glucose, no infection. Of note, pt was
not getting insulin via peripheral pump.
Past Medical History:
Type 1 DM - since age 3 - on insulin pump (Novolog) x ~3 years
on lisinopril for renal protection/microalbuminemia
Autoimmune hepatitis, dx by liver biopsy about . Follows w/
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Social History:
Pt is a student at [**University/College **]. She lives off campus w/
roommate. She denies tobacco use. She uses ETOH occasionally
([**2-14**] drinks on the weekend). She denies illicit drug use.
Family History:
Her father has Type 1 DM.
Her FGF and MGF - CAD - 70s, 49
No history of other endocrine disorders
Physical Exam:
vitals: tc 100, tm 100, 124/68 (110-120s/50-60s), p132
(120-132), rr24, 98%RA. BG 371
GEN: well appearing, well nourished young female, lying flat,
NAD
HEENT: flushed, PERRL, EOMI, clear OP, MMM
CVS: tachycardic, hyperdynamic, no m/g/r
Lungs: CTAB, no c/w/r
Abd: soft, NT, ND, +BS, insulin pump in place
Ext: no edema
Pertinent Results:
CXR: IMPRESSION: No acute cardiopulmonary process.
.
CBC:
[**2111-2-5**] WBC-14.5*# RBC-4.53 Hgb-14.1 Hct-40.4 MCV-89 MCH-31.1
MCHC-34.9 RDW-12.3 Plt Ct-270
[**2111-2-5**] WBC-16.2* RBC-3.80* Hgb-12.0 Hct-34.1* MCV-90 MCH-31.6
MCHC-35.2* RDW-12.3 Plt Ct-226
[**2111-2-6**] 07:45AM BLOOD WBC-10.0 RBC-3.41* Hgb-10.4* Hct-29.9*
MCV-88 MCH-30.5 MCHC-34.8 RDW-12.4 Plt Ct-202
[**2111-2-7**] 05:29AM BLOOD WBC-5.6 RBC-3.54* Hgb-11.0* Hct-31.0*
MCV-88 MCH-31.1 MCHC-35.5* RDW-12.3 Plt Ct-195
[**2111-2-5**] 02:00AM BLOOD Neuts-90.7* Bands-0 Lymphs-6.9* Monos-2.2
Eos-0 Baso-0.1
[**2111-2-5**] 02:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Burr-1+
.
[**2111-2-5**] 02:00AM BLOOD Glucose-393* UreaN-13 Creat-0.9 Na-133
K-4.8 Cl-95* HCO3-12* AnGap-31*
[**2111-2-5**] 05:20AM BLOOD Glucose-387* UreaN-13 Creat-0.9 Na-136
K-5.0 Cl-103 HCO3-9* AnGap-29*
[**2111-2-5**] 07:11AM BLOOD Glucose-260* UreaN-12 Creat-0.7 Na-139
K-3.8 Cl-109* HCO3-12* AnGap-22*
[**2111-2-5**] 08:00AM BLOOD Glucose-214* UreaN-11 Creat-0.7 Na-138
K-3.8 Cl-112* HCO3-11* AnGap-19
[**2111-2-5**] 09:20AM BLOOD Glucose-206* UreaN-11 Creat-0.7 Na-137
K-3.9 Cl-111* HCO3-12* AnGap-18
[**2111-2-5**] 10:30AM BLOOD Glucose-202* UreaN-10 Creat-0.7 Na-137
K-4.0 Cl-111* HCO3-15* AnGap-15
[**2111-2-5**] 11:45AM BLOOD Glucose-202* UreaN-10 Creat-0.6 Na-138
K-4.1 Cl-111* HCO3-15* AnGap-16
[**2111-2-5**] 06:45PM BLOOD Glucose-346* UreaN-12 Creat-0.8 Na-133
K-4.7 Cl-102 HCO3-8* AnGap-28*
[**2111-2-6**] 01:40AM BLOOD Glucose-368* UreaN-16 Creat-0.9 Na-131*
K-4.9 Cl-103 HCO3-5* AnGap-28*
[**2111-2-6**] 06:36AM BLOOD Glucose-177* UreaN-11 Creat-0.7 Na-134
K-3.6 Cl-111* HCO3-10* AnGap-17
[**2111-2-6**] 07:45AM BLOOD Glucose-136* UreaN-10 Creat-0.7 Na-135
K-3.5 Cl-113* HCO3-12* AnGap-14
[**2111-2-6**] 11:30AM BLOOD Glucose-191* UreaN-8 Creat-0.7 Na-136
K-4.1 Cl-112* HCO3-14* AnGap-14
[**2111-2-6**] 03:59PM BLOOD Glucose-87 UreaN-8 Creat-0.6 Na-137 K-4.0
Cl-111* HCO3-17* AnGap-13
.
[**2111-2-5**] 10:30AM BLOOD ALT-45* AST-27 LD(LDH)-106 AlkPhos-60
Amylase-86 TotBili-0.3
.
[**2111-2-5**] 10:30AM BLOOD Lipase-21
[**2111-2-5**] 10:30AM BLOOD Albumin-3.4 Calcium-7.2* Phos-2.1*
Mg-1.5*
[**2111-2-5**] 06:45PM BLOOD Calcium-8.2* Phos-2.9 Mg-1.8
[**2111-2-6**] 06:36AM BLOOD Calcium-7.1* Phos-1.9*# Mg-1.8
[**2111-2-6**] 11:30AM BLOOD Calcium-7.6* Phos-1.7* Mg-1.7
[**2111-2-7**] 05:29AM BLOOD Calcium-8.0* Phos-1.8* Mg-1.6
[**2111-2-5**] 10:01PM BLOOD Type-ART pO2-130* pCO2-16* pH-7.28*
calHCO3-8* Base XS--16
.
[**2111-2-6**] 06:21AM BLOOD Type-ART pO2-124* pCO2-22* pH-7.30*
calHCO3-11* Base XS--13
.
[**2111-2-6**] 11:38AM BLOOD Type-ART Temp-36.9 pO2-134* pCO2-27*
pH-7.37 calHCO3-16* Base XS--7 Intubat-NOT INTUBA Comment-ROOM
AIR
.
[**2111-2-5**] 10:01PM BLOOD freeCa-1.18
Brief Hospital Course:
On admission to the floor, pt was restarted on her insulin pump.
Pt was feeling well and tolerated lunch and dinner without any
difficulties. PM labs were drawn and pt was found to have blood
glucose of 346, bicarb of 8, anion gap of 23. ABG was
7.28/16/130; lactate 2.2. Pt was given insulin bolus (6U) via
pump. Pt was started on IVF: NS@500cc/hr. Of note, PM wbc count
increased from 14.5 to 16.2. At that time, the patient had low
grade fever of 100. Denies chills, cough, n/v/abd pain/diarrhea,
CP. Pt does have some SOB. Hence, she was transferred to the ICU
for close monitoring of her blood sugars.
.
MICU Course:
# DKA: For the DKA, there was no clear precipiating infection or
drastic change in her daily life that could have precipitated
this event. She did have an elevated WBC count with low grade
temp. However, UA and CXR negative for infection and blood
cultures were pending as of [**2111-2-7**]. No recent stressors. There
was a question of pump failure, especially in light of the fact
that the pt went back into DKA when restarted on her insulin
pump.
.
The patient was in DKA with anion gap 23, acidosis,
hyperglycemia on MICU txfer. Electrolytes were stable. Gluc
decreased from 371 to 320 over past hours after 6U novolog.
She was managed with
- insulin gtt for target BS 150-200.
- aggressive IV hydration with NS -> started D5 1/2 NS when
glucose<250
- electrolytes q2hours until sustained improvement x 4 hours and
monitoring of her anion gap
- q1h finger sticks
- urine ketones were negative
- give K supplementation in IVF. d/c once K is >5.5
- anzemet prn for nausea
.
- on HOD #2, while BS were stable in the MICU, [**Last Name (un) **] consult
felt that patient would benefit from an additional night of
close monitoring since she went into DKA despite being on her
pump. Hence she was monitored overnight - her anion gap closed
and her blood sugars were well controlled. She was transitioned
back over to her insulin pump and the drip was turned off with
30 minutes of overlap. ELectrolytes were repleted as necessary
and patient received copious IVF (D5 1/2NS).
.
# DM:
- Last hgb A1c of 7 in [**12-19**].
- cont ACE for known proteinuria
- [**Last Name (un) **] was consulted to help in the management of this
patient.
.
# Leukocytosis: No infectious source was identified. Possible
stress rxn.
.
# Tachycardia- Most likely related to dehydration, N/V.
- resolved with IVF.
.
# GI- autoimmune hepatitis, dx by liver biopsy
- appears to be stable, LFTs WNL, ALT slightly elevated.
- continue current dose of steroids/ Imuran
- patient's hepatologist was contact[**Name (NI) **] regarding her admission.
.
# FEN- IVF. replete electrolytes. She was restarted on a PO diet
on day of discharge.
.
# She was discharged to home with f/u with her endocrinologist
and PCP. [**Name10 (NameIs) **] was given [**Last Name (un) 9718**] number for local f/u (if she
chooses to).
.
Medications on Admission:
Insulin pump- basal rate typically 1-1.5 units/hr (novolog).
Carb counts w/ 1U: 10 gram ration. Does not know sensitivity
Prednisone- now tapered down to 18mg/day
Imruan 100mg
Zestril 10mg
Ca/Vitamin D
OCPs- patient can't remember the name
Discharge Medications:
1. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Insulin
Please manage your insulin pump as directed by the [**Last Name (un) **]
physicians.
4. Prednisone
Please continue your prednisone taper as prior to this brief
hospitalization.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Discharge Condition:
AAO x 3
Hemodynamically stable
BS well controlled
Discharge Instructions:
Please continue to manage your insulin pump as per
recommendations of [**Hospital **] clinic. If you notice that you are
having difficulty in managing your blood sugars, please call
your endocrinologist, your primary care physician or come back
to the emergency department.
Followup Instructions:
Please follow up with:
1. Your endocrinologist
2. Dr. [**Last Name (STitle) **]
|
[
"V5867"
] |
Admission Date: [**2123-9-13**] Discharge Date: [**2123-9-20**]
Date of Birth: [**2071-4-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2123-9-13**] - CABGx2 (Left internal mammary artery to the left
anterior descending artery, vein graft to the obtuse marginal
artery); Mitral Valve Replacement (27mm [**Company 1543**] Mosaic Tissue
Valve); Diagnostic Cardiac Catheterization
History of Present Illness:
52 year old female with IDDM and CAD who ruled in for an MI in
[**2123-5-25**]. Work-up revealed severe left main and three vessel
disease. An echo showed moderate mitral valve regurgitation. Her
surgery was originally delayed due to uterine bleeding which was
caused by endometriosis. She now presents for surgical
management of her coronary arerty disease.
Past Medical History:
IDDM
Hyperlipidemia
HTN
PVD s/p Right Fem-[**Doctor Last Name **] Bypass
CAD
MI
Uternine bleeding d/t endometriosis s/p Endometrial ablation.
Depression
Social History:
Married and lives in [**State 108**]. 25 pack year smoking hostory
quitting in [**2123-2-25**]. Denies alcohol use.
Family History:
Noncontributory
Physical Exam:
PE: middle aged female, chronic-ill appearing. lying in bed. NAD
T Afeb BP 112/62 P 68
skin: Warm, dry, No C/C/E
lymph: not palpable at cervical region
HEENT: oral mucosa dry
neck: supple, no JVD, no thymomegaly
chest: lungs CTAB
CVS: RRR, quiet late systolic I/VI murmur
abd: soft, NT, BS normal
ext: No edema bilaterally, distal pulses decreased bilaterally.
Right GSV harvaest. Left appears suitable.
neuro: nonfocal
Pertinent Results:
[**2123-9-13**] ECHO
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are mildly
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Moderate to severe (3+)
mitral regurgitation is seen. The MR jet is directed
posteriorly. Moderate [2+] tricuspid regurgitation is seen.
There is no pericardial effusion.
Post-CPB: Patient is on phenylephrine gtt. A well-seated and
functional mitral prosthesis is seen with no MR [**First Name (Titles) **] [**Last Name (Titles) **]-valvular
leak. Good RV systolic fxn. Moderate LV depression, with EF35 -
40%. Aorta intact. Other parameters as pre-bypass.
[**2123-9-16**] CXR
Small bilateral pleural effusions, greater on the left side, are
unchanged. Left lower lobe retrocardiac opacity consistent with
atelectasis is persistent. There has been mild increase in right
lower lobe opacity consistent with atelectasis. Postoperative
cardiomediastinal silhouette is unchanged. There is no
pneumothorax. Right IJ line and chest tubes have been removed.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2123-9-13**] for surgical
management of her coronary artery disease. She was taken
directly to the operating room where she underwent a cardiac
catheterization followed by coronary artery bypass grafting to
two vessels and a mitral valve replacement using a 27mm
[**Company 1543**] Mosaic Tissue Valve. Postoperatively she was
transferred to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Mrs. [**Known lastname **] awoke
neurologically intact and was extubated. She was transfused a
unit of red blood cells for postoperative anemia. She was slow
to wean from pressors. Eventually she was resumed on her beta
blockade and a statin. On postoperative day three, she was
transferred to the step down unit for further recovery. Mrs.
[**Known lastname **] was gently diuresed towards her preoperative weight. Her
blood sugars were difficult to control and the [**Last Name (un) 387**] diabetes
service was consulted for assistance in her care. Appropriate
changes were made to her insulin regimen. The physical therapy
service was consulted for assistance with her postoperative
strength and mobility. Mrs. [**Known lastname **] had episodes of confusion
postoperatively which slowly resolved during her postoperative
course. Haldol was used as needed with good effect. The [**Last Name (un) **]
diabetes service continued to aggressively manage her blood
sugars as they were labile. Mrs. [**Known lastname **] continued to make steady
progress and was discharged home on postoperative day seven. She
will follow-up with Dr. [**Last Name (STitle) 1290**], her cardiologist and her
primary care physician as an outpatient.
Medications on Admission:
Lantus 40units Qday
humalog s/s
Lipitor 40mg one tablet daily
Capoten 25mg 1 tablet twice a day for hypertension
Paxil 40mg
Neurontin 100mg
Trazodone 100mg 3 po qhs
Klonopin 1mg 1 [**1-26**] po qhs
Aspirin 81mg
Iron once daily
Zetia 10mg one daily
Norethindrone Acetate 5mg one daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*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. Paroxetine HCl 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily). Tablet(s)
5. Insulin Glargine 100 unit/mL Solution Sig: as dir
Subcutaneous at bedtime.
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
10 days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
14. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
CAD s/p CABG
IDDM
PVD s/p Right Fem-[**Doctor Last Name **] Bypass
HTN
Hyperlipidemia
Uterine bleeding
Hypothyroid
MI
MR
[**Name13 (STitle) 19458**] disease
Discharge Condition:
Good.
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-26**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 19459**] in 2 weeks. [**Telephone/Fax (1) 19460**]
[**Hospital Ward Name 121**] 2 wound clinic as instructed.
Please call all providers for appointments.
Completed by:[**2123-9-20**]
|
[
"41401",
"4240",
"4019",
"2720",
"2449"
] |
Admission Date: [**2126-8-3**] Discharge Date: [**2126-8-29**]
Date of Birth: [**2126-7-29**] Sex: F
Service: Neonatology
ID: [**Known firstname 37958**] Girl [**Known lastname **] is a 1 month old former 36 [**5-23**] wk twin with a
history of intraventricular hemorrhage and seizures who is being
discharged from the [**Hospital1 18**] NICU.
HISTORY: [**Known firstname 37958**] Girl [**Known lastname **] was born on [**2126-7-29**] at [**Hospital6 **] as the 1860 gram product of a 36 and [**5-23**] week twin
gestation to a 39 year-old, G1 P0 to 2 mother. Maternal prenatal
screens: Blood type B negative, antibody negative, hepatitis
surface antigen negative, Rubella immune, RPR nonreactive, and
GBS negative. Pregnancy complicated by IVF dichorionic,
diamniotic twin gestation, and was also notable for advanced
maternal age and gestational diabetes which was diet
controlled. Mother presented on date of delivery with
spontaneous rupture of membranes of twin A. Twin B was
breech presentation, which prompted Cesarean section
delivery. Rupture of membranes of twin B was at delivery. In
the delivery room, twin B was noted to be hypotonic with
respiratory distress. Blow-by oxygen and stimulation was
provided and Apgars were assigned of 7 and 8.
HISTORY OF HOSPITAL COURSE AT [**Hospital6 **]:
Initial hospital course at [**Hospital **] Hospital was notable for:
- Discordant twin size, with this twin growth restricted at less
than 10th percentile and other twin appropriate size for
gestational age;
- Mild respiratory distress and oxygen requirement that resolved
over first 12 hours of life, most consistent with TTN;
- Initial hypoglycemia, treated with intravenous glucose with a
maximum of D-15 concentration;
- Polycythemia with variable hematocrit values, with initial
hematocrit of 64% and reaching 73% by day of life 3, prompting
partial exchange transfusion;
- Mild thrombocytopenia with platelet counts 70-80s, diminishing
to 50s following exchange transfusion;
- Sepsis evaluation on two occasions, with initial treatment with
ampicillin and gentamicin and subsequent reinitation of
ampicillin and cefotaxime, with both blood cultures negative;
- Mild hypocalcemia, which resolved;
- Mild hyperbilirubinemia which treated with phototherapy (infant
blood type B-, coombs -).
On day of life 5, infant was noted to have generalized tonic
clonic seizure activity. She was loaded with phenobarbital, and
transferred to the [**Hospital1 18**] NICU. Head CT performed shortly after
admission to [**Hospital1 **] revealed a large right intraventricular
hemorrhage with parenchymal involvement.
PHYSICAL EXAMINATION: On admission to [**Hospital1 190**], physical examination revealed the following:
General: SGA white female, quiet, asleep but responsive with
good tone. Well perfused but pale pink, mild jaundice.
Normal caput. Anterior fontanel soft, flat, sutures not
split. Eyes with moderate dilatation of pupils but reactive
to light. Red reflex present bilaterally. Good facial
muscular tone. Ears, nose, mouth appear within normal
limits. Neck within normal limits. Chest: Clear breath
sounds, regular respirations with good respiratory effort.
Cardiovascular: S1 and S2, within normal limits. No murmur.
Pulses within normal limits in all extremities. Abdomen
soft, nontender. Right upper quadrant mass, distinct from
liver, egg-shaped, palpable, no apparent hepatosplenomegaly.
Full abdomen, non tense. Normal female genitalia with
edematous labia. Anus patent. Back within normal limits.
Skin: No apparent petechiae, bruising, purpura on
examination, except evidence of site of multiple needle
sticks, no apparent bleeding. Neurologic examination on
admission: Sleepy, quiet, status post loading dose of
Phenobarbital but very responsive to examination. Good tone.
Normal reflexes. Normal posture.
HISTORY OF HOSPITAL COURSE AT [**Hospital3 **]:
1. Respiratory: The infant was stable throughout admission,
breathing comfortably in room air without apnea or desaturation
episodes.
2. Cardiovascular: The infant was stable throughout admission,
without evidence of hemodynamic instability.
3. Fluids, electrolytes and nutrition: Birth weight was 1860
grams. Admission weight to the [**Hospital1 188**] was [**2116**] grams. Her discharge weight is 2395 grams. On
admission to [**Hospital1 69**], the infant was
initially maintained NPO and on IVF. Serum chemistries including
calcium and magnesium were within normal limits. Enteral
feedings were started on [**8-6**] via gavage tube. Advancement
of feedings was limited by frequent vomiting. As described
below, the infant underwent evaluation for the abdominal mass
palpated on admission, thought to be most consistent with
duplication cyst. Evaluation included an upper GI study which
did not suggest obstruction. Feedings were continued, and
eventually tolerance improved and infant was able to be given
full volume feeds. Caloric density was increased to max 26
calories per ounce to aid weight gain. As infant's overall
status improved, oral feedings were introduced, with eventual
transition to full oral feeds. By the time of discharge, the
infant has been feeding PO ad lib Neosure 26 calorie/oz formula
for greater than three days, taking over 140 cc/kg/day. Urine
and stool output have been normal.
4. Gastrointestinal/Genitourinary: Abdominal mass palpated
on admission. Ultrasound was performed on [**8-5**], demonstrating
a cystic mass in the mid upper abdominal region to the right of
the midline measuring 3 x 3 x 3.5 cm, separate from the liver and
adjacent to the gallbladder. Differential
diagnoses included duplication cyst, mesenteric cyst, and less
likely a choledochal cyst or macrocystic lymphatic mass. Surgery
from [**Hospital3 1810**] (Dr. [**Last Name (STitle) 37080**] was consulted. The mass
was followed clinically at first, but due to issues with vomiting
with introduction of enteral feeds, further evaluation was
performed with repeat ultrasound and upper GI study, performed on
[**2126-8-14**] at [**Hospital3 1810**]. Repeat ultrasound suggested the
mass was most consistent with duplication cyst, and upper GI
study showed displacement of the duodenal loop but no evidence of
obstruction of flow. Feedings were resumed following the
studies, and were gradually able to be well tolerated. Plan at
the time of discharge is for follow-up with surgery at [**Hospital1 **]
as an outpatient, with elective excision of the mass in the
future.
She required treatement for hyperbilirubinemia with phototherapy
for several days after transfer.
5. Hematology: Blood type is B negative, Coombs negative.
Initial hematocrit on admission to [**Hospital1 190**] was 56, and remained stable in follow-up. Last Hct
on [**8-29**] was 33.4. In light of IVH, coagulation studies were
performed and were basically within normal limits. Initial PT
was mildly elevated, although normal on repeat, and a factor 7
level was sent and that was normal. Hematology was consulted and
considered the coagulation studies to be overall reassuring.
On admission to the [**Hospital1 69**], she
had a platelet count of 43 and was given a platelet transfusion.
Platelet count post-transfusion was 143, and then remained
stable, with last count of 272 on [**8-9**].
6. Infectious disease: In light of the seizure activity,
acyclovir was added to the ampicillin and cefotaxime the infant
had been on at the time of transfer. An LP was performed which
was noted to be bloody. CSF PCR was sent and results were
negative. Blood cultures remained negative. Antibiotics were
discontinued on [**8-6**] and the Acyclovir was discontinued on
[**8-8**].
7. Neurology: As noted above, infant was loaded with
phenobarbital following seizure activity at [**Hospital **] Hospital.
Head CT was performed on [**8-3**], demonstrating bilateral
germinal matrix bleed with extension into the ventricular and
peri-ventricular matter on the right side. There was no
ventricular dilatation. An additional clinical seizure was seen
on [**8-3**], and EEG performed on [**8-4**] and 20 suggested ongoing
subclinical seizure activity, prompting additional doses of
phenobarbital with an eventual level of 36. Clinical seizures
resolved, and EEG on [**8-8**] demonstrated no seizure activity.
Neurology from [**Hospital1 **] was consulted and has been actively
involved in this case.
Multiple head ultrasounds showed expected evolution of the
right-sided intraventricular hemorrhage, with gradual cystic
changes noted in the periventricular areas bilaterally. Mild
ventricumegaly was seen, but was stable. Head circumferences
were followed daily, and remained stable, increasing
appropriately from 31 cm to 33 cm. Head MRI was performed on
[**8-28**], and revealed bilateral right greater than left
multicystic encephalomalacia, primarily in the periventricular
areas but also extending slightly beyond. Hemorrhagic changes
were seen within the damaged white matter areas, with a large
subependymal hemorrhage in the right lateral ventricle. Overall
these findings were thought to be most consistent with a prior
hypoxic ischemic injury, with secondary hemorrhage.
Clinically, infant showed very gradually improving activity and
mental status over course of hospitalization. With no further
seizure activity seen and slow improvement in activity level,
target phenobarbital level was reduced to 25-30, and
phenobarbital dose was reduced accordingly. Last two
phenobarbital levels were 21, last on [**8-29**], and dose was
increased to 12 mg per day. Repeat EEG was also performed on
[**8-23**], secondary to persistent limited PO feeding, and revealed a
generally normal background without seizure activity. Infant did
begin to demonstrate more rapid improvement in activity level and
PO feeding after that time, and by the time of discharge, infant
is appropriately active and vigorous with exam.
Occupational therapy has been following the infant throughout,
and has noted increased tone diffusely. Stretching exercises
have been performed regularly, and taught to the parents, with
some improvement in tone seen.
8. Psychosocial: This family is invested and involved and has
been working with the social worker who can be contact[**Name (NI) **] at
[**Telephone/Fax (1) 8717**]. The social worker is [**Name (NI) 4457**] [**Name (NI) 36244**].
CONDITION ON DISCHARGE: Stable. Weight 2395 grams.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 56527**], [**Hospital 17566**] Pediatrics,
[**Telephone/Fax (1) 52275**].
CARE RECOMMENDATIONS:
1. Diet: Neosure 26 cals/oz made by concentration.
2. Medications: Phenobarbital 12 mg (3 mL) PO daily.
3. Car seat position screening: passed on [**2126-8-27**].
4. State newborn screen: last sent on [**8-13**], results all WNL.
5. Immunizations received: received Hepatitis B vaccine # 1 on
[**2126-8-28**]. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
FOLLOW-UP APPOINTMENTS AND RECOMMENDATIONS:
- Dr. [**Last Name (STitle) 56527**] (PMD) in 1 day; VNA in 2 days.
- Dr. [**Last Name (STitle) 37080**], General Surgery, [**Hospital3 1810**] ([**Last Name (un) 9795**] 3),
[**9-18**], 9:15 am.
- Neonatal Neurology Program, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital3 18242**], 2-3 months after discharge (referral made).
- Early intervention (referral made to Criterion-[**Location (un) 270**] Child
Development.
DISCHARGE DIAGNOSES:
1. Hypoxic-ischemic brain injury.
2. Intraventricular hemorrhage.
3. Seizures.
4 Rule out sepsis with antibiotics.
5. Abdominal mass, likely duplication cyst.
6. Thrombocytopenia.
7. Polycythemia.
8. Hyperbilirubinemia.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2126-8-14**] 00:07:12
T: [**2126-8-14**] 05:07:07
Job#: [**Job Number 63567**]
|
[
"7742",
"V053"
] |
Admission Date: [**2135-6-15**] Discharge Date: [**2135-7-22**]
Date of Birth: [**2073-8-16**] Sex: M
Service: MEDICINE
Allergies:
Cortisone
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Back wound
Major Surgical or Invasive Procedure:
Debridement of back wound by Neurosurgery and Plastic Surgery
Flap placement and closure by Plastic Surgery
Flap revision by Plastic Surgery
multpile PICC line placements
History of Present Illness:
61 yo male w/o significant past medical history
transferred from [**Hospital 3844**] hosp for wound evaluation. Pt has
large back wound, which he has never actually seen, but has
noticed over past 1-2mo draining fluid. Pt states that he fell
backwards ten feet into the foundation of a home in [**9-15**] and
developed a wound in the back. Since his fall, he has been
packing the wound w/ a cut out square of a T shirt, paper
towels, and Neosporin. He has noticed pus dripping from the
wound for the last month. He decided to go the
hospital today in NH when it started to smell bad. Given the
complexity of the wound and exposure of spinous processes, he
was brought to [**Hospital1 18**] for further management.
.
In [**Name (NI) **], pt febrile to 101.8 w/ "labile" BP w/ SBP in the 80's.
Code sepsis initiated. Pt given 5L IVF, central line (R IJ
placed) and pressors started. Plastics & spine consults were
obtained. Given vanco/zosyn. Admitted to the MICU for HD
monitoring & stabilization.
.
In the MICU, the patient was maintained on empiric abx and
aggressive IVF repletion. Plastics and spine still following.
Once hemodynamically stable and afebrile, the patient was
transferred out to the floor.
.
Currently, the patient denies pain (although visibly in distress
when laying back in bed), and denies f/c/n/v/dizziness.
.
On ROS, the patient denies parasthesias/weakness in his
extremities, no changes in bowel or bladder function. He admits
to a 20lb weight loss over 1 year but attributes this to new
retirement. He denies any other B symptoms. He denies
diarrhea/nightsweats/palpitations.
Past Medical History:
pt has not seen a physician [**Name Initial (PRE) 14169**] [**2098**]
Social History:
Worked as a electrician, retired one year ago.
Lives alone, estranged from family. Has two children who moved
away with mother. [**Name (NI) **] brother nearby, but not in close contact
with him. Remote history of tobacco/ETOH.
Family History:
mom - cancer of unclear etiology
Physical Exam:
Vitals: T 98.5; BP 81/39; P 82; RR 18; 98% RA
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple, no carotid bruit
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Skin: ulcerating skin wound from ~ C7-T6 eroded through
paraspinal muscles and exposes necrotic spinous processes. 22 cm
at greatest width.
Extremities: no c/c/e.
Neuro: CNII-XII in tact, strength in tact UE/LE equal
bilaterally, sensation in tact. No clonus, DTR's 2+, Babinski
down b/l.
Pertinent Results:
[**2135-6-15**] 07:00PM WBC-11.7* RBC-3.74* HGB-9.6* HCT-28.1*
MCV-75* MCH-25.5* MCHC-34.0 RDW-14.8
[**2135-6-15**] 07:00PM NEUTS-79.7* LYMPHS-14.4* MONOS-5.4 EOS-0.4
BASOS-0.1
[**2135-6-15**] 07:00PM PLT COUNT-715*
[**2135-6-15**] 07:00PM GLUCOSE-102 UREA N-16 CREAT-0.8 SODIUM-127*
POTASSIUM-5.9* CHLORIDE-97 TOTAL CO2-19* ANION GAP-17
[**2135-6-15**] 07:18PM LACTATE-1.3
.
[**2135-6-16**]: CXR: IMPRESSION: 1. Standard position of the right
internal jugular line with no evidence of complications. 2. New
large left lower lobe consolidation might be accompanied by
pleural effusion. Given its fast appearance, it might represent
aspiration. 3. Questionable left upper lobe nodule. Repeated PA
and lateral chest radiographs are recommended for precise
evaluation of these findings.
.
[**2135-6-16**]: TTE: Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Left
ventricular systolic
function is hyperdynamic (EF 80%). Tissue Doppler imaging
suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no
ventricular septal defect. The right ventricular cavity is
dilated. Right
ventricular systolic function is normal. The ascending aorta is
mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal
with trivial mitral regurgitation. There is no mitral valve
prolapse. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2135-6-16**]: CT abd/pelvis: IMPRESSION:
1. Multiple lung nodules, which may represent metastases or
infection. However, no definite primary cancer identified.
2. Open wound in left upper back and over the thoracic spine.
However, no drainable collection identified.
3. Bilateral pleural effusions, left greater than right and left
loculated.
4. Ascites.
5. No suspicious sclerotic lesions seen in the bones. However,
CT is not specific for evaluating bony metastases.
.
[**2135-6-17**]: CT Head: IMPRESSION: No evidence of intracranial
metastatic disease.
.
[**2135-6-17**]: MR [**Name13 (STitle) 2854**] - FINDINGS: There are extensive signal
intensity abnormalities of all of the visualized vertebral
bodies. This finding is most strongly suggestive of diffuse
metastatic disease. There is no definite evidence of rupture of
tumor through the cortex. However, as noted below, there are
areas where it is difficult to distinguish tumor from the
infection.
There is a large defect in the skin and musculature posterior to
the spine. The superior extent of this defect appears to be
located at approximately T1. This appears to extend to
approximately T11. At the greatest depth of the defect, it
appears to extend to the spinous processes and lamina. There is
extensive soft tissue abnormality, with enhancement, surrounding
the thecal sac, most prominent from approximately T2 to T6.
Throughout these levels, there also appears to be abnormal
enhancement of the vertebral bodies themselves. The spinous
processes and lamina at T2 through T4 appear markedly
hypointense on the MR images suggesting sclerosis due to chronic
osteomyelitis.
There are large bilateral pleural effusions, larger on the left
than right. A right lung nodule is identified in the limited
views of the lung included in this study.
There is a protrusion of the T7-8 intervertebral disc with
indentation on the spinal cord. This is incompletely visualized
on these images.
The findings described above suggest both infectious and
neoplastic pathology with the diffuse vertebral body signal
intensity abnormalities, and the right lung nodule,
characteristic of metastatic disease. The large ulceration of
the posterior soft tissues and the enhancement surrounding the
thecal sac presumably represent infection. However, this
intraspinal soft tissue may also contain tumor. There may well
be an intraspinal epidural abscess or phlegmon. No drainable
fluid collection is noted within the spinal canal.
CONCLUSION: Findings suggesting both metastatic disease and
chronic infection with intraspinal enhancement most suspicious
for epidural abscess or phlegmon.
Right lung nodule.
Bilateral pleural effusions.
T7-8 disc protrusion.
.
[**2135-6-19**]: MR L/C spine:
IMPRESSION:
1. Epidural abnormality which could represent phlegmon or early
abscess, from the T3 through T5 level. At the T4-T5 level, this
deforms the dorsal surface of the thecal sac.
2. Foci of increased signal on the T1 post-gadolinium sequence
at the T3-T4 level within the thecal sac which could represent
enhancing nerve roots, vessels, or artifact. It is unlikely to
be intrathecal extension of infection.
3. Erosion of the spinous processes of T2 through T8 with
extensive posterior soft tissue phlegmon and inflammation. At
T3-T4, T4-T5 and T5-T6, this soft tissue extends into the neural
foramina, and into the epidural space.
4. No cervical or lumbar epidural abnormalities, and no cervical
or lumbar cord signal abnormalities.
5. Bilateral pleural effusions and multiple lung nodules, which
are better assessed on the recent CT of the torso.
6. Multifocal signal changes within vertebral bodies in the
cervical, thoracic and lumbar spine are most suggestive of
multifocal osseous metastatic disease.
Overall, the study of the thoracic spine does not demonstrate
significant change since [**2135-6-17**].
.
[**2135-6-20**]- pathology report:
SPECIMEN SUBMITTED: SPINOUS PROCESS (BONE) (1).
Procedure date Tissue received Report Date Diagnosed
by
[**2135-6-20**] [**2135-6-21**] [**2135-6-29**] DR. [**Last Name (STitle) **]. LOMO/lxl??????
DIAGNOSIS:
Spinous process bone:
.
Metastatic carcinoma with squamous features (see Note).
.
Acute osteomyelitis with necrosis.
.
Note: Immunostains will be performed and the results reported in
an addendum.
.
[**2135-6-20**]: EKG: Sinus rhythm. Left atrial abnormality. No previous
tracing available for comparison.
.
[**2135-6-21**]: Pleural Fluid Cytology: Pleural fluid: NEGATIVE FOR
MALIGNANT CELLS.
.
SWAB THORAC BACK.
.
**FINAL REPORT [**2135-6-22**]**
.
GRAM STAIN (Final [**2135-6-15**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
.
WOUND CULTURE (Final [**2135-6-19**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND STRAIN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| | PSEUDOMONAS
AERUGINOSA
| | |
CEFEPIME-------------- 4 S 2 S
CEFTAZIDIME----------- 4 S <=1 S
CIPROFLOXACIN--------- 0.5 S <=0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S 4 S <=1 S
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM------------- <=0.25 S <=0.25 S
OXACILLIN-------------<=0.25 S
PIPERACILLIN---------- 8 S <=4 S
PIPERACILLIN/TAZO----- 8 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- S
ANAEROBIC CULTURE (Final [**2135-6-22**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
.
[**2135-6-20**] 6:00 pm TISSUE LUMBAR INFECTION.
**FINAL REPORT [**2135-6-26**]**
GRAM STAIN (Final [**2135-6-20**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
TISSUE (Final [**2135-6-26**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 72682**] ([**6-23**]).
STAPH AUREUS COAG +. RARE GROWTH.
Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- <=0.5 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 4 R
MEROPENEM------------- S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 64 S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- S
ANAEROBIC CULTURE (Final [**2135-6-24**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
61yo M estranged from medical care for >35yr who presents w/
extensive back wound, pentrating to spinous processes, and
smaller L back/axillary wound. Pt septic on admission.
.
# Sepsis: When the patient was initially admitted, he was
hypotensive with the obvious source being the large infected
back wound with associated chronic vertebral osteomyelitis and
possible epidural abscess. Additionally, blood cultures from
OSH grew pseudomonas, though blood cultures here were without
growth (except for cornybacterium, which is presumed
contamination). The patient was started on broad antibiotic
coverage with vancomycin and zosyn. He was aggressively fluid
resuscitated (>12L) and required pressors for approximately
24hrs. Thereafter, he was hemodynamically stable and afebrile.
Workup of his hypotension was unrevealing for adrenal
insufficiency or cardiogenic source (EF>80%). Likewise, TTE
showed no gross evidence of endocarditis. His wound swab
ultimately grew MSSA and pseudomonas. Antibiotics were changed
to naficillin/cipro/flagyl given sensitivities of cultures. Pt
was changed to high-dose Levaquin and Flagyl to complete 6 week
course. Stop date [**2135-8-18**].
.
# Back wounds: wound culture grew MSSA and pan-sensitive
pseudomonas. Patient was treated initially in the MICU with
vancomycin & zosyn, and ultimately tailored to nafcillin, cipro,
flagyl on the floor. Plastic surgery and neurosurgery took the
patient to the OR together on [**2135-6-20**] for initial debridement
and was thereafter followed by plastic surgery who took him back
to the OR on [**6-27**] for flap closure. He was kept on a wound vac.
It was taken down on [**2135-7-2**], and because the flap didn't take,
he needed to be taken back to the OR on [**7-6**] for a wound
wash-out and another vac dressing. Plastic surgery recommending
that patient is able to be d/c'ed with [**Hospital1 **] dressing changes and
outpatient follow-up, with plan to consider another skin graft
in the future.
.
# Osteomyelitis: because the wound had exposed vertebral
processes (by definition osteomyelitis), ID recommended several
weeks of IV antibiotics. Pt received IV naficillin until
discharge. Medication changed to high-dose Levaquin and Flagyl
on discharge to complete 6 week course on [**2135-8-18**]. Acute care as
outlined above.
.
# Question of malignancy: MRI revealed extensive vertebral body
changes throughout the thoracic spine that were suggestive of
malignancy/metastatic disease. The patient has no known prior
malignancy, although he did not have any medical care for over 3
decades. Pan-CT scan notable for multiple lung nodules as well
as left sided pleural effusion. This effusion was tapped by
Interventional Pulmonary, which showed predominant lymphocytosis
with cytology negative for evidence of malignancy. A specimen of
the spinous process was sent to pathology and under special
staining revealed likely non-small cell lung cancer, stage IV.
Hematology/oncology was consulted who felt that the prognosis
was likely poor with an estimated lifespan of 8 months; they
offered the patient palliative chemotherapy (which would not be
able to be initiated until the ulcers healed) and the patient
has initially refused but will arrange follow up in New
[**Location (un) **] if patient is amenable.
.
# ARF: On presentation, the patient had a slight bump in his
creatinine, thought to be prerenal azotemia versus contrast
nephropathy versus ATN secondary to either medication or
hypovolemic insult during sepsis and then again with second
hypotensive episode following incomplete fluid resuscitation in
the PACU following his second surgery. Urine electrolytes
indicated a FENa of 2.2, which indicates a more likely intrinsic
mechanism for renal failure, such as ATN. He was treated with
IVF and all medications were renally dosed. Subsequent to these
events, the patients renal funtion returned to [**Location 213**] and has
remained normal through discharge.
.
# FEN: tolerates a regular diet, although has refused most meals
since [**7-4**] since complaining that his pills (specifically
cipro/flagyl) were altering his sensation of taste. Cipro and
flagyl were switched to IV, but the patients po intake continues
to be poor so medications were restarted po. Pt. only accepted
cans of Ensure.
.
# Access: pt initially had R IJ, then PICC placed on [**2135-6-19**] for
long-term access.PICC DC'd prior to discharge.
.
# However, despite multiple attempts by PT to encourage exercise
and OOB activity, he has become deconditioned and at this point
will need PT services at home.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Bismuth Subsalicylate 262 mg/15 mL Suspension Sig: Fifteen
(15) ML PO TID (3 times a day).
3. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
27 days.
Disp:*27 Tablet(s)* Refills:*0*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 27 days.
Disp:*81 Tablet(s)* Refills:*0*
5. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health and Hospice
Discharge Diagnosis:
Primary:
1. Stage IV Non-small cell lung cancer.
2. Metastasis and osteomyelitis of thoracic spine.
3. Malignant back ulcer with superinfection - MSSA, Pseudomonas
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a large back ulcer that involved the
bones of your spine. You were initially taken to the ICU, as
bacteria had entered your bloodstream, and you were taken to the
operating room three times, first by neurosurgery and
subsequently, by plastic surgery, to clean and then close the
wound. You were maintained on intravenous antibiotics throughout
the admission.
.
Additionally, on imaging it was noted that you had evidence of
malignancy in the bones of your spine. A sample of bone was
taken for analysis during surgery, which came back as non-small
cell lung cancer metastasized to the bone. Hematology/Oncology
has offered palliative chemotherapy and will arrange follow up
for you in [**Location (un) 3844**] if you are amenable.
.
You have been accepted as a patient at the [**Location (un) **] Family
Practice. Please follow-up with your PCP after your discharge
from the hospital.
Followup Instructions:
It is recommended that you be followed by hematology/oncology,
infectious diseases and plastic surgery upon discharge. Your PCP
can arrange appointments with these specialty services for you.
|
[
"5849"
] |
Admission Date: [**2174-6-21**] Discharge Date: [**2174-6-29**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Failure to thrive, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 75001**] is an 87M with a history of CVAs, HTN, CKD and
hypothyroidism who was brought in by his daughter on [**6-21**] for
failure to thrive and difficulty taking care of him at home.
This is all occurring in the setting of a recent disruption in
home VNA and PT services. Since these services stopped, the
patient has been needing 24/7 help with all ADLs. On the
morning of admission the patient was found down presumably after
falling off of the couch. There was no loss of consciousness or
head trauma. His ROS is only notable for decreased PO intake at
home with minimal weight loss. He has not had any other
symptoms at home, she denies any fevers, cough, SOB, abdominal
pain, nausea, vomiting or diarrhea.
.
In the emergency department he had a fever to 102F rectally, and
elevated CK to 2100 with a troponin of 0.17. Otherwise his
vital signs were stable. An EKG was difficult to interperet in
the setting of a LBBB and a V-paced rhythm. CT head and C-spine
were negative. A UA was negative. He was given Vancomycin,
levofloxacin and IVF; and sent to the ICU.
.
In the ICU, a cardiology consult did not feel the patient had an
acute MI. An infectious work-up revealed blood cultures 4/4
bottles positive for GPC's in pairs, clusters, and chains. A CT
of the chest showed multiple bronchial, calcified and
noncalcified pulmonary nodules associated with bronchiectasis
and bronchial impaction concentrated in the upper lobes,
suggesting nonacute nontuberculous mycobacterial infection or
[**Doctor First Name **]. The patient was placed on vancomycin and on respiratory
isolation. The team was unable to obtain sputum for AFB smear.
He was transferred to the floor for further work up.
Past Medical History:
1. Recent temporal lobe CVA [**9-18**]
2. h/o right PICA stroke
3. h/o TIA in [**5-15**] (left weakness, slurred speech)
4. Hypertension
5. Hyperlipidemia (LDL 58, HDL 100 [**3-18**])
6. Hypothyroidism: h/o [**Doctor Last Name 933**], now hypothyroid
7. Chronic kindey disease (baseline mid 2s)
8. Anemia (baseline mid-high 30s): Normal iron studies in [**3-18**]
9. Diverticulosis and internal hemorrhoids
Social History:
Previously took care of his wife, who is severely demented. No
history of tobacco, alcohol or drug use.
Family History:
Non-contributory.
Physical Exam:
Tmax: 96.4 Tcurrent: 95 BP: 97-127/54-77... HR:65-89...
96-100% RA
UOP: 25-40cc/hr
GENERAL: This is a cachectic elderly caucasian male, responsive
to verbal stimuli, minimally responsive to sternal rub
CARDIAC: rrr no murmurs
LUNGS: decreased breath sounds diffusely, RR ~10
ABDOMEN: Scaphoid, NABS, NTTP, soft
HEENT: NC, erythmatous area over righ eyebrow with a small
scrape. No bleeding or oozing.
NEURO: limited, will respond to verbal stimuli but will not
follow commands such as "open your eyes", seems to be refusing
to respond, not unresponsive. Bilateral ankle clonus. Upgoing
toe on the right, down going on the left. able to squeeze
fingers bilaterally, weak, [**3-16**]. Unable to move upper or lower
extremities on command. Pupils are reactive bilaterally.
Pertinent Results:
CT CHEST
1. No acute pulmonary process. Multiple bronchial, calcified,
noncalcified pulmonary nodules associated with bronchiectasis
and bronchial impaction concentrated in the upper lobes suggest
nonacute nontuberculous mycobacterial infection or [**Doctor First Name **]. If
clinically indicated, a followup can be performed in one year.
2. Extensive coronary artery calcifications.
.
CT spine
1. No acute fractures or alignment abnormalities.
.
CT head
1. No acute intracranial process.
2. Left temporal lobe encephalomalacia, likely sequela of an old
infarct.
.
US abdomen
1. Trace amount of pericholecystic fluid with gallbladder
"sludge ball."
2. Large right and small left pleural effusions with trace
amount of free
fluid in the right lower quadrant.
3. 6-mm saccular outpouching from the posterior aspect of the
infrarenal
abdominal aorta which may represent a small saccular aneurysm;
in the setting of known enterococcal bacteremia, endovascular
infection with mycotic aneurysm cannot be excluded.
4. Left hydroureteronephrosis with increased echogenicity of
bilateral renal cortex, suggesting chronic "medical renal
disease" consistent with patient's renal insufficiency.
.
Echocardiogram
Probable small aortic valve vegetation. Mild aortic
regurgitation. Severe global left ventricular systolic
dysfunction. Compared with the prior study (images reviewed) of
[**2173-9-2**], aortic valve abnormality is new. Left ventricular
systolic function has significantly deteriorated.
Brief Hospital Course:
HOSPITAL COURSE BY PROBLEM
.
1. Bacteremia: The patient was found to have persistent
Enterococcal and staphylococcal bacteremia despite broad
spectrum coverage with vancomycin. Abdominal ultrasound was
obtained on [**6-23**] which showed a saccular aneurysm on the
infrarenal aorta, which is concerning for a mycotic aneurysm as
a possible source. Echocardiogram obtained on [**6-24**] showed a
vegetation on the aortic valve. The patient was not likely to
be a good candidate for vascular surgery, given his poor
prognosis and functional capacity. He continued to be
hypothermic and bacteremic on surveillance cultures despite
broad spectrum coverage. The desicion was made by the family to
make him CMO.
.
2. Altered mental status: Likely a result of high grade
bacteremia, we were unable to image with MRI or CT with contrast
as the patient has a pacer and CKD
.
3. Findings on CT chest: The patient was ruled out for pulmonary
TB with three negative AFB smears and taken off of precautions.
.
4. Aspiration risk: The patient was evaluated by speech and
swallow as we had high suspicion for aspiration risk. They
deemed him a high risk and the patient was NPO for several days.
An attempt at an NG tube was unsuccessful, as the patient
refused it and pulled it out. The family was presented with the
options of a percutaneous feeding tube, as TPN was not an option
in the setting of high grade bacteremia. They did not feel that
this was a good option given his prognosis and decided to make
him CMO
Medications on Admission:
ASA 81 mg daily
Levothyroxine 150 mcg daily
Zydis 5 mg [**Hospital1 **]
Acetaminophen 325 mg q4h prn
Simvastatin 20 mg daily
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1H
(every hour) as needed for pain.
4. Lorazepam 0.5 mg IV Q4H:PRN agitation
5. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
Enterococcal and staphylococcal bacteremia
Endocarditis
Aneurysm (possibly mycotic)
Failure to thrive
Discharge Condition:
Comfort measures only
Discharge Instructions:
You were admitted with fevers and confusion, and we found you to
have a very severe bloodstream infection. We held a family
meeting to discuss the likelihood of recovery, and the decision
was made to maximize your comfort only, and stop invasive
measures. You will transferred to a facility that focuses on
comfort measures.
Followup Instructions:
None
|
[
"40390",
"5859",
"2449",
"2724"
] |
Admission Date: [**2196-4-2**] Discharge Date: [**2196-4-4**]
Service: MEDICINE
Allergies:
Clozapine / Propranolol
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
sent from rehab for hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
86 y/o F w/severe dementia, recent femur fx [**1-31**], who earlier on
[**2196-4-1**] was reportedly witnessed aspirating jello. She was then
noted to be febrile to 103, tachycardic in the 120s. She was
begun on ceftriaxone and flagyl for presumed aspiration
pneumonia, and a PICC line was placed. She was hydrated with NS
at 125 cc/hr. Over the course of the day, she became more
hypotensive to 90/46 and then to 80/40 (after having been 156/60
earlier in the day). Her o2 saturation was 88% on 3L NC. Of
note, in a progress note from the day prior ([**2196-3-31**]), it states
she had been having diarrhea and loose stools which was
concerning to her caretakers at [**Hospital 100**] Rehab given their
[**Name (NI) **] outbreak.
.
In our ED, her vitals were 100.6, 84/42, 100, 28, and 88% on 6L
NC (improved to 98% on a NRB). She was begun on levophed, and
her pressure dropped as low as 69/31. She was given vancomycin
and zosyn. After discussion with her legal guardian, it was
decided she would not want any invasive lines but would want
pressors and antibiotics. She was admitted to the MICU.
Past Medical History:
PMHX:
Schizophrenia, tardive dyskinesia
HTN
DVT [**3-29**] in LLE
Iron def anemia
OA
Dysphagia, on pureed solids and nectar-thickened liquid diet
Hypothyroid
R eye blindness
CHF, unknown LVEF, hypoalbuminemia (2.2)
?PAF - in one note from rehab, though not listed in PMH
CVA
Osteoporosis
Obesity
Hyperlipidemia
COPD
h/o PPD(+), s/p 6mth course of tx
L ischium decub ulcer, Stage 2
Social History:
DNR/DNI with form from Heb Reheb; Legal Guardian [**Name (NI) **] [**Name (NI) 29768**]
[**Telephone/Fax (1) 29769**](h), [**Telephone/Fax (1) 29770**](c). Unknown etoh, tob, drug
history.
Family History:
NC
Physical Exam:
T: 99.6 BP: 80/40 P: 84 R: 20 O2 sat: 100% on NRB
Gen: yelling incoherently, does not respond to questions,
gurgling secretions
HEENT: MM very dry
Lungs: rhonchorous although difficult to hear over yelling
CV: RRR, II/VI SEM at RUSB
Abd: soft, nt/nd, +bs
Ext: left leg in immobilizer, left foot with 3+ edema, no edema
on right, 1+ dp pulses bilaterally
Skin: erythema over left ischium without open ulceration
Pertinent Results:
Chest X-ray on [**2196-4-2**]:
IMPRESSION:
1. Improved interstitial edema.
2. Bibasilar effusions, worse on the left. Adjacent left
basilar opacity may represent atelectasis or pneumonia.
[**2196-4-4**] 05:36AM BLOOD WBC-16.5* RBC-3.27* Hgb-9.1* Hct-29.4*
MCV-90 MCH-28.0 MCHC-31.2 RDW-17.6* Plt Ct-206
[**2196-4-3**] 06:10AM BLOOD WBC-21.7* RBC-3.39* Hgb-9.4* Hct-30.0*
MCV-89 MCH-27.6 MCHC-31.2 RDW-17.8* Plt Ct-196
[**2196-4-2**] 04:30AM BLOOD WBC-28.0*# RBC-3.78* Hgb-10.5* Hct-33.3*
MCV-88 MCH-27.8 MCHC-31.6 RDW-17.7* Plt Ct-227#
[**2196-4-2**] 04:30AM BLOOD Plt Ct-227#
[**2196-4-3**] 06:10AM BLOOD PT-18.8* PTT-36.8* INR(PT)-1.8*
[**2196-4-3**] 06:10AM BLOOD Plt Smr-NORMAL Plt Ct-196
[**2196-4-4**] 05:36AM BLOOD PT-18.9* PTT-32.8 INR(PT)-1.8*
[**2196-4-2**] 04:30AM BLOOD Glucose-70 UreaN-46* Creat-2.0*# Na-146*
K-5.5* Cl-111* HCO3-23 AnGap-18
[**2196-4-2**] 08:36AM BLOOD K-5.0
[**2196-4-2**] 09:59AM BLOOD K-5.0
[**2196-4-2**] 05:17PM BLOOD Glucose-111* UreaN-39* Creat-1.1 Na-148*
K-4.8 Cl-114* HCO3-24 AnGap-15
[**2196-4-3**] 06:10AM BLOOD Glucose-65* UreaN-37* Creat-0.9 Na-149*
K-4.2 Cl-116* HCO3-25 AnGap-12
[**2196-4-4**] 05:36AM BLOOD Glucose-59* UreaN-31* Creat-0.5 Na-152*
K-4.4 Cl-119* HCO3-26 AnGap-11
[**2196-4-2**] 08:36AM BLOOD Cortsol-22.2*
Brief Hospital Course:
86 year-old female with dementia and femur fracture who
presented with hypotension, fever, tachycardia, likely urosepsis
vs aspiration pneumonia.
.
# Septic shock: Urine appears grossly infected although UA not
remarkable. Obviously given witnessed aspiration, pneumonia is
also a likely contributor. GNR bactaremia per [**Hospital 100**] rehab [**4-27**]
bottles. Has had vomiting and diarrhea, most likely [**Location (un) 27292**]
given where she came from, but could also have C. Diff. [**Month (only) 116**]
potentially become hypovolemic, became more confused, then
aspirated. Another source of infection is her decubitis ulcer
although it appears intact. Currently appears severely volume
depleted by exam, labs, and poor urine output. Responded to IV
fluid hydration and was successfully weaned off of pressors.
Initially started on meropenem for broad-spectrum antibiotic
coverage but narrowed to ciprofloxacin prior to discharge, to
complete a 2 week course on [**2196-4-15**]. [**Month (only) 116**] need to adjust
antibiotics based on further sensitivities.
.
# Acute renal failure: Creatinine was 2.0 on admission. Most
likely pre-renal azotemia from volume depletion as creatinine
normalied with IV fluids. Urine negative for eosinophils.
.
# Hypoxia: Was hypoxic to 88% on 6L NC. Most likely due to
aspiration pneumonia/pneumonitis given hx. Currently saturating
well on a face tent. Wean O2 as tolerated.
.
# Elevated troponin: Unclear the significance of this. No ECG
changes, ck/mb are flat, and has an elevated creatinine. Likely
combination of renal failure and demand ishcemia in the setting
of sepsis, no need for heparin.
.
# Status-post femur fracture: continue knee immobilizer. On
tylenol for pain and PRN morphine.
.
# Schizophrenia/dementia: Hold po meds for now as patient unable
to take po's. Will continue home meds if appropriate with MS at
future date.
.
# COPD: cont albuterol/atrovent nebs
.
# Hx DVT: It appears patient had DVT in [**2195-3-25**], so it has
been 12 months since the DVT. We have held warfarin for this
reason, but can be decided whether patient needs to continue for
prophylaxis at Rehab, given history of femur fracture.
.
# Hypothyroidism: Can resume synthroid once patient is
tolerating POs.
.
# FEN: Aggressive IVF resuscitation. Hypernatremia likely
related to volume depletion and lack of access to free water.
Continue IVF of LR. Currently strict NPO given aspiration, but
can resume PO if tolerating later.
.
# Ppx: PPI, sub-cutaneous heparin while warfarin is being held.
Can discontinue heparin SC and restart warfarin if appropriate,
as above.
.
# Communication: Legal Guardian [**Name (NI) **] [**Name (NI) 29768**] [**Telephone/Fax (1) 29769**](h),
[**Telephone/Fax (1) 29770**](c).
.
# Code: DNR/DNI, no invasive procedures, no NG tubes, no
arterial lines. Discuss utility of future inpatient
hospitalizations with guardian.
Medications on Admission:
Tylenol q6h
Duoneb prn
Norvasc 10 mg daily
Abilify 20 mg daily
Divalproex 250 mg qam, 375 mg qpm
Ferrous sulfate 325 mg daily
Lasix
Lisinopril 20 mg hs
Levothyroxine 100 micrograms daily
Losartan 50 mg qam
Roxanol
Sorbitol
Coumadin
Zeasorb
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP < 100.
5. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO qam.
6. Divalproex 125 mg Capsule, Sprinkle Sig: Three (3) Capsule,
Sprinkle PO qpm.
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day. Tablet(s)
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO at bedtime:
Hold for SBP < 100.
9. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP < 100.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP < 100.
12. Roxanol Concentrate 20 mg/mL Solution Sig: As per outpatient
regimen. PO As directed.
13. Zeasorb 0.1 % Powder Topical
14. Sorbitol Miscellaneous
15. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN Sig:
As directed as directed: 10 ml NS followed by 2 ml of 100
Units/ml heparin (200 units heparin) each lumen Daily and PRN.
Inspect site every shift. .
16. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1) dose
Intravenous Q12H (every 12 hours) for 14 days: to complete
course on [**2196-4-15**].
17. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis:
Sepsis
Femur fracture
Secondary diagnoses
1. Schizophrenia, tardive dyskinesia
2. Hypertension
3. Deep venous thrombosis
4. Iron deficiency anemia
5. Osteoarthritis
6. Dysphagia, on pureed solids and nectar-thickened liquid diet
7. Hypothyroidism
8. R eye blindness
9. Congestive heart failure, unknown LVEF
10. CVA
[**00**]. Osteoporosis
12. Obesity
13. Hyperlipidemia
14. Chronic obstructive pulmonary disease
15. h/o PPD(+), s/p 6mth course of tx
16. L ischium decub ulcer, Stage 2
Discharge Condition:
Blood pressure stable, off of pressors, afebrile.
Discharge Instructions:
You were admitted for hypotension, hypoxia. You were treated
for sepsis with antiobiotics. Please complete the 14 day course
of antibiotics as listed below.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**1-26**] weeks.
Completed by:[**2196-4-4**]
|
[
"0389",
"78552",
"496",
"5849",
"42731",
"4280",
"5070",
"99592",
"2449",
"4019",
"2724"
] |
Admission Date: [**2190-9-10**] Discharge Date: [**2190-9-10**]
Date of Birth: [**2124-2-1**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines / Zinc
Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 year-old F with Castelman's syndrome, recurrent aspiration
PNA, HTN who presents s/p fall. She fell yesterday while trying
to get up from bed and was put back to bed by her Home Health
Aid; today she fell again and her aid 'dragged' her to bed and
called EMS. Some head and L hip trauma (no LOC).
.
In the ED she received MSO4 2 mg IV for pain. Her C-spine was
cleared. Head CT and hip films were negative. Fall was thought
to be mechanical and social work was consulted re question of
elder abuse/neglect. At midnight pt spiked to 102 rectal,
received tylenol. CXR and UA negative. She was admitted for
observation and placement.
.
Of note, pt was recently discharged from [**Hospital1 **] on [**2190-8-27**] for
Pseudomonas PNA.
.
ROS: Pt is poor historian. She c/o L hip pain. She [**Date Range **] fever/
chills/ sweats. Denied headache, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness. Denied nausea, vomiting, diarrhea, or constipation.
No dysuria or rash.
Past Medical History:
Past Medical History:
1. Castleman's disease (unicentric) s/p splenectomy in [**2176**].
Lymph node bx revealed reactive lymph tissue; followed in
Heme/Onc by Dr. [**Last Name (STitle) 410**]
2. H/O anaplastic thyroid cancer s/p radical neck dissection;
age 15
3. Esophageal webs and esophageal dysmotility s/p multiple
dilatations
4. Recurrent aspiration pneumonias s/p PEG (sputum with
klebsiella sensitive to Meropenem, MRSA, strep pneumo, [**Last Name (STitle) **])
5. Chronic Respiratory Disease; bronchiectasis, [**Last Name (STitle) 1570**]'s revealed
Restrictive physiology, ?interstitial lung disease. On 2L home
O2 at baseline
6. MRSA osteomyelitis of olecranan s/p multiple debridements
7. Bipolar d/o
8. GERD
9. ?Seizure d/o (may be in setting of hypoglycemia)
10. Hx Grave's disease
11. Osteoporosis: has broken both hips, left in [**11-7**], right
with failed ORIF and redo at [**Hospital1 2025**]; s/p short gamma nail fixation
of a left hip basicervical fracture [**9-7**]
12. h/o zoster
13. HTN
Social History:
Social History:
Used to work as a social worker at the VA. Was at [**Hospital1 **] until
[**6-9**] when she was discharged to home. Home health aide 24
hrs/day. No tobacco or EtOH.
Family History:
NC
Physical Exam:
Vitals: T: 98.9 ax P: 80 BP: 128/72 RR: 18 SaO2: 100% 2L NC
General: very thin, chronically-ill appearing female, lying in
bed with hyperextended neck, awake, in NAD.
HEENT: NC/AT, PERRL + L cataract, EOMI. MMM, OP without lesions.
Neck: able to rotate and flex neck.
Pulm: diffuse fine crackles, no rhonchi or wheezes
Cardiac: RRR, nl S1/S2, 2/6 SEM
Abdomen: soft, NT/ND, + BS. PEG in place, site c/d/i.
Ext: No edema b/t, L hip without ecchymosis
Skin: multiple areas of bruises in various stages of healing
Pertinent Results:
[**2190-9-10**] 01:20AM WBC-21.6 Hct-29.1 MCV-90 RDW-16.3 Plt Ct-211
.
[**2190-9-9**] 06:45PM PT-12.8 PTT-26.2 INR(PT)-1.1
.
[**2190-9-10**] 05:05AM Glucose-102 UreaN-34 Creat-1.7* Na-138 K-4.7
Cl-104 HCO3-27 AnGap-12
[**2190-9-9**] 06:45PM CK-MB-4 cTropnT-0.02* proBNP-225
.
[**2190-9-10**] 01:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2190-9-10**] 01:20AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
Brief Hospital Course:
66 yo F with Castleman's syndrome, recurrent aspiration PNA, HTN
who presents s/p fall with concern for elderly neglect, and
fever.
.
* s/p fall: mechanical in nature. Neg head CT, hip films,
C-spine imaging. No infection on CXR or UA. EKG unremarkable.
She ruled out for MI with two sets of negative troponins. She
was continued on her home pain regimen. She denied abuse by her
caretaker.
.
* Fever: leukocytosis with left shift. no localizing si/sx. CXR
and UA negative for infection. nl lactate. given recent Abx for
PNA, there is concern for CDiff. In looking back, her white
count is normal and likely secondary to her lymphoproliferative
disorder. She was not given antibiotics.
.
* Recurrent aspiration PNA: Had speech and swallow eval on last
admission recommending no POs, but she continues to eat. No
clinical evidence of PNA.
.
* Restrictive Lung Dz: unclear etiology. on 2L home O2.
Continued on O2 by NC. Continued ipratropium and albuterol nebs.
.
* Hypothyrodism: post thyroid Ca tx. Continued home
levothyroxine.
.
* ARF: Cr of 1.7 on admission, up from baseline of 1.3. likely
prerenal. s/p 1L IVF in ED. came back to baseline.
.
* HTN: cont metoprolol
.
Medications on Admission:
1. Acetaminophen 650 mg Suppository Rectal Q4-6H as needed.
2. Cholecalciferol 800 unit PO DAILY (Daily).
3. Levothyroxine 100 mcg PO DAILY
4. Ipratropium Bromide 0.02 % Inhalation Q6H (every 6 hours).
5. Albuterol Sulfate 0.083 % Inhalation Q6H as needed.
6. Gabapentin 400 mg PO HS
7. Ferrous Sulfate 325 (65) mg Tablet PO DAILY (Daily).
8. Lamotrigine 100 mg Tablet PO DAILY
9. Lansoprazole 30 mg Susp,One PO DAILY (Daily).
10. Metoclopramide 10 mg Tablet PO QIDACHS
11. Quetiapine 200 mg PO HS as needed.
12. Sodium Polystyrene Sulfonate 15 g/60mL Suspension PO DAILY
13. Prochlorperazine 5 mg PO Q6H as needed.
15. Oxycodone 10 mg PO Q4-6H as needed.
16. Venlafaxine XR 150 QD
17. Lorazepam 2 mg PO QID
18. Alendronate 70 mg PO QSAT
19. Metoprolol Tartrate 12.5mg PO BID
21. Polyvinyl Alcohol 1.4 % Drops 1-2 Drops Ophthalmic PRN
22. Fentanyl 50 mcg/hr Patch 72HR
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day/Year **]: One (1)
Tablet PO BID (2 times a day).
3. Levothyroxine 100 mcg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2)
Puff Inhalation QID (4 times a day).
5. Albuterol Sulfate 0.083 % Solution [**Month/Day/Year **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Day/Year **]: One (1) PO DAILY
(Daily).
7. Lamotrigine 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon [**Month/Day/Year **]: One
(1) PO DAILY (Daily).
9. Metoclopramide 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
10. Quetiapine 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
11. Sodium Polystyrene Sulfonate 15 g/60mL Suspension [**Month/Day/Year **]: One
(1) PO DAILY (Daily).
12. Prochlorperazine 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
13. Oxycodone 5 mg/5 mL Solution [**Month/Day/Year **]: Two (2) PO Q4-6H (every 4
to 6 hours) as needed.
14. Venlafaxine 75 mg Capsule, Sust. Release 24HR [**Month/Day/Year **]: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
15. Lorazepam 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QID (4 times a
day).
16. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO BID (2
times a day).
17. Polyvinyl Alcohol 1.4 % Drops [**Month/Day/Year **]: 1-2 Drops Ophthalmic PRN
(as needed).
18. Fentanyl 50 mcg/hr Patch 72HR [**Month/Day/Year **]: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
19. Alendronate 70 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a week:
Saturday.
20. Gabapentin 400 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO at
bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
s/p fall x 2
Castleman's syndrome s/p splenectomy [**2176**]. followed by Dr
[**Last Name (STitle) 410**].
recurrent aspiration PNA - s/p PEG (sputum with pseudomonas,
klebsiella sensitive to Meropenem, MRSA, strep pneumo, [**Last Name (STitle) **])
anaplastic thyroid Ca s/p radical neck dissection - 50 yrs ago
bipolar disorder
OA
HTN
esophageal webs and esophageal dysmotility s/p multiple
dilatations
chronic Respiratory Disease; bronchiectasis, [**Last Name (STitle) 1570**]'s revealed
Restrictive physiology, ?interstitial lung disease. On 2L home
O2 at baseline
h/o MRSA osteomyelitis of olecranan s/p multiple debridements
?Seizure d/o (may be in setting of hypoglycemia)
H/o Grave's disease
Osteoporosis: has broken both hips, left in [**11-7**], right with
failed ORIF and redo at [**Hospital1 2025**]; s/p short gamma nail fixation of a
left hip basicervical fracture [**9-7**]
h/o zoster
Discharge Condition:
fair
Discharge Instructions:
Continue your home medications. You need to seriously consider
rehab since you are likely to fall at home again soon.
Followup Instructions:
Please schedule an appointment in the next 2 weeks: PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2936**].
|
[
"5070",
"51881",
"5849",
"5990",
"5859",
"4280",
"4019",
"311"
] |
Admission Date: [**2151-12-13**] Discharge Date: [**2151-12-20**]
Date of Birth: [**2104-4-9**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
increasing DOE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 47 yo female with h/o HTN, osteoporosis, sleep
apnea and severe COPD with FEV1 of 13 % who orginally presented
on [**12-13**] with 2-3 weeks of increasing dyspnea that has limited
her ability to the point she had difficulty ambulating even a
few steps and had increased her home 02 from 2-4L in this [**3-19**]
week period. The day prior to admission she had some rhinorrhea
and cold sx. She was admitted to the ICU due to increased work
of breathing. She was briefly on CPAP, but was quickly weaned to
NC and was stable. Previous symptoms suggestive of URI and
possible COPD exacerbation. Ruled out for flu by nasal aspirate.
Given stressed dosed steroids and started on Levofloxacin to
complete a 7 day course. Pt ruled out for PE with CTA and MI by
cardiac enzymes. For remainder of her ICU stay she was on 5 L of
NC as per her new baseline. in addition, she has chronic
tachycardia and was started on diltiazem.
.
On transfer from the ICU, she reports that her breathing seems
to be at baseline. She was able to get up and walk about 50 feet
with PT. Denies CP, worsened SOB, palpitations, headache, N/V.
She has her chronic back pain. She does report some abdmiinal
fullness and crampimg which has improved today after a BM with
bowel regimen
.
ROS: Positive as above and also for occasional feeling of
lightheadedness on standing, occasional sharp substernal chest
pain (isolated episodes, 2-3 times in the last several weeks)
now resolved. Otherwise she has no symptoms of vomiting,
headache, dysuria, abdominal pain, cough, change in sputum
(always yellow), passing out.
.
In the ED: patient's intial vitals were HR 140, BP 110/80, RR
30, 02 sat 100% RA. She received Xoponex, Combivent neb x 1,
Ativan, Methylprednisolone, 1 L NS, magnesium. Additionally
blood cultures were sent. Patient had increasing work to breathe
and then required CPAP.
.
On admission to the ICU, the patient required CPAP, but was able
to answer questions appropriately and did not have any acute
symptoms of pain or dyspnea. She was quickly weaned to nasal
canula and felt that her breathing had improved.
Past Medical History:
1. COPD, PFTs in [**9-19**] with FEV1 0.30 (13%), FVC 1.02 (34%) and
FVC/FEV1 38% - on Home O2 at 3L NC, on chronic steroids, hx of
prolonged intubation requiring trach for resp failure in [**1-15**],
[**3-21**]. She was recently taken off the lung transplant list at the
[**Hospital6 1708**] due to compression fractures. Has
previous history of asthma per OMR
2. Hypertension
3. Anxiety
4. Leukocytosis of unknown etiology with negative BMBx.
5. Osteoporosis with compression fractures
6. Shoulder pain
7. History of positive PPD s/p 6mos of isoniazid
8. Mitral valve prolapse
9. Obstructive sleep apnea on BiPAP (15/12 every night)
Social History:
Single, quit smoking one year ago. Prior to that, she used to
smoke less than a pack a day since the age of 16. She has no
alcohol consumption, and lives with her mother and has one
child.
Family History:
Great uncle had MI in 50s, Maternal & Paternal GMs had CVAs in
50s.
Physical Exam:
Vitals: T 96.5 HR 124 BP107/58 P104 R17 O2 100% CPAP
Gen: Well-appearing woman in NAD.
HEENT: NC/AT. MMM no erythema/exudate. JVP not seen. Neck supple
w/o LAD.
Pulm: Faint crackles B bases.
CV: Distant heart sounds.
Abd: Soft, tender to palpation diffusely especially on RUQ, no
rebound or guarding. Bowel sounds are hypoactive. No
organomegaly
Ext: 2+ dorsalis pedis/radial pulses; no edema, clubbing, or
cyanosis.
Neuro: AAOx3. CNII-XII grossly intact. 5/5 strength throughout
Pertinent Results:
[**2151-12-13**] 01:00PM BLOOD WBC-18.3* RBC-3.88* Hgb-11.3* Hct-33.3*
MCV-86 MCH-29.1 MCHC-33.9 RDW-14.1 Plt Ct-485*
[**2151-12-13**] 01:00PM BLOOD Neuts-94.1* Bands-0 Lymphs-4.1*
Monos-1.6* Eos-0.2 Baso-0.1
[**2151-12-13**] 01:00PM BLOOD Glucose-160* UreaN-15 Creat-0.8 Na-137
K-4.5 Cl-92* HCO3-38* AnGap-12
[**2151-12-13**] 01:00PM BLOOD ALT-22 AST-28 LD(LDH)-228 AlkPhos-127*
Amylase-50 TotBili-0.1
[**2151-12-13**] 01:00PM BLOOD Lipase-16
[**2151-12-13**] 05:41PM BLOOD CK-MB-8 cTropnT-0.04*
[**2151-12-13**] 01:00PM BLOOD Calcium-9.6 Phos-3.2# Mg-2.0
[**2151-12-13**] 05:41PM BLOOD TSH-0.23*
[**2151-12-14**] 04:10AM BLOOD Free T4-1.0
[**2151-12-20**] 09:10AM BLOOD WBC-19.0* RBC-3.62* Hgb-10.1* Hct-31.7*
MCV-87 MCH-27.9 MCHC-32.0 RDW-14.5 Plt Ct-374
[**2151-12-17**] 04:25AM BLOOD PT-12.5 PTT-27.0 INR(PT)-1.1
[**2151-12-20**] 09:10AM BLOOD Glucose-109* UreaN-12 Creat-0.8 Na-136
K-3.8 Cl-89* HCO3-41* AnGap-10
[**2151-12-20**] 09:10AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.8
.
CTA CHEST W&W/O C &RECONS [**2151-12-13**] 11:55 PM
INDICATION: 37-year-old woman with COPD and increasing dyspnea
on exertion in the setting of chest pain. Evaluate for pulmonary
embolism.
CTA OF THE CHEST: No filling defects or pulmonary emboli are
identified within the pulmonary arteries to the level of the
segmental branches. Scattered aortic calcifications are seen,
however the aorta is within normal caliber and contour
throughout its course.
CT OF THE CHEST WITH IV CONTRAST: Soft tissue window images
demonstrate no pathologically-enlarged mediastinal, hilar, or
axillary lymphadenopathy. The heart and pericardium are normal
in appearance. No pleural or pericardial effusions are seen.
Lung window images demonstrate no pulmonary nodules or
parenchymal consolidation. Scattered emphysematous changes are
seen diffusely throughout the lungs.
Limited images of the superior portion of the abdomen
demonstrate a cyst with calcification within the superior pole
of the left kidney. The visualized parts of the liver, spleen,
right kidney, adrenal glands, and pancreas are within normal
limits.
BONE WINDOWS: Compression deformities are seen within several
mid thoracic vertebral bodies, of indeterminate age.
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential
in delineating the anatomy and pathology.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Extensive emphysematous changes are seen bilaterally.
3. Hypodensity within the superior pole of the left kidney with
wall calcification likely represents a complex cyst.
4. Multiple compression farctures of the thoracic vertebrae.
.
CHEST (PORTABLE AP) [**2151-12-13**] 12:46 PM
INDICATION: Shortness of breath.
FINDINGS: Allowing for apical lordotic projection,
cardiomediastinal contours are within normal limits. There are
no focal areas of consolidation within the lungs, and no pleural
effusions are identified on this single projection. Attenuation
of the upper lobe vasculature is suggestive of underlying
emphysema.
IMPRESSION: Emphysema. No pneumonia.
Brief Hospital Course:
A/P: 47 yo with COPD admitted with increasing respiratory
disress now stable at baseline and transferred to floor.
.
# Respiratory distress- As the patient has severe disease and
has a history of intubation and severe decompensation, the
patient was felt to require MICU care but rapidly improved. The
cause for her decompensation is likely a viral infection given
her recent fatigue and shortness of breath coupled with her
occasional rhinorrhea. Already r/o flu and r/o MI. (Of note,
bronchial washing in OMR were logged incorrectly and are not
from this patient) Will continue to treat for COPD
- prednisone 40mg; plan [**Month/Day/Year 15123**] back to prednisone 20mg over the
next 3 days
- completed 7 days Levofloxacin for COPD exacerbation
- Ipratroprium, atrovent q6h prn
- continue home pulm meds: montelukast, advair 500-50,
tiotropium 18mcg daily
- viral cultures negative
- RISS while on steroids
.
# Tachycardia: Patient with chronic history of sinus
tachycardia. Cause unclear. Fluid resuscitated. TFTs checked.
- Continue dilt
.
# Osteoporosis: Patient with history of persistent fractures as
a result of persistent steroid administration.
- Continue Forteo as per outpatient regimen
- Con't Vitamin D and calcium
.
# Hypertension- Currently normotensive, will continue on home
regimen
.
# Leukocytosis- Infectious causes ruled out and afebrile. Likely
[**3-18**] steroids
- Con't to monitor
.
# Abdominal discomfort: Likely [**3-18**] constipation as improved with
bowel movement and LFT unremarkable.
- continue bowel regimen
.
# Anxiety: Continue outpatient medications.
.
# Sleep apnea: continued nightly CPAP.
.
# Pain control: Likely due to chronic fractures. Will continue
oxycodone SR and IR for pain control as per outpatient regimen.
.
# FEN- [**Doctor First Name **] diet, has elevated HCO3 due to chronic CO2 retention
at baseline, monitor lytes.
Medications on Admission:
1. Prednisone 20 mg (finished [**Doctor First Name 15123**] 2 weeks ago)
2. Furosemide 80 mg PO DAILY
3. Advair Diskus 500-50 mcg/Dose Disk with Device 1 Inh [**Hospital1 **]
4. Montelukast 10 mg PO QHS
5. Verapamil 80 mg PO Q8H
6. Nexium 40 mg PO BID
7. Tiotropium Bromide 18 mcg Capsule Inh DAILY
8. Quetiapine 25 mg PO BID
9. Mirtazapine 15 mg PO once a day
10. Gabapentin 600 mg PO HS
11. Oxybutynin Chloride 5 mg PO BID
12. Citracal Plus 2 tabs qam, 1 tab qhs
13. Cholecalciferol (Vitamin D3) [**Numeric Identifier 1871**] unit PO 2x weekly
14. Dulcolax QHS PRN
15. Clonazepam 1 mg PO QHS
16. Clonazepam 0.5 mg PO QAM
17. Sertraline 50 mg PO DAILY
18. Potassium 20 mEq PO BID
19. MVI PO Daily
20. Lisinopril 5 mg po daily
21. Senna QHS PRN
22. Potassium 20 mEq QD
23. Baclofen 10 mg TID
24. Oxycodone SR 10 mg [**Hospital1 **]
25. Forteo QD
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
Two (2) pufss Inhalation twice a day.
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 7 days: two tabs (=40mg) daily on [**12-21**] and [**12-22**], then 20mg
daily ([**Month/Day (4) 15123**] back to home dose).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
9. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for
constipation.
11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
14. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 2X/WEEK (MO,FR).
15. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
16. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
17. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Insulin Lispro (Human) 100 unit/mL Solution Sig: Two (2)
units Subcutaneous ASDIR (AS DIRECTED): 2 units for FSBG
151-200, 4 units for FSBG 201-250, 6 units for FSBG 251-300, 8
units for FSBG 301-350, 10 units for FSBG 351-400.
19. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
20. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
21. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
22. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
24. Teriparatide 750 mcg/3 mL Pen Injector Sig: Three (3) ML
Subcutaneous daily () as needed for osteoporosis.
25. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
26. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
27. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every 4-6 hours as needed for dyspnea.
28. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: [**2-15**] puff
Inhalation every 4-6 hours as needed for dyspnea.
29. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day: 1 packet = 20 mEq.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
1. COPD, PFTs in [**9-19**] with FEV1 0.30 (13%), FVC 1.02 (34%) and
FVC/FEV1 38% - on Home O2 at 4L NC, on chronic steroids, hx of
prolonged intubation requiring trach for resp failure in [**1-15**],
[**3-21**]. She was recently taken off the lung transplant list at the
[**Hospital6 1708**] due to compression fractures. Has
previous history of asthma per OMR
2. Hypertension
3. Anxiety
4. Leukocytosis of unknown etiology with negative BMBx.
5. Osteoporosis with compression fractures
6. Shoulder pain
7. History of positive PPD s/p 6mos of isoniazid
8. Mitral valve prolapse
9. Obstructive sleep apnea on BiPAP (15/12 every night)
Discharge Condition:
Stable. Requires 4 liters oxygen by nasal cannula.
Discharge Instructions:
Call your doctor for increasing shortness of breath or
increasing oxygen needs or anything that is medically concerning
to you.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-12-23**] 2:25
Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-12-23**] 2:45
Call Dr [**Last Name (STitle) **] for an appointment within the next month.
[**Telephone/Fax (1) 250**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
|
[
"4019",
"4240",
"32723",
"4168",
"42789"
] |
Admission Date: [**2133-8-20**] Discharge Date: [**2133-8-25**]
Service: MEDICINE
Allergies:
Flagyl / Proton Pump Inhibitors (Benzimidazole)
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 85 year old male with history of diastolic heart
failure, copmlete heart block (now s/p PPM [**6-7**]) ESRD on HDHD,
h/o MRSA bacteremia and thrombocytopenia, likely secondary to
drug reaction (PPI?) who presents from [**Hospital 100**] rehab with
dyspnea. Patient reports SOB x 1 day. He denies any chest
pain, palpitations, N/V, abdominal pain, diarrhea, fevers,
chills or recent cough. Patient states he was walking with
PT/OT and became SOB and dizzy. Per ED report patient felt
better after HD yesterday, but continued with SOB today along
with AMS. ABG done at [**Hospital 100**] Rehab which showed increased CO2
and decreased PaO2 from baseline so he was transferred to [**Hospital1 18**]
for further care.
In the ED: Temp 97, HR 71, BP 122/53, RR 15 88% on RA 99%
on NRB and then on CPAP. CXR done which showed worsening
bilateral pleural effusions. He was given CTX 1gm x 1, Levaquin
500mg IV x 1, Vanco 1gm IV x 1 and was transferred to MICU.
On arrival, patient stated he was feeling well. +mild SOB.
CPAP was removed and patient was with 98% O2 saturation on 2LNC.
ABG: 7.21 // 77 // 149 // 32
Past Medical History:
Diastolic Congestive Heart Failure: ECHO [**3-7**] EF of 50% &
severe LVH
Atrial fibrillation previously on Coumadin (until GI bleed
[**6-7**]), failed cardioversion
s/p Pacemaker placement [**6-7**] for complete heart block
Peripheral vascular disease s/p right lower extremity bypass
Hiatal hernia with intrathoracic stomach (confirmed by [**2133-6-16**]
CT)
Hypertension
Gout
?Prostate followed by Urology (denies symptoms of BPH)
Chronic Kidney Disease on HD
Social History:
Patient has an insurance business and worked daily until recent
sicknesses. No current tobacco use. There is no history of
alcohol abuse.
Occupation: Owns Insurance business
Drugs: None
Tobacco: None
Alcohol: None
Other:
Family History:
There is no family history of premature coronary artery disease
or sudden death. Patient's daughter had "kidney disease" and is
now s/p renal transplant. 2 sons and 1 daughter.
Physical Exam:
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 70 (70 - 76) bpm
BP: 107/53(64) {82/16(37) - 112/93(97)} mmHg
RR: 27 (14 - 27) insp/min
SpO2: 100%
Heart rhythm: AV Paced
Height: 65 Inch
General Appearance: Well nourished, No acute distress,
Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t)
Conjunctiva pale, No(t) Sclera edema
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,
No(t) Endotracheal tube, No(t) NG tube
Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical
adenopathy
Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal,
No(t) Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t)
Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Percussion: No(t) Resonant : , No(t) Hyperresonant: ), (Breath
Sounds: No(t) Clear : , Crackles : midway up posterior lung
fields, No(t) Bronchial: , No(t) Wheezes : , Diminished:
bilateral bases)
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender: , No(t) Obese
Extremities: Right: 2+, Left: 2+, to ankles bilaterally
Musculoskeletal: No(t) Muscle wasting
Skin: Not assessed, Rash:
Neurologic: Follows simple commands, Responds to: Not assessed,
Oriented (to): person, place, time, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
[**2133-8-20**] 01:21PM PT-14.5* PTT-31.3 INR(PT)-1.3*
[**2133-8-20**] 01:21PM PLT SMR-VERY LOW PLT COUNT-61*
[**2133-8-20**] 01:21PM NEUTS-68 BANDS-0 LYMPHS-13* MONOS-9 EOS-10*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2133-8-20**] 01:21PM WBC-6.9 RBC-3.30*# HGB-10.8* HCT-36.9*#
MCV-112* MCH-32.7* MCHC-29.2* RDW-17.3*
[**2133-8-20**] 01:21PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.4
[**2133-8-20**] 01:21PM CK(CPK)-28*
[**2133-8-20**] 01:21PM GLUCOSE-106* UREA N-20 CREAT-3.8*# SODIUM-140
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-31 ANION GAP-14
[**2133-8-20**] 01:30PM cTropnT-0.23*
[**2133-8-20**] 01:31PM LACTATE-0.9
[**2133-8-20**] 01:31PM TYPE-ART PO2-149* PCO2-77* PH-7.21* TOTAL
CO2-32* BASE XS-0 INTUBATED-NOT INTUBA
[**2133-8-20**] 03:59PM TYPE-ART PO2-95 PCO2-58* PH-7.30* TOTAL
CO2-30 BASE XS-0
Brief Hospital Course:
Pt is an 85 year old male with history of diastolic heart
failure, copmlete heart block (s/p PPM [**6-7**]) ESRD on HDHD, h/o
MRSA bacteremia and thrombocytopenia, likely secondary to drug
reaction (PPI?) who presented from [**Hospital 100**] rehab with dyspnea.
Initially admitted to MICU with dyspnea and ? CO2 retention
requiring BiPAP. Pt was called out to the floor and did well for
several days. He was then noted to be hypoxic at dialysis. he
also underwent therapeutic thoracentesis on right side with good
relief. The following morning, he was found to be somnolent
with myoclonic jerking. ABG demonstrated 7.24/70/89 on 3 L/min.
He was transferred back to the MICU for ? bipap. He was noted
to be continually hypercarbic throughout his admission.
Pt's BPs continued to drop and he became unable to tolerate HD.
On the day prior to death, dialysis had to be stopped
prematurely (removed 2.2L) due to hypoxia and hypotension. The
morning of his death, he was noted to be acutely hypoxic and
hypercarbic. CXR revealed a collapsed left lung and increase in
right sided pleural effusion. Discussed situation with family
and it was decided to not escalate care (had been decided upon
to make him DNR/DNI the night before). Over the course of the
day, he became increasinly hypoxic, hypercarbic, acidotic, and
hypotensive. He was pronounced deat at 17:25 on [**2133-8-25**].
Family was present and declined autopsy.
.
#. Dyspnea: Patient presented from rehab with acute dyspnea
and SOB with walking the day of admission likley from increasing
pleural effusions. Patient had been afebrile, without
leukocytosis, bandemia or cough making PNA very unlikely. Given
that CTX/Levaquin/Vanco started in the ED were D/Ced. Nephrology
was notified that the patient was admitted and Pt was sent to HD
for ultrafiltration on the day of transfer off of the MICU. CEs
were negative.
#. End Stage Renal Disease: Patient on MWF HD treatments. Pt
continued HD as an in patient with removal of excess fluid.
#. C Diff colitis: Patient with (+) C diff tox x 3 during
admission in [**Month (only) 205**]. On Vanco at [**Hospital 100**] rehab until [**2133-8-24**].
Vanco 250mg PO QID was continued as an in patient.
#. Diastolic heart failure: Last ECHO [**2133-7-17**] with EF >55% and
mild mitral regurgitation. HD was done as above.
#. Atrial Fibrillation: Patient is currently V-paced. We
continued outpatient amiodarone. Anticoagulation was held given
recent history of GI bleed.
#. Thrombocytopenia: Thought to be [**1-31**] to drug reaction one
month ago (PPI), currently at 61, down from 113 at last
admisstion. This suggests the possibility of MDS. Follow up with
a hematologist may be indicate in the future as an outpatient,
but since the remainder of his counts are WNL no H/O consult was
called.
Medications on Admission:
Amiodarone 200mg daily
Calcium Gluconate 650mg TID
Midodrine 5mg TID
Simethicone 80mg [**Hospital1 **]
Vanco 250mg PO QID
Vit B/Vit C/Folic Acid
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2133-8-25**]
|
[
"40391",
"5180",
"51881",
"2762",
"4280",
"42731",
"4240"
] |
Admission Date: [**2195-9-14**] Discharge Date: [**2195-9-14**]
Date of Birth: [**2121-1-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
consulted for SDH found on CT at OSH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 year old male on coumadin for ICD was not feeling well
around 8 pm last night and he went to sleep at that time. This
morning at 5:30 am his wife noticed that he had not moved
positions since he went to bed and one of his legs was hanging
over the side of the bed. She was unable to arouse him and he
went to an OSH. He was intubated and had a head CT which
revealed
a large right SDH with midline shift. The patient was given
cerebryx and 50 mg of mannitol and sent to [**Hospital1 18**]. When
neurosurgery was called the patient the ER had ordered another
50
mg of mannitol to be given as well as vitamin K and Profiline
Past Medical History:
Has ICD - on coumadin
adenocarcinoma of the prostate - s/p brachytherapy
Social History:
lives with wife, has a daughter, son, and
daughter-in-law who are here in the ER with him
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM upon admission:
T:99.8 BP:109/56 HR:74 RR:16 O2Sats:100% vented
Gen: intubated and sedated
HEENT: Pupils:5mm, unreactive bilaterally EOMs-unable
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Unresponsive.
Cranial Nerves:
I: Not tested
II: Pupils 5 mm, unreactive bilaterally.
III-XII: unable to test
Motor: Upper extremities extending to pain. Lower extremities
withdrawing to pain.
Toes upgoing bilaterally
Pertinent Results:
CT Head from OSH [**2195-9-14**]:
The patient had a very large right SDH with midline shift and
herniation. Formal read is unavailable at this time.
Brief Hospital Course:
The patient was admitted to the ICU after the decision was made
to keep him comfortable since he had a devasting hemorrhage with
herniation. He was extubated several hours later after the
family had a chance to see him and spend some time with him. The
patient expired about 1 [**1-23**] after extubation.
Medications on Admission:
Vytorin 10-80 mg PO QHS
HCTZ 25 mg PO daily
Lopressor 200 mg PO BID
KCL 20 mEq PO daily
Diovan 320 mg PO daily
Coumadin dose changes
Tylenol 80-160 mg PO PRN pain
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right SDH with mass effect and herniation
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2195-9-14**]
|
[
"4019"
] |
Admission Date: [**2162-1-25**] Discharge Date: [**2162-1-30**]
Service: GENERAL SURGERY
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname 2470**] is a 78-year-old
female who is status post open cholecystectomy for acalculous
cholecystitis on [**2162-1-2**]. She was admitted for that
procedure for 5 days and was doing well
postoperatively and in follow up.
She came to the Emergency Room at [**Hospital6 2018**] on [**2162-1-24**] for complaints of nausea, vomiting,
and fever for two days. There was mild abdominal pain. There
were no sick contacts. She also complains of anorexia for one day
duration, fever to 100.9 at home. There was no jaundice. No
chest pain. No diarrhea. No constipation. No dysuria or
pyuria. She had also complained of some slight cough.
PAST MEDICAL HISTORY:
1. History of hypertension
2. Perforated Diverticulitis
3. History of palpitations
4. History of hysterectomy
5. History of appendectomy
6. History of colon resection/Diverting Colostomy
7> Colostomy Takedown
HOME MEDICATIONS:
1. Lipitor 10 mg per day.
2. Zestril 10 mg q.d.
3. Klonopin 0.5 b.i.d.
4. Metoprolol 25 b.i.d.
ALLERGIES: The patient is allergic to penicillin.
SOCIAL HISTORY: The patient denied a history of alcohol or
tobacco use.
PHYSICAL EXAMINATION ON ADMISSION: The patient was an
elderly female in no acute distress. Her temperature was
101.1, heart rate 126, blood pressure 151/65, breathing at 18
times per minute on room air, 02 saturation at 100%. Her
extraocular movements were intact. The pupils were equal and
reactive to light. There was no JVD. The chest was clear to
auscultation bilaterally. The heart revealed a regular rate
and rhythm. Normal heart sounds with no murmurs. The
abdominal examination showed a soft nondistended abdomen with
surgical scars healing, no drainage, no erythema, moderately
tender in midgastric regions. The extremities had no edema.
LABORATORY DATA ON ADMISSION: White blood cell count 15.6,
hematocrit 31.2%, platelets 436,000. Sodium 135, potassium
1.9, chloride 97, bicarbonate 22, BUN 29, and creatinine 0.8.
The blood sugar level was 144. ALT 352, AST 177, alkaline
phosphatase 1,991, total bilirubin 2.0, amylase 8, lipase 8.
A urinalysis was negative.
The patient was admitted and an ultrasound showed a [**4-20**] x 5
cm fluid collection in the gallbladder fossa likely to be a
hematoma, biloma or abscess. A CT scan performed confirmed this
collection and it had enhancing features consistent with an
abscess.
The chest x-ray was negative.
HOSPITAL COURSE: The patient was admitted to the hospital
for a subhepatic abscess in the gallbladder fossa and she needed
underwent ultrasound guided percutaneous drainage and antibiotic
treatment on [**2162-1-25**]. She was transferred to the
Surgical Intensive Care Unit after the drainage for management of
fluid status and hypotension. She was hydrated in the SICU with
close monitoring. She received 1 unit of packed red blood cells.
She subsequently recovered very well. She was treated
prophylactically with vancomycin, gentamicin, and clindamycin
until her microbiology results came back which showed a pan
sensitive Klebsiella pneumoniae
She was subsequently treated with Ciprofloxacin 500 mg b.i.d.
Initially, her drain put out a approximately 500cc of bile and
purulent drainage which subsequently diminished over the course
the next 2-3 days [**2162-1-29**]. The drain stopped putting
out fluid and an MRCP was also obtained to evaluate for an
undrained fluid collections or common bile duct stones or sludge.
There was no final report yet as of the time of her discharge. A
brief review of the film showed no obvious fluid collection and
there does not appear to be any common bile duct obstruction
as well.
The patient did very well on pain control with oral pain meds and
she is discharged to home with VNA Service for drain
management. She will resume her outpatient medications in
addition to Percocet for pain control, Colace, and
ciprofloxacin 500 mg b.i.d. She will follow-up with Dr. [**First Name (STitle) 2819**]
in approximately ten days.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSIS:
1. Right upper quadrant abscess, status post ultrasound guided
drainage and pigtail catheter placement
2. Hypovolemia and sepsis requring 48 hour ICU stay
3. Anemia requiring blood transfusion
DISCHARGE STATUS: To home with VNA services for drain care
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**]
Dictated By:[**Name8 (MD) 6276**]
MEDQUIST36
D: [**2162-1-30**] 11:09
T: [**2162-1-30**] 11:20
JOB#: [**Job Number 100621**]
|
[
"0389",
"2859",
"4019"
] |
Admission Date: [**2144-9-26**] Discharge Date: [**2144-10-3**]
Date of Birth: [**2066-9-8**] Sex: M
Service: MEDICINE
Allergies:
Triaminic
Attending:[**Doctor First Name 1402**]
Chief Complaint:
transfer from [**Hospital3 3583**] with temporary pacing wire for
complete heart block in order to get pacemaker and possible
implanted defibrillator
Major Surgical or Invasive Procedure:
Insertion of Cardiac Pacemaker
History of Present Illness:
This is a 78 y/o male with HTN, Hypercholesterolemia, S/P AVR
(St. [**Male First Name (un) 923**], [**2132**], on coumadin) who was transferred from [**Hospital1 **](after presenting with dizziness) for AV conduction
defect, likely complete heart block. At [**Hospital3 3583**] he was
found to have heart rate in the 30's with markedly long PR
intervals witha baseline left bundle branch block. He was
asymptomatic and hymodynamically stable. He had a noraml CXR,
was ruled out for MI by cardiac enzymes. He had a temporary
pacing wire placed in Right IJ with rate 60, MA of 10 and
Sensitivity of 0.5.
.
He denies CP, SOB, N/V, diaphoresis with these episodes. He has
had stable anginal pain in past but has not had it during these
episodes. He has two pillow orthopnea. He denies PND. He reports
nocturia.
He has not started any new medications or chnged an y of his
medications. He has been on atenolol and stable for some time.
.
ROS: no history of lung disease, no cough, has GERD symptomes,
no abdominal pain, no nausea, no vomiting, no constipation, no
diarrhea, no bleeding (melena, hematochezia), no h/o liver
disease, has history of joint pain/arthritis, no claudication.
Past Medical History:
HTN
AVR ([**2130**], St. [**Male First Name (un) 923**] Mechanical Valve on COumadin at home)
Left Bundle Branch Block
Prostate Ca treated with Radiation and Turp
Social History:
Lives with wife in [**Name (NI) 3320**]. No children. Former Surveyor.
Smoked for 40 years 1.5 ppd. No alcohol use. No drug use.
Family History:
Father lived to [**Age over 90 **] years old of diabetes complications. Mother
lived to [**Age over 90 **] years old. Died of CVA.
Physical Exam:
VITALS: T 97.8 HR 60 BP 189/56 RR 20 Sat 96 Pain 0/10
GENERAL: well developed, older male in NAD. Pleasant, very
talkative.
GAIT: not assessed for risk of fall.
SKIN: chronic venous stasis changes of lower legs
HEAD: NC/AT
EARS: Normal external structure
EYES: EOMI, Anicteric, PERRL
NOSE: Non deviated septum
THROAT: tongue midline, upper dentures
NECK: No stiffness, No masses, No LAD, Palpable carotid pulses,
soft left bruits, no tracheal deviation
CHEST: no supraclavicular or axillary LAD, Lungs Clear to
Asculation, No Wheezes/Rhonchi/Crackles
HEART: RRR, No Murmurs/Gallops/Rubs
ABDOMEN: Mildly Obese, No scars, NABS, mildly Distended, Soft,
No organomegaly, No masses, No guarding, No rebound
EXT: No clubbing/cyanosis/edema. 2+ Pulses right DP, Decreased
pulse in left DP.
NEURO:
MS oriented to person, place, time
CN II-XII intact
Muscle Strength RUE [**5-28**] LUE [**5-28**] LLE [**5-28**] RLE [**5-28**]
Coord intact FTN nl HTS nl
Pertinent Results:
Labs From [**Hospital 63139**] Hospital [**2144-9-26**]
141 108 23 136 AGap 10
5.0 23 1.4
Ca: 9.2 Mg: 1.9 P: 3.9
.
.....13.3..92
7.6>-----< 180
.....39.4
.
PT: 23.5 PTT: 35.9 INR: 2.22
CPK 130->102->78
cTropI <0.038 x 2
.
Labs on Admission at [**Hospital1 18**] [**2144-9-26**]
5:49p
142 110 22 105 AGap 10
4.6 22 1.2
Ca: 9.5 Mg: 1.9 P: 3.7
.
....13.4..91
10.3>---< 160
....38.0
.
PT: 18.4 PTT: 30.7 INR: 2.3
.
EKG: V Paced at 60 bpm. Left bundle branch block.
.
Echo [**2144-9-27**]:
Conclusions:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with septal, anterior and
apical hypokinesis. The inferior wall also appears mildly
hypokinetic. The lateral wall moves best. No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
and free wall motion are normal. A mechanical aortic valve
prosthesis is present. The prosthetic aortic valve leaflets are
thickened. The transaortic gradient is normal for this
prosthesis. A paravalvular aortic valve leak is probably
present. Mild (1+) aortic regurgitation is seen. No valvular
vegetations seen but cannot exclude opn the basis of this study.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is no pericardial effusion.
IMPRESSION: Moderate to severe regional LV systolic dysfunction
c/w CAD.
Mechanical aortic prosthesis with normal gradients but mild
paravalvular
regurgitation.
.
Echo [**2144-9-29**]:
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. The interatrial septum is aneurysmal, but no atrial
septal defect is seen by 2D or color Doppler. There are complex
(>4mm, non-mobile) atheroma in the descending thoracic aorta and
simple atheroma in the ascending aorta. A bileaflet aortic valve
prosthesis is present. The aortic prosthesis leaflets appear to
move normally. No masses or vegetations are seen on the aortic
valve. No aortic valve abscess is seen. Mild (1+) aortic
regurgitation is seen. [The amount of regurgitation present is
normal for this prosthetic aortic valve.] The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
IMPESSION: Well seated, normal functioning aortic bileaflet
prosthesis.
Interatrial septal aneurysm. No vegetations or abscess
identified.
Brief Hospital Course:
78 y/o male with HTN, Hypercholesterolemia, S/P AVR (St. [**Male First Name (un) 923**]
Mechanical Valve, [**2132**], on coumadin) presented with
dizziness/lightheadedness to [**Hospital3 3583**] and found to have
complete heart block. Had temporary pacing wire placed and then
transferred for pacememker and possible defibrilator.
1. Complete heart block: He was admitted with temporary pacing
wire and had pacemaker placed. His heart rhythm was continusly
monitored by telemetry. His atenolol was held on admission and
restarted after the pacer was placed. He was started on a
heparin drip as his coumadin was being held for procedure and
heparin and coumadin werelater restarted. He was followed by Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 63140**] of EP. He was transfered from CCU
to step down floor after pacer implanted.
.
2. CAD: EF of 38% from nuclear study in [**8-28**]. He was not cathed
at [**Hospital1 18**]. He has a history of anginal symptomes and is followed
by Dr. [**Last Name (STitle) 47696**] at [**Hospital3 3583**]. We started him on aspirin
during his stay. Up titrated his isordil and increased his dose
of BB at time of discharged.
.
3. AVR: S/P AVR with mechanical St. Jude valve in [**2132**]. He was
on coumadin at home. We held his coumadin for the procedure and
start heparin drip for anticoagulation. He was discharged with
therapeutic range INR on coumadin.
.
4. HTN: His blood pressure was elevated at times during his
hospital stay. We added Lisinopril and HCTZ and increased his
dose of isordil and BB.
.
5. Hypercholesterolemia: We continued him on his home dose of
atorvaststin.
.
6. GERD: We gave him protonix for his GERD history.
.
7. Left lower extremity pain: Pt notes increased left "calf"
pain when he walks. Palpable L PT and warm, so not at risk for
limb-threatening ischemia. Would benefit from formal ABI's as
outpt and treatment based on these studies.
Medications on Admission:
HOME MEDS:
Lipitor 5mg QD
Isordil 20 mg TID
Lisinopril 2.5 mg TID
Coumadin 3 mg QD
Terazosin 3 caps QD
Atenolol 12.5 mg QD
Omeprazole 40mg QD
.
TRANSFER MEDS:
Lipitor 5mg QD
Pantoprazole 40 QD
Reglan PRN
Anzimet PRN
Atropine PRN
.
ALLERGIES:
Triaminic (unable to void when he took it)
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Complete Heart Block
Secondary: Stable chronic angina
Discharge Condition:
Good, without dizziness.
Discharge Instructions:
Please call your cardiologist, Dr. [**Last Name (STitle) 5310**], FIRST THING on
Monday. You need to be seen by him on Monday for 3 reasons:
1) Interrogation of pacemaker
2) Inspection of pacemaker pouch
3) Labs as follows: HCT, INR, Creatinine.
IF Dr. [**Last Name (STitle) 5310**] can't see you on Monday, or cannot
interrogate the pacemaker, Please follow up at the [**Hospital1 18**] Device
Clinic on Monday [**2144-10-5**] at the [**Hospital Ward Name 23**] center at [**Hospital1 18**] at 2PM
so that the Cardiologists can check on your pacemaker.
PLEASE have Dr. [**Last Name (STitle) 5310**] contact [**Hospital1 18**] with the results of
his examinations on Monday. He can call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
([**Telephone/Fax (1) 63141**]. Or email [**University/College 63142**]
Please follow up with the coumadin clininc in [**Location (un) 3320**] to have
your blood checked frequently while on coumadin.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2144-10-5**] 2:00
|
[
"4240",
"53081",
"2720",
"4019",
"41401",
"V5861"
] |
Admission Date: [**2169-7-7**] Discharge Date: [**2169-7-19**]
Date of Birth: [**2111-10-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Tetracycline / Sulfa (Sulfonamides) / Morphine /
Codeine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Severe diffuse tracheobronchomalacia.
Major Surgical or Invasive Procedure:
[**2169-7-7**]: Right thoracotomy and tracheoplasty with mesh, right
main stem bronchus/bronchus intermedius bronchoplasty with mesh,
left main stem bronchus bronchoplasty with mesh, bronchoscopy
with bronchoalveolar lavage.
[**2169-7-10**]: Flexible Bronchoscopy
[**2169-7-16**]: Trach changed to 6.0 Portex Trach cuff deflated
History of Present Illness:
Mrs. [**Known lastname 42611**] is a 57 y/o, female with severe TBM with previous
silicone-Y-stent and tracheostomny tube that resulted in
symptomatic improvement but the patient was hesitant to undergo
a TBP at that time. She developed another episode of respiratory
failure with septic shock 2 months ago in the setting of
pneumonia which required another silicone-Y-stent and
tracheostomy tube and then later on, had the silicone-Y-stent
removed secondary to granulation tissue. The patient was
discharged to [**Hospital1 **] Rehab where she was weaned off
mechanical ventilation and has been tolerating continuous red
capping for the last few weeks. She has been participating in
physical therapy and reports being "active" while she denies any
dyspnea, chest pain, neck pain, cough, hemoptysis, wheezing,
feve, chills, night sweats. She has been tolerating oral feeding
and denies any dysphagia. She is being admitted following her
trachealplasty.
Past Medical History:
# tracheobronchial malacia: s/p stent placement in [**2167-11-14**] then
removal in [**2168-11-13**] due to persistent secretions
# obesity
# GERD
# avascular necrosis of the L hip s/p L hip replacement in [**2161**]
# alcohol abuse
# RUE DVT in [**2167-10-14**]
# COPD
# granulomas in L lung
# s/p TAH
# s/p appendectomy
Social History:
Ms. [**Known lastname 42611**] had been a regional manager at insurance company.
She lived with boyfriend > 10 years. She had not been in contact
with her brother in ~1 year, however, brother has visited her
frequently while in the hospital and he is from [**State **] area and
lives at a distance. Patient has history of significant
alcoholism. Former smoker
Family History:
Noncontributory
Physical Exam:
VS: T 96.5 HR: 93 SR BP: 110/70 Sats: 93% TM 50%
General: 57 year-old sitting in chair in no apparent distress
HEENT: mucus membranes moist
Neck: trach in place. Site clean
Card: RRR
Resp; decreased breath sounds with scattered crackles
GI: benign. PEG in place
Extr: warm no edema
Incision: Right thoracotomy site clean, margins well
approximated
Neuro: awake, alert, responds appropriately
Pertinent Results:
[**2169-7-18**] WBC-6.4 RBC-3.17* Hgb-8.3* Hct-26.5 Plt Ct-303
[**2169-7-16**] WBC-8.2 RBC-3.11* Hgb-8.1* Hct-26.3 Plt Ct-238
[**2169-7-18**] Glucose-111* UreaN-19 Creat-0.7 Na-146* K-4.2 Cl-105
HCO3-35
[**2169-7-16**] Glucose-105* UreaN-18 Creat-0.8 Na-145 K-4.0 Cl-105
HCO3-33
[**2169-7-12**] Glucose-135* UreaN-11 Creat-1.1 Na-145 K-4.0 Cl-105
HCO3-34
[**2169-7-7**] Glucose-200* UreaN-19 Creat-0.8 Na-143 K-3.8 Cl-108
HCO3-27
Cultures: [**2169-7-8**] SPUTUM Endotracheal.
GRAM STAIN (Final [**2169-7-8**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2169-7-10**]):
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
CXR:
[**2169-7-18**] FINDINGS: The tracheostomy tip is 4 cm above the
carina. The heart size is at the upper limits of normal. The
mediastinal contours appear mildly widened but unchanged from
prior study. The lung volumes are low. Bibasilar opacities may
represent atelectasis, although underlying infectious process
cannot be ruled out. Blunting of the costophrenic angles
bilaterally is consistent with small pleural effusions. A coiled
tube projecting over the epigastrium is most consistent with a
percutaneous feeding tube. The osseous structures demonstrate
mild scoliosis.
[**2169-7-17**]: continued low lung volumes with some elevation of the
right hemidiaphragmatic contour. Although
bibasilar opacifications persist, there appears to be some
increased aeration on the left. This most likely represents some
effusion and atelectasis, though superimposed pneumonia must be
considered if there are appropriate clinical symptoms.
[**2169-7-13**]: : In comparison with the study of [**7-13**], there are
continued low lung volumes in a patient with tracheostomy tube.
Bibasilar opacification is consistent with atelectasis and
effusions. In the appropriate clinical
setting, the possibility of supervening pneumonia could not be
excluded.
[**2169-7-7**]: Right basal chest tube is in place. There is no
evident pneumothorax. There are low lung volumes. Bibasilar
opacities are likely atelectases, right greater than left. There
is mild right subcutaneous emphysema. Tracheostomy tube is in
standard position. Cardiac silhouette is obscured by lung
abnormality. Catheter projects over the upper abdomen.
Brief Hospital Course:
Ms. [**Known lastname 42611**] was admitted to the Thoracic surgery service at [**Hospital1 18**]
on [**2169-7-7**] after she was taken to the operating room on [**2169-7-7**]
for tracheoplasty by Dr. [**Last Name (STitle) **]. Please see operative
report for full details. She remained ventilated with Trach mask
trials until [**2169-7-17**] when she tolerated Trach mask x 24 hours
with oxygen saturations stable at 93-95% on 50% humidified
oxygen.
Neuro: Awake alert with episodes of anxiety which responded to
Seroquel.
Pulmonary: The patient required aggressive pulmonary toilet,
mucolytic nebs, chest PT and ambulation. She continued to do
well on Trach collar. Her Trach was downsized to a 6.0 Portex
w/o inner cannula, cuff (deflated) from #7 [**Last Name (un) 295**]. She
tolerated this well. Oxygen saturations with 50% humidified air
were 93-95%.
CV: The patient was maintained on TID diltiazem in SR 80-90.
Hemodynamic stable with blood pressures 110-140.
GI: Her bowel function returned with bowel regime in place.
Nutrition: She was seen by nutrition who recommended Replete
with fiber to a Goal of 70 mL/hr. Strict NPO. Sit upright when
receiving tube feeds.
Speech: She was seen by Speech for PMV evaluation initially but
was unable to tolerate [**2-14**] edema. Repeat swallow evaluation on
[**2169-7-18**] her oxygen saturations decreased. Vocal quality is
strained likely [**2-14**] irritation and swelling, but she can wear it
for trials throughout the day. Her vocal quality is improved
with
cues to "have an easy onset" to speech.She was taken for a
video-swallow on [**2169-7-19**] which showed aspiration. She should
remain NPO including all medications. Initiate swallow therapy
to improve oral and pharyngeal strength.
Renal: renal function within normal range with good urine
output. Electrolytes were replete as needed.
ID: Bronchoscopy x 2 for mucus plug with BAL GNR consistent with
normal flora. She completed a 7 Day course of Levofloxacin.
Heme: HCT stable at baseline 26.0-30. Anticoagulation was not
restarted since she completed her treatment for Right cephalic
thrombus.
Endocrine: blood sugars were 88-140's requiring occasional
insulin sliding scale coverage immediately postoperatively.
Pain: Epidural Bupivacaine and Dilaudid was managed by the Acute
pain service, once removed she was converted to PO pain
medications via PEG, and Lidocaine patch placed on either side
of the right thoracotomy site.
Disposition: She was followed by physical therapy. She continue
to make steady progress but continued need for aggressive
physical and speech therapy is required.
She was discharged to [**Hospital1 700**] in [**Location (un) 701**]
[**2169-7-19**].
Medications on Admission:
Polyethylene Glycol
Senna
Docusate Sodium
Folic Acid
Sucralfate 1 g. PO QID
Tiotropium Bromide one inhalation daily
Diltiazem HCL 360 mg PO daily
Artificial Tears
Miconazole
Acetaminophen
Albuterol Sulfate nebulized solution Q6Hrs. PRN
Ipratropium Bromide nebulized solution Q6Hrs. PRN
Magnesium Hydroxide
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for SOB.
3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Diltiazem HCl 60 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day): give via PEG.
5. Quetiapine 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day): give via PEG.
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): cut in
[**1-14**] on either side of right thorocotomy incision.
7. Acetylcysteine 20 % (200 mg/mL) Solution [**Street Address(2) **]: Three (3) ML
Miscellaneous Q12H (every 12 hours) as needed for thick
secretions: mix with albuterol to prevent bronchospasm.
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Street Address(2) **]: [**5-22**] mL
PO every 4-6 hours as needed for pain: via PEG.
9. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
10. Acetaminophen 325 mg/10.15 mL Suspension [**Last Name (STitle) **]: Ten (10) mL PO
every six (6) hours as needed for pain.
11. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO twice
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
-Tracheobronchomalacia s/p tracheoplasty
-Atrial fibrillation- new [**3-/2169**] controlled with diltiazem
-TBM
-avascular necrosis of the L hip s/p L hip replacement in [**2161**]
-alcohol abuse
-R Cephalic DVT in [**2167-10-14**]
-COPD
-granulomas in L lung
-s/p TAH
-s/p appendectomy
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:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Trach concerns.
-Incision develops drainage
-You may shower. No tub bathing or swimming
-Strict NPO
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3020**] Date/Time:[**2169-8-8**]
9:30 in the [**Hospital Ward Name 121**] Building Chest Disease Center [**Hospital1 **] I
Chest X-Ray [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology 30
minutes prior your appointment
Completed by:[**2169-7-24**]
|
[
"5180",
"42731",
"496"
] |
Admission Date: [**2135-12-26**] Discharge Date: [**2135-12-31**]
Date of Birth: [**2071-11-22**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
female with approximately a 6-month history of progressive
leg weakness and burning sensation below the waist, as well
as tingling sensation in her feet and fingers. The patient
is status post multiple laminectomies and presents with
approximately a 15-month long history of progressive leg
weakness and burning sensation and tingling in her feet and
fingers.
PAST MEDICAL HISTORY: She has a past medical history of
hypertension, dyspnea on exertion secondary to obesity,
depression, hypothyroidism, lower extremity edema, a 70-pound
weight loss with diet and fluid loss. The patient has had a
normal MIBI scan in [**2133**] with left ventricular ejection
fraction of 66%.
ALLERGIES: She has an allergy to DEMEROL.
PHYSICAL EXAMINATION ON PRESENTATION: On examination her
blood pressure was 115/50, heart rate 66. On physical
examination head, ears, nose, eyes and throat revealed
normocephalic and atraumatic. Thyroid was enlarged,
fluctuant limited neck motion. Her chest was clear to
auscultation bilaterally. Cardiovascular revealed first
heart sound and second heart sound. No murmurs, rubs or
gallops. The abdomen was soft and nontender, positive bowel
sounds. Extremities were warm. No edema. Positive
peripheral pulses.
HOSPITAL COURSE: The patient was admitted status post a
transthoracic T7-T8 discectomy under general anesthesia which
was tolerated well. Two chest tubes were in place and placed
on low-wall suction. The patient was transferred intubated
and ventilated to the Surgical Intensive Care Unit where she
remained intubated overnight.
She was extubated on postoperative day one after remaining
stable that day. The patient had no radiographic evidence of
pneumothorax. The patient was transferred to the floor.
Chest tubes were put to water seal on postoperative day two.
Chest x-rays continued to show no evidence of pneumothorax.
her chest tube were removed on [**2135-12-29**]. The patient
continued to do well, and her pain was well controlled with
morphine and Dilaudid orally.
DISCHARGE DISPOSITION: Her postoperative course was
uneventful, and the patient was transferred to rehabilitation
in stable condition on [**2135-12-31**].
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) 1327**] on [**1-10**] for staple removal.
MEDICATIONS ON DISCHARGE:
1. MS Contin 15 mg p.o. q.4-6h. p.r.n.
2. Dilaudid 2 mg to 6 mg p.o. q.4-6h. p.r.n.
3. Tylenol 650 mg p.o. q.6h. p.r.n.
4. Ativan 1 mg p.o. q.h.s. p.r.n.
5. Zoloft 50 mg p.o. q.h.s.
6. Lasix 50 mg p.o. in the morning and 40 mg p.o. in the
evening.
7. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. q.d.
8. Levoxyl 1.75 mg p.o. q.d.
CONDITION AT DISCHARGE: The patient was in stable condition
at the time of discharge.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2136-1-2**] 11:47
T: [**2136-1-4**] 09:38
JOB#: [**Job Number 104361**]
|
[
"2449",
"4019"
] |
Admission Date: [**2138-5-5**] Discharge Date: [**2138-5-15**]
Date of Birth: [**2070-2-18**] Sex: M
Service: VSU
CHIEF COMPLAINT: Left ankle-foot nonhealing ulceration.
HISTORY OF PRESENT ILLNESS: This patient was hospitalized
from [**2138-4-9**] to [**2138-4-11**], for his nonhealing
ulceration. He underwent a diagnostic lower extremity
angiogram. Patient was determined to be a surgical candidate.
He now returns for elective revascularization.
PAST MEDICAL HISTORY: Type 2 diabetes with triopathy, end-
stage renal disease, hemodialysis Monday, Wednesday, Friday,
history of coronary artery disease with cardiomyopathy,
history of systolic congestive heart failure, pulmonary edema
compensated, status post coronary artery bypasses x2 with
vein complicated by respiratory failure requiring a
tracheostomy, history of pneumonia, history of catheter
sepsis, MRSA; history of atrial fibrillation, history of
bilateral DVTs with pulmonary embolus anticoagulated, history
of depression, history of hypertension, history of GERD,
history of gastroparesis, history of morbid obesity.
SOCIAL HISTORY: Patient lives at rehab. He does not smoke or
drink.
PHYSICAL EXAM: Patient was in no acute distress, oriented
x3. He had an irregularly, irregular rhythm without murmur,
gallop, or rub. Lungs were clear to auscultation bilaterally.
Abdominal exam was unremarkable except for obese,
protuberant, soft, nontender belly. The left ankle had a 2.5-
cm nonhealing ulceration with purulence. There was dry eschar
with an erythematous rim. The pulse exam showed palpable DP
and PTs bilaterally.
MEDICATIONS ON ADMISSION: Bupropion 100 mg daily, donepezil
5 mg at bedtime, lactulose 10 grams in 15 cc, 30 cc Tuesdays,
Sundays, and Thursdays, Reglan 5 mg b.i.d., calcium acetate
tablets, atorvastatin 20 mg at bedtime, Nephrocaps daily,
mirtazapine 45 mg at bedtime, niacin 500 mg at bedtime,
levothyroxine 50 mcg daily, Prozac 20 mg daily, fluconazole
110 mcg inhaler puffs 2 b.i.d., sublingual nitroglycerin 0.04
p.r.n.
HOSPITAL COURSE: Patient was admitted to the vascular
service. Vancomycin, ciprofloxacin, and Flagyl were
instituted. The patient was prepared for surgery and prior to
surgery, underwent dialysis. Patient proceeded to surgery on
[**2138-5-6**]. He had a redo left mid SFA to BK-[**Doctor Last Name **] bypass with
nonreverse saphenous vein left, angioscopy and valve lysis.
Urology was consulted intraoperatively to place a Foley. The
patient underwent a cystoscopy which showed slight narrowing
at the bulbar urethra. Patient was dilated, and a Foley
catheter was placed. This remained in for 7 days
postoperatively.
Patient was transferred to the PACU in stable condition.
Postoperative day 1, there were no acute events.
Postoperative day 2, patient's T. max was 101. Blood cultures
were obtained which were no growth. The patient remained in
the VICU. On physical exam, he had a left Dopplerable DP and
PT. Potassium was 7.2. Patient went to dialysis.
Wound care service was requested to see the patient for a
type stage I pressure ulceration on the sacrum.
Recommendations were turn frequently. Keep heels off of bed
surface at all times and apply protective ointment to the
area after cleaning the area carefully.
Postoperative day 3, patient's T. max was 98.0. His potassium
improved postdialysis. He was sent to the regular nursing
floor for continued care. Patient had very poor venous
access, and a PICC was recommended. It was determined at this
time that his antibiotics will be converted to oral agents,
and the vancomycin would be dosed at dialysis.
Postoperative day 5, patient continued to progress. He
remained afebrile and ambulation to chair was begun.
Postoperative day 6, the patient was afebrile. He complained
of mild dyspnea with desaturation which responded to face
mask. The chest x-ray demonstrated near white of the left
chest. The CT was considered. CT scan was done which showed
collapse of the left lung. Patient was transferred to the
ICU, where he underwent a bronchoscopy. Was intubated and
ventilator support overnight.
Postoperative day 7, patient remained in the unit, intubated,
and bronchoscopy was repeated with improvement in left lung
aeration. At this point, they felt the patient, from
pulmonary standpoint, had improved enough to be extubated and
transferred back to the regular nursing floor. Patient did
require transfusion for a hematocrit of 23.7.
Pulmonary was consulted on postoperative day 9 for continued
left lower lobe changes, concerns for pneumonia and
appropriate treatment. Their recommendations were to continue
aggressive pulmonary PT. Discontinue the Mucomyst as this can
increase secretion thickness. Discontinue the Tylenol since
it may be hiding a fever. Recommend fluid removal at dialysis
if blood pressure will tolerate. Will avoid sedating
medications. Begin albuterol nebulizers q.4 hours standing
and q.2 hours p.r.n. with Atrovent nebulizers q.6 hours. Felt
he did not need to be rebronched at this time to consider
starting CPAP for possible OSA at night. Continue his
antibiotics, vancomycin and levofloxacin. Add cefepime for
concerns for hospital-acquired pneumonia. Maintain
saturations greater than 91%. Keep patient on right side as
much as possible for postural drainage. Continue to monitor
pulmonary status by daily x-rays.
Sputum culture was obtained which showed no microorganisms on
Gram stain and it was finalized of rare growth of
oropharyngeal flora. This cefepime was discontinued. The
patient will be continued on vancomycin and levofloxacin for
total of 7 more days. The vancomycin will be given at
hemodialysis when the level is less than 15. Vancomycin will
be orally. Patient was made n.p.o. for potential rebronch on
[**2138-5-15**]. Patient will return to his nursing home once
patient is medically stable.
DISCHARGE INSTRUCTIONS: Patient may ambulate essential
distances. Please elevate the leg when patient is sitting in
a chair. Please call us if he develops a fever greater than
101.5 or the leg wounds become erythematous, drain, or he has
groin swelling. The patient may shower, but no tub baths.
Please continue all medications as ordered. Random levels on
a daily basis to determine when to dose at dialysis of
vancomycin. Sacral decubitus care should be continued with
adequate cleansing and protective ointment to the skin.
DISCHARGE MEDICATIONS: Miconazole powder to effected area
p.r.n., senna tablets 8.6 mg tablets 1 b.i.d., fluconazole
110 mcg actuation aerosol +2 b.i.d., paroxetine 20 mg daily,
niacin 500 mg daily, levothyroxine 50 mcg daily, mirtazapine
15 mg tablets 3 at bedtime, calcium acetate 667 mg capsules 1
t.i.d. with meals, donepezil 5 mg at bedtime, B complex,
vitamin C, folic acid, capsule 1 mg daily, lactulose 30 cc
daily, atorvastatin 20 mg daily, Reglan 5 mg a.c. and at
bedtime, bupropion 100 mg sustained release q.a.m.,
amiodarone 200 mg daily, lansoprazole 30 mg daily, Colace 50
mg in 5 cc b.i.d., metoprolol 25 mg b.i.d., albuterol sulfate
0.083% solution inhalation q.2 hours, ipratropium bromide
0.02% solution inhalation q.6 hours, levofloxacin 500 mg q.48
hours for a total of 7 days, acetaminophen 325 mg tablets [**1-7**]
q.4-6 hours p.r.n., vancomycin 1 gram at dialysis when random
level is less than 15 for a total of 7 days, glargine U100
eight units subcutaneously daily at breakfast. Humalog
sliding scale before meals: Glucoses less than 150: No
insulin, 151-200: 1 unit, 201-250: 2 units, 251-300: 3 units,
301-350: 4 units, 351-400: 5 units, greater than 400: Notify
physician. [**Name10 (NameIs) **] bedtime sliding scale glucoses less than 250:
No insulin, 251-300: 2 units; 351-400: 3 units; glucoses
greater than 400: Notify physician.
DISCHARGE DIAGNOSES: Ischemic left foot ulceration,
nonhealing; peripheral vascular disease status post
diagnostic arteriogram on [**2138-4-10**], history of type 2
diabetes with triopathy, controlled; history of end-stage
renal disease on hemodialysis Monday, Wednesday, Friday,
history of coronary artery disease with cardiomyopathy,
status post coronary artery bypass graft x2 complicated by
congestive heart failure, systolic; respiratory failure,
pneumonia, status post tracheostomy, history of methicillin-
resistant Staphylococcus aureus catheter sepsis, history of
pneumonia, history of atrial fibrillation, history of
pulmonary embolus secondary to deep venous thrombosis,
anticoagulated, history of depression, history of
hypertension, history of gastroparesis, history of gastric
reflux, history of morbid obesity, urethral stenosis status
post cystoscopy with dilatation and Foley placement on [**5-6**],
postoperative blood loss anemia, transfused; postoperative
left lower lobe collapse secondary to bronchial mucus
plugging, status post bronchoscopy x2.
MAJOR SURGICAL PROCEDURES: Cystoscopy with urethral
dilatation and Foley placement on [**2138-5-6**], redo left mid
SFA BK-[**Doctor Last Name **] with nonreverse saphenous vein, left angioscopy
and valve lysis, [**2138-5-6**], status post bronchoscopy x2 [**5-13**] and [**5-14**].
FOLLOW UP: Patient should follow up with Dr. [**Last Name (STitle) 1391**] in 2
weeks' time. He should call for an appointment at ([**Telephone/Fax (1) 72527**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2138-5-15**] 09:50:29
T: [**2138-5-15**] 10:33:22
Job#: [**Job Number 72528**]
|
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"V4581",
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Admission Date: [**2166-7-13**] Discharge Date: [**2166-7-18**]
Date of Birth: [**2092-7-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Neck swelling
Major Surgical or Invasive Procedure:
[**2166-7-14**]: Removal of packing. Mediastinoscopy. Flexible
bronchoscopy and bronchoalveolar lavage (BAL).
[**2166-7-13**]: Redo mediastinoscopy. Packing of wound.
History of Present Illness:
73 y/o M with COPD found to have new RUL mass who is s/p
mediastinoscopy on [**2166-7-9**] presents with acute onset neck
swelling. The neck swelling began this morning and he is
complaining of dysphagia and difficulty breathing. He did not
some chest discomfort and took his home SL nitro with no change.
He has extensive cardiac history and is on Coumadin for AFib.
The coumadin was held 1 week prior to the medistinoscopy and he
was to be discharged home on coumadin with lovenox bridge.
According to the patient he did not take his home coumadin and
has been on the Lovenox only. He denies any fevers/chills, N/V,
abd pain, hematochezia/melena.
Past Medical History:
Bilateral pulmonary nodules
Hypothyroidism
DM II
Hypertension
Hyperlipidemia
CAD s/p DEstents in [**2159**] to LAD, RCA, PLV,
Atrial fibrillation on warfarin
Gastritis
COPD
Anemia
Hyponatremia
Cerebral aneurysm
CKD
PVD
Social History:
Married lives with family. Tobacco: 40 pack-year. Quit 40 years
ago. ETOH none
Occupation: bartender
Family History:
non-contributory
Physical Exam:
VS: T: 96.0 HR: 82-86 SR BP: 150-160/70-80 Sats: 96% RA
General: 74 year-old male sitting in chair in no distress
HEENT: normocephalic, mucus membranes moist
NEck: mild anterior neck swelling, incision site w/steri-strips
no erythema mild dark heme drainage
Card: RRR
Resp: decreased breath sounds on left otherwise clear
GI: benign
Extr: warm no edema
Neuro: awake, alert oriented
Pertinent Results:
[**2166-7-18**] WBC-16.9* RBC-3.98* Hgb-12.6* Hct-36.9* MCV-93 MCH-31.8
MCHC-34.3 RDW-15.2 Plt Ct-260
[**2166-7-17**] WBC-17.3* RBC-4.25* Hgb-13.0* Hct-38.4* MCV-91 MCH-30.6
MCHC-33.9 RDW-15.7* Plt Ct-223
[**2166-7-13**] WBC-11.2* RBC-2.75* Hgb-8.2* Hct-25.1* MCV-92 MCH-30.0
MCHC-32.8 RDW-16.6* Plt Ct-271
[**2166-7-18**] Glucose-182* UreaN-26* Creat-0.8 Na-133 K-4.0 Cl-94*
HCO3-24
[**2166-7-17**] Glucose-250* UreaN-27* Creat-0.8 Na-129* K-4.1 Cl-94*
HCO3-26
[**2166-7-13**] Glucose-322* UreaN-20 Creat-1.0 Na-121* K-4.6 Cl-87*
HCO3-22
[**2166-7-17**] Albumin-3.4* Calcium-8.7 Phos-1.7* Mg-2.2
CXR:
[**2166-7-16**]: The lungs show an unchanged right apical pneumothorax
with confluent lower lobe opacities, and mild edema unchanged. A
right lung mass is unchanged as well. A moderate left effusion
is unchanged as well. An NG tube terminating in the stomach is
unchanged.
[**2166-7-13**]: Lungs are low in volume. The cardiac silhouette is
mildly enlarged. The mediastinal silhouette is mildly prominent,
which may be post-procedural, or partially due to low lung
volumes. Bilateral lower lobe opacities are new. The hilar
contours are unremarkable. Previously noted pulmonary vascular
engorgement has resolved. Known nodular opacities in the right
upper lobe and lingular are stable. There are small bilateral
effusions. No pneumomediastinum or pneumothorax identified.
MICRO: all cultures were negative.
Brief Hospital Course:
Mr. [**Known lastname 89251**] was admitted [**2166-7-13**] for neck swelling secondary to
bleed after restarting Lovenox following cervical
mediastinoscopy on [**2166-7-9**]. He was taken to the operating room
for Redo mediastinoscopy with Packing of wound. No source of
bleeding was found. He was transfer to the TSICU intubated,
hypovolemic SBP 70's, Transfused 2 Unit of PRBC, CXR with Right
pleural effusion, CT placed with 600 mL serosanguinous drainage.
On [**2166-7-14**] he was taken back to the OR for Mediastinoscopy
Flexible bronchoscopy and bronchoalveolar lavage (BAL) and
packing removal.
Transferred back to TICU intubated and successfully extubated.
His oxygenation improved, titrated off oxygen with saturations
96% on room air.
Heme: Transfused 3 units of PRBC in OR & ED and 2 units while in
the SICU for HCT 25. Serial HCTs where followed and he remained
stable in the high 30.s
Hypertension: hypertensive SBP 180-200 requiring Labatelol drip
until taking PO's. His SBP improved 150's baseline 140's. His
home medications were restarted Lisinopril, felodipine.
Atrial Fibrillation: rate controlled with metropolol.
Anticoagulation: Warfarin was held. Aspirin restarted. Spoke
with his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 487**] whom agreed with Warfarin 3 mg with No
lovenox bridge.
Nutrition: Seen by speech and swallow for laryngeal edema on
[**7-15**]. He remained NPO for signs & symptoms of aspiration. An
NGT was placed and Tube feeds were started.
Speech continued to follow him. [**2166-7-16**] his laryngeal edema
improved the NGT was removed, a puree nectar thick liquid was
started. Video-swallow on [**2166-7-17**] showed improved pharyngeal
edema. He was transition to a soft mechanical diet with thin
liquids and aspiration precautions.
Endocrine: insulin sliding scale to maintain BS < 150. His home
dose Prandin was restarted when taking PO. Levothyroxine
restarted to once taking PO.
Hypervolemia: IV Lasix was given to Goal negative > 1. Liter
with good results. His home PO dose was restarted.
Electrolytes were replete as needed.
Pleural: small left pleural effusion. Ultrasound by
interventional pulmonology of left pleural effusion showed
approximately 300 mL. No thoracentesis was performed.
Disposition: He continue to make steady progress. Was seen by
physical therapy who recommended home with PT. He was
discharged on [**2166-7-18**].
Medications on Admission:
Tiotropium Bromide 18 mcg', Esomeprazole 40 mg', Albuterol
2puffs q4-6H, Furosemide 40 mg daily, Simvastatin 80 qhs,
Ferrous sulfat 325 mg daily, Coumadin, Cholecalciferol, Vitamin
D, Lisinopril 40 mg daily, Prandin 0.5 prior to meals, atenolol
100 mg daily, levotyroxine 75 mcg daily, felodipine 5 mg daily,
NTG, MVI
Discharge Medications:
1. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. felodipine 5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO TIDAC (3
times a day (before meals)).
10. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO every four (4) hours.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Cervical mediastinoscopy [**2166-7-9**] complicated by bleed s/p Redo
mediastinoscopy, Packing of wound [**2166-7-13**]
Bilateral pulmonary nodules
Hypothyroidism
DM II
Hypertension
Hyperlipidemia
CAD s/p DEstents in [**2159**] to LAD, RCA, PLV,
Atrial fibrillation on warfarin
Gastritis
COPD
Anemia
Hyponatremia
Cerebral aneurysm
CKD
PVD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Difficulty breathing, swallowing or new hoarsness
-Increased bleeding for neck incision
Neck incision
-Cover with a clean dry dressing as needed. It will ooze for a
few days. Please call if there is a large amount of discharge
from the site.
-Steri-strips remove in 10 days or sooner should they start to
come off
Pain:
-Acetaminophen 650 mg every 6 hours as needed for pain
-Oxycodone 5 mg every 4-6 hours as needed for pain
-Take stool softners with narcotics
Activity
-Shower daily. Wash incisions with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-Do Not apply any lotions or creams to incisions
Warfarin
-Restart you standing dose on Sunday night. Take 3 mg Sunday and
Monday evening.
-Follow-up with your PCP on Tuesday for further warfarin
instructions.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2166-7-29**] 11:30 on
the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Follow-up with Dr.[**First Name (STitle) 487**] [**Telephone/Fax (1) 68410**] for warfarin managenment
on Tuesday.
Completed by:[**2166-7-18**]
|
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] |
Admission Date: [**2174-2-23**] Discharge Date: [**2174-3-4**]
Service: CARDIOTHORACIC
Allergies:
Protamine Sulfate / Gluten / Milk / Wheat Flour
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath, atrial fibrillation s/p MVR ( 25 Mosaic
procine), Maze, ligation of left atrial appendage [**2174-2-8**]
Major Surgical or Invasive Procedure:
Re-do sternotomy, evacuation of pericardial and pleural
effusions [**2174-2-24**]
MVR (25 Mosaic, porcine), MAZE, Ligation of left atrial
appendage
History of Present Illness:
85 year old female s/p MVR (25 Mosaic porcine),Maze, ligation of
left atrial appendage [**2174-2-8**]. Readmitted from rehab with
shortness of breath, atrial fibrillation.
Past Medical History:
Paroxysmal atrial fibrillation
Rheumatic heart disease
Moderate-to-severe mitral stenosis
Hypertension
Hypothyroidism
Glaucoma
Osteoporosis
Social History:
She currently lives alone but has a daughter
Retired
[**Name2 (NI) 1139**] denies
ETOH denies
Family History:
non contributory
Physical Exam:
admit history and physical
vs: 99.2, 94/55, 66, 18, 96% on 2 liters
neuro: alert and oriented x3, non-focal
resp: lings CTA bilat,-decreased at the bases, no rhonchi or
wheezing.
cardiac RRR S1, S2, no murmur
GI: soft, tender bilat lower quadrants, non-distended, +BS
Extrem: upper extremities: warm, pulses +2, no edema. lower
extremities: Cool, Pulses +1, +1 edema.
Skin: Sternal incision- healing, no erythema, no drainage,
stable
Pertinent Results:
[**3-4**]: WBC 7.9 *Hgb 11.4* HCT 35.0* Plt 319
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 77013**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77015**]Portable TTE
(Complete) Done [**2174-2-23**] at 4:37:43 PM 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: [**2088-7-7**]
Age (years): 85 F Hgt (in): 64
BP (mm Hg): / Wgt (lb): 119
HR (bpm): 66 BSA (m2): 1.57 m2
Indication: H/O cardiac surgery. Pericardial effusion.
ICD-9 Codes: 423.3, V42.2
Test Information
Date/Time: [**2174-2-23**] at 16:37 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2009W0-0:00 Machine: Vivid [**6-6**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 1.0 m/s
Right Atrium - Four Chamber Length: *5.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 1.9 cm
Left Ventricle - Fractional Shortening: 0.42 >= 0.29
Left Ventricle - Ejection Fraction: 65% to 75% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Arch: 2.8 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - Pressure Half Time: 91 ms
Mitral Valve - MVA (P [**12-3**] T): 2.4 cm2
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.56
Mitral Valve - E Wave deceleration time: *270 ms 140-250 ms
TR Gradient (+ RA = PASP): *29 mm Hg <= 25 mm Hg
Pericardium - Effusion Size: 2.2 cm
Findings
Left pleural effusion
This study was compared to the prior study of [**2174-2-11**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Normal
regional LV systolic function. Overall normal LVEF (>55%). No
resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Normal aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR
well seated, with normal leaflet/disc motion and transvalvular
gradients. No MR.
TRICUSPID VALVE: Moderate to severe [3+] TR. Mild PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: Large pericardial effusion. Effusion
circumferential. Stranding is visualized within the pericardial
space c/w organization. No echocardiographic signs of tamponade.
No RV diastolic collapse.
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is no
ventricular septal defect. with borderline normal free wall
function. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. A
bioprosthetic mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. No mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is a large
pericardial effusion. The effusion appears circumferential.
Stranding is visualized within the pericardial space c/w
organization. No right ventricular diastolic collapse is seen,
however there are indirect signs of elevated intrapericardial
pressure (RV free wall diastolic flattening)
Compared with the prior study (images reviewed) of [**2174-2-11**],
the large pericardial effuison is new.
IMPRESSION: Large circumfirential pericardial effusion with
early organization. No overt tamponade.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2174-2-23**] 17:04
Brief Hospital Course:
Pt was admitted to intially to the cardiac surgical floor then
had an ECHO which revealed pericardial effusion and was
transferred to the cardiac ICU to monitor for tamponade. Of
note, Ms. [**Name14 (STitle) 77017**] was c-diff positive at rehab abd was being
treated with flagyl. Her urine was also positive for gram neg
rods and was treated with cipro. Ms. [**First Name (Titles) 77017**] [**Last Name (Titles) 1834**] aggressive
diuresis. On HD #2 Ms. [**Known lastname **] was taken to the OR with Dr.
[**First Name (STitle) **] for pericardial window for drainage of pericardial
effusion and bilat pleural effsuions (left 1 liter and right
500cc). She was treated with periop vanco. She was readmitted to
the ICU post operatively intubated and on neosynephrine. She
weaned from the vent and pressors and was extubated. She was
seen by electrophysiology and her dofetilide was maintained and
VERY LOW DOSE COUMADIN was recommended when stable. She was
transferred from the ICU to the floor. Bilateral chest tubes
remained in place to suction for drainge. when chest tubes were
placed to water seal, she developed pneumothoracies and was
placed back to suction. Chest tubes were later removed and Ms.
[**Name14 (STitle) 77018**] CXR showed stable bilateral 20% pneumothoracies. She
was evaluated by physical therapy and reab was recommended.
On POD#8 she was discharged to rehab.
SHE WILL NEED HER INR CHECKED DAILY AND RECIEVE ONLY LOW DOSE
COUMADIN- 1MG DAILY. SHE WILL ALSO NEED HER RENAL AND LIVER
FUNCTION MONITORED CLOSELY WHILE ON DOFETILIDE. SHE WILL HAVE
CLOSE FOLLOW UP WITH DR. [**Last Name (STitle) **]- APPOINTMENT IS SCHEDULED.
Medications on Admission:
Coumadin held since [**2-21**], ASA, Levoxyl 75/D, Effexor XR 75/D,
Vanco po for cdiff
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
17. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 1 months.
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
19. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
20. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
pericardial and pleural effusion after MVR (25 Mosaic, porcine),
MAZE, Left atrial appendage ligation
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
DAILY INR CHECKS- VERY LOW COUMADIN FOR AFIB.
CLOSE MONITORING OF LIVER FUNCTION AND RENAL TESTS WHILE ON
DOFETILIDE.
Followup Instructions:
Make the following appointments:
Dr. [**Last Name (STitle) 17863**] (primary care)UPON DISCHRAGE FROM REHAB
You have the following appointments:
DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-3-10**]
11:40
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2174-3-14**]
1:00
DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-5-19**]
10:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2174-3-4**]
|
[
"5119",
"42731",
"2449"
] |
Admission Date: [**2163-11-7**] Discharge Date: [**2163-11-11**]
Date of Birth: [**2088-8-8**] Sex: F
Service: MEDICINE
Allergies:
Vitamin K (intravenous formulation)
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Shortness of breath, Pericardial Effusion
Major Surgical or Invasive Procedure:
Pericardiocentesis with drain placement
Removal of pacemaker
History of Present Illness:
75-year-old female with a past medical history of CHF, afib,
COPD, HTN pacer placement approximately 7 days prior on Coumadin
who presented to an outside hospital with worsening SOB since
yesterday morning with exertion. As per patient's HCP, since
being discharged from the hospital pt was doing well and
developed dyspnea after breakfast yesterday morning. An echo
showed a moderate-large pericardial effusion with possible RV
diastolic collapse, INR was 4, she was given 5 VitK, and sent to
[**Hospital1 18**] for further eval. At [**Hospital1 18**], initial vitals were 98.0 63
129/63 18 99% 2L Nasal Cannula. Bedside TTE showed a moderate
pericardial effusion with some RV/RA diastolic collapse. Pulsus
[**10-19**] with JVP 10. INR was 6.9, BNP 5705, Trop .62. She was
given 2 units FFP, 5 VitK, and admitted to the CCU. On
transfer, vitals 98.2 57 115/62 18 100% on 3L.
.
On transfer to the floor, the patient was found to been in
respiratory distress, with stridorous breath sounds throughout
lungs fields; had hives on back, as well as chest. Patient was
tachypneic, with labored respirations. Given IV epinephrine
followed by subQ doses, solumedrol IV push, famotidine,
diphenhydramine and taken to cath lab for intubation and
pericardial drainage.
.
Cath Lab Course: Pt taken to cath lab, intubated without
complications, and found to have perforation of RV by pacer lead
which was found to be within the pericardial space. Pericardial
drain placed with drainage of ~350cc's of bloody fluid.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY: Notable for CAD, recent NSTEMI, Sick sinus
syndrome causing cardiogenic syncope, atrial fibrillation on
coumadin
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD: Single lead pacer placed c/b perforation of RA,
RV, LV
3. OTHER PAST MEDICAL HISTORY:
-Atrial fibrillation on coumadin
-CHF
-Insomnia
-Anxiety
-GERD
-Osteoporosis
-Ostearthritis
-Transaminitis (unknown etiology)
Social History:
- Tobacco history: None
- ETOH: None
- Illicit drugs: None
Family History:
- Positive for CAD and pacemaker
Physical Exam:
ADMISSION EXAM:
GENERAL: disheveled, elderly woman, sitting up in bed,
tachypneic, labored breathing, audible stridor.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP of [**10-19**]
CARDIAC: Rapid rate, regular rhythm, no murmurs/rubs/gallops
LUNGS: stridor throughout lung fields
ABDOMEN: Soft, NTND, +BS
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: +hives on back and chest
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE EXAM:
Vitals: T36.6 ??????C (97.9 ??????F), HR: 89 (77 - 110) bpm, BP: 93/54(65)
{84/45(58) - 117/73(86)} mmHg, RR: 18 (15 - 25) insp/min, SpO2:
97%, Heart rhythm: AF (Atrial Fibrillation) Wgt (current): 64.8
kg (admission): 69 kg
GENERAL: elderly woman, NAD, sitting up comfortably in bed
HEENT: NCAT. Sclera anicteric.
NECK: Supple, JVP to edge of mandible
CARDIAC: Rapid rate, irregular rhythm, no murmurs/rubs/gallops
LUNGS: fine inspiratory crackles halfway up the lung fields b/l
CHEST: site of pericardial drainage, dressing clean/dry/intact
ABDOMEN: Soft, NTND, +BS
EXTREMITIES: warm, well perfused, trace pedal edema b/l, trace
UE edema b/l, L arm with bruising
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2163-11-7**] 03:23AM WBC-16.7* RBC-3.26* HGB-10.8* HCT-33.4*
MCV-103* MCH-33.2* MCHC-32.4 RDW-13.1
[**2163-11-7**] 03:23AM NEUTS-90.6* LYMPHS-5.8* MONOS-3.2 EOS-0.3
BASOS-0.2
[**2163-11-7**] 03:23AM PLT COUNT-460*
[**2163-11-7**] 03:23AM PT-62.3* PTT-36.2* INR(PT)-6.9*
[**2163-11-7**] 03:23AM GLUCOSE-136* UREA N-24* CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
[**2163-11-7**] 03:23AM ALT(SGPT)-25 AST(SGOT)-34 CK(CPK)-24* ALK
PHOS-76 TOT BILI-0.5
.
PERTINENT LABS:
[**2163-11-7**] 02:07PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2163-11-7**] 02:07PM URINE RBC-23* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-2
[**2163-11-7**] 03:23AM BLOOD CK-MB-2 proBNP-5705*
[**2163-11-7**] 03:23AM BLOOD cTropnT-0.62*
[**2163-11-7**] 11:10PM BLOOD CK-MB-4 cTropnT-0.57*
[**2163-11-7**] 07:32AM BLOOD Lactate-5.4*
[**2163-11-7**] 06:33PM BLOOD Lactate-1.5
[**2163-11-9**] 04:38AM BLOOD Lactate-1.3
.
DISCHARGE LABS:
[**2163-11-11**] 04:41AM BLOOD WBC-13.2* RBC-3.89* Hgb-12.8 Hct-39.9
MCV-103* MCH-33.0* MCHC-32.2 RDW-14.3 Plt Ct-401
[**2163-11-11**] 04:41AM BLOOD Glucose-93 UreaN-37* Creat-0.9 Na-144
K-4.2 Cl-101 HCO3-33* AnGap-14
[**2163-11-9**] 02:24PM BLOOD Type-ART Temp-36.9 pO2-86 pCO2-39
pH-7.46* calTCO2-29 Base XS-3
.
ECHO [**2163-11-7**]
The left atrium is elongated. The estimated right atrial
pressure is 5-10 mmHg. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). with
normal free wall contractility. The aortic valve is not well
seen. Trace aortic regurgitation is seen. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a moderate sized pericardial effusion. The effusion
appears circumferential. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. No right
ventricular diastolic collapse is seen.
IMPRESSION: Moderate pericardial effusion. Elevated
intrapericardial pressure without overt tamponade.
.
ECHO [**2163-11-9**]
FOCUSED STUDY FOR PERICARDIAL EFFUSION: The left atrium is
dilated. The right atrium is dilated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
dilated with depressed free wall contractility. The mitral valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a small pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
.
Compared with the prior study (images reviewed) of [**2163-11-8**],
the pericardial effusion is similar in size.
PERICARDIOCENTESIS [**2163-11-7**]
COMMENTS:
Using the sharp-tip needle, we performed pericardiocentesis via
the
subxyphoid approach. There was inadvertent needle puncture of
the RA, RV
and LA before appropriate needle position was obtained in the
pericardial space. A wire was advanced, the tract was dilated,
and the
pericardial drain was inserted into the pericardial space. 370
cc of
bloody fluid was removed and echocardiography confirmed minimal
residual
effusion. Because of respiratory acidosis, she was intubated at
the
conclusion of the procedure. The pericardial drain was sutured
into
place.
.
EKG [**2163-11-10**]
Atrial fibrillation. Non-specific anterior T wave changes. Low
voltage in the limb leads. There is non-specific T wave
flattening in leads V5-V6. Compared to the previous tracing of
[**2163-11-7**] there is now atrial fibrillation and non-specific T
wave flattening. Clinical correlation is suggested.
.
CXR [**2163-11-9**]
PORTABLE AP CHEST: The endotracheal tube, orogastric tube, and
left chest
wall pacer and associated leads have been removed. A small-bore
catheter
projecting over the heart could represent a pericardial drain.
Cardiac silhouette remains markedly enlarged. There is decreased
vascular
congestion and edema. Moderate right and likely left pleural
effusions
persist. No new opacity concerning for pneumonia.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
75 year-old female with a recent s/p NSTEMI at OSH and pacemaker
placement 7 days ago on coumadin presenting with new pericardial
effusion.
.
ACTIVE ISSUES:
# Pericardial effusion: From recent pacemaker placement with
inadvertent perforation of myocardium in setting of
supratherapeutic INR. Pericardiocentesis was performed, however
this was complicated by inadvertent puncture of the RA, RV, and
LV. The drain was left in place until it stopped draining and
wasa then removed. Post removal echocardiogram showed resolution
of the pericardial effusion. The pacemaker wire was removed and
placement of a pacemaker will be re-evaluated as an outpatient.
She was also placed on colchicine for two weeks to decrease
inflammation of her pericardium.
.
# Respiratory distress/Anaphylaxis: Pt was found to have hives
and in respiratory distress with stridorous breath sounds most
likely from a component of the IV Vitamin K given to patient in
ED. She was given epinephrine and intubated. She was extubated
uneventfully after the pericardiocentesis.
.
# CAD s/p NSTEMI: S/P recent NSTEMI at OSH. Pt without chest
pain throughout admission. Aspirin was changed from 81 mg to 325
mg daily. Lovastatin was changed to Atorvastatin 80mg.
Metoprolol was increased form 100mg daily to 200mg daily and
diltiazem was discontinued. Also started plavix 75mg daily.
.
# Rhythm: Had pacemaker placed at an OSH for sinus pauses after
her MI by report. While on telemetry she did not have pauses
after her pacemaker was removed. She was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
of hearts monitor to monitor for pauses. She will follow up with
EP. Her heart rhythm while admitted was atrial fibrillation with
RVR. Her heart rate was controlled with higher doses of
metoprolol while discontinuing diltiazem. Her CHADS score is 3.
Her INR was supratherapeutic on admission so she was given 10 mg
IV Vitamin K in the ED and 2U FFP. Her warfarin was restarted
after her procedures. Her INR was subtherapeutic on discharge
but in the setting of her recent bleeding and the low daily risk
of CVA she was not anticoagulated with heparin or lovenox. Her
INR should be followed to ensure adequate anticoagulation.
.
#Diastolic CHF: LVEF >55% this admission. Volume overload
worsened by IVFs and FFP. She was diuresed with IV lasix and
switched to PO lasix on discharge.
.
#Borderline hypotension: She has been asymptomatic with systolic
blood pressures in the high 80s to low 100s. Her blood pressure
is relatively low from her blood pressure medications. These
blood pressure ranges should be tolerated unless she becomes
symptomatic.
.
# Leukocytosis: Pt admitted with white count of 16, now 13.2,
afebrile. Likely stress response related to pericardial
tamponade, cardiac trauma, and anaphylaxis. Blood cultures were
negative for five days though final culture report still
pending. UA negative. Initial Ucx growing 4,000cfu/ml of
enterococcus, repeat urine culture was negative.
.
CHRONIC ISSUES:
#HLD: Lovastatin was changed to Atorvastatin 80mg PO daily for
ACS as above.
.
#Possible COPD: Has unclear history of COPD. She denies any
prior diagnosis as well as any smoking history. She was
initially treated with ipratropium though her respiratory
difficulty was more likely from fluid overload.
.
TRANSITIONAL ISSUES:
#INR monitoring: Her INR was subtherapeutic at discharge. This
should be monitored to ensure that her INR becomes therapeutic.
.
#Borderline hypotension: She has been asymptomatic with systolic
blood pressures in the high 80s to low 100s. Her blood pressure
is relatively low from her blood pressure medications. These
blood pressure ranges should be tolerated unless she becomes
symptomatic.
.
#[**Doctor Last Name **] of hearts monitor: Had pacemaker placed at OSH for sinus
pauses after her MI by report. While on telemetry she did not
have pauses after her pacemaker was removed. She was discharged
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor to monitor for pauses. She will
follow up with electrophysiology.
Medications on Admission:
Vitamin D3 1000 unit tab
Lovastatin 40 mg qhs
Omeprazole 20 mg qday
Coumadin 2 mg qday
Metoprolol 50 mg [**Hospital1 **]
Aspirin 81 mg daily
Diltiazem CD 180 mg daily
Lactobacillus 2 caplets PO BID
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
3. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
4. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. lactobac acidoph-bifidobac [**Male First Name (un) **] 16 mg Capsule Sig: Two (2)
Capsule PO twice a day.
9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 13 days: Start on [**2163-11-10**]. Stop on [**2163-11-24**]. .
10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Health Care Center
Discharge Diagnosis:
Pericardial Effusion
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **]:
.
You were admitted to [**Hospital1 69**] with a
pericardial effusion (fluid around your heart). The fluid was
removed and a drain was temporarily placed. The pacemaker that
was recently placed was also removed because one of the wires
from the pacemaker was most likely the cause of the effusion.
.
The changes below were made to your medications.
.
START taking the following medications:
1. START taking Colchicine 0.6 mg by mouth twice a day for two
weeks. This medication will help to prevent a scar from forming
in the space around your heart (pericardial space). This
medication was started on [**2163-11-10**] and should be taken through
[**2163-11-24**].
2. START taking Atorvastatin 80 mg by mouth at night. Your
outpatient providers may decide to switch you back to Lovastatin
40 mg by mouth at night but we recommend that you take
Atorvastatin for now.
3. START taking Lisinopril 5 mg by mouth daily. This medciation
will help protect your heart from changes to the muscle
following your heart attack.
.
Change the following medications:
1. CHANGE your Metoprolol. You were admitted on Metoprolol
tartrate 50 mg by mouth twice a day. The dose was increased and
you were changed to a longer acting formulation called
Metoprolol succinate. START taking Metoprolol succinate 200 mg
by mouth daily.
2. The dose of your Aspirin was increased from 81 mg by mouth
daily to 325 by mouth daily.
.
STOP taking the following medications:
- STOP taking Diltiazem. This medication was stopped because the
dose of your Metoprolol was increased.
Followup Instructions:
Please follow up with your cardiologist, Dr. [**Last Name (STitle) **], on [**11-21**] at 12:30.
.
Please set up an appointment with your primary care doctor
within one week after levaing the rehabilitation facility.
|
[
"4280",
"42731",
"41401",
"496",
"4019",
"2724",
"53081",
"V5861"
] |
Admission Date: [**2151-12-10**] Discharge Date: [**2151-12-19**]
Date of Birth: [**2093-8-11**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Transfer fr OSH with sepsis and respiratory failure
Major Surgical or Invasive Procedure:
line placement
History of Present Illness:
58F w/rheumatoid arthritis on periodic prednisone, HTN who
presented to OSH on [**12-9**] w/SOB, F/C, productive cough x 1 wk.
Family members report intermittent URI Sx (cough, rhinorrhea)
since 6 wks ago when pt returned fr [**State 108**] (where she & husband
were doing some construction work on their house). Denies any
more recent travel. Over the week PTA, pt noticed worsening
cough productive of yellowish sputum, increasing DOE, and
generalized fatigue/malaise. Pt works as a nurse but does not
have any direct patient contact. Only [**Name2 (NI) **] contact is pt's
husband reports being Dx with "mild pneumonia" and is on Abx for
this.
.
At OSH [**Name (NI) **], pt was mentating well but O2Sat 85-6% on NRB so
intubated and admitted to their ICU. CXR w/bilat patchy
infiltrates; started on levoflox, clinda, imipenem, and vanco.
Labs revealed pancytopenia (reportedly new), ARF (peak creat
3.3). Pt's blood Cx fr [**2151-12-9**] grew out in [**3-28**] bottles on
[**12-10**]. Decision made to transfer care to [**Hospital1 18**] so medflighted
in. Upon arrival here [**2151-12-10**] 1 pm, MAPs 40s on levophed but
responded to IVF bolus & addition of vasopressin. Vent was AC
350 x 20, 20 PEEP, 100% FiO2 & initial ABG here was 7.12/66/79
(was 7.14/67/103 at OSH just prior to transfer).
Past Medical History:
- Rheum arthritis on periodic prednisone 5 qd (pt manages this
herself & family unsure if she has been taking prednisone
recently)
- HTN on atenolol & HCTZ
Social History:
[**2-25**] glasses of wine qd but no h/o withdrawal; no TOB; no IVDU;
lives w/husband; has 3 children
Family History:
noncontributory
Physical Exam:
VS: MAP initially mid-40s on levophed but increased to 70s after
IVF bolus & after vasopressin started; 101/55 now. HR 100-120.
Sat 90-97% on vent.
Gen: middle-age F sedated, intubated
Skin: small ecchymosis L shoulder; o/w C/D/I w/o rashes
HEENT: ETT in place, PERRLA, conjunctiva clear
Heart: S1S2 RRR, tachycardic, no murmurs appreciated
Lungs: course B.S. throughout all bilat lung fields
Abdom: hypoactive bowel sounds, soft, no masses apprec, liver
not felt below costal margin
Extrem: 2+ pulses, no edema, cold extrem to touch but good cap
refill, not mottled
Neuro/Psych: sedated, unable to assess
Pertinent Results:
.
Brief Hospital Course:
Ms. [**Known lastname **] is a 58 F w/rheumatoid arthritis, HTN transferred fr
OSH after p/w respir distress, intubated, & became septic
w/strep pneumo in blood Cx.
She was found to have ARDS/Pulm likely from initial CAP. She
had Apache score 26 so started on APC (Zygris) x 96 hrs (started
[**12-10**]). She was continued on propofol and placed on a paralytic
(chose Cisatracurium due to sepsis & multiorgan failure) due to
dyssynchronous breathing w/vent.
.
# ID/Sepsis: HPI c/w CAP; bacteremic/septic at OSH. Micro fr OSH
w/pan-sensitive Strep pneumo so changed Abx to levoflox &
ceftriaxone for double coverage.
.
# HypoTN: likely fr sepsis & dehydration. She was started on
IVF, vasopressin, and titrate levophed along with stress dose
steroids (hydrocort 50 mg IV q6h).
For H/o moderate EtOH consumption ([**2-25**] glasses wine/day): her
thiamine and folate were supplemented.
.
She was found to have ARF: creat was 3.3 @ OSH, now 1.3 after
hydration. Good UOP. Renal U/S @ OSH WNL.
.
She was started on IV protonix (NPO & on steroids) and
pneumoboots. A R fem line (double lumen) & L A-line were placed
[**12-9**] @ OSH. Also 1 PIV.
Ms. [**Known lastname **] eventually succumbed to pneumonia with sepsis and
multiorgan failure.
Medications on Admission:
Meds @ Home: atenolol 25 qd, HCTZ 25 qd, celebrex 200 [**Hospital1 **], &
prednisone 5 qd (sometimes)
.
Meds upon transfer: levoflox 250 iv qd, imipenim 250 iv q6h,
clindamycin 600 iv q8h, vanco 1 g q24h, hydrocort 100 iv q8h,
protonix 40 iv q24h, thiamine iv qd, folate iv qd, SC heparin,
bicarb drip
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
multiorgan failure sepsis pneumonia
|
[
"51881",
"78552",
"5849",
"99592",
"4019"
] |
Admission Date: [**2188-8-5**] Discharge Date: [**2188-8-14**]
Date of Birth: [**2129-7-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
pericardiocentesis
History of Present Illness:
This is a 59 year old Chinese woman with minimal known past
medical history who initially presented yesterday ([**8-5**]) with
four days of naseau and vomiting and no bowel movements.
.
Pt was in her usual state of health until one month ago. She
reportedly worked as temp in a candy shop for 3 days, and had
extreme fatigue that was thought out of her usual condition. She
stopped working afterwards, and later developed a productive
cough, which gradually worsened in the past month. There was no
hemoptysis. Patient was evaluated by her PCP at [**Hospital3 **] on
[**7-21**], and again on [**7-30**]. A PPD was placed on [**7-30**], and
was read on [**8-1**] as nonreactive (completely negative). In the
past week, patient developed shortness of breath, malaise, and
could only ambulate to the bathroom. She c/o nausea, bilious
vomiting, intolerable to po intake. Her family also endorsed
night sweats in the past week, and an 8lbs weight loss in the
past 2 weeks. Of note, patient immigrated to US 10 months ago
from southern [**Country 651**]. She recently visited her daughter in [**Name (NI) 6607**]
two months ago.
During workup in the ED she had a CXR which showed a large
cardiac silloute and fluid overload with possible RML infection.
Her EKG showed diffusely low voltages but no ST depressions.
LFTs showed mild transaminitis (60s) with alk phos 120 with dir
bili 0.6.
.
She was initially treated for CHF, but did not respond well with
diuresis.
On the second day, an RUQ ultrasound in the ED showed a possible
pancreatic head mass (otherwise negative). Surgery recommended
an abdominal CTA with pancreatic protocol to further evaluate.
Overnight she was stable and breathing comfortably on room air.
She was hypertensive to 140s-170s. Vitals otherwise were stable.
On CT, circumferetial pericardial effusion was seen. Patient was
found to have a pulsus paradoxus of 20 mmHg. She was stat
intubated, underwent a pericardiocentesis in the cath lab, and
admitted to CCU.
Past Medical History:
beta thalessemia
atrophic gastritis
Social History:
Mandarin/[**Name (NI) **] speaking. Immigrated from [**Country 651**] 10 months
ago. Currently living with daughter, son in law, and 3
grandchildren.
Recently returned from 3 month visit in [**Country 6607**].
Works in a candy factory
Denies Smoking, Drinking or Recreational drug use.
Family History:
beta thalessemia
Physical Exam:
ADMISSION EXAM:
VS: T96.7 BP137/92 HR87 RR18 95% RA
GEN: AOx3, dry mucosal membrane.
HEENT: PERRLA. no LAD. flat jvp. neck supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, bilateral crackle / rhonchi
Abd: Soft, NT/ND, +BS, no hepatosplenomegaly.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities.
.
DISCHARGE EXAM:
VS: Tmax: 99.2 Tc: 98.0 HR: 77 (77-85) BP: 139/90
(128-143/60-90) RR: 18 SpO2: 95% RA
Pulsus of 8.
GEN: Patient was lying flat in bed in no acute distress or pain.
Moist mucosal membrane.
HEENT: PERRLA. Conjunctival pallor. Neck supple.
Cards: 7cm JVP. RRR S1/S2 normal. not distant. no
murmurs/gallops/rubs.
Pulm: Clear to auscultation bilaterally
Abd: Soft, NT/ND, +BS, no hepatosplenomegaly.
Extremities: No edema. Radial pulses, DPs, PTs 2+.
Skin: No rashes or bruising
Neuro: CNs II-XII intact. 4-/5 strength in IP. Full strength in
quads, hamstrings, tib anteriors, gastrocs. 1+ biceps, triceps,
patellar reflexes, 0 ankle reflexes bilaterally. Babinskis mute
bilaterally. Sensory exam intact to light touch and
proprioception.
Pertinent Results:
ADMISSION LABS
[**2188-8-5**] WBC-10.9 RBC-4.99 Hgb-11.2* Hct-34.0* MCV-68* MCH-22.5*
MCHC-33.0 RDW-16.1* Plt Ct-371
[**2188-8-5**] Neuts-85.2* Lymphs-8.2* Monos-5.8 Eos-0.6 Baso-0.3
[**2188-8-5**] Glucose-138* UreaN-20 Creat-0.6 Na-138 K-4.1 Cl-102
HCO3-21* AnGap-19
[**2188-8-5**] ALT-78* AST-69* AlkPhos-123* TotBili-2.4* DirBili-0.6*
IndBili-1.8
[**2188-8-5**] Calcium-9.6 Phos-3.8 Mg-2.1
[**2188-8-6**] calTIBC-244* Hapto-195 Ferritn-806* TRF-188*
[**2188-8-6**] Type-ART pO2-77* pCO2-41 pH-7.39 calTCO2-26 Base XS-0
[**2188-8-6**] calTIBC-244* Hapto-195 Ferritn-806* TRF-188*
[**2188-8-5**] Lactate-2.8*
[**2188-8-5**] Lactate-2.9*
[**2188-8-6**] Lactate-3.9*
[**2188-8-6**] Lactate-1.3 Na-139 K-3.9 Cl-107 calHCO3-24
.
DISCHARGE LABS
[**2188-8-11**] WBC-9.3 RBC-5.01 Hgb-11.4* Hct-34.7* MCV-69* MCH-22.7*
MCHC-32.8 RDW-16.5* Plt Ct-330
[**2188-8-11**] Glucose-112* UreaN-9 Creat-0.7 Na-142 K-3.9 Cl-104
HCO3-28 AnGap-14
[**2188-8-9**] ALT-241* AST-97* AlkPhos-98 TotBili-1.4
[**2188-8-11**] Calcium-9.5 Phos-3.4 Mg-2.2
[**2188-8-7**] HBsAg-NEGATIVE HBsAb-POSITIVE IgM HBc-NEGATIVE IgM
HAV-NEGATIVE
[**2188-8-7**] HCV Ab-NEGATIVE
.
.
PERTINENT STUDIES
# [**8-5**], Abd US
IMPRESSION:
1. No cholelithiasis or evidence of acute cholecystitis.
2. Possible pancreatic lesion. Correlate with nonemergent
pancreatic CT or MRI.
.
# [**8-5**], Portable CXR
FINDINGS: There are diffuse bilateral interstitial alveolar
opacities. There is a markedly tortuous aorta. The cardiac
silhouette is enlarged. Small bilateral pleural effusions are
evident. There is no pneumothorax. The osseous structures are
unremarkable.
.
IMPRESSION: Excessive volume overload likely due to cardiogenic
etiology. Repeat radiography after appropriate diuresis
recommended to assess for underlying infection. In particular,
there is slight confluent opacity in the right perihilar region
which likely reflects confluent edema; however, an underlying
pneumonia cannot be entirely excluded.
.
# [**2188-8-6**] ECHO (pre-pericardiocentesis)
FOCUSED STUDY: The right ventricular cavity is unusually small.
There is a large pericardial effusion which ranges in size from
2.4 to 3.5 cm. The effusion appears circumferential. There is
right ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
.
# [**2188-8-6**] ECHO (post-pericardiocentesis)
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2188-8-6**],
the large pericardial effusion has resolved. The heart rate has
normalized. The right ventricular cavity is larger and function
is normal.
.
# [**2188-8-7**], ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5 mmHg. 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. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Trivial pericardial effusion without
echocardiographic evidence of tamponade. Mild pulmonary artery
systolic hypertension.
.
# TTE ([**2188-8-11**])
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is a
very small pericardial effusion. No right atrial or right
ventricular diastolic collapse is seen. Compared with the prior
study (images reviewed) of [**2188-8-7**], the pericardial effusion
is minimally larger, but remains very small.
.
.
# [**2188-8-7**] ECG
Sinus rhythm. Non-specific ST-T wave changes. Compared to the
previous tracing the rate is slower.
.
# [**2188-8-7**] CT chest w/ contrast
IMPRESSION:
1. Right lower lobe mass with centrilobular nodules and
interlobular septal thickening is concerning for primary lung
malignancy with lymphangitic carcinomatosis.
2. Extensive infiltrative mediastinal lymphadenopathy.
3. Small, malignant pericardial effusion following
percardiocentesis. No
tamponade.
4. Lytic metastasis, D11 vertebral body with invasion of the
spinal canal and impingement on thecal sac anteriorly.
5. Probable left adrenal metastasis.
.
# [**2188-8-8**] C/T/L spine MRI
Evaluation of the cervicothoracic spine demonstrates osseous
metastases at C2, C7 and T11. A posterior element lesion is also
noted at T4. Due to motion artifact, axial images are markedly
limited. At T11, there is marked motion artifact, but suggestion
of left sided anterior epidural disease . There is no
significant cord compression or myelomalacia present at this
time, however.There is bulging of the posterior vertebral body
into the canal and mild compression deformity at this level.
Evaluation of the lumbar spine demonstrates no evidence for
osseous metastatic disease. No epidural disease is seen. There
are multilevel disc bulges. Posterior element hypertrophy is
also present at multiple levels.
IMPRESSION:
Osseous metastatic disease at C2, C7, T4 and T11 as described.
At T11, there is mild compression deformity and small amount of
epidural tissue,
particularly on the left, without significant cord compression
at this time. Degenerative changes in the lumbar spine.
.
# [**2188-8-10**] ECG
Sinus rhythm. T wave inversions and poor R wave progression in
the anterior precordial leads are consistent with prior anterior
wall myocardial infarction of indeterminate age. Compared to the
previous tracing of [**2188-8-7**] the R wave progression is less
prominent.
.
Brief Hospital Course:
59F Chinese immigrant with no significant past medical history
admitted with four days of nausea and was noted to have
pericardial effusion with tamponade physiology s/p
pericardiocentesis with cytology showing adenocarcinoma. Further
workup showed metastatic lung adenocarcinoma to the spine c/b
T11 compression fracture without cord compression.
# Cardiac tamponade secondary to adenocarcinoma:
Pt developed shortness of breath, and tachycardia, with a pulsus
>20 mmHg on hospital day 2. CT abdomen showed circumferential
fluid in pericardium. Bedside ECHO showed RV collapse
consistent with tamponard physiology. Due to shortness of
breath and inability to lie flat, pt was intubated and sent to
cath lab for pericardiocentesis, which drained ~700 cc sanguous
fluid. Patient was admitted to CCU for further management.
Post-procedure ECHO showed minimal residue fluid accumulation.
Interval changes measured by ECHO and daily pulsus did not show
evidence of reaccumulation of pericardial fluid. Pt remained
asymptomatic for the remainder of her hospital course with a
baseline pulsus of <14.
# metastatic adenocarcinoma-lung primary:
Pt's presenting chest x-ray showed diffuse reticulonodular
pattern, concerning for TB, or carcinomatosis. As part of the
workup, pt underwent bronchoscopy with BAL. Of note, both
pericardiofluid and BAL showed positive adenocarcinoma on
cytology, but negative AFB. Pathology stain of the
pericardiofluid and BAL showed adenocarcinoma of lung primary.
Patient was seen by heme/onc who recommended further outpt
testing for typing and an MR head for complete staging. Pt
declined at this time. Hem/onc f/u appt to be set up in
approximately 2 weeks, where pt will discuss potential
treatment. Lung metastastes were noted at multiple vertebral
bodies, adrenals, and liver on imaging.
# Compression fracture at T11 without cord compression.
Spinal MRI was obtained due to patient's complaints of lower
back pain. There was evidence of compression fracture at T11 on
both chest CT and spinal MRI, without significant cord
compression. There was also evidence of osseous metastatic
disease at C2, C7, and T4. Pt had normal neural exam including
intact sphincter tone. Pt was evaluted by Neurosurgery, who
felt that there was no imminent risk of cord compression. Pt was
also evaluated by rad-onc who felt that radiation treatment was
not indicated at this time. Pt was fitted with a TLSO brace to
be used when upright or out of bed. Pain management included
lidocaine patch, ibuprofen and gabapentin. Tylenol was avoided
due to patient's transaminitis. Patient will have bisphosphonate
therapy arranged through her Oncologist as an outpatient.
.
# Post-obstructive pneumonia:
Pt developed fever to 101.6 on hospital day 3. Chest CT
revealed bilateral pleural effusion and density in RLL
concerning for post-obstructive pneumonia. Given patient
continued high O2 requirement, and history of cough, the
suspicion for pneumonia was high. BAL, sputum culture, blood
culture, urine culture showed no growth. Patient was treated
with Vancomycin and Zosyn for a total of 5 days. Her oxygen
requirements remained stable.
.
# Transaminitis
Patient presented with transaminitis and indirect bilirubinemia.
No evidence of biliary obstruction was found on abdominal US.
Hepatitis panel was also negative. Initial DDx include hepatic
congestion secondary to cardiac tamponarde or metastasis of
adenocarcinoma. Of note, there was a ~ 7 mm hypoenhancing foci
in right hepatic lobe on the abdominal CT, and marked
gallbladder wall edema consistent with congestive heart failure.
Patient's liver enzymes peaked on HD3 and has been down
trending since then, suggesting the transaminitis is largely
caused by hepatic congestion.
.
# Disclosure of medical information
Pt initially expressed wishes to disclose medical news to family
only, but later wanted to know herself. Given the special
culture background, social worker was involved, and family
meeting was held in the presence of patient's family, CCU team
and social worker. Agreement was reached that medical
information will be released to patient with presence of her
husband for emotional support.
.
CHRONIC ISSUES
# beta thalassemia
Patient presented with microcytic anemia, consistent with her
reported history of beta thalassemia. Her HCT remained stable
throughout this admission.
.
TRANSITIONAL ISSUES
Patient declared a full code at admission, but changed to
DNR/DNI on [**2188-8-13**]. Pt and husband initially considered
returning to [**Country 651**], given that their son-in-law did not want
them returning to the house. However, after much conversation,
pt's daughter agreed to let them return home. Patient has
follow up appointment with hem/onc in approximately 2 weeks
regarding potential treatment. As patient and husband are
[**Name (NI) 8230**] speaking only, they were given the name and number for
the [**Name (NI) 8230**] hem/onc patient nagivator to help facilitate
further care. They were also given prescriptions for 2 weeks
for pain medications to be filled at the free pharmacy, however
the patient decided to leave prior to getting authorization for
the lidocaine patches. Patient continued to refuse head MRI
during hospitalization, which made complete staging of her
disease impossible.
Language and social barriers are likely to continue to be
problem[**Name (NI) 115**] with this patient and she would benefit from close
contact with the [**Name (NI) 8230**] patient nagviator to ensure she
receives adequate care.
Medications on Admission:
Unclear Chinese Medication (two items)
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Please
wear patch for 12 hours/day, and then take off for 12 hours.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*1*
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*42 Tablet(s)* Refills:*1*
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*14 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. lung adenocarcinoma
2. cardiac tamponade
3. thoracic compression fracture without spinal cord compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) - should wear spine brace while sitting up or
ambulating.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because of abdominal pain,
vomiting and constipation. You were found to have fluid around
your heart (tamponade) which had to be drained to help you
breath. The fluid was found to be caused by a lung cancer,
which has spread to your spine and liver. The cancer has caused
a fracture in your lower spine, which is contributing to your
pain. You should wear the back brace whenever you are sitting
up or standing. Please follow-up with your primary care doctor,
as well as the cancer doctors.
The following changes were made to your medications:
1. Please start taking Gabapentin 300mg by mouth daily
2. Ibuprofen 600mg my mouth three times a day
3. Lidocaine patch daily for up to 12 hours
Followup Instructions:
Name: [**Name6 (MD) 27839**] [**Name8 (MD) **], MD
Specialty: Internal Medicine
When: Tuesday [**8-19**] at 2:30p
Location: [**Hospital3 8233**]
Address: [**State 8234**], [**Location (un) **],[**Numeric Identifier 8235**]
Phone: [**Telephone/Fax (1) 8236**]
Please call ([**2188**] immediately to schedule an appointment
with the cancer doctors - Thoracic Oncology with Dr. [**Last Name (STitle) **],
or Dr. [**Last Name (STitle) 3274**] or Dr. [**Last Name (STitle) **].
Please call ([**Telephone/Fax (1) 89355**] if questions about spinal brace.
Please call [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Last Name (NamePattern1) 8230**]-speaking patient advocate
and cancer navigator, for social work questions.
Completed by:[**2188-8-16**]
|
[
"486"
] |
Admission Date: [**2123-11-1**] Discharge Date: [**2123-11-5**]
Date of Birth: [**2060-8-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain/Dyspnea
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 3 (LIMA-LAD, SVG-PDA, SVG-OM) [**2123-11-1**]
History of Present Illness:
63 year old gentleman who developed exertional dyspnea over this
past summer. A stress test was obtained in [**Month (only) 359**] which reveal
inferior hypokinesis as well as scar in the infra-apical region
with peri-infarct ischemia. Given the findings, he was referred
on for a cardiac catheterization which revealed a 70% stenosed
left main coronary artery and three vessel disease. Given the
severity of his disease, he has been referred for surgical
revascularization.
Past Medical History:
Myocardial infarction
Hypertension
peripheral vascular disease
Hyperlipidemia
Obesity
COPD
scrotal raphe abscess
Right subclavian stenosis
Active tobacco use
Past Surgical History:
[**2110**] Right inguinal hernia repair
Nasal Septum Repair x2
[**2118**] Left inguinal hernia repair c/b epididymal hematoma
Social History:
Lives with: Wife in [**Name2 (NI) 47**]. 3 kids.
Occupation: Farmer
Tobacco: Active smoker 1 pack per day for 50 years.
ETOH: Denies
Family History:
Mother died at 88/Father alive at 91
Physical Exam:
Pulse:63 Resp: O2 sat: 98%
B/P Right: Left: 168/86
Height:5'9" Weight: 215 #
General:obese, using cane today for support as right groin is
still sore from cath
Skin: Warm[x] Dry [x] intact [x]
HEENT: NCAT[x] PERRLA [x] EOMI [x]anicteric sclera,edentulous
with the exception of one tiny partial tooth stump
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur-none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM, obese
Extremities: Warm [x], well-perfused [x] Edema -trace BLE
right groin ecchymosis s/p cath
Varicosities: bil. superficial spider veins
Neuro: Grossly intact, MAE [**4-7**] strengths, nonfocal exam
Pulses:
Femoral Right: 1+ Left:1+
DP Right: NP Left: NP
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2123-11-4**] 04:55AM BLOOD WBC-12.4* RBC-3.48* Hgb-10.8* Hct-30.5*
MCV-88 MCH-30.9 MCHC-35.4* RDW-13.9 Plt Ct-180
[**2123-11-3**] 04:55AM BLOOD WBC-14.4* RBC-3.66* Hgb-11.1* Hct-32.2*
MCV-88 MCH-30.3 MCHC-34.4 RDW-14.0 Plt Ct-168
[**2123-11-4**] 04:55AM BLOOD Glucose-105* UreaN-18 Creat-0.6 Na-134
K-3.9 Cl-95* HCO3-32 AnGap-11
Intra-op TEE [**2123-11-1**]
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%). with mild global free wall hypokinesis. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is AV-Paced, on no inotropes.
Preserved biventricular systolic fxn. Mild MR, no AI.
Aorta intact.
Brief Hospital Course:
The patient was brought to the operating room on [**2123-11-1**] where
the patient underwent CABG x 3. See operative note for details.
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. The patient
was transferred to the telemetry floor for further recovery.
Wellbutrin SR was initiated for smoking cessation. Chest tubes
and pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4, the patient was ambulatory, yet deconditioned, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to [**Location (un) 44563**] in [**Hospital1 10478**] in
good condition with appropriate follow up instructions.
Medications on Admission:
Aspirin 81mg daily
metoprolol SR 25 mg daily
HCTZ 25mg daily
Norvasc 5mg daily
nicotine 21 mg /24 hr patch daily
Zocor 40mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-5**]
Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea.
14. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 44563**] Nursing and Rehabilitation Center - [**Hospital1 10478**]
Discharge Diagnosis:
Coronary Artery Disease
PMH
Myocardial infarction
Hypertension
peripheral vascular disease
Hyperlipidemia
Obesity
COPD
scrotal raphe abscess
Right subclavian stenosis
Active tobacco use
Past Surgical History:
[**2110**] Right inguinal hernia repair
Nasal Septum Repair x2
[**2118**] Left inguinal hernia repair c/b epididymal hematoma
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema [**1-6**]+ bilateral LEs
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. [**Last Name (STitle) **] at MWMC Thursday, [**2123-11-25**] 9am
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] Tues, [**2123-11-30**], 1pm
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) 8758**] [**Telephone/Fax (1) 67950**] in [**3-8**] weeks
Completed by:[**2123-11-5**]
|
[
"41401",
"496",
"412",
"4019",
"2724",
"3051"
] |
Admission Date: [**2161-3-1**] Discharge Date: [**2161-3-10**]
Service: VSU
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: This is an 82-year-old female
with a known abdominal aortic aneurysm who has been monitored
by Dr. [**Last Name (STitle) 1391**]. The patient is being admitted for elective
repair.
PAST MEDICAL HISTORY: Type 2 diabetes diet controlled, lung
carcinoma status post radiation therapy, history of
hyperlipidemia, history of COPD by chest x-ray.
PAST SURGICAL HISTORY: Tonsillectomy.
ALLERGIES: No known allergies.
MEDICATIONS: Include Lescol 80 mg daily and Advair 250 mg
twice a day.
SOCIAL HISTORY: The patient has a 67 pack year history of
smoking which is current. The patient does have a history of
alcohol use 1-2 drinks per day.
PHYSICAL EXAMINATION: Vital signs: The patient is afebrile,
pulse is 80, respirations 16, oxygen saturation 94% in room
air. Blood pressure is 148/78. General appearance: An alert
white female in no acute distress, oriented x3. Heart:
Regular rate and rhythm without murmurs, rubs or gallops.
Lungs: Diminished breath sounds throughout but clear.
Abdomen: Soft, nontender with palpable prominent aorta.
Extremities: Without edema. There are palpable femorals
bilaterally and dopplerable pedal pulses bilaterally.
HOSPITAL COURSE: The patient was admitted to the vascular
service. She was prepared for surgery. She underwent on
[**2161-3-2**], an aorto-bifemoral bypass graft for
resection of abdominal aortic aneurysm. She received 300 cc
of cell [**Doctor Last Name 10105**] and 1 unit of packed cells. She tolerated the
procedure well and was transferred to the PACU in stable
condition. An epidural was placed intraoperatively for
analgesic control. Her vital signs, she was hemodynamically
stable in the recovery room. Her postoperative hematocrit was
26.8. She was transfused. BUN 15, creatinine 0.7. The patient
continued to do well and was transferred to the VICU for
continued monitoring and care. Postoperative day 1, there
were no overnight events. She did develop mild confusion and
agitation which progressed during the day. Her confusion
required Haldol but the agitation continued and she developed
a temperature with tachycardia. She was placed on a CIWA
scale and transferred to the ICU for continued monitoring and
care. Her PA pressures were elevated at this time and a chest
x-ray was consistent with congestive heart failure. She was
diuresed. It was also noted that platelet count had dropped
from 120,000 to 79,000 and a HIT panel was sent. While in the
unit, her urinary output improved with diuresis. Blood
cultures were sent for the temperature. The urine did grow E.
Coli which was treated with ciprofloxacin. She remained
afebrile. The patient's epidural was discontinued on
postoperative day 2. She was given pain medications IV along
with q.1 hour neurologic signs for her low platelet count
after removal of the epidural. She did continue to require
diuresis postoperative day 3. The NG tube was removed on
postoperative day 1. Sips were begun on postoperative day 3
and her diet was advanced as tolerated. She continued to
require Lasix and she was given 25 grams albumin for her
hypoalbuminemia. The patient continued to show improvement in
her congestive failure. She remained in the ICU. Her cardiac
enzymes remained unremarkable. Her PA line was converted to a
central line on postoperative day 4. Her heparin was
restarted secondary to the HIT being negative. Her wounds
looked clean, dry and intact. She had bowel sounds. She still
remained awake but mildly agitated. Her glycemic control was
excellent. The patient was transferred to the VICU for
continued monitoring and care. Ambulation was begun and
physical therapy was requested to evaluate the patient for
discharge planning. She did require an increase in her
metoprolol to maintain her heart rate less than 80. On
postoperative day 5, she continued to progress. Physical
therapy felt that she would benefit from rehabilitation. On
postoperative day 6, her central line was discontinued and a
peripheral line was placed. She was transferred to the floor.
She continued to be diuresed. Her hematocrit remained stable
at 28.3. The remaining hospital course was unremarkable. The
patient did have a bowel movement on postoperative day 7. She
would be transferred to rehabilitation when medically stable
when bed available.
DISCHARGE DIAGNOSES:
1. Abdominal aortic aneurysm.
2. History of chronic obstructive pulmonary disease by chest
x-ray.
3. History of lung cancer, status post radiation therapy.
4. History of hyperlipidemia.
5. History of type 2 diabetes, diet controlled.
6. History of smoking 67 pack years, current smoker.
7. Postoperative confusion, resolved.
8. Postoperative withdrawal, treated.
9. Postoperative thrombocytopenia, HIT negative.
10. Postoperative blood loss anemia, transfused.
11. Postoperative acute renal failure, resolved.
12. Postoperative volume depletion, fluid resuscitated.
13. Postoperative congestive heart failure, diuresed.
14. Postoperative hypercarbia, resolved.
15. Postoperative urinary tract infection, treating for E.
Coli.
MAJOR SURGICAL PROCEDURE: Abdominal aortic aneurysm repair
with aorto-bifemoral bypass graft on [**2161-3-2**].
DISCHARGE DISPOSITION: The patient may ambulate as tolerated
and slowly progress. Diet is as tolerated. No heavy lifting
greater than 2 pounds for 6 weeks. Continue all medications
as directed. She may shower but no tub baths. No driving
until seen in follow-up. If her groin wounds become red,
swollen or drain, she should call Dr.[**Name (NI) 1392**] office. If
she develops a fever greater than 101.5, call Dr.[**Name (NI) 1392**]
office. She should continue on the stool softener while on
pain medication to prevent constipation.
DISCHARGE MEDICATIONS: Fluticasone/salmeterol 250/50 mcg
disk twice a day, ipratropium bromide 0.02% solution
inhalation q.6 hours as needed, Nicotine 14 mg 24 hour patch
daily, oxycodone/acetaminophen 5/325 elixir 5-10 cc q.4-6
hours p.r.n., quetiapine 12.5 mg twice a day, Dulcolax
tablets daily as needed, Colace 100 mg twice a day,
metoprolol 12.5 mg twice a day, aspirin 81 mg daily,
albuterol sulfate 0.083% solution q.4 hours p.r.n.,
ciprofloxacin 500 mg q.12 hours x1 day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2161-3-10**] 09:52:36
T: [**2161-3-10**] 10:40:44
Job#: [**Job Number 31418**]
|
[
"496",
"4280",
"5990",
"2875",
"2851",
"5849",
"3051",
"25000",
"2724"
] |
Admission Date: [**2149-10-22**] Discharge Date: [**2149-10-26**]
Date of Birth: [**2106-9-6**] Sex: F
Service:
ADMISSION DIAGNOSES: Left breast cancer.
DISCHARGE DIAGNOSES: Left breast cancer.
ATTENDING PHYSICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], [**Name Initial (NameIs) **].D.
DISCHARGE MEDICATIONS:
1. Percocet 325 mg 1-2 tablets po q.4-6h p.r.n. for pain.
2. Clindamycin 150 mg capsules 2 capsules po q.6h x1 week.
3. Colace 100 mg po b.i.d. x2 weeks.
DISPOSITION: The patient was discharged to home with follow
up instructions for an appointment with Dr. [**First Name (STitle) 3228**] in 7 to 10
days.
HOSPITAL COURSE: The patient is a 43 year old African-
American female who was admitted on [**2149-10-22**] to
undergo a skin sparing left mastectomy and immediate [**Last Name (un) 5884**]
flap reconstruction. She tolerated this without complication
and postoperatively recovered in the post anesthesia care
unit. On day #1 her flap was noted to be well perfused and
the patient was allowed out of bed to a chair. Her diet was
advanced to clears. On postoperative day #2 the patient had a
migraine headache overnight that was relieved with narcotic
administration. She had a low grade temperature to 101.1, but
was afebrile by morning. Her left breast flap remained well
perfused and the patient was allowed out of bed to ambulate
with assistance. Her Foley catheter was removed and her diet
was advanced to regular as tolerated. On postoperative day #3
the patient was allowed to ambulate with increased frequency
and was allowed to shower and sponge bathe. She was
tolerating a regular diet and some mild nausea had improved
with antiemetic medication. On postoperative day #4 the
patient was without significant pain, was ambulating without
difficulty, was voiding spontaneously, and was tolerating a
regular diet. She was felt to be in stable and satisfactory
condition for discharge to home.
PROCEDURES PERFORMED: Procedures performed during this
admission was a left mastectomy on [**2149-10-22**], and
also a left [**Last Name (un) 5884**] flap reconstruction on [**2149-10-22**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], M.D. [**MD Number(2) 8076**]
Dictated By:[**Last Name (NamePattern1) 8077**]
MEDQUIST36
D: [**2150-2-24**] 09:45:39
T: [**2150-2-24**] 10:18:59
Job#: [**Job Number 8078**]
|
[
"4019"
] |
Admission Date: [**2122-7-14**] Discharge Date: [**2122-7-14**]
Date of Birth: [**2080-2-22**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Demerol / Valium / Percocet / Phenergan
Attending:[**First Name3 (LF) 69390**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 27363**] is a 42 yo female with a hx of atypical CP, PE x 2,
recurrent DVT (on chronic coumadin), and SVT s/p multiple
ablation with most recent RA of AVNRT in [**2115**]. She was admitted
on [**7-11**] to [**Hospital3 6592**] after she experienced the sudden onset
of pleuritic CP with palpitations while driving, similar to her
prior 'PE pain'. She presented to the the [**Hospital1 **] ED,
whereinitial ECG showed significant inferolateral ST
depressions. ? resolution with nitroglycerin. CP was relief
following morphine and ASA. ECG returned to baseline. INR was
subtherapeutic at 1.65, and given her known severe contrast
allergy, it was decided to increase her warfarin dose to treat
empirically for pulmonary embolus. There was still question as
to whether her sx were related to ACS vs PE. She received an
echo today showed normal LV function with no clear regional wall
motion abnormalities. Pharmacologic MIBI study with Lexiscan
produced severe chest pain and significant ST depressions, which
were both relieved with Aminophylline, nitroglycerin, and a 5 mg
of IV metoprolol. Her perfusion imaging was normal. However, in
view of her substantial symptoms and EKG changes with
pharmacologic stress, she is planned for transfer to [**Hospital1 18**] for
cardiac catheterization, which is currently being arranged.
Sometime overnight prior to transfer she had severalruns of NSVT
that were reportedly asymptomatic.
.
On transfer fromt he OSH she had [**8-28**] CP for which she received
nitro, ASA and dilaudid with improvement to [**4-28**] CP.
.
She is currently experiencing [**4-28**] CP that is pleuritic in
nature and occasionally associated with nausea. She denies
diaphoresis, vommiting or GERD symptoms. She does have an
allergy to CT contrast but not to cardiac catheterization dye.
.
Regarding her historty of DVT/PE, her w/u for hypercoaguable
state has been neg with the exception of her LA which was
positive on coumadin. Her 1st PE occurred as a complication of
her ablation in [**2115**].
.
Regarding her hx of atypical CP, She also has a history of
atypical chest discomfort with multiple hospital visits (q 4-6
wks). SHe is s/p cardiac catheterization x3, most recently at
[**Hospital1 112**] in [**2121**], which showed no significant coronary disease. There
has been concern expressed in the past of Munchausen's syndrome.
.
Regarding her hx of SVT, she has been refractory to
antiarrhythmics including flecainide (dizziness), amiodarone and
propafenone, and she is currently maintained on metoprolol. She
has had numerous ablations and EP studies at [**Hospital3 9947**],[**Hospital1 112**], and most recently at [**Hospital3 **]
Past Medical History:
1. CARDIAC RISK FACTORS: No Diabetes, Dyslipidemia, or
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none, most recent cath
clean in [**2121**]
-PACING/ICD: none
SVT
HYPOTHYROIDISM
THROMBOPHLEBITIS
LOW BACK PAIN
Obesity
Thyroid nodule
Radial artery occlusion, right
Palpitations
Pulmonary embolism
Social History:
Pt is divorced from an abusive relationship, has two children
age 12 and 16. She works in an ambulance as an EMT and also has
a 3rd job at a Sheriffs Department. She denies current tobacco
use. She denies any current ETOH use and denied any other drug
use.
Family History:
Father: first MI in mid 50s, h/o vtach, afib, T2DM
Son: AV nodal reentry
Aunt: Breast CA at age 52
Physical Exam:
Admission/Discharge Exam:
82 BP 1154/69 O2Sat 93%
HEENT: NC AT
CHEST: CTA BL
CV: RRR NO MRG
Abd: NT ND +BS
Ext: WWP no erythema, warmth or edema.
Pertinent Results:
ADMISSION/DISCHARGE LABS
[**2122-7-14**] 08:06AM BLOOD WBC-6.5# RBC-3.76* Hgb-12.4 Hct-36.3
MCV-97 MCH-32.9* MCHC-34.1 RDW-13.8 Plt Ct-210
[**2122-7-14**] 08:06AM BLOOD Neuts-72.6* Lymphs-18.9 Monos-6.7 Eos-1.3
Baso-0.5
[**2122-7-14**] 08:06AM BLOOD PT-41.2* PTT-47.7* INR(PT)-4.0*
[**2122-7-14**] 08:06AM BLOOD Glucose-120* UreaN-10 Creat-0.8 Na-137
K-3.9 Cl-105 HCO3-24 AnGap-12
[**2122-7-14**] 08:06AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
[**2122-7-14**] 08:06AM BLOOD D-Dimer-<150
IMAGING:
ECHO:
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%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size is borderline dilated and free wall motion is
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure is probably normal (however the spectral Doppler
recording of the tricuspid jet is technically suboptimal). There
is no pericardial effusion.
CXR:
AP upright portable chest radiograph is obtained. The lungs are
well expanded and clear. There is no pleural effusion or
pneumothorax. The heart is normal in size with normal
cardiomediastinal contours.
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
42 yo female with a PMH notable for SVT refractory to
medications and ablations, atypical CP, and PEx2/DVT who is
transferred from OSH for cath after being admitted with
pleuritic CP.
.
Chest pain: Possible causes of her CP are ACS (however she had
clean coronaries in [**2111**] and [**2121**], EKG is normal without
reported enzyme elevations) Nothing to suggest dissection,
pericarditis, PNA or pneumothorax. Does not appear to be MSK in
nature. Pleuritic and associtated with tachycardia in this
young woman with history of unprovoked VTE's on chronic coumadin
in the setting of subtherapeutic INR raises the specter of
recurrent PE although D-dimer was 150. In addition, repeat INR
was 4.0 so she is therapuetic on her coumadin again despite
being subtherapuetic on arrival to OSH. ECHO was also
unremarkable. She slept for a few hours and on re-evaluation,
her pain had improved. She wanted to go home and we felt that
given her extensive work up was negative that she was ok for
discharge. She has close follow up with Dr. [**First Name (STitle) **] the day after
discharge on [**2122-7-15**].
.
# Tachyarrhthmia: The Telemetry tracings from [**Hospital3 6592**]
were reviewed in detail. Possible etiologies include
non-sustained Mono-morphic VT, SVT with abberency, or artifact.
It was clear the the 'narrow' QRS complex marched through the
'wide-complex' beats consistent with artifact. We continued her
home lopressor and she will follow up with Dr. [**First Name (STitle) **] on [**2122-7-15**].
.
# Elevated INR: Was 4 on admission. She was not given her
coumadin today. She will follow up with [**University/College **] vangaurd
coumadin clinic to maintain a goal INR of 2.5-3.0.
# Hypothyroidism: Continue thyroxine
.
# Anxiety: Continue lorazepam
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Warfarin 17.5 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA)
3. Metoprolol Tartrate 25 mg PO TID
4. Lorazepam 0.5 mg PO TID:PRN anxiety
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Lorazepam 0.5 mg PO TID:PRN anxiety
3. Metoprolol Tartrate 25 mg PO TID
4. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Chest Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital1 69**]
from another hospital for further evaluation of your chest pain.
Your chest pain was not cardiac in nature. There was concern
that this pain was related to a PE, but your D-dimer is low and
this make it very unlikely. In addition, your INR was elevated
at 4.0. We also do not believe this is referred pain from you
abdomen. Overall, your work up has been negative and we are
reassured that since the pain has improved since arrival that
you are ready to be discharged home.
Since you INR is elevated, please do not take your coumadin
today. It is important that you have your INR drawn in the next
48 hours and restart you coumadin to maintain a goal INR of
2.5-3.
The following medication was STOPPED:
Coumadin to be restarted when INR within goal.
There were no other changes to your medication at this time.
Followup Instructions:
Please Keep your appointment with Dr. [**First Name (STitle) **] on [**2122-7-15**].
[**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 69391**]
|
[
"42789",
"V5861",
"2449"
] |
Admission Date: [**2168-1-3**] Discharge Date: [**2168-1-15**]
Date of Birth: [**2115-7-19**] Sex: F
Service: SURGERY
Allergies:
Ibuprofen / Aspirin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
[**2168-1-6**] Exploratory laparotomy and Revision of jejunojejunostomy
History of Present Illness:
Ms. [**Known lastname 47700**] is a 52 yo F s/p laparoscopic RNY gastric bypass in
[**2158**] with Dr. [**Last Name (STitle) **] who is transferred from OSH for SBO. She
began to have epigastric abdominal pain on Wednesday, described
as constant ache with breakthrough sharp pains, that was
persistent. She continued to tolerate PO and had flatus, until
yesterday, when she presented to the OSH ED after 1 episode of
emesis. Her meals have included vegetable [**Location (un) 6002**], broth,
hamburger in the past few days, which she has all tolerated
before. Of note, she has had back pain for the past 2 weeks. She
complains of persistent nausea.
At the OSH ED, NGT was placed, labs were reportedly normal and
she was hemodynamically stable. She was given morphine IV and
transferred to [**Hospital1 18**] for further care.
Past Medical History:
HTN - no longer takes medications; HLD - resolved, formerly on
crestor
Past Surgical History: cholecystectomy [**2140**], lap RNY gastric
bypass [**2158**]
Social History:
Lives at home with her husband. [**Name (NI) **] EtOH or smoking.
Family History:
Noncontributory, patient is adopted
Physical Exam:
On Admission:
Vitals 98.7 176/108 97 16 96% RA FS 210
General: mild distress, uncomfortable, A&Ox3
CV: RRR, nl s1 s2
Pulm: CTAB, no rhonchi/rales
Abd: soft, focal epigastric tenderness to light palpation, no
peritoneal signs, nondistended
Ext: WWP, no edema
On Dishcarge:
VS: T 98.9 HR 85 BP 119/78 RR 18 O2 100% RA FS 103
Constitutional: NAD
Neuro: Alert and oriented x 3
Cardiac: RRR, NL S1,S2
Lungs: CTA B/l, no respiratory distress.
Abdomen: Soft, mildly tender to palpation, no rebound
tenderness/ guarding
Wound: Abd midline incision c/d/i without steri-strips and with
some inferior border erythema that is improving
Ext: mild edema, no c/c. MAE.
Pertinent Results:
[**2168-1-3**] CT Abdomen: Findings: A large amount of stool is present
within the ascending and transverse colon. The ascending colon
is distended with bowel loops measuring up to approximately 9.5
cm in diameter. Additionally, a few mildly distended loops of
small bowel are present in the left mid abdomen near surgical
chain sutures. The small bowel measures up to about 4.3 cm in
diameter. No free intraperitoneal air is identified. Nasogastric
tube is present within the body of the stomach. Within the
chest, lungs are clear except for minimal linear atelectasis at
the bases.
IMPRESSION: Findings which may be related to partial small-bowel
obstruction as reported on review of recent outside hospital CT
by Dr. [**Last Name (STitle) **]. Recommend short-term followup radiographs or
CT.
[**2168-1-5**] CT ABD & PELVIS WITH CONTRAST:
IMPRESSION:
1. High-grade small bowel obstruction with oral contrast failing
to pass the proximal portion the efferent loop. Along with
mesenteric tortuosity
engorgement and swirl; these findings are concerning for an
internal hernia.
2. New abdominal and pelvic free fluid. No evidence of
perforation.
[**2168-1-5**] ECG:
Sinus rhythm. Consider inferior myocardial infarction. T wave
abnormalities. No previous tracing available for comparison.
[**2168-1-5**] CHEST (PORTABLE AP):
IMPRESSION:
1. Proper position of the endotracheal tube and nasogastric
tube.
2. Right internal jugular catheter ends in the right atrium
approximately 1 cm from the superior atriocaval junction.
[**2168-1-8**] CHEST (PORTABLE AP):
FINDINGS: In comparison with the study of [**1-7**], there are
continued low lung volumes. The right IJ catheter has been
removed and the nasogastric tube again extends to the upper
stomach.
There is opacification at the bases most likely reflecting small
right
effusion and bilateral atelectasis. In the appropriate clinical
setting,
superimposed pneumonia would have to be considered.
[**2168-1-8**] CHEST PORT. LINE PLACEM:
IMPRESSION:
1. PICC wire ends at the atriocaval junction. If the catheter
extends beyond the wire, would consider pulling back 2-3 cm.
2. Stable small bilateral pleural effusions and mild bibasilar
atelectasis.
[**2168-1-15**] 05:20AM BLOOD WBC-14.1* RBC-3.26* Hgb-9.6* Hct-28.6*
MCV-88 MCH-29.3 MCHC-33.5 RDW-14.8 Plt Ct-635*
[**2168-1-14**] 04:50PM BLOOD WBC-16.2* RBC-2.71* Hgb-7.8* Hct-23.8*
MCV-88 MCH-28.9 MCHC-32.9 RDW-15.4 Plt Ct-597*
[**2168-1-14**] 04:34AM BLOOD WBC-14.1* RBC-2.52* Hgb-7.4* Hct-22.5*
MCV-89 MCH-29.3 MCHC-32.9 RDW-15.2 Plt Ct-549*
[**2168-1-13**] 08:15AM BLOOD WBC-14.6*# RBC-2.79*# Hgb-8.1*#
Hct-24.3*# MCV-87 MCH-29.2 MCHC-33.5 RDW-15.6* Plt Ct-522*#
[**2168-1-9**] 09:09AM BLOOD WBC-5.2 RBC-4.54 Hgb-13.8 Hct-40.6 MCV-90
MCH-30.3 MCHC-33.9 RDW-15.0 Plt Ct-223
[**2168-1-8**] 02:26PM BLOOD WBC-7.9 RBC-4.24# Hgb-12.4# Hct-37.7#
MCV-89 MCH-29.2 MCHC-32.9 RDW-15.4 Plt Ct-194
[**2168-1-8**] 03:47AM BLOOD WBC-12.2* RBC-2.81* Hgb-8.3* Hct-25.0*
MCV-89 MCH-29.5 MCHC-33.1 RDW-15.4 Plt Ct-243
[**2168-1-7**] 02:03AM BLOOD WBC-9.9 RBC-2.82* Hgb-8.3* Hct-25.1*
MCV-89 MCH-29.2 MCHC-32.9 RDW-15.1 Plt Ct-220
[**2168-1-6**] 02:47AM BLOOD WBC-14.0* RBC-3.19* Hgb-9.5* Hct-27.4*
MCV-86 MCH-29.6 MCHC-34.5 RDW-15.2 Plt Ct-343
[**2168-1-5**] 07:50PM BLOOD WBC-13.1* RBC-4.02* Hgb-12.0 Hct-34.8*
MCV-86 MCH-29.9 MCHC-34.6 RDW-14.5 Plt Ct-424
[**2168-1-5**] 07:10AM BLOOD WBC-16.0* RBC-4.58 Hgb-13.4 Hct-39.3
MCV-86 MCH-29.3 MCHC-34.1 RDW-14.8 Plt Ct-393
[**2168-1-4**] 07:16AM BLOOD WBC-17.1* RBC-4.70 Hgb-13.7 Hct-40.9
MCV-87 MCH-29.1 MCHC-33.4 RDW-14.4 Plt Ct-353
[**2168-1-3**] 08:40PM BLOOD WBC-20.0*# RBC-4.65 Hgb-13.8 Hct-40.7
MCV-88 MCH-29.7# MCHC-33.9# RDW-14.6 Plt Ct-337
[**2168-1-7**] 02:03AM BLOOD Neuts-86.2* Lymphs-8.2* Monos-3.8 Eos-1.5
Baso-0.3
[**2168-1-6**] 02:47AM BLOOD Neuts-85* Bands-8* Lymphs-4* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2168-1-5**] 07:50PM BLOOD Neuts-56 Bands-29* Lymphs-8* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2168-1-7**] 02:03AM BLOOD PT-18.9* PTT-42.5* INR(PT)-1.8*
[**2168-1-5**] 07:50PM BLOOD PT-12.7* PTT-24.2* INR(PT)-1.2*
[**2168-1-5**] 08:40AM BLOOD PT-11.5 PTT-24.6* INR(PT)-1.1
[**2168-1-15**] 05:20AM BLOOD Glucose-96 UreaN-14 Creat-0.5 Na-131*
K-4.9 Cl-99 HCO3-24 AnGap-13
[**2168-1-13**] 08:15AM BLOOD Glucose-91 UreaN-8 Creat-0.5 Na-133 K-4.5
Cl-100 HCO3-23 AnGap-15
[**2168-1-11**] 07:18AM BLOOD Glucose-114* UreaN-7 Creat-0.4 Na-137
K-3.8 Cl-102 HCO3-25 AnGap-14
[**2168-1-9**] 09:09AM BLOOD Glucose-126* UreaN-6 Creat-0.4 Na-136
K-3.5 Cl-99 HCO3-29 AnGap-12
[**2168-1-6**] 04:22PM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-137
K-3.4 Cl-105 HCO3-24 AnGap-11
[**2168-1-5**] 07:50PM BLOOD Glucose-126* UreaN-13 Creat-0.7 Na-137
K-3.5 Cl-104 HCO3-21* AnGap-16
[**2168-1-5**] 07:10AM BLOOD Glucose-127* UreaN-8 Creat-0.6 Na-134
K-3.4 Cl-97 HCO3-26 AnGap-14
[**2168-1-4**] 07:16AM BLOOD Glucose-138* UreaN-7 Creat-0.6 Na-137
K-4.0 Cl-102 HCO3-22 AnGap-17
[**2168-1-3**] 08:40PM BLOOD Glucose-174* UreaN-6 Creat-0.6 Na-137
K-3.5 Cl-105 HCO3-21* AnGap-15
[**2168-1-7**] 02:03AM BLOOD ALT-79* AST-82* LD(LDH)-280* AlkPhos-51
TotBili-0.6
[**2168-1-6**] 02:47AM BLOOD ALT-140* AST-119* AlkPhos-55 TotBili-0.9
[**2168-1-5**] 07:10AM BLOOD ALT-62* AST-37 LD(LDH)-238 AlkPhos-55
Amylase-70 TotBili-0.6
[**2168-1-4**] 07:16AM BLOOD ALT-90* AST-75* LD(LDH)-284* AlkPhos-56
Amylase-372* TotBili-0.5
[**2168-1-3**] 08:40PM BLOOD ALT-64* AST-105* AlkPhos-56 Amylase-616*
TotBili-0.9
[**2168-1-5**] 07:10AM BLOOD Lipase-59
[**2168-1-4**] 07:16AM BLOOD Lipase-615*
[**2168-1-3**] 08:40PM BLOOD Lipase-2094*
[**2168-1-15**] 05:20AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.1
[**2168-1-13**] 08:15AM BLOOD Albumin-3.0* Calcium-8.2* Phos-4.0 Mg-1.8
[**2168-1-14**] 04:34AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.1 Iron-12*
[**2168-1-6**] 02:47AM BLOOD Albumin-3.4* Calcium-8.1* Phos-2.5*
Mg-2.1
[**2168-1-4**] 07:16AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.7 Cholest-200*
[**2168-1-3**] 08:40PM BLOOD Albumin-4.5 Calcium-9.3 Phos-3.2 Mg-1.7
Iron-170*
[**2168-1-14**] 04:34AM BLOOD calTIBC-220* VitB12-682 Ferritn-167*
TRF-169*
[**2168-1-3**] 08:40PM BLOOD VitB12-816 Folate-GREATER TH
[**2168-1-4**] 07:16AM BLOOD Triglyc-105 HDL-36 CHOL/HD-5.6
LDLcalc-143*
[**2168-1-6**] 11:39AM BLOOD Lactate-1.8
[**2168-1-6**] 03:07AM BLOOD Lactate-2.3*
[**2168-1-5**] 07:58PM BLOOD Lactate-2.9*
[**2168-1-5**] 05:09PM BLOOD Glucose-134* Lactate-2.3* Na-132* K-4.0
Cl-105
[**2168-1-5**] 04:00PM BLOOD Glucose-133* Lactate-1.9 K-3.3 Cl-104
[**2168-1-5**] 07:12AM BLOOD Lactate-2.2*
[**2168-1-4**] 07:32AM BLOOD Lactate-2.0
[**2168-1-3**] 10:43PM BLOOD Lactate-1.5
[**2168-1-6**] 03:07AM BLOOD freeCa-1.12
[**2168-1-5**] 04:00PM BLOOD freeCa-1.04*
[**2168-1-9**] 09:09AM BLOOD VITAMIN B1-Test
Brief Hospital Course:
The patient was transferred from an OSH on [**2168-1-3**] for concern
of small bowel obstruction s/p laparoscopic RNY gastric bypass
by Dr. [**Last Name (STitle) **] in [**2158**]. On admission, abdomen was noted to be
soft and without peritoneal signs. Admission labs noted
elevated pancreatic enzymes, a leukocytolysis to 20K, and a mild
tansaminitis. Radiologists at [**Hospital1 18**] reviewed the outside films
which were read as an obstruction at the jejunal anastomosis
with fluid in the abdomen, and question of internal
hernia. Discussed CT with [**Hospital1 18**] radiologist who believed the
scan was consistent with
partial obstruction, without evidence of internal hernia, and
with stool going all the way to the rectum. The patient was
made NPO, with IVF, and a foley for urine output monitoring.
The patient received IV morphine o/n and was transitioned to a
morphine PCA on HD1. On HD3, the patient experienced worsening
abdominal pain prompting a repeat Abd/ Pelvic CT scan, which
suggested high-grade small bowel with 'mesenteric tortuosity
engorgement and swirl' concern for internal hernia. Given these
findings, the patient was brought to the operating room
emergently where she underwent an exploratory laparotomy with
revision of jejunojejunostomy (reader referred to operative note
for complete detail). The patient required pressors
intraoperatively and was kept intubated overnight due to concern
for possible lactic acidosis and worsening cardiopulmonary
function which never presented itself. Patient was able to be
weaned off pressors over the next 24 hours and was extubated on
POD 1 without incident.
Neuro: Pre-operatively pain was managed with IV morphine while
NPO to good effect and a morphine PCA was started on HD 1.
Post-op, the patient experienced intermittent delirium while on
a dilauid PCA in the intensive care unit, which resolved by POD
2 after being transferred to morphine PCA with IV tylenol; When
tolerating a diet, patient was transitioned to PO pain
medications on POD 6 - initially roxicet, then transitioned to
liquid tylenol and liquid oxycodone.
CV: The patient was noted to be hypertensive upon admissions
with SBP 150-170s. Patient has a history of hypertension but no
longer takes medications for this. Blood pressure improved with
IV lopressor and better pain control, however, it remained in
the 150s. Intraoperatively the patient required pressors which
were continued until POD 1. Additionally, she was tachycardic
until POD1 which improved with aggressive fluid resuscitation,
however, she remained intermittently tachycardic throughout the
remainder of her hospitalization requiring transition to oral
metoprolol. She was hemodynamically stable by POD 3 and
transferred tot he floor. At time of discharge, her
hypertension and tachycardia were resolving and she was
instructed to follow up with her PCP about her cardiovascular
physiology and need for continuation of this medication.
Pulmonary: The patient remained intubated post-operatively. She
was gradually weaned from the ventilator and extubated on POD1.
Once extubated, she was weaned from to room air over the next 2
days and remained stable from a pulmonary standpoint. Good
pulmonary toilet, ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient was made NPO with IVF and an NGT upon
admission, with a foley catheter for UOP monitoring. On HD3,
the patient experienced worsening abdominal pain prompting a
repeat Abd/ Pelvic CT scan, which suggested high-grade small
bowel with 'mesenteric tortuosity engorgement and swirl' concern
for internal hernia. Given these findings, the patient was
brought to the operating room emergently where she underwent an
exploratory laparotomy with revision of jejunojejunostomy (as
described above). Post-operatively, the patient was transferred
to the intensive care unit for further management. She was kept
NPO with NGT and IVF postoperatively - requiring aggressive
fluid resuscitation until POD2. A PICC line was placed on POD3
and TPN started. As bowel function returned NGT was
discontinued and her diet was advance on POD 6 which was well
tolerated. On POD 7 she was advanced to a bariatric stage 4
diet which resulted in increased nausea and bloating and she was
told to restrict her diet and reduced to Stage 3 and
subsequently had poor PO intake. TPN was subsequently restarted
on POD 8.
Her urine output was only about 20/hr overnight on POD 0 but
after resuscitation patient started making 40/hr by the
afternoon of POD 1 and maintained good UOP thereafter. Patient
complained of burning upon urination near the end of her
hospital stay but urinalysis failed to demonstrate a UTI and
patient was not any treatment for this complaint. Patient's
intake and output were closely monitored.
ID: Patient presented with a white count of 20,000 which was
downtrending by HD1. She received intraoperative Kefzol and
Flagyl which were continued for 24 hours. The patient's fever
curves were closely watched for signs of infection, of which
there were none. However, on POD 9 the patient's midline
incision began to demonstrate erythema on the inferior border
and in light of a bump in her WBC she was started on IV ancef
until discharge at which time she was transition to keflex x 1
week. Her white count was down trending at time of discharge.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; she also received
protonix for GI prophylaxis while NGT was in place. She was
encouraged to get up and ambulate throughout her stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions including: 1 week intake of oral
antibiotic, follow up with PCP regarding overall condition and
hospital course, addition of new medications including
metoprolol and discussion with PCP about discontinuation, diet
information, follow up appointments, need to return to [**Hospital1 18**] for
further care, warning signs, and activities all of which she
stated she understood and was in agreement with the discharge
plan.
Medications on Admission:
Iron, MTV 1 tab daily, glucosamine, Vitamin D, colace
Discharge Medications:
1. TPN
Volume: 1450mL. Amino Acid: 95g Dextrose 170 Fat 35
Electrolytes: NaCl 155 NaAc 0 NaPO4 20 KCl 25 KAc 0 KPO4 15
MgS04 12 CaGlu 10.
Cycle: 12 hours. Add standard multivitamin
Quantity 30 bags.
2. Outpatient Lab Work
ALT, AST, Albumin, Chem 10, Triglycerides
3. PICC Care
Weekly PICC care including prn dressing and cap change
4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**3-25**]
hours as needed for pain: Crush.
Disp:*60 Tablet(s)* Refills:*2*
5. oxycodone 5 mg/5 mL Solution Sig: [**4-28**] ml PO Q3H (every 3
hours) as needed for pain.
Disp:*500 ml* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Crush.
Disp:*60 Tablet(s)* Refills:*0*
7. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
8. calcium citrate-vitamin D3 500 mg calcium -400 unit Tablet,
Chewable Sig: Two (2) Tablet, Chewable PO once a day.
9. eszopiclone 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for insomnia.
10. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice
a day as needed for constipation.
Disp:*250 ml* Refills:*2*
11. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO twice a
day.
Disp:*600 mL* Refills:*0*
12. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
High Grade Small Bowel Obstruction with Internal Hernia
s/p Exploratory laparotomy and revision of jejunojejunostomy
Acute Pancreatitis
Constipation
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 severe abdominal pain
related to a small bowel obstruction. This became progressively
worse during your hospitalization requiring an urgent operation.
You have recovered in the hospital and are now preparing for
discharge to home on nocturnal intravenous nutrition with
follow-up scheduled on [**2168-1-27**] with Dr. [**Last Name (STitle) **] and
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RD.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down 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.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
*Please present to [**Hospital1 18**] if possible for any future
complications.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-28**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. Continue to get up and walk several times a day as
tolerated.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES. Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Please contact your primary care provider to schedule [**Name Initial (PRE) **]
follow-up appointment within 1-2 weeks.
Department: BARIATRIC SURGERY
When: WEDNESDAY [**2168-1-27**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RD [**Telephone/Fax (1) 305**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BARIATRIC SURGERY
When: WEDNESDAY [**2168-1-27**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD [**Telephone/Fax (1) 305**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Pleae contact your PCP to schedule an appointment within the
next 2 weeks. Update him on your hospital course and current
medication regimen including addition of lopressor and have him
make adjustments as needed.
|
[
"2762",
"4019",
"49390"
] |
Admission Date: [**2163-6-6**] Discharge Date: [**2163-6-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
invasive sqamous scalp ca
Major Surgical or Invasive Procedure:
PICC line placement, neurosurgical intervention cancelled,
History of Present Illness:
Patient is a [**Age over 90 **] year old female with afib, cad, dm who was
transferred from [**Hospital1 **] [**Hospital1 **] for lesion on scalp (can see
brain matter). She was evaluated as an outpatient intially by
dermatology that did a biopsy of the scalp mass and she was
diagnosed with squamous cell carcinoma. The ulcerative lesion
eroding skull extending intracranially and was to have
neurosurgical intervention but the patient was supertheraputic
INR of 7.7 so she was sent to the MICU. She was reversed with
reversed with 10 IV K, 2u FFP. She was also noted to have arf
with cr of 2, anuric, dry on exam with a
sodium 158-->161. She received a NS bolus and then D5W and
avoiding lasix and acei given renal failure, renal ultrasound
with R hydro and pelvic mass (family does not want w/u). Patient
was placed on vanc and cetriaxone for meningitis proprolaxis
since there is CSF communicating with skin secondary to scc.
Patient is having PICC placed in the AM for long-term abx and
fluids. Cultures are pending.
Family is aware of poor prognosis and she is dnr/dni, family
wants conservative med management.
Past Medical History:
CHF-unknown type or EF.
bradycardia s/p pacemaker
afib-s/p cardioversion at [**Hospital1 112**]
htn
hyperthyroidism
arthritis
hernia repair
anxiety
h.o SCC of the scalp year ago per records
glaucoma
Social History:
Lives in [**Location **]. No tobacco, EtOH, or illicit drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.9, 102/666, 64, 22, 98% RA, FS140
General: Alert, trembling, cooperative
HEENT:PERRLA, 3x3cm irregular discolored raised mass, EOMI,
anicteric, MMM
neck-JVD to ear?positional, no LAD
chest-b/l ae no w/c/r
heart-s1s2 4/6 systolic murmur heard throughout precordium
abd-+bs, soft, Nt, ND
ext-NO c/c/e 1+ puluses, cold, r first toe ichemic ulcer
neuro-aaox2, moves all extremities.
Pertinent Results:
[**2163-6-6**] 05:35PM PT-63.8* PTT-41.1* INR(PT)-7.7*
[**2163-6-6**] 05:35PM WBC-13.1*# RBC-3.65* HGB-10.8* HCT-35.6*
MCV-98 MCH-29.7# MCHC-30.5* RDW-13.7
[**2163-6-6**] 05:35PM cTropnT-0.07*
[**2163-6-6**] 05:35PM WBC-13.1*# RBC-3.65* HGB-10.8* HCT-35.6*
MCV-98 MCH-29.7# MCHC-30.5* RDW-13.7
[**2163-6-6**] 05:35PM CK(CPK)-33
[**2163-6-6**] 05:55PM LACTATE-1.7
CT head:
TECHNIQUE: Axial non-contrast images performed in an outside
hospital
([**Hospital3 **]) were submitted for review. No
reconstructions were
available. No formal report was provided.
FINDINGS:
Within the brain parenchyma, there is global parenchymal
atrophy, indicated by
enlargement of the ventricles and sulci. There is also
periventricular and
subcortical white matter hypodensity, consistent with small
vessel ischemic
disease. A right cerebellar lacunar infarct is also noted. There
is no
hemorrhage, edema, or mass effect. There is no shift of normally
midline
structures. The [**Doctor Last Name 352**]-white matter differentiation appears
preserved.
There is a large destructive lesion involving the vertex of the
calvarium.
There is no underlying brain mass lesion or brain abscess,
although there is
an extra- axial, likely subdural, soft tissue/fluid component to
this lesion,
although this is difficult to evaluate due to volume averaging
at the vertex
and the lack of reconstructions. The lesion at the vertex causes
significant
osseous destruction. There is subcutaneous gas, which also
extends
intracranially, with resultant pneumocephalus.
IMPRESSION:
1. Extensive destructive lesion involving the calvarial vertex,
with
intracranial extension indicated by pneumocephalus and
extra-axial,
intracranial soft tissue/fluid component. This does not appear
to be of
primary CNS etiology. Differential includes infectious process
or a
subcutaneous or osseous malignancy. Further evaluation with
contrast-enhanced
MRI is recommended.
2. Small vessel ischemic disease, lacunar infarcts, and global
parenchymal
atrophy. There are no brain mass lesions or brain abscesses
identified.
Renal ultrasound [**2163-6-7**]:
FINDINGS: The left kidney measures 9 cm in length. There is no
left-sided
hydronephrosis. The right kidney measures 9.5 cm in length.
There is
moderate right-sided hydronephrosis. There is no renal mass or
stone. There
is a large > 15 cm cystic pelvic mass, which cannot be further
characterized.
Bladder is not visualized.
IMPRESSION:
1. Moderate right-sided hydronephrosis.
2. Non-specific, large cystic pelvic mass.
Brief Hospital Course:
Patient was a [**Age over 90 **] year old female with h.o CHF, DM, afib, who
presented with invasive scalp squamous cell carcinoma with
intracranial extension who died after code status was CMO.
.
# CMO - Had family meeting [**6-10**]. Discussed to stop vital signs,
non-essential medications other than eye drops, pain meds, and
PO antibiotics. Patient was continued on maintainance IV fluids.
.
# Pain control - This was the family's primary goal of care.
There were multiple etiologies of the pain including her chonic
right shoulder pain, sacral decubiti with possible abcess,
painful scalp leison, or the >15cm pelvic mass. Pain control was
transitioned from outpatient oxycontin pills to fenanyl patch
and oxycodone liquid. Patient was comfortably sedated and only
required additional pain medication when she was moved.
Palliative care was involved in pain management.
.
# Squamous cell ca, intracranial- The carcinoma developed over
an unknown time period. It probably developed before her care to
nursing home facility given that there was a rapid decline in
her functional status and intracraninal involvement of the
tumor. She was evaluated as an outpatient by dermatology and
was determined to have a squamous cell ca as per biopsy on [**5-25**].
Initially, the family wanted to have a neurosurgical
intervention, but the patient's INR was 7.7 so she was
transferred to the MICU for reversal. Later, the family decided
not to have surgery once it became apparent that the morbity was
high. Patient was started on vancomycin and ceftriaxone for
meningitis ppx and this was changed to PO cefepoxidime after a
family meeting determining that she would not want IV
antibiotics. Wound care was done to address her head wound.
.
# Resolved hypovolemia/ acute renal failure/ hypernatremia -
secondary to dehydration and intravascular hypovolemia in the
setting of diruetic use. Cr 2.0 on admission, most recent
baseline at [**Hospital1 18**] 1.1. This was the reason for the PICC line
placement and why the family wanted IVF.
.
# Pelvic mass - There is a large > 15 cm cystic pelvic mass seen
on renal ultrasound. This may be a source of pain.
.
# afib not on anticoagulation - Patient has a history of atrial
fibrillation but was placed on anticoagulation for a recent
phelbiltis. Given that the scalp wound oozes blood, the family
has decided that they do not want anticoagulation.
.
# DM-HISS
.
COMFORT MEASURES ONLY
DISCHARGE TO DEATH
Medications on Admission:
Medications at home:
Lasix 40 mg PO daily
Lisinopril 40 mg PO daily
OxyContin 20 mg PO q12, 10mg PO qHS
Xalatan 0.005 % Eye Drops 1 Drops(s) Once Daily, at bedtime
Azopt 1 % Eye Drops Ophthalmic 1 drop daily
Tylenol 1g PO TID
Serax 10mg PO BID
MVI PO daily
Pro-Stat 64 -- Unknown Strength, Twice Daily
Zinc Chelated 50 mg PO daily
Vitamin C 500 mg SR PO daily
Simethicone 80 mg chewable tab PO prn
.
Medications on transfer:
CeftriaXONE 1 gm IV Q24H
Vancomycin 1000 mg IV ONCE (dose by level)
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Humalog insulin sliding scale
Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Pantoprazole 40 mg PO Q24H
Docusate Sodium (Liquid) 100 mg PO BID
Multivitamins 1 TAB PO DAILY
Oxazepam 10 mg PO BID:PRN anxiety
Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
Bisacodyl 10 mg PO/PR DAILY:PRN
Senna 1 TAB PO BID:PRN
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
intracranial extension of invasive sqamous cell carcinoma
Secondary:
resolved acute renal failure secondary to dehydration
pelvic mass of unknown etiology
atrial fibrillation, chronic
hypertension
diabetes mellitus, type 2
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2163-6-15**]
|
[
"5849",
"2760",
"4280",
"42731",
"41401",
"25000",
"4019"
] |
Admission Date: [**2146-7-7**] Discharge Date: [**2146-7-25**]
Date of Birth: [**2082-3-15**] Sex: M
Service: [**Hospital1 139**] Medicine
This discharge summary reflects the patient's admission from
[**2146-7-7**] through [**2146-7-17**].
CHIEF COMPLAINT: Transfer from [**Hospital6 8972**]
for right foot gangrene and MRSA sepsis with seating of left
wrist and a left ventricular thrombus.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old man
who was initially sent from the nursing home where he resides
to [**Hospital6 8972**] on [**2146-7-1**] for gangrene of his
right second and third toes. Upon admission to [**Location (un) **] his
vital signs were temperature 97, heart rate 58, respiratory
rate 16. He was alert and oriented times three and his
physical exam was unremarkable other than the gangrene.
LABORATORY DATA: Initial labs were white blood cell count of
16.7 with 94% neutrophils, hematocrit 33.3, platelet count
240,000, sodium 136, potassium 4.1, chloride 103, CO2 21, BUN
63, creatinine 1.8, glucose 237 with anion gap equal to 12,
albumin .7, normal LFTs, CK of 153, CK MB 5.7. Urinalysis
was positive for nitrites with 11-20 white blood cells, 0-2
red blood cells and many bacteria with tract protein.
Initial chest x-ray showed left lower lobe pneumonia. The
patient was then started on Cipro. The final read of the
chest x-ray showed chronic changes. However, blood cultures
4/4 bottles grew out MRSA. His antibiotics were changed from
Cipro to Vancomycin and Rifampin. Repeat blood cultures from
[**7-4**] and [**7-6**] have been negative to date. The patient's
right foot was managed with local wound care. On [**2146-3-4**] the
patient was found to become increasingly lethargic and
bradycardic to a heart rate of 37. His left wrist was noted
to be inflamed and his BUN and creatinine increased to 85 and
3.6 respectively. His left wrist was tapped and grew gram
positive cocci consistent with MRSA septic arthritis.
Atenolol was discontinued due to bradycardia. Pacemaker was
not placed due to MRSA bacteremia and because the patient was
not hemodynamically stable. From [**7-4**] to [**7-7**] his
bradycardia continued without improvement. A transthoracic
echocardiogram was obtained for evaluation endocarditis and
was notable for a large left ventricular thrombus, a
decreased EF equal to 15-20% with globally decreased systolic
function, moderate pulmonary hypertension, thickening of
aortic valve, trace mitral, aortic, and tricuspid
insufficiency. He was begun on Heparin for the left
ventricular thrombus. Furthermore, the patient was noted to
have colonic distention on KUB consistent with an ileus.
There were also reports of bright red blood per rectum.
Hospital course at [**Hospital1 **] was further complicated
by oliguric acute on chronic renal failure. His renal
function continued to deteriorate with a FENa less than 1,
consistent with a prerenal azotemia. On [**2146-7-7**] the patient
was begun on Dopamine for bradycardia, both sinus and
junctional, with relative hypotension. The patient was then
transferred to the [**Hospital1 69**] MICU
for further management.
PAST MEDICAL HISTORY: 1) Coronary artery disease with
history of a non Q wave myocardial infarction on [**2146-5-31**]. 2)
Arteriosclerotic peripheral vascular disease, status post
left BKA, status post right 4th and 5th toe amputation. 3)
Type 2 diabetes mellitus requiring insulin with retinopathy,
neuropathy and nephropathy. 4) Gout. 5) Depression. 6)
Question benign prostatic hypertrophy.
ALLERGIES: Penicillin.
MEDICATIONS: Outpatient medications: Lipitor 20 mg [**Hospital1 **],
Allopurinol 100 mg q d, NPH 22 units q a.m., 16 units q h.s.,
Humalog 2 units q a.m., 8 units at dinner, Nitro patch 0.4 mg
from 7 a.m. to 10 p.m., Nitro 0.4 mg sublingual prn, Celexa
40 mg q d, Flomax 0.4 mg q d, q h.s., Coumadin 2.5 mg q d,
Colace 100 mg q d, Tylenol prn, Milk of Magnesia prn.
Medications on admission to [**Hospital1 188**]: Dopamine drip 7 mcg/kg/minute, Wellbutrin 50 mg q d,
Lipitor 20 mg q h.s., Colace 100 mg q d, Nitro patch 0.4 mg
on in the a.m. and off at night, Flomax 0.4 mg q h.s.,
Allopurinol 100 mg q d, Celexa 40 mg q d, Rifampin 300 mg
[**Hospital1 **], Vancomycin renal dosing, Insulin NPH 11 units subcu q
a.m., 8 units subcu q p.m. and a regular insulin sliding
scale, Heparin drip as per protocol.
SOCIAL HISTORY: The patient is a [**Country **] veteran. He denies
any alcohol or tobacco use. He resides in a nursing home.
The patient's son [**Name (NI) 1158**] [**Name (NI) 43845**], is his health care proxy and is
making all medical decisions for him. The patient's son is
currently on duty for the National Guard and available only
by cell phone, [**Telephone/Fax (1) 43846**].
FAMILY HISTORY: Significant for cardiac disease.
HOSPITAL COURSE: While in the MICU, the patient's admission
labs at [**Hospital1 69**] were as follows:
White blood count was 22.4 with 96% neutrophils, hematocrit
33, platelet count 353,000, sodium 125, potassium 4, chloride
92, CO2 17, BUN 109, creatinine 4.4, glucose 93, calcium 6.9,
magnesium 3.2, phosphorus 7.5, albumin 2.8, ALT 35, AST 47,
LDH 291, alkaline phosphatase 117, total bilirubin 5.2,
triglycerides 87, Vancomycin level 13.5, lipase 85, troponin
1.9. CK 252. Consults which were obtained during the
patient's MICU stay include ID, renal, plastic, vascular and
psychiatry.
1. ID: The patient was initially begun on Vancomycin and
Rifampin IV. Later due to the patient's hyperbilirubinemia,
Rifampin was discontinued. Plastics and hand surgery were
consulted on [**2146-7-8**] suggesting an MRI of the left hand and
wrist when the patient was stable and to keep the wrist
elevated at all times. Wrist films on [**2146-7-8**] showed no
evidence of osteomyelitis, however, were positive for
osteopenia. Urine cultures were positive for greater than
100,000 yeast. Blood cultures have been negative to date.
2. Vascular: Vascular was consulted on [**2146-7-8**] and their
recommendation was that the patient requires a right above
the knee amputation since transmetatarsal amputation would
not control the infection adequately.
3. Cardiac: A PA catheter was placed on [**7-8**] for management
of acute renal failure. Initial values were CVP 15, wedge
14, cardiac output was 3.4, later improved to 4.0, cardiac
index 1.8, later improved to 2.1 and SVF was normal. The
patient was transfused two units of packed red blood cells
and given fluid to keep wedge greater than 18, however, this
did not improve renal perfusion. Furthermore, Dopamine drip
was attempted to increase cardiac output and chronotropia,
however, this caused his cardiac output to drop and SVR to
increase and therefore was discontinued. The PA catheter was
pulled on [**2146-7-10**] and his blood pressure has since improved.
Transthoracic echocardiogram on [**2146-7-8**] showed a right and
left atrium mildly dilated, mild symmetric left ventricular
hypertrophy, left ventricular function is seriously depressed
with a large left ventricular thrombus, severe global RV wall
hypokinesis, tract AR, physiologic MR, 1+ TR, mild pulmonary
hypertension, no echocardiographic evidence of endocarditis.
The patient had a slight troponin leak without EKG changes or
elevations in CK MB. Currently Aspirin was held given the
risk of bleeding with pericarditis as well as patient being
pre-op for surgery. The patient had episodes of rapid atrial
fibrillation and SVT, then returning to bradycardia in the
50's or 60's. His ectopy seemingly resolves with management
of potassium and magnesium. A uremic friction rub was
auscultated on [**2146-7-9**] indicating uremic pericarditis,
hemodialysis was initiated for treatment of this. A Heparin
drip was continued for the left ventricular clot. At this
point it was unclear if the clot was infected or not.
4. Pulmonary: Mild pulmonary edema by physical exam,
however, patient was maintaining good oxygenation.
5. GI: The patient had a KUB on [**2146-7-8**] which showed
colonic ileus. Reglan was started, however, later
discontinued due to prolonged QT intervals. KUB on [**2146-7-12**]
showed resolving dilated bowel loops. The patient was found
to have hyperbilirubinemia. His Rifampin and Lipitor were
discontinued due to this. Right upper quadrant ultrasound on
[**2146-7-9**] showed sludge in the gallbladder, however, no
pericholecystic fluid or gallbladder wall thickening or
evidence of biliary obstruction.
6. Renal: Hemodialysis was initiated on [**2146-7-9**] for uremic
pericarditis. The patient had a high phosphate level
secondary to acute renal failure which was treated with
calcium carbonate tid. Urine was sent for urine sodium and
creatinine and urine culture showing a prerenal picture.
7. Heme: The patient was transfused two units of packed red
blood cells on [**2146-7-8**] with good response of hematocrit from
28.2 to 35.1. The patient received a dose of Epogen on
[**2146-7-9**]. His iron level is 57, TIBC is decreased at 146, TRF
is decreased at 112, ferritin is 356, consistent with anemia
of chronic disease.
8. Fluids, Electrolytes & Nutrition: Ectopy is decreased
with increasing the potassium during the dialysis. The
patient's high phosphate level is treated with calcium
carbonate tid and Amphojel times two days.
9. Psychiatry: It was recommended by psychiatry consult
that Wellbutrin and Celexa be held at this point. His RPR
was non reactive, his Vitamin B12 was greater than [**2143**], his
Folate was greater than 20 and his TSH was still pending in
the MICU.
Labs on [**2146-7-12**] when the patient was transferred to the
medicine floor, white blood cells 21.3, hematocrit 33.2,
platelet count 138,000, PT 15, PTT 67.8, INR 1.6, sodium 135,
potassium 4.1, chloride 100, CO2 24, BUN 35, creatinine 2.1
and glucose 138, calcium 7.5, magnesium 2.1, phosphorus 3.2,
total bilirubin 13.7.
Physical exam on admission to the medicine floor: Vital signs
were 97.4, blood pressure 112/74, heart rate 67, respiratory
rate 15. In general, the patient was in no apparent
distress, sluggish to response, sleeping yet arousable to
voice. HEENT: Scleral icterus, moist mucus membranes,
slight thrush, right IJ is in place. Chest is clear to
auscultation bilaterally from anterior, however, bibasilar
rales. Cardiovascular, regular rate and rhythm, normal S1
and S2, unable to appreciate friction rub. Abdomen soft,
nontender, minimal distention, positive bowel sounds. GU,
scrotal edema. Extremities, 2+ pitting edema bilateral lower
extremities, 2+ pitting edema in bilateral upper extremities
and hands. The patient is status post left BKA. The
patient's right foot is dressed in a Multi Podus boot. The
patient's left wrist is dressed in a splint.
IMPRESSION: The patient is a 64-year-old man with a history
of coronary artery disease and type 2 diabetes mellitus
requiring insulin, admitted for MRSA bacteremia from primary
infected gangrenous right foot. Admission has been
complicated by a septic left wrist, bradycardia, with
tachycardic episodes, acute on chronic renal failure, uremic
pericarditis and left ventricular thrombus.
HOSPITAL COURSE: While on [**Hospital6 **].
1. Infectious Disease: The patient was continued on
Vancomycin, being dosed according to trough levels less than
15. Vancomycin levels were checked q day to determine
dosing. The patient was treated with Nystatin swish and
swallow to treat his thrush. The patient is currently
awaiting MRI for further evaluation of his septic left wrist.
Due to the 100,000 yeast noted in his urine, the patient's
Foley catheter was discontinued.
2. Vascular: The patient was taken to the operating room on
[**2146-7-15**] for a right guillotine BKA. Due to the patient's
critical condition and after consultation with anesthesia, it
was seemed safer to proceed with the guillotine right BKA
under MAC anesthesia and to proceed with AKA at a later date
after some of the [**Hospital 228**] medical issues have resolved.
The patient's right upper extremity was found to be cool on
[**2146-7-14**] and right upper extremity ultrasound was performed
which ruled out an upper extremity DVT. The patient will be
taken back to the operating room within 5-7 days under
general anesthesia to undergo a right AKA.
3. Cardiovascular: The patient continued to have episodes
of supraventricular tachycardia and paroxysmal atrial
fibrillation, alternating with relative bradycardia to the
50's and 60's. This is somewhat improved when the patient's
potassium and magnesium are above 4 and 2 respectively. The
patient is still medically too unstable to undergo pacemaker
at this time, however, when his infection clears and after
surgery is complete, EP studies will be done and the patient
will require pacemaker. The patient was continued on Heparin
sliding scale for left ventricular thrombus treatment. It is
not thought at this time that the thrombus is infected due to
the fact that blood cultures obtained here at [**Hospital1 346**] all have been negative to date. On
the evening of [**2146-7-13**] the patient was believed to have had
high blood pressure in the right arm ranging from the
200-300/dopplerable to blood pressures of 110-120/dopplerable
in the left arm. The patient also was complaining of some
vague upper back pain, therefore it was decided to rule the
patient out for an aortic dissection. Patient underwent CT
with and without contrast of the chest with pretreatment of
Mucomyst and which showed no evidence of aortic dissection
due to the absence of an intimal flap in the face of fluid
density surrounding the anterior mediastinum adjacent to the
ascending aorta. Calcified aorta of normal caliber; a small
pericardial effusion along with small left and trace right
pleural effusion; left lower lobe patchy coapts adjacent to
the effusion posteriorly; small amount of free fluid in the
abdomen surrounding the liver, spleen and tracking to the
right lower quadrant. Chest x-ray at the time showed no
enlargement of mediastinum and a left basilar opacity. It
was determined with discussions with the attending that the
patient's arteries are significantly calcified and therefore
pose difficulty in obtaining appropriate blood pressures.
When the patient was monitored that day in hemodialysis with
a Dinamap machine there were no problems getting his blood
pressures and they ranged in the 100's to one teens over 50's
to 60's. The patient has been continually monitored with the
Dinamap machine on the floor with no further issues with high
blood pressure.
4. GI: Most recently the patient's stools were guaiac
negative. An abdominal ultrasound obtained on [**2146-7-14**] for
evaluation of the biliary and urinary systems showed no signs
of biliary or urinary obstruction and was positive only for
gallbladder sludge. This study was obtained due to the
patient's continued high creatinine as well as the patient's
continued hyperbilirubinemia.
5. Renal: The patient continues on hemodialysis
approximately every other day. The patient was receiving
hemodialysis through a left femoral Quinton catheter until
[**2146-7-16**] when the catheter was pulled. The patient will
require placement of Perma-cath on Monday, [**2146-7-18**] in
preparation for hemodialysis on Tuesday, [**2146-7-19**].
6. Hematology: The patient is on Heparin sliding scale for
the left ventricular thrombus. His hematocrit was stable
subsequent to his transfusions in the MICU until [**2146-7-15**] when
his hematocrit dropped to 28.7 and after surgery the
patient's hematocrit was 27.8, therefore he was transfused
one unit of packed red blood cells with good response to
hematocrit of 30.3. The patient's PT, PTT and INR were
monitored throughout his stay. It was noted by the blood
bank that the patient had delayed transfusion reaction
forming allo antibodies. This does not preclude him from
getting further transfusions as the blood bank will merely
screen for these antibodies in the future.
7. Fluids, Electrolytes & Nutrition: When the patient was
transferred out from the MICU, he was on tube feeds running
at 35 cc per hour. These were continued throughout his stay
on the medicine floor. The patient began to take better po
on [**2146-7-15**] being begun on a renal diet. Calorie counts will
be performed and need for tube feeding in the future via NG
tube will be assessed.
8. Endocrine: The patient is currently on a regular insulin
sliding scale for his type 2 diabetes. He will be restarted
on his NPH regimen once adequate po intake is established.
9. Psychiatry: The patient has a history of depression, we
are holding his psychiatric medications as per psych
consult's request.
10. Code Status: The patient is a full code.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684
Dictated By:[**Last Name (NamePattern1) 7432**]
MEDQUIST36
D: [**2146-7-17**] 00:35
T: [**2146-7-24**] 18:35
JOB#: [**Job Number 20739**]
|
[
"5849",
"42731"
] |
Admission Date: [**2113-6-20**] Discharge Date: [**2113-11-1**]
Date of Birth: [**2113-6-20**] Sex: F
Service: NB
HISTORY: [**Known lastname **] [**Known lastname **], twin number 1, was born at 26 and 6/7
weeks gestation by cesarean section for preterm labor and
breech presentation of twin number 2. Mother is a 39-year-old
gravida 3, para 1, now 3 woman. Her prenatal screens are
blood type O positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, and group B
strep positive. This pregnancy was achieved with a Clomid
assisted intrauterine insemination resulting in a diamniotic,
dichorionic twin gestation that had been reduced from
quadruplets at 12 weeks gestation. The mother was admitted to
the hospital at 24 weeks gestation with preterm labor and
vaginal bleeding which was treated with magnesium and
betamethasone. Her course of betamethasone was complete on
[**2113-6-7**]. Due to progressive preterm labor, cesarean
section delivery was done. Membranes were intact at delivery
and there was no intrapartum antibiotic prophylaxis. This twin
emerged with good tone and spontaneous cry. Apgars were 8 at 1
minute and 8 at 5 minutes.
Birth weight was 775 grams, birth length 31 cm, and birth
head circumference 23.5 cm.
PHYSICAL EXAMINATION: An active premature infant in moderate
respiratory distress. Fontanel soft and flat. Ears, eyes and
nares normal. Palate intact. Coarse breath sounds. Poor
aeration. Grunting, flaring and retracting present. Heart
with regular rate and rhythm. No murmurs. Age appropriate
tone and reflexes.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: [**Known lastname **] was intubated soon after admission. She
received two doses of survanta for RDS. She remained
ventilated until day of life 51 when she weaned to
nasopharyngeal continuous positive airway pressure. On day of
life 92, she was successfully weaned to nasal cannula oxygen
and on day of life 112 she successfully weaned to room air
where she remains. She was treated with caffeine citrate for
apnea of prematurity from day of life 21 until day of life 71.
Her last episode of bradycardia occurred with an oral feeding
on [**2113-10-26**]. She was started on Diuril for chronic
lung disease on day of life 48 and she remains on that at the
time of discharge with a plan to outgrow her dose. Her
arterial blood gas on [**2113-10-31**], was pH 7.38, PCO2 46,
PO2 87, bicarbonate 28, and base excess of 0.
On examination her respirations are comfortable. Lung sounds
are clear and equal.
CARDIOVASCULAR: [**Known lastname **] was treated with 2 courses of
Indomethacin for patent ductus arteriosus first on day of
life 1 and then on day of life 5. A followup cardiac echo on
[**2113-6-27**], revealed no patent ductus, and a structurally
normal heart. Her echoes were repeated on [**6-27**], and [**2113-7-4**], due to a heart murmur, both were negative for patent
ductus. She did require pressor support for the first 24
hours of life and has remained normotensive since that time.
An EKG was done on day of life No. 2 for an irregular heart
rate. It showed premature atrial contractions which have
since resolved. No follow up was planned. On examination, she
has a heart with regular rate and rhythm. No murmurs. She is
pink and well perfused.
FLUIDS, ELECTROLYTES AND NUTRITION: At the time of discharge,
her weight is 4080 grams, her length 52 cm, head
circumference 37 cm.
Enteral feeds were begun on day of life 16 and advanced to
full-volume feedings by day of life 23. She was then advanced
to 30 calories per ounce feedings due to inconsistent weight
gain. We have been unable to successfully wean the calorie
concentration and so she is being discharged home on 30
calorie per ounce Enfamil, made with 6 calories per ounce of
Enfamil powder and 4 calories per ounce of corn oil. She is
also receiving potassium chloride supplements. Her last set
of electrolytes on [**2113-10-31**], were sodium 136,
potassium 5.7, chloride 103, bicarbonate 23. There was no
change made in her potassium chloride supplements and those
have now been at the same dose for several weeks. Her oral
intake is approximately 130 ml per kg per day. She has been
eating on an ad lib schedule.
She was evaluated by the [**Hospital3 1810**] feeding team on
[**10-30**]. They felt that she did show some immaturity of
feeding and would only need follow up with them as necessary.
GASTROINTESTINAL: [**Known lastname **] was treated with phototherapy for
hyperbilirubinemia of prematurity from day of life number 1
until day of life 24. Her peak bilirubin occurred on day of
life 11 and was total 4.9, direct 0.3. She has also been
treated with prune juice 1 teaspoon daily to assist with
regular bowel movements.
HEMATOLOGY: She has received multiple transfusions of packed
red blood cells during her NICU stay, the last one on [**2113-8-8**]. Her last hematocrit on [**10-31**], was 34.7 with a
reticulocyte count of 1.7%. She is receiving supplemental
iron of 2 mg per kg per day. Her blood type is O positive.
Her DAT is negative.
INFECTIOUS DISEASE: [**Known lastname **] was started on ampicillin and
gentamycin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours when the
blood cultures were negative and the infant was clinically
well. She remained off the antibiotics until day of life 10
when she was started on vancomycin and gentamycin for
clinical presentation of sepsis. She then completed 7 days of
antibiotics for presumed sepsis. Her blood cultures and
cerebrospinal fluid remained negative from that time. She
remained off antibiotics until [**2113-8-2**], when she again
had a clinical presentation of sepsis. At that time her
tracheal aspirate revealed Klebsiella. She did then complete
7 days of Unasyn and gentamycin for Klebsiella pneumonia. Her
blood cultures and cerebrospinal fluid remained negative from
that time. She has remained off antibiotics since that time.
NEUROLOGY: Her first head ultrasound on [**6-22**] was within
normal limits. Her follow up head ultrasound on [**6-27**] showed
a grade 2 intraventricular right sided hemorrhage and follow
up ultrasound showed mildly dilated lateral ventricles.
Serial head ultrasounds over the course of her NICU stay were
done showing some resolution. The last one done on [**2113-8-29**], showing resolving right subependymal hemorrhage and
stable mildly dilated lateral ventricles.
OPHTHALMOLOGY: Her eyes were last examined on [**2113-10-16**], and showed mature retinal vessels and resolved
retinopathy of prematurity. Follow up ophthalmology
examination was recommended in 6 months.
PSYCHOSOCIAL: Mom has been very involved in the infant's care
during her NICU stay. The infant is discharged home with her
mother.
She is discharged in good condition.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 63800**]. Telephone
number [**Telephone/Fax (1) 63801**].
CARE RECOMMENDATIONS AFTER DISCHARGE:
1. Feedings - 30 calorie per ounce Enfamil made with 6
calories per ounce of Enfamil powder and 4
calories per ounce of corn oil at an ad lib schedule.
2. Medications:
1. Ferrous sulfate (25 mg per ml) 0.5 ml PO daily.
2. Prune juice 5 ml PO daily
3. Diuril 69 mg PO twice a daily.
4. potassium chloride supplement 4.6 mEq 3 times a day.
3. She has passed the car seat position screening test.
4. Her last State Newborn Screens were sent on [**2113-8-30**], and was within normal limits.
5. Immunizations received:
Hepatitis B vaccine on [**2113-7-20**].
Pediarix #1 on [**2113-8-20**].
Pediarix #2 on [**2113-10-22**].
HIB #1 on [**2113-8-21**].
HIB #2 on [**2113-10-22**].
Pneumococcal vaccine #1 on [**2113-10-22**].
Synagis #1 on [**2113-10-25**].
RECOMMEND IMMUNIZATIONS:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following three criteria.
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with two of the
following: daycare during the RSV season, a smoker in
the household, neuromuscular disease, airway
abnormalities, or school age siblings.
3. with chronic lung disease.
2. Influenza immunization is recommended annually in the
Fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
Follow up appointments recommended:
1. Early Intervention at the Criterion [**Location (un) 270**] Early
Intervention Program. Telephone No. [**Telephone/Fax (1) 43148**].
2. Visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 53861**] Home Care. Telephone No. [**Telephone/Fax (1) 63802**].
3. Infant follow up program at [**Hospital3 1810**]. Telephone
No. [**Telephone/Fax (1) 37126**].
4. Ophthalmology (Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **]) telephone No.
[**Telephone/Fax (1) 54018**] at 6 months after discharge.
5. Pediatrician, Dr. [**Last Name (STitle) 63800**], on [**11-3**]
6. Pulmonary Clinic at [**Hospital3 1810**] (Dr. [**Last Name (STitle) 37305**] on
[**12-1**]. [**Telephone/Fax (1) 38834**] (page)
DISCHARGE DIAGNOSIS:
1. Prematurity at 26 and 6/7 weeks gestation, now 46 weeks.
2. Twin No. 1.
3. Respiratory distress syndrome, treated.
4. Apnea of prematurity, resolved.
5. Chronic lung disease on diuril.
6. Feeding discoordination, improved.
7. Hyperbilirubinemia of prematurity, treated.
8. Patent ductus arteriosus, treated.
9. Premature atrial contractions, resolved.
10. Hypotension, treated.
11. Presumed sepsis, treated.
12. Klebsiella pneumonia, treated.
13. Intraventricular hemorrhage, Grade II, resolved.
14. Stable mild ventriculomegaly.
15. Retinopathy of prematurity, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 58465**]
MEDQUIST36
D: [**2113-10-31**] 21:09:12
T: [**2113-11-1**] 00:39:30
Job#: [**Job Number 63803**]
|
[
"7742",
"V053",
"53081"
] |
Admission Date: [**2136-1-20**] Discharge Date: [**2136-1-22**]
Date of Birth: [**2089-5-3**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Aphasia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
[**Known firstname **] [**Known lastname 22950**] is a 46-year-old man, with history of glioblastoma
multiforme, s/p resection in [**2135-6-6**], chemo-irradiation with
Nuvigil, 2 cycles of adjuvant temozolomide, and 3 cycles of
XL-184. He was most recently on cycle 3 XL-184 on [**2136-1-17**]. He
presents to ED on [**2136-1-20**] with complaints of
expressive/receptive aphasia. Please see admission note for
full details. He states on the morning of admission and did not
feel "quite right". His family came home found found him to be
confused and having difficulty expressing himself. They state
that it seemed like he knew what he wanted to say, but would
just say "gibberish" and would become frustrated due to this.
The patient did not recall any clonic activity and this is not
his usual symptom after having a seziure. He was seen by Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] 2 days ago and was recommended to decrease his
dexamethasone dose from 0.5 mg QOD to 0.25mg QOD. Therefore, he
did not take his dose 1 day prior to admission. Before coming
to the ED the family spoke with a nurse in the [**Hospital **]
clinic and recommended to take his dexamethasone dose as well as
increase his Keppra afternoon dose in case this may have been a
seizure.
While in the ED, he was noted to be hypertensive with SBPs 180s.
Dr. [**Last Name (STitle) 724**] was called while patient was in the ED, and
recommended BP control with hydralazine, as well as giving
increased dexamethasone for persistent headache and possible
cerebral edema. He was given hydralazine 25 mg x 1, and
dexamethasone 4 mg IV x 1 in ED. His BP improved to 150s, and
his aphasia did seem to improve in the ER per report. Patient
reported some blotchiness with hydral in ER. He had a head CT
while in the ED which showed possibly small punctate area of
hemorrhage, as well as some edema which was noted on MRI 2 days
ago. Neurosurgery was consulted in ED, and did not feel there
was any surgical issue at this time. Patient was admitted to
the MICU for blood pressure control.
Past Medical History:
PAST ONCOLOGICAL HISTORY:
(1) a stereotaxic brain biopsy by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on
[**2135-6-17**],
(2) s/p gross total surgical resection by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on
[**2135-6-22**],
(3) received involved-field cranial irradiation with
temozolomide to [**2135-7-11**] to [**2135-8-22**],
(4) started Nuvigil on [**2135-7-12**] and stopped on [**2135-9-5**],
(5) s/p 2 cycles of adjuvant temozolomide at 200 mg/m2/day x 5
days since [**2135-9-24**], and
(6) s/p 2 cycle of XL-184, which was started on [**2135-11-25**].
PAST MEDICAL HISTORY:
Arthritis
GERD
Hashimoto's thyroiditis
Glaucoma
[**Last Name (un) 8061**]
Status post shoulder surgery
Seizures
Social History:
He lives at home with wife. [**Name (NI) **] denies tobacco, drugs, or
alcohol.
Family History:
Mother with brain tumor (astrocytoma).
Physical Exam:
Neurosurgery Examination in ED:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Unable to speak states "Ah-um"
Language: Unable to process any speech
Naming not intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5 to 3 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-9**] throughout. No pronator drift
Sensation: Intact to light touch
On transfer to OMED:
VITAL SIGNS: Temperature 98.2 F, blood pressure 119/82, pulse
65, respiration 18, and oxygen saturation 95% in room air.
GENERAL: NAD, Comfortable, appears stated age, pleasant, some
minimal difficulty with word finding
SKIN: No lesions, rashes, bruises
HEENT: AT/NC, PERRLA, EOMI, anicteric, no conjuctival pallor,
MMM, clear oropharynx, no erythema
NECK: Supple, trachea midline, no LAD
LUNG: Clear to auscultation bilaterally, no R/R/W
CARDIOVASCULAR: S1&S2, RRR, no R/G/M
ABDOMEN: Soft, +BS, NT, ND, no rebound, no guarding
EXTREMITIES: No C/C/E. +2 pulses radial, DP, PT b/l &
symetrical
NEUROLOGICAL EXAMINATION: His Karnofsky Performance Score is
70. He is awake, alert, and oriented times 3. His language is
fluent with good comprehension, naming, and repetition. His
short-term recall is fine. Cranial Nerve Examination: His
pupils are equal and reactive to light, 4 mm to 2 mm
bilaterally. Extraocular movements are full; there is no
nystagmus. Visual
fields are full to confrontation. His face is symmetric.
Facial sensation is intact bilaterally. His hearing is intact
bilaterally. His tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: There is no drift or pronation. His muscle
strengths are [**5-9**] at all muscle groups. His muscle tone is
normal. His reflexes are 2- and symmetric bilaterally. His
knee jerks are 2-. His ankle jerks are absent. His toes are
down going. Sensory examination is intact to touch and
proprioception. Coordination examination does not reveal
dysmetria. Gait and stance are deferred.
Pertinent Results:
On admission:
[**2136-1-20**] 03:41PM BLOOD WBC-4.5 RBC-4.66 Hgb-13.9* Hct-39.9*
MCV-86 MCH-29.7 MCHC-34.8 RDW-15.0 Plt Ct-258
[**2136-1-20**] 03:41PM BLOOD Neuts-63.9 Lymphs-18.4 Monos-3.7
Eos-12.6* Baso-1.4
[**2136-1-20**] 03:41PM BLOOD PT-11.5 PTT-21.2* INR(PT)-1.0
[**2136-1-20**] 03:41PM BLOOD Glucose-138* UreaN-10 Creat-0.9 Na-138
K-4.2 Cl-101 HCO3-28 AnGap-13
[**2136-1-20**] 03:41PM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.3 Mg-1.9
[**2136-1-20**] 03:41PM BLOOD ALT-54* AST-42* LD(LDH)-337* AlkPhos-91
TotBili-0.3
[**2136-1-20**] 03:41PM BLOOD TSH-5.0*
On discharge:
[**2136-1-22**] 07:25AM BLOOD WBC-5.9# RBC-4.77 Hgb-14.2 Hct-42.3
MCV-89 MCH-29.8 MCHC-33.6 RDW-15.0 Plt Ct-294
[**2136-1-22**] 07:25AM BLOOD Glucose-113* UreaN-17 Creat-1.0 Na-142
K-4.4 Cl-110* HCO3-19* AnGap-17
[**2136-1-22**] 07:25AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2
[**2136-1-22**] 07:25AM BLOOD ALT-47* AST-29 LD(LDH)-273* AlkPhos-82
TotBili-0.5
Imaging:
[**2136-1-20**] CT HEAD
1. Stable appearance to extensive vasogenic edema in the left
temporoparietal lobe. There is punctate hyperdensity, likely
hemorrhage, within the surgical bed. The acuity of this
hemorrhage is uncertain as there are no recent prior CTs for
comparison, although some susceptibility artifact in this region
on the prior MR suggests that it was present at that time.
There are no areas of hemorrhage outside of the lesional cavity.
2. No new mass effect. MRI is more sensitive for the detection
of acute ischemia.
[**2136-1-20**] Chest X-Ray: Mild left basilar atelectasis.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 22950**] is a 46-year-old man, with history of glioblastoma
multiforme, s/p resection in [**2135-6-6**], chemo-irradiation with
Nuvigil, 2 cycles of adjuvant temozolomide, and 3 cycles of
XL-184. He is presented with expressive/receptive aphasia and
hypertensive urgency.
(1) Aphasia: CT head with edema, possibly small punctate foci
of hemorrhage in surgical bed, but edema unchanged from prior
MRI 2 days ago. His symptoms were thought to be most consistent
with post-ictal aphasia after a seizure than due to edema or
stroke. He had no evidence of increased intracranial pressure
on serial neuro exams. He was continued on his home Keppra and
Lamictal. His dexamethasone was increased, to be taken 4 mg
every other day at time of discharge. He was also started on
acetazolamide for its anti-seizure properties.
(2) Glioblastoma Multiforme: CT head was stable. Pt was started
on cycle 3 of C3 XL-184 on [**2136-1-17**]. He will call Dr. [**First Name (STitle) **] T.
[**Doctor Last Name **] office for follow-up.
(3) Hypertensive Urgency: Possibly elevated BP due to increased
dexamethasone dose. There was no evidence of increased
intracranial pressure on serial neurological examinations. His
blood pressure was initially controlled with labetalol 100 mg
[**Hospital1 **] which was uptitrated to 200 mg [**Hospital1 **]. Hoewver, as he
subequently became hypotensive, this was discontinued. His
blood pressure control stabilized prior to floor transfer.
(4) Glaucoma: Patient continued on home eye drop medications.
(5) GERD: Patient continued on home famotidine.
(6) CODE: Full. Health care proxy is wife [**Name (NI) **]: [**Telephone/Fax (1) 82286**]).
Medications on Admission:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
3. Dexamethasone 0.5 mg daily
4. LeVETiracetam 1000 mg QAM/ 500 mg Q3PM /1250 mg QHS
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE [**Hospital1 **]
6. Docusate Sodium 100 mg PO BID
7. Famotidine 20 mg PO/NG Q12H
8. Multivitamins 1 TAB PO/NG DAILY
9. LaMOTrigine 150 mg / 75 mg / 150 mg
10. Thyroid 45 mg PO/NG DAILY
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
3. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO every other
day: Start on [**2136-1-24**]. Disp:*30 Tablet(s)* Refills:*0*
4. Levetiracetam 500 mg Tablet Sig: As directed Tablet PO three
times a day: Plesae take 1000mg qAM, 500mg q3pm, 1250mg qhs.
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Lamotrigine 25 mg Tablet Sig: As directed Tablet PO three
times a day: Please take 150 mg qAM, 75 mg q3PM, and 150 mg qHS.
10. Thyroid 30 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
11. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Aphasia, likely post-ictal
- Hypertensive urgency
Secondary
- Glioblastoma multiforme
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You presented to the hospital for confusion and difficulty
speaking. Your CT head showed no evidence of a stroke but your
blood pressures were initially elevated in the emergency room.
You were admitted to the ICU but you were transferred to the
floor after your symptoms resolved. They were thought to be an
after effect of a seizure.
The following changes were made to your medications:
- INCREASED dexamethasone
- STARTED acetazolamide
Please take all medications as prescribed.
Thank you for allowing us to take part in your medical care.
Followup Instructions:
Please call Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 1844**] to
schedule your follow up appointment with him.
|
[
"4019"
] |
Admission Date: [**2145-6-9**] Discharge Date: [**2145-6-14**]
Date of Birth: [**2094-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 [**2145-6-10**] with the left
internal mammary artery to the second diagonal artery and
reverse saphenous vein grafts to the posterior descending
artery, left anterior descending artery, and the first obtuse
marginal artery.
History of Present Illness:
History of Present Illness: New onset chest and back pain
associated with indigestion and diaphoresis over the last
several
weeks. Seen by PCP and in ER where he ruled in for MI. Then
brought to cardiac catheterization lab where he was found to
have
three vessel coronary artery disease. In ER Trop 0.1, CK 303,
CK-MB 18.7
Past Medical History:
none
Social History:
Race: caucasian
Last Dental Exam:
Lives with: wife and 3 children
Occupation: commercial banker
Tobacco: denies
ETOH: [**2-3**] glasses of wine/night
Recreational drugs: denies
Family History:
father had MI at age 55
Physical Exam:
Pulse: 58 Resp: 16 O2 sat: 99% RA
B/P Right: 112/78 Left:
Height: 5'[**46**]" Weight: 84.4K
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact, nonfocal exam
Pulses:
Femoral Right: cath site Left: 2+
DP Right: - Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit no Right: Left:
Pertinent Results:
intraop 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. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe apical, mid and distal anterior, and distal anteroseptal
and anterolateral hypokinesis. Left ventricular ejection
fraction is in the 40 to 45% range. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
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. Physiologic mitral
regurgitation is seen (within normal limits). Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
Post bypass
Patient is A paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Aorta is intact
post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting
physician
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2145-6-10**] where the patient underwent Coronary
artery bypass grafting x4 with the left
internal mammary artery to the second diagonal artery and
reverse saphenous vein grafts to the posterior descending
artery, left anterior descending artery, and the first obtuse
marginal artery [**2145-6-10**].
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 on no inotropic or vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD #4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home in good condition with appropriate
follow up instructions.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] of [**Hospital3 **]
Discharge Diagnosis:
Coronary artery disease
Coronary artery bypass grafting x4 [**2145-6-10**] with the left
internal mammary artery to the second diagonal artery and
reverse saphenous vein grafts to the posterior descending
artery, left anterior descending artery, and the first obtuse
marginal artery.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
You have a follow up appointment with your surgeon Dr.[**Last Name (STitle) **]
[**2145-7-28**] at 1:00pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr. [**First Name (STitle) **] [**Last Name (NamePattern4) 85529**] [**Telephone/Fax (1) 43460**] in [**1-2**] weeks
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] [**Telephone/Fax (1) 3658**] in [**1-2**] weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2145-6-14**]
|
[
"41071",
"2851",
"41401"
] |
Admission Date: [**2107-8-20**] Discharge Date: [**2107-8-26**]
Date of Birth: [**2033-4-27**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
female, with past medical history significant for
schizophrenia, a recent T12 burst fracture complicated by
bilateral lower extremity paresis, diabetes mellitus and
COPD, who presented from her rehab with fever, change in
mental status and hypotension. In rehab, there was concern
for pneumonia, so she was given empiric Flagyl and
levofloxacin. In the emergency department, temperature was
104, heart rate 130, BP 168/63, respiratory rate 36-42, 100%
on nonrebreather, unable to answer questions. She
subsequently developed respiratory distress and was
intubated. Her orogastric tube put out small amounts of
reddish fluid. Her stool was guaiac positive. She developed
supraventricular tachycardia at a rate of approximately 150,
subsequently read out as sinus tachycardia, and she was
admitted to the ICU.
REVIEW OF SYSTEMS: Unable to be obtained at the time of
admission.
MEDS AT TRANSFER FROM OUTSIDE FACILITY: Levaquin 500 mg p.o.
x1, insulin - Lispro per sliding scale, Ativan 0.5 mg p.o.
p.r.n. anxiety, metoprolol 50 mg p.o. b.i.d., albuterol nebs,
Atrovent nebs, calcitonin 200 units inhaled q. day, Haldol 50
mg IM q. month, fluticasone 110 mcg b.i.d., Zyprexa 7.5 mg
p.o. once daily, mirtazapine 30 mg p.o. at bedtime, senna
daily, aspirin daily, Colace daily, nicotine patch q. 24 h.
11 mg, lactulose 30 mL p.o. b.i.d. p.r.n., heparin subcu
b.i.d., multivitamin, Cogentin 1 mg p.o. b.i.d.
ALLERGIES: Include Risperdal and an ACE inhibitor for which
she developed angiolaryngeal edema requiring intubation.
PAST MEDICAL HISTORY: Dementia, schizophrenia, history of GI
bleed for which she declined work-up, gastroesophageal reflux
disease, COPD, hypertension, diabetes mellitus,
osteoarthritis, neuropathy, urinary incontinence, recent T12
burst fracture complicated by bilateral lower extremity
paresis, status post T12 vertebrectomy and T11-L1 fusion by
Dr. [**Last Name (STitle) 363**]. Her OR course at that time was complicated by a
lung collapse requiring a chest tube placement, spinal,
status post PEG placement in [**2107-7-9**].
FAMILY HISTORY: Has siblings with schizophrenia, otherwise
noncontributory.
SOCIAL HISTORY: Longstanding mental illness, presently
living in nursing home.
PHYSICAL EXAM ON ADMISSION: She was intubated, sedated.
Pupils equal, round and reactive to light. Oropharynx could
not be assessed. Neck: Right IJ in place with dressing.
Chest: A few crackles at base, decreased breath sounds, no
wheezes. Cardiac: Normal S1, S2, II/VI systolic ejection
murmur heard across the chest. Abdomen soft, nontender. PEG
tube without erythema or draining. Extremities warm, no
cyanosis, clubbing or edema, 2+ DPs bilaterally. Neuro:
Unable to assess. Skin: No rash.
PERTINENT LABS TIME OF ADMISSION: White count 12.9,
hematocrit 28.8, platelets 447, 84% neutrophils, 10%
lymphocytes, INR 1.2. Chem-7 was notable for hypernatremia,
sodium 150, mild hyperglycemia--161, and a BUN and creatinine
of 51 and 0.8. There were low-grade troponin elevations of
0.17 and 0.18, but there was no significant change throughout
the hospitalization. Iron studies revealed a ferritin of 160,
an iron of 58, TIBC of 191, TSH was 1.8. Initial lactate was
2.7.
HOSPITAL COURSE: The patient was admitted to the ICU,
treated with broad-spectrum antibiotics and intubated for
respiratory failure. There was initial concern that she might
have a source of infection in her low back from recent
instrumentation. Full imaging with MRI was precluded by the
placement of hardware; however, she did have a CT and an
evaluation by orthopedics who now feel that this was the
source. Despite broad cultures, no specific organism was
identified; however, during the hospital stay she was noted
to have a left lower lobe consolidation which may be the
primary etiology of her sepsis syndrome. She was successfully
extubated and transferred to the medical floor where she
continued on vancomycin and ceftazidime. Remainder of course
by problems.
1. SCHIZOPHRENIA: Patient was restarted on olanzapine and
Cogentin and remained stable through her hospitalization.
1. SINUS TACHYCARDIA: Patient had intermittent bursts of a
sinus tachycardia at a rate of approximately 140-150;
however, despite the cardiology read this could be an
atrial tachycardia, although flutter seemed unlikely. In
order to treat this, her beta blockers were titrated up
with good effect.
1. DIABETES MELLITUS: She was continued on sliding scale
insulin with good glucose control.
1. She was noted to have several small bullous lesions on
her lower extremities which remained stable.
RELEVANT IMAGING STUDIES:
CT of the chest,INDICATION: Fever, altered mental status.
Recent spine surgery. Evaluate for abdominal source of
infection.
TECHNIQUE: MDCT-acquired axial images from the thoracic inlet to
the pubic symphysis were acquired with the use of intravenous and
oral contrast material and displayed with 5-mm slice thickness.
COMPARISONS: No prior studies are available on PACS for
comparison.
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There is bilateral
lower lobe atelectasis, left larger than right and small left
pleural effusion. No consolidations are seen. The heart appears
normal and there is no pericardial effusion. There are coronary
artery calcifications and calcifications of the
aortic arch and left subclavian origin. There are stable
mediastinal lymph nodes, [**Location (un) **] of which meet size criteria for
pathologic enlargement. No hilar or axillary lymphadenopathy is
seen. There are pedicle screws\t the level of
L2. There are fusion rods extending up to the level of T6. A
metallic cage is seen in the space that appears to be resected
T12 vertebral body. There are transverse fixations screws in the
vertebral bodies of L1 and T11. No paravertebral fluid
collection is seen to suggest the presence of an abscess.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The gallbladder
contains several gallstones but no signs of cholecystitis are
seen. The liver, spleen, pancreas, stomach and small and large
bowel loops appear unremarkable. A G- tube is seen in
appropriate position. No free air is seen. There is no
ascites. No localized fluid collections are seen to suggest the
presence of an abscess. The kidneys contain multiple
hypoattenuating lesions, sub-centimeter in size, too small to
characterize. The right adrenal gland appears normal, the left
adrenal gland contains a 19 x 16 mm nodule which may represent an
adenoma but cannot be fully characterized on this single phase
study.
CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: There is
sigmoid diverticulosis without evidence of diverticulitis. The
rectum appears unremarkable. The bladder contains a Foley
catheter and appears unremarkable. The uterus is not well seen,
and may be atrophic or surgically absent. No
free fluid is seen in the pelvis. No abscess is seen. No pelvic
lymphadenopathy is seen.
BONE WINDOWS: Extensive post-surgical changes as described in
the chest section. There is a bony defect in the right iliac
[**Doctor First Name 362**] consistent with a bone graft harvest site. No suspicious
lytic or sclerotic lesions are seen.
IMPRESSION:
1. Status post extensive spine surgery without evidence of
paraspinal abscess.
2. Bilateral dependent atelectasis and small left pleural
effusion.
3. Cholelithiasis without evidence of cholecystitis.
4. Multiple hypoattenuating lesions in both kidneys, too small
to characterize. Statistically, these most likely represent
cysts.
5. Sigmoid diverticulosis without evidence of diverticulitis.
6. Possible left adrenal adenoma. A dedicated CT may be
performed for further evaluation if clinically inicated.
ECHOCARDIOGRAM:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened. There
is no aortic valve stenosis. Mild to moderate ([**1-10**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
PORTABLE CHEST X-RAY: Compared to portable film from [**107-8-21**], there is placement of a left PICC terminating in the mid
SVC. A new patchy infiltrate is seen retrocardiac in the left
lower lobe representing either atelectasis or consolidation. The
endotracheal tube has been removed. The remainder of the
examination appears unchanged since prior film.
IMPRESSION: Placement of left PICC terminating in the distal
SVC. Interval removal of endotracheal tube. Atelectasis versus
consolidation in left lower lobe.
MAJOR INTERVENTIONS: Include endotracheal intubation, right
internal jugular subclavian vein triple-lumen catheter, and
left antecubital PICC line placement.
-Lopressor 50 mg Tablet Sig: 75 mg Tablets PO twice a day.
-Combivent 103-18 mcg/Actuation Aerosol Sig: [**1-10**] Inhalation
four times a day.
-Ceftazidime 1 g Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 3 days: Stop on [**8-28**].
-Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every
twelve (12) hours for 3 days: stop on [**8-28**].
-Nicotine 11 mg/24 hr Patch 24HR Sig: One (1) Transdermal once
a day.
-Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a
-Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
-Cogentin Sig: 1 mg PO once a day.
-Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Inhalation
twice a day.
-Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1)
Subcutaneous four times a day: As per Sliding Scale.
-Calcium 500 500 mg Tablet Sig: One (1) Tablet PO three times
a day.
-Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
-Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
-Lactulose 10 g/15 mL Solution Sig: Three (3) PO twice a day
as needed for constipation.
-Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
-Remeron 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
-Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
-Nystatin 100,000 unit/mL Suspension Sig: One (1) PO three
times a day as needed: swish&swallow.
-Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal once a day.
-Haldol Decanoate 100 mg/mL Solution Sig: 80mg Intramuscular
once a month.
-Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
-Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO 2x/week
for 3 months.
-Bactroban 2 % Ointment Sig: One (1) Topical twice a day: To
open bullae on right lower extremity
DISCHARGE DIAGNOSES -
PRIMARY:
1. Sepsis.
2. Respiratory failure.
3. Left lower lobe pneumonia.
4. Delirium.
5. 19 x 16 mm nodule left adrenal adenoma, outpatient follow-up
recommended.
DISCHARGE DIAGNOSES - SECONDARY:
1. Dementia.
2. Schizophrenia.
3. Chronic gastrointestinal bleed for which she declined
gastrointestinal work-up.
4. Gastroesophageal reflux disease.
5. Chronic obstructive pulmonary disease.
6. Vitamin D deficiency.
7. Hypertension.
8. Diabetes mellitus.
9. Osteoarthritis.
10. Neuropathy.
11. Urinary incontinence.
12. Status post T12 burst fracture complicated by paraplegia
status post T11 through L1 fusion.
13. Chest tube placement for lung collapse.
14. Laryngeal edema requiring intubation secondary to ACE
inhibitor.
15. Methicillin resistant Staphylococcus aureus.
16. Percutaneous endoscopic gastrostomy tube placement.
CONDITION ON DISCHARGE: Patient stable for transfer to
[**Hospital **] Healthcare which is the facility from which she
came.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Last Name (NamePattern1) 28140**]
MEDQUIST36
D: [**2107-8-26**] 11:57:10
T: [**2107-8-26**] 13:04:31
Job#: [**Job Number 98706**]
|
[
"0389",
"51881",
"486",
"496",
"2760",
"99592",
"42789",
"25000",
"53081",
"2859",
"2720",
"4019"
] |
Admission Date: [**2112-9-12**] Discharge Date: [**2112-10-5**]
Date of Birth: [**2049-6-22**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Transferred to [**Hospital1 18**] for STEMI/cardiogenic shock
Major Surgical or Invasive Procedure:
Cardiac catheterization, placement of two stents in the left
dircumflex coronary artery.
Placement of intra-aortic balloon pump.
Placement of Swan-Ganz catheter via femoral access.
Cardioversion x 3 for ventricular tachycardia.
Emergent repeat cardiac catheterization.
History of Present Illness:
The patient is a 63 year old male transfered to [**Hospital1 18**] from an
OSH for STEMI, in cardiogenic shock on pressors.
Pt initially presented to [**Hospital3 3583**] on [**2112-9-11**] with SOB
and chest pain of approximately 1 wk duration. In OSH ED, was
found to have RML PNA. He also reported fall one week prior with
facial ecchymosis, found to have nasal fx by CT. EKG showed
sinus tach in the 130s with Qs in II,III,aVF with nl. axis and
intervals and T-waves inverted in inferior leads and ST
depressions in the lateral leads. Pt received ASA, b-blockers,
morphine, nitro paste, levaquin and was pain-free with sats in
the 90%s on 100%NRB. Troponin was 0.525 with flat CK. T max
99.1. WBC 15.9, Hct 44.5%. Received lovenox sq, with last dose
at 12am [**2112-9-12**].
On [**9-12**] at noon, pt became SOB and diaphoretic with pain, and
sats fell to 77% on 100%NRB with HR120. Received 40mg of lasix,
4mg morphine, and was intubated at 12:30pm. At 1pm, EKG showed
sinus at 100, nl intervals and axis with Qs in III & aVF, ST
elevations in III>II, and ST depressions in I,aVL. Blood
pressure fell s/p intubation to 60s/20s requiring fluid
resuscitation and dopamine 10mcg/kg/min. O2 sats rose to 88% on
AC700mlx14/min + 5PEEP. CXR showed worsening of a R lung
alveolar process with extrusion to the L side, with a
differential of infection vs R>L pulmonary edema. Patient was
then transferred to [**Hospital1 18**].
Past Medical History:
1. Gout
2. EtOH abuse
3. Hypercholesterolemia
Social History:
History of EtOH abuse. No PCP.
Physical Exam:
Gen: intubated, sedated. Not responsive to calling name or
sternal rub.
Skin: Abdominal rash resolved. Feet less mottled. +posterior
scrotal excoriations. + 3 bullae filled with clear liquid on L
ventral wrists and L thumb - improving.
HEENT: PERRL, MM moist.
Heart: RRR. II/VI Holosystolic murmur at apex.
Lungs: slight crackles B vs. upper airway noise (ant
auscultation).
Abd: soft. hypoactive bowel sounds.
Extrem: tr pitting edema B LE.
Neuro/Psy: Not following commands.
Access: R IJ swan in place. L wrist with A-line.
Pertinent Results:
[**2112-9-12**] 07:58PM WBC-16.5* RBC-4.43* HGB-13.7* HCT-40.3 MCV-91
MCH-31.0 MCHC-34.1 RDW-13.2
[**2112-9-12**] 07:58PM PLT COUNT-217
[**2112-9-12**] 07:58PM PT-13.9* PTT-32.9 INR(PT)-1.2
[**2112-9-12**] 06:46PM GLUCOSE-189* LACTATE-2.2* K+-3.9
[**2112-9-12**] 03:07PM TYPE-ART PO2-57* PCO2-45 PH-7.33* TOTAL
CO2-25 BASE XS--2 INTUBATED-INTUBATED
[**2112-9-12**] 07:58PM ALT(SGPT)-14 AST(SGOT)-33 LD(LDH)-361*
CK(CPK)-214* ALK PHOS-140* AMYLASE-49 TOT BILI-0.8
[**2112-9-12**] 07:58PM GLUCOSE-179* UREA N-24* CREAT-1.5* SODIUM-136
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17
[**2112-9-12**] 11:49PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2112-9-12**] 11:49PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2112-9-12**] 11:49PM URINE RBC-[**3-25**]* WBC-0-2 BACTERIA-MANY
YEAST-NONE EPI-0-2
CATH [**2112-9-12**]: LMCA had a 40% lesion. LAD had diffuse luminal
irregularities but was free of significant stenoses and supplied
2 moderate-sized diagonal branches which were also free of
significant disease. LCX had a hazy 60% lesion in the mid
vessel and a hazy 80% lesion in the distal vessel. The RCA was a
small
vessel and was totally occluded in the mid segment. A R-PDA was
seen
filling via L-R collaterals. Resting hemodynamics revealed
evidence of cardiogenic shock with an aortic pressure of 94/53
mmHg, a cardiac index of 1.3 L/min/m2 and a
PCWP of 30 mmHg on an infusion of dopamine at 10 mcg/kg/min.
stented
with a 3.5 x 13 mm cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 55492**] and 3.0 x 13 mm cypher
[**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 22595**] at 14 atms with no residual stenosis, no dissection and
timi 3
flow.
Transthoracic Echo [**2112-9-13**]:
EF 70% The overall left ventricular ejection fraction is normal
(borderline
hyperdynamic) but the lateral wall and adjacent segments of
anterior free wall
are hypokinetic relative to the frankly hyperdynamic inferior
and posterior
walls. Right ventricular systolic function appears depressed.
There is a
trivial/physiologic pericardial effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2112-9-12**], the cardiac rhythm is atrial fibrillation with ventricular
tachycardia;
the lateral wall (which now appears relatively hypokinetic) was
not
well-visualized on the prior study; therefore no direct
comparison of
contractile function in this territory can be made.
Transesophageal Echo [**2112-9-13**]:
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. Left
ventricular wall thickness, cavity size, and systolic function
are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter
and free of atherosclerotic plaque. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion. Trace aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. The mitral
leaflets are
myxomatous. There is moderate/severe posterior mitral leaflet
prolapse. There
is partial mitral leaflet flail. There is moderate thickening of
the mitral
valve chordae. Severe (4+) mitral regurgitation is seen.
Brief Hospital Course:
The patient was admitted to the CCU service after his
catheterization. Overall the following weeks the pt was
determined to be extremely sick with multiple organ system
failure. He needed a mitral valve replacement surgery, however,
in order to have this surgery he would need to be extubated and
afebrile. He was treated with hemodialysis and further diuresis
was attempted with IV diuretics and BNP, however the pt's
respiratory status remained tenuous. Furthermore, he did not
wake up when sedation was weaned. He was evaluated by Neuro with
an EEG that showed only diffuse slowing and a head CT that
showed no acute changes. It was felt likely that due to his
episodes of hypotension with the VT and other hemodynamic
instability later that he had sustained anoxic brain injury.
This was all discussed with the family who felt that the pt
would not have wanted to be kept alive on a ventilator long-term
when any hope of recovery was extremely slim. As all attempts to
wean him from the ventilator were unsuccessful he was made CMO
and made comfortable with morphine. He died shortly after.
Medications on Admission:
unknown
Discharge Medications:
pt expired.
Discharge Disposition:
Home
Discharge Diagnosis:
Pt expired of respiratory failure.
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
[
"4280",
"4240",
"42731",
"5845",
"486"
] |
Admission Date: [**2115-11-20**] Discharge Date: [**2115-11-22**]
Date of Birth: [**2115-11-20**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: This late preterm infant born at
36 and 4/7 weeks was admitted to the newborn ICU for
management of respiratory distress. He was born to a 38-year-
old G1 P0 to 1 mother with prenatal screens as follows, blood
type A positive, antibody negative, group B strep negative,
hepatitis B surface antigen negative, RPR nonreactive.
Past obstetrical history remarkable for a myomectomy in
[**2114-10-23**]. Antepartum was reportedly benign. Admitted
yesterday with preterm contractions. Given uterine scar and
risk for dehiscence or abruption, decision was made to
deliver by C section under spinal anesthesia. Apgars were 8
and 9 at 1 and 5 minutes. In the delivery room the baby was
noted to be grunting, flaring and retracting, thus prompting
admission to the newborn ICU.
PHYSICAL EXAMINATION: Upon admission remarkable for preterm
infant in mild to moderate respiratory distress with vital
signs of 97.5, heart rate 120, respiratory 24, blood pressure
65/39 with a mean of 49. The baby was [**Name2 (NI) **]. Anterior
fontanelle was open and soft. Normal faces. Intact [**Last Name (un) **].
Mild retractions with fair air entry. Regular rate and
rhythm. Grade 1/6 systolic murmur at the lower left sternal
border. Present femoral pulses. Abdomen is flat, soft,
nontender without hepatosplenomegaly. Normal phallus, testes
and scrotum. Stable hips. Fair profusion, fair tone and
normal activity.
HOSPITAL COURSE: Respiratory. The infant continued to have
mild grunting with intermittent tachypnea and required blow
by oxygen intermittently for the first 12 hours. Since that
time has been in room air, breathing comfortably with
respiratory rate 30s to 40s. O2 saturation is greater than
92% in room air.
Cardiovascular. Continues to be hemodynamically stable with
blood pressures 60//40 with a mean of 47, AP 130s to 150.
Chest x-ray was done on admission revealed normal heart size,
normal bony structures, prominent pulmonary vascularity
consistent with retained fetal lung fluid, small bilateral
pleural effusions also noted. Normal sinus.
FEN. Because of the mild respiratory distress, the baby was
maintained NPO with a peripheral IV in place delivering D10W
at 60 mls per kilo per day. Baby has voided and passed
meconium stool. He has been euglycemic with D stick in the 90
range on running IV fluids. Baby started to feed on day of
life 1 and has been feeding well and IV fluids have been
discontinued. He is breast feeding.
GI. Bilirubin will be obtained with a newborn state screen
prior to discharge. No clinical evidence at this time of
jaundice.
Heme/ID. A CBC and blood culture were obtained upon
admission. The CBC showed a white count of 14.5 with 53
polys, 10 bands and 29 lymphocytes, a hematocrit of 43.2 and
platelets 230,000. Blood culture has remained negative and
infant completed a 48 hour course of antibiotics pending
cultures and clinical course.
Neurological. Baby is acting appropriate for gestational age.
Sensory. Ophthalmology exam is not indicated at this gestation
[**Doctor Last Name **]
age.
Psycho/social. Intact family. First baby.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: To the newborn nursery.
PRIMARY PEDIATRICIAN: Has not yet been identified by the
family.
CARE AND RECOMMENDATIONS AT DISCHARGE:
Feedings, continue breast feeding, supplement as needed.
Medications: s/p ampicillin and gentamicin.
Car seat position screening has not yet been performed.
State newborn screening has not yet been performed.
Immunizations, there have been none to date.
Hearing screen: to be done prior to discharge
Immunizations recommended, Synagis RSV should be
considered [**Month (only) **] through [**Month (only) 958**] for infants who meet any of
the following 3 criteria, infants born at less than 32 weeks,
infants born between 32 and 35 weeks with 2 of the following,
day care during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings and 3 infants with chronic lung disease. Influenza
immunization is recommended annually in the fall for all
infants once they reach 6 months of age. Before this age and
for the first 24 months of the childs life, immunization
against influenza is recommended for household contacts and
out of home caregivers.
Follow up appointments recommended with the primary care
physician once identified.
DISCHARGE DIAGNOSES:
1) Prematurity at 36 and 4/7 weeks,
2)transient tachypnea of the newborn, and
3) r/o sepsis with antiobitics.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31759**], MD [**MD Number(1) 43886**]
Dictated By:[**Last Name (NamePattern1) 54678**]
MEDQUIST36
D: [**2115-11-22**] 02:08:25
T: [**2115-11-22**] 06:33:44
Job#: [**Job Number 69905**]
|
[
"V290",
"V053"
] |
Admission Date: [**2153-4-27**] Discharge Date: [**2153-5-10**]
Date of Birth: [**2078-4-14**] Sex: M
Service: [**Hospital1 **]
CHIEF COMPLAINT: Chest pain
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
Russian speaking male with a past medical history significant
for coronary artery disease, status post myocardial
infarction in [**2143**], status post percutaneous transluminal
coronary angioplasty and stent to the LAD and left circumflex
in [**2152-10-21**] in [**Location (un) **] who presents with worsening
and more frequent episodes of chest pain.
The patient notes daily angina at rest, as well as when
exerting himself which is substernal in location without
radiation. There was no associated nausea, vomiting,
diaphoresis or shortness of breath. Prior to the day of
admission, the daily chest pain was responsive to 3 to 10
sublingual nitroglycerin per day, but over the last 24 hours
his chest pain has been refractory to nitroglycerin and so he
decided to come in. Of note, the patient was seen by his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15490**], in clinic
approximately one weeks prior to admission where the increase
in his angina had been noted. There was a plan for an
outpatient ETT and possible catheter pending those results.
REVIEW OF SYSTEMS: Negative for any orthopnea or paroxysmal
nocturnal dyspnea. There were no fevers or chills, nausea,
vomiting or diarrhea. The patient denied any abdominal pain.
In the Emergency Room, the patient was afebrile and had
stable vital signs. His electrocardiogram showed no acute
changes. His chest pain was not responsive to three
sublingual nitroglycerin, but it completely resolved with 2
mg of morphine.
PAST MEDICAL HISTORY:
1. Coronary artery disease. The patient has had multiple
cardiac catheterizations with the most recent one being done
in [**Location (un) **] in [**2152-10-21**] at which time a stent was
placed in the LAD and left circumflex. His most recent
catheter done at [**Hospital6 256**] prior
to this admission was in [**2151-4-22**]. That catheter showed
a 20% lesion in the left main, 50% in the LAD, 50% in the
left circumflex, previously placed stent which was deemed to
be hemodynamically insignificant and a 75% right coronal
artery lesion. Most recent stress MIBI done in [**2151-4-22**]
showed ischemia in the inferolateral region.
2. Benign prostatic hypertrophy
3. Hypertension
4. Hypercholesterolemia
5. History of pancreatitis during his admission in [**Location (un) **]
for his cardiac catheterization
6. Status post pacer placement in [**2148-12-22**] for sick
sinus syndrome which was upgraded in [**2152-12-22**] for
lead upgrades and generator change.
ADMISSION MEDICATIONS:
1. Aspirin 325 mg po q day
2. Lipitor 40 mg po q day
3. Prevacid 30 mg po q day
4. Prinivil 5 mg po q day
5. Toprol XL 25 mg po q day
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is originally from [**Country 532**]. He
has lived in the United States for approximately six years.
He speaks limited English. He drinks occasional alcohol. He
denies tobacco. He is married. He has one son who lives
nearby as well as a daughter who is a nurse [**First Name8 (NamePattern2) **] [**Name (NI) **].
PHYSICAL EXAM:
VITAL SIGNS: The patient was afebrile. Blood pressure
117/78, heart rate of 52, respiratory rate 18, saturating
97%.
GENERAL: The patient is alert and oriented x3 in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light. Extraocular movements intact. There was
no jugular venous distention.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm, no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended. There was no
hepatosplenomegaly. There were normoactive bowel sounds.
EXTREMITIES: Without cyanosis, clubbing or edema. The PT
pulses were 2+ bilaterally.
ADMISSION LABS: White count of 7.2, hematocrit of 47.3, MCV
of 88, platelets of 173, PT of 12.4, INR 1.1, PTT of 25.
Sodium of 144, potassium of 4.0, chloride of 110, bicarbonate
of 24, BUN of 19, creatinine of 1.0, glucose of 113, CK of
130, MB of 3, troponin less than 0.3. Electrocardiogram -
most recent cholesterol in [**2153-4-21**] showed total
cholesterol of 169, LDL of 102, HDL of 48. Electrocardiogram
showed normal sinus rhythm at 51 beats per minute with normal
axis and normal intervals, except for slight prolongation of
the QRS at 124 milliseconds. There were no acute ST or T
wave changes.
HOSPITAL COURSE: In summary, the patient is a 75-year-old
male with significant coronary artery disease who is admitted
for worsening chest pain. There was concern for possible in
stent restenosis given the patient's recent cardiac
catheterization in [**2152-10-21**]. The patient was
admitted for rule out myocardial infarction.
1. CARDIOVASCULAR: The patient was admitted as already
stated and his cardiac enzymes were cycled. Over the first
24 hours, the patient's CKs remained flat at 130 to 125 to
156, however the MB fraction went from3 to 6 to 9.
Initially, it was unclear whether the patient did have
unstable angina or not given that his enzymes were not
positive and his initial troponin was less than 0.3 despite
over one day of chest pain at home unresponsive to
nitroglycerin. In addition, there was a confounding lab
discovery of acute pancreatitis and it was felt that this may
explain the patient's pain as well. A repeat troponin on the
second hospital day came back positive at 4.4. At that time,
cardiology was consulted for cardiac catheterization given
the fact that the evidence was now showing the patient was
having unstable angina.
Cardiology saw the patient in the morning and recommended
that the patient undergo cardiac catheterization that same
day. However, the patient refused this procedure and wanted
to wait. The urgency was stressed with the patient, but he
still refused the procedure. He was started on an Integrilin
drip, as well as nitroglycerin and heparin drip. He was
continued on his beta blocker and ACE inhibitor. The hope
was that his family could convince him to undergo cardiac
catheterization and the medications would help protect
against further cardiac damage. The patient was chest pain
free with the above interventions, however his platelets
dropped after being on the Integrilin drip for 24 hours and
therefore the Integrilin had to be discontinued.
The importance of cardiac catheterization was again stressed
with the patient and his daughter was [**Name (NI) 653**] and he
finally agreed to go to cardiac catheterization. He was
scheduled to on Monday morning, the fourth hospital day and
he was stable until Monday morning. However, prior to being
transported for catheter, he then developed severe [**8-30**]
substernal chest pain and was rushed to catheterization
emergently. At catheterization, he was found to have 100%
restenosis of his LAD stent, as well as 99% occlusion of the
tube.
He also had 40% proximal in stent stenosis in the left
circumflex artery as well as 50% distal occlusion in the left
circumflex. He also had 70% calcified mid RCA lesion at 60%,
posterolateral RCA lesion. The LAD was restented with good
results. However, the patient did suffer an acute anterior
myocardial infarction prior to catheterization with his CK
peaking at 1334. His electrocardiogram evolved with eventual
development of Qs in leads V2 through V6.
After cardiac catheterization, the patient was scheduled to
return to the general medical floor, but suffered recurrent
chest pain in the recovery suite. Therefore, he was rushed
back into catheter for a re-look. There were no significant
changes during the re-look procedure and no additional
interventions were made. The patient was then transferred to
the CCU for closer monitoring given his unstable nature and
large anterior myocardial infarction.
The patient initially did well after his cardiac
catheterization, however did have intermittent chest pain
with no electrocardiogram changes. However, two days after
cardiac catheterization the patient was found to be
unresponsive to voice, tactile or noxious stimuli. An
emergent head CT was performed (an MRI could not be performed
given the patient's pacemaker as well as recent stent
placement) and it showed no evidence of a bleed, but possible
new stroke in the thalamic region.
From a cardiac standpoint, the patient has been stable
following his catheterization. His blood pressure
medications were held for a period given his acute stroke,
but has since been restarted at low doses. His blood
pressure goal at this point is around a systolic of 120. He
had an echocardiogram performed after his cardiac
catheterization and acute myocardial infarction and his
ejection fraction was found to be down to only 25%. There
was severe depression of overall left ventricular systolic
function. There was severe global hypokinesis with some
preservation of the basal wall motion. This was new compared
with prior echocardiogram. There was no evidence of left
ventricular thrombus.
Given the patient's new depressed ejection fraction, he was
started on a low dose of Lasix to prevent congestive heart
failure. He was on 20 mg po q day. However, on the day of
this discharge summary this has been held as the patient
appears to be getting too dry with this dose. He likely will
need to be on a lesser dose, possibly 20 mg po q o day.
The patient is on Plavix 75 mg for one month given his stent
placement. He is also to continue on aspirin 325 mg q day.
2. NEUROLOGIC: As already stated, the patient suffered an
acute stroke on [**2153-5-2**]. The stroke was felt to be
most likely embolic in origin possibly from plaque that had
been dislodged during the cardiac catheterization.
Neurologic exam immediately after the event showed the
patient to have no eye opening. He was spontaneously
breathing with a normal pattern. There was no blink to
threat. The right pupil was 6 mm and fixed. The left pupils
was 1 mm and could not be assessed for reactivity given how
small it was. There was sluggish response to the doll's
maneuver, but the patient was able to cross midline
bilaterally. There was no facial asymmetry to grimace. The
patient withdrew both arms to nail bed pressure and lifted
them off the bed briefly with at least antigravity power to
the deltoids. He withdrew his left leg and pulled his heel
back all the way to the buttocks. His right leg was
externally rotated and withdrew a few inches. His plantar
responses were noted to be flexor initially.
As already stated, his blood pressure was initially run
higher or attempted to be run higher at greater than 140 by
holding his blood pressure medications. Despite holding his
blood pressure medications however, his blood pressure was
never above the 120 to 130 range. He was started on
Coumadin, both given his low ejection fraction as well as to
help prevent against future cerebral events. He was
continued on heparin as a bridge. His exam was followed
closely.
At the time of this discharge summary, the patient has
improved in regards to his neurologic status. Most recent
neurologic exam performed with an interpreter shows the
patient to be somnolent, but arousable to loud stimuli. He
will open his eyes intermittently on the left. He follows
some simple commands such as sticking out his tongue or
showing two fingers or wiggling his toes. He can answer
simple questions. However, his speech was noted to be
severely dysarthric. He is noted to have a left hemiparesis,
including face, arms and legs. He also has frontal release
signs consistent with possible underlying dementia.
At the time of this discharge summary, we are repeating a
head CT to evaluate extent of the stroke and we are starting
low dose methylphenidate at 5 mg to see if this will help
with the patient's attention and arousability. The neurology
team feels that the patient has a good prognosis given his
degree of recovery in only a few days. At the time of this
discharge summary, the patient's blood pressure has been
allowed to be lower, given that it has been approximately one
week since the event.
3. PULMONARY: The patient was noted to have developed a
pneumonia during the time of his stroke. It was felt to be
likely secondary to aspiration. He was started on Levaquin
and Flagyl and on [**5-10**] he was on day 9 of 14. He is
still having thick secretions, but is improving overall. He
is requiring only 2 liters of oxygen at this point and has
been on room air during the day saturating 95% requiring
oxygen only at night.
4. GASTROINTESTINAL: An nasogastric tube was placed for
tube feeds, given that the patient was not able to feed
himself. Gastrointestinal was consulted for possible PEG
placement given that this will likely be a long term need for
the patient. They did not feel comfortable placing a PEG
given that the patient cannot be taken off Plavix for 30 days
given his high risk for restenosis. A pediatric nasogastric
tube was placed on [**5-9**] in interventional radiology.
The issue with the nasogastric tube is that the patient
continues to grab at it when his hands are unrestrained. At
the time of this discharge summary, we are going to attempt
mittens to see if this will prevent the patient from pulling
out the tube.
In addition, we will see if interventional radiology would be
willing to put in the PEG despite having Plavix on board. If
there was no way to place a PEG, then this would have to be
done when his course of Plavix is finished.
5. HEME: The patient had [**Last Name **] problem in regards to his
hematocrit. His platelets, which had dropped when he was on
the 2B3A have recovered. His most recent hematocrit was 41.9
with most platelets of 246. His Coumadin is currently being
held given the possibility of invasive procedures. He is
being heparinized.
6. FLUIDS, ELECTROLYTES AND NUTRITION: The patient is on
ProMod with fiber at 75 cc an hour with 200 cc free water
boluses 4x daily.
DISCHARGE CONDITION: Fair
DISCHARGE MEDICATIONS:
1. Captopril 6.25 mg po tid, holding for systolic blood
pressure less than 110
2. Levaquin 500 mg per nasogastric tube 24 hours, day 9 of
14
3. Flagyl 500 mg per nasogastric tube tid, day 9 of 14
4. Ritalin 5 mg po q a.m.
5. Metoprolol 12.5 mg po bid, holding for systolic pressure
less than 110 and heart rate less tan 55.
6. Tylenol prn
7. Lipitor 40 mg po q day
8. Plavix 75 mg po q day for 30 days stated on [**4-30**]
9. Senna two tablets q hs
10. Prevacid 30 mg po q day
11. Colace 100 mg [**Hospital1 **]
12. Coumadin dose to be determined with an INR goal of 2 to 3
13. Heparin sliding scale
14. Aspirin 325 glioblastoma multiforme po q day, currently
on hold for possible PEG placement. It has been on hold
since [**5-8**].
15. Lasix 20 mg po q od
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post acute myocardial
infarction
2. LAD, in stent restenosis status post new stent placement
in the LAD on [**4-30**]
3. Hypercholesterolemia
4 Aspiration pneumonia
5. Acute cerebrovascular accident to the right thalamus
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 6859**]
MEDQUIST36
D: [**2153-5-10**] 11:46
T: [**2153-5-10**] 11:41
JOB#: [**Job Number 47275**]
|
[
"5070",
"2875",
"41401"
] |
Admission Date: [**2174-5-19**] Discharge Date: [**2174-5-21**]
Date of Birth: [**2124-12-2**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Left face numbness with tingling and left arm weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 year old right handed man who was diagnosed with HTN 4 years
ago, but has not been taking meds, presents with left face
tingling, and left finger tip tingling since yesterday morning.
He describes his left finger tips as feeling as if they were
frost bitten. He took the day off work because he did not feel
"right." When the symptoms persisted today, he decided to come
into the ER. Mr [**Known lastname **] has not been taking HCTZ in over 3 years
due to concerns of impotence. He has been hypertensive for 4
years. He has not been adherent to a healthy diet.
Past Medical History:
HTN
Social History:
He works as a mailman. He has 4 children, ranging in age from
19-29. He started smoking aged 13 and gave up at age 26, smoking
about 5 cigarettes per day. He drinks about 3-4 beers per week.
He does not use any recreational drugs.
Family History:
Mother had HTN, no strokes. His father died of a lymphoma.
Physical Exam:
Exam:
T-97.8 HR-71 BP-195/125-->212/125 RR-16 SpO2-100
Gen: Lying in bed, prominent eyes but not proptotic, and
slightly
injected
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] and writing
intact. Registers [**2-9**], recalls [**2-9**] in 5 minutes. No right left
confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Fundoscopy shows some silver wiring b/l consistent
with HTN changes. Visual fields are full to confrontation.
Extraocular movements intact bilaterally, no nystagmus.
Sensation
reduced to 85% on the face in V1-V3 on the left. Facial
movement
symmetric. Hearing intact to finger rub bilaterally. Palate
elevation symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
His left arm drifts down.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, vibration and proprioception
throughout. However, if he closes his eyes and attempts to touch
his nose with his left index finger, he hits his eye. Pinprick
is
diminished in the left hand in each terminal phalanx. No
extinction to DSS
Reflexes:
2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger is clumsy on the left, heel to
shin normal, RAMs are clumsy on the left.
Gait: Narrow based, steady.
Romberg: Negative
Pertinent Results:
CT head [**5-20**]
1. Stable focus of intraparenchymal hemorrhage centered in the
posterior limb of the right internal capsule.
2. Stable scattered periventricular and subcortical white matter
hypodensities likely representing the sequelae of chronic
ischemic
microvascular disease.
CXR [**5-19**] - no acute cardiopulmonary process
TTE [**5-20**]
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Basal inferior hypokineis sis suggested in some
views (clips 48,49), but could not be confirmed. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with
preserved global systolic function and ?basal inferior
hypokinesis. Dilated ascending aorta.
[**2174-5-19**] 11:18PM GLUCOSE-92 UREA N-16 CREAT-1.2 SODIUM-139
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2174-5-19**] 11:18PM ALT(SGPT)-14 AST(SGOT)-25 CK(CPK)-413* ALK
PHOS-53
[**2174-5-19**] 11:18PM CK-MB-5 cTropnT-<0.01
[**2174-5-19**] 11:18PM CALCIUM-9.8 PHOSPHATE-5.5* MAGNESIUM-2.2
CHOLEST-181
[**2174-5-19**] 11:18PM %HbA1c-5.9 eAG-123
[**2174-5-19**] 11:18PM TRIGLYCER-129 HDL CHOL-38 CHOL/HDL-4.8
LDL(CALC)-117
[**2174-5-19**] 11:18PM TSH-2.8
[**2174-5-19**] 11:18PM WBC-3.3* RBC-4.90 HGB-13.3* HCT-40.8 MCV-83
MCH-27.1 MCHC-32.5 RDW-13.7
[**2174-5-19**] 11:18PM PLT COUNT-205
[**2174-5-19**] 11:18PM PT-12.4 PTT-25.2 INR(PT)-1.0
[**2174-5-19**] 03:18PM CK(CPK)-544*
[**2174-5-19**] 03:18PM CK-MB-6 cTropnT-<0.01
[**2174-5-19**] 07:25AM GLUCOSE-100 UREA N-13 CREAT-1.2 SODIUM-135
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-29 ANION GAP-13
[**2174-5-19**] 07:25AM ALT(SGPT)-21 AST(SGOT)-41* ALK PHOS-68 TOT
BILI-0.6
[**2174-5-19**] 07:25AM LIPASE-37
[**2174-5-19**] 07:25AM cTropnT-<0.01
[**2174-5-19**] 07:25AM WBC-3.8*# RBC-5.58 HGB-14.8 HCT-46.7 MCV-84
MCH-26.4* MCHC-31.6 RDW-13.6
[**2174-5-19**] 07:25AM NEUTS-48.2* LYMPHS-41.7 MONOS-5.2 EOS-3.2
BASOS-1.7
[**2174-5-19**] 07:25AM PLT COUNT-251#
[**2174-5-19**] 07:25AM PT-11.5 PTT-23.3 INR(PT)-1.0
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to neurology ICU service under care of
stroke team. He was closely observed regarding his neurological
status and was put on cardiac telemetry monitering.
Neuro
He underwent frequent neuro checks. He showed rapid subjective
as well as objective improvment in the symptoms of facial
numbness on the left side and fingertips of the left hand,
especially the index finger. He underwent repeat CT scan on [**5-20**]
which did not show any significant change in the size of bleed
on right thalamic/basal ganglia region.
Cardiac
Blood pressure was very high (212/125) on presentation. He was
in initially started on labetalol drip followed by nicardipine
drip in the ED for better control og blood pressure. He was
started on oral lisinopril 10 mg /day and did not require
nicardipine drip or prn hydrallazine shortly after coming to the
ICU. EKG , cardiac enzymes were negative for acute ischemia. He
underwent TTE which showed LVH but was otherwise not remarkable
Lipid profile showed LDL 117 and HDL 38, TG were 129. he was
advised about diet modification and increasing physical
activity. HbA1c was 5.9
FEN
he underwent bedside swallow test and was started on heart
healthy diet.
Gen care
pneumoboot for DVT prophylaxis were used. he was transfered out
of ICU to stroke floor on [**2174-5-21**].
Medications on Admission:
HCTZ (dose unknown, the patient had not taken this in over 3
years)
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Stroke - intraparenchymal hemorrhage centered in the posterior
limb
of the right internal capsule
Discharge Condition:
Normal neurological examination with no deficits.
Discharge Instructions:
You have had a stroke due to poorly controlled blood pressure.
You must take your blood pressure medication (Lisinopril) daily.
Your primary care physician, [**Name10 (NameIs) **] [**Last Name (STitle) 849**], was away, so we
communicated with her PA [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16249**] who wanted you to get
follow up with the stroke service since you are being discharged
today. In addition to your risk of stroke, your echocardiogram
showed that you heart has changes because of your high blood
pressure. Your kidney function (creatinine 1.2) has remained
stable with the addition of your lisinopril.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2174-7-4**] 2:00 pm.
|
[
"4019"
] |
Admission Date: [**2178-9-3**] Discharge Date: [**2178-9-5**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall
Head Trauma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo woman with CAD who presents after fall from standing
position today, causing a hip fracture as well as significant
SAH and left temporal lobe contusion. She was initially awake
and alert then declined in responsiveness. Intubated in ED.
Past Medical History:
appendectomy
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
98.5 70 173/95 16 96% intubated
Gen: verbalizing incoherently --> non-verbal; disoriented; GCS
10
Head: hematoma at occiput, PERRL
Neck: c-collar in place, no appreciable C-spine stepoffs
CV: RRR
Lungs: CTAB
Abd: soft/NT/ND
Ext: L leg externally rotated and fore-shortened
Back: no C-spine stepoffs
Rectal: guaic neg, nl tone
Pertinent Results:
[**9-3**] Head CT :Large subarachnoid hemorrhage extending along the
interhemispheric fissures and anterior aspect of the suprasellar
cistern and anterior left temporal lobe. Small left
intraparenchymal hemorrhage within the anterior left temporal
lobe. No evidence of herniation.
[**9-3**] CT C-spine: No evidence of fracture or listhesis.
Degenerative changes predominantly at the level of C5-C6 as
described above.
[**9-3**] CTA Head: no aneurysm or dissection. COW and major
tributaries opacify symmetrically. vertebrobasilar system
opacifies well. Right frontal intraparenchymal hemorrhage.
[**9-3**] Blat Hips: L intertroch femur fx
[**9-3**] Head CT:Significant interval progression of right frontal
intraparenchymal hemorrhage which now causes significant mass
effect including subfalcine herniation to the left of
approximately 11 mm. Effacement of the suprasellar cistern is
concerning for possible uncal herniation.
Brief Hospital Course:
Ms. [**Known lastname 7049**] [**Last Name (Titles) 7050**] initially awake and alert, answering questions on
arrival in the Emergency Department, but over several hours
become less and
less responsive. Her diminished mental status was felt likely
related to intracerebral hemorrhages (SAH and a small
intracranial hemorrhage). Over the course of HD #1 the
intraparenchymal hemorrhage expanded, causing mass effect
including subfalcine herniation. A family meeting was held on
[**2178-9-4**] at which time she was made CMO, extubated, and morphine
gtt was started. Ms. [**Known lastname 7049**] [**Last Name (Titles) **] on [**2178-9-4**] at 6:18 AM.
Medications on Admission:
unknown
Discharge Medications:
N/A
Discharge Disposition:
[**Date Range **]
Discharge Diagnosis:
intracerebral hemorrhage
subfalcine herniation
L intertrochanteric femur fracture
Discharge Condition:
[**Date Range **]
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2179-3-17**]
|
[
"5990",
"2761"
] |
Admission Date: [**2162-2-8**] Discharge Date: [**2162-2-23**]
Date of Birth: [**2079-12-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Nabumetone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
[**2162-2-12**] Aortic valve replacement with 21 mm [**Company **] mosiac
ultra porcine valve and coronary artery bypass graft times four.
History of Present Illness:
Ms. [**Known lastname 80837**] is an 82 year old woman who has been followed for
some time for aortic stenosis and mitral regurgitation. She
recently became symptomatic with a syncopal episode. She
therefore was referred for cardiac surgery.
Past Medical History:
aortic stenosis
mitral regurgitation
hypothryroidism
syncope
hypertension
s/p cerebral vascular incident
Social History:
Ms. [**Known lastname 80837**] is a retired legal secretary. She denies any
tobacco history.
Family History:
Her family history is unremarkable.
Physical Exam:
At the time of admission, Ms. [**Known lastname 80837**] was found in no acute
disress. Her skin exam was unremarkable, as was her head, ears,
eys, nose, and throat examination. Her neck was supple with
full range of motion. Her lungs were clear to ausculatation
bilaterally. Her heart was of regular rate and rhythm and a
grade III/VI systolic ejection mumur was appreciated. Her
abdomen was soft, non-tender, and non-distended. No edema or
varicosities were noted. Her neurological exam was grossly
intact. Her femoral, dorsal pedis, posterior tibial, and radial
pulses were noted to be 2+ bilaterally.
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 80838**]Portable TTE
(Complete) Done [**2162-2-17**] at 12:36:31 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2079-12-28**]
Age (years): 82 F Hgt (in): 60
BP (mm Hg): 107/45 Wgt (lb): 136
HR (bpm): 69 BSA (m2): 1.59 m2
Indication: Mitral Regurgitation. Pericardial effusion. S/p
AVR/CABG.
ICD-9 Codes: 423.9, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2162-2-17**] at 12:36 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.36 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Arch: 2.2 cm <= 3.0 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *25 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 14 mm Hg
Aortic Valve - Pressure Half Time: 447 ms
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 2.00
Mitral Valve - E Wave deceleration time: 241 ms 140-250 ms
TR Gradient (+ RA = PASP): 25 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal aortic
arch diameter.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
leaflets move normally. Normal AVR gradient. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild (1+) MR. [Due to acoustic
shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**1-15**]+] TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Bilateral pleural effusions.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The aortic valve prosthesis
leaflets appear to move normally with normal gradient for this
prosthesis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Well seated aortic bioprosthesis with normal
gradient, but trace aortic regurgitation. At least mild mitral
regurgitation. Normal biventricular cavity sizes with preserved
global biventricular systolic function.
CLINICAL IMPLICATIONS:
Based on [**2160**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2162-2-17**] 16:46
PA AND LATERAL CHEST ON [**2162-2-21**]
INDICATION: Status post CABG and AVR-followup.
COMPARISON: [**2162-2-19**].
FINDINGS: Bilateral posterior effusions are evident. Frontal
views show no
significant interval change with no new consolidation and no
pneumothorax.
[**2162-2-22**] 06:40AM BLOOD WBC-12.9* RBC-3.03* Hgb-9.7* Hct-28.5*
MCV-94 MCH-32.0 MCHC-34.0 RDW-14.9 Plt Ct-257
[**2162-2-22**] 06:40AM BLOOD Plt Ct-257
[**2162-2-22**] 06:40AM BLOOD Glucose-89 UreaN-28* Creat-1.3* Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
[**2162-2-8**] 09:55PM BLOOD ALT-33 AST-58* LD(LDH)-226 AlkPhos-84
TotBili-0.2
Brief Hospital Course:
On [**2162-2-12**] Ms.[**Known lastname 80837**] was taken to the operating room and
underwent an aortic valve replacement with a 21mm [**Company 1543**]
Mosiac Ultra Porcine valve and coronary artery bypass grafting
times four (LIMA to LAD, SVG to DIAG, SVG to OM, and SVG to
PDA).Please refer to Dr[**Last Name (STitle) **] operative report for further
details. She tolerated the procedure well and was transferred in
critical but stable condition to the surgical intensive care
unit. She awoke neurologically intact, pressors were weaned and
she was extubated by post-operative day one. All lines and
drains were removed in a timely fashion. Ms.[**Known lastname 80837**] was
transferred to the surgical step down floor on post-operative
day two. There she was found to be in atrial fibrillation and
was placed on amiodarone. Due to hypotension she was
transferred back to the surgical intensive care unit for fluid
status management and tenuous pulmonary status. POD#6 Chest Ct
scan performed to evaluate tracheal malacia. Scan revealed a
sizeable left pleural effusion. left thoracentesis was done,
which drained 700cc serosanguinous fluid. Anticoagulation was
started with coumadin for atrial fibrillation. She was placed on
antibiotics for a left arm phlebitis.She continued to improve
and POD#8 she was transferred back to the step down unit. The
remainder of her post operative course was essentially
uneventful. Ms.[**Known lastname 80837**] continued to progress and she was ready
for discharge to a rehab facility by post-operative day 10 for
further increase in endurance,strength, and increase in daily
activities. All follow up appointments were advised.
Medications on Admission:
synthroid 88mcg, aspirin 325mg, ramipril 10mg, multivitamins,
calcium, vitamin D
Discharge Medications:
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
syncope
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
(AFib)
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 68568**] for Thyroid function test, TSH
6.0 so dose was increased from 88mcg 5x/wk to daily.
See Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 68568**] ([**Telephone/Fax (1) 80839**] PCP [**Last Name (NamePattern4) **] [**1-15**] weeks.
See Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] cardiology in [**1-15**] weeks.
See Dr. [**Last Name (STitle) **] cardiac surgeon ([**Telephone/Fax (2) 80840**] in [**2-16**] weeks at
[**Hospital **] Hospital.
Completed by:[**2162-2-23**]
|
[
"4241",
"2762",
"5119",
"4240",
"4280",
"41401",
"4019",
"2449",
"42731"
] |
Admission Date: [**2145-9-6**] Discharge Date: [**2145-9-10**]
Date of Birth: [**2068-11-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain; decreased exercise tolerance
Major Surgical or Invasive Procedure:
[**2145-9-6**] - Aortic valve replacement, 25 mm [**Company 1543**] Mosaic
tissue (porcine)valve.
History of Present Illness:
76 year old gentleman with known aortic stenosis who has been
followed by serial echocardiograms. His most recent
echocardiogram has demonstrated worsening aortic stenosis as
well as aortic regurgitation in the setting of left ventricular
hypetropy. He is mildly symptomatic with chest pain with
activity and a decreased exercise tolerance. Given the
progression of his disease, he has been referred for surgical
evaluation. Cardiac cath done today for pre-op w/u revelaed nl.
cors.
Past Medical History:
Aortic stenosis/aortic insufficiency
Depression
Basal cell skin cancer
ocular migraines
mild hypothyroidism
mild memory loss
SVT
Social History:
Last Dental Exam: Every 6 months
Lives with: Alone
Occupation: Retired
Tobacco: Denies
ETOH: Denies
Family History:
Brother with AF
Physical Exam:
Pulse:61 Resp: O2 sat: 99%
B/P Right:146/60 Left:146/69
Height: 68" Weight: 140 (63.5 kg)
General: WDWN in NAD
Skin: Dry, warm and intact. Multiple actinic keratosis. some
seborrheic keratosis noted. Few well healed small scars.
HEENT: NCAT [X] PERRLA [X] EOMI [X] sclera anicteric; OP benign
Neck: Supple [X] Full ROM [X] No JVD[X]
Chest: Lungs clear bilaterally [X]anterolaterally ( on bedrest)
Heart: RRR, IV/VI holosystolic murmur radiates to carotids
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema -none
Varicosities: None (lying down on bedrest)
[X]several small healed scars BLE
Neuro: Grossly intact. Mild word finding difficulty.
Pulses:
Femoral Right:cath dressing in place Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit- Transmitted vs. Bruit bilaterally
Pertinent Results:
[**2145-9-10**] 05:10AM BLOOD WBC-5.5 RBC-3.51* Hgb-10.8* Hct-30.1*
MCV-86 MCH-30.8 MCHC-35.9* RDW-13.3 Plt Ct-169#
[**2145-9-10**] 05:10AM BLOOD Glucose-110* UreaN-21* Creat-1.0 Na-137
K-4.2 Cl-101 HCO3-29 AnGap-11
[**2145-9-10**] 05:10AM BLOOD Mg-2.2
HISTORY: Status post AVR with pleural effusion, evaluate for
interval change.
FINDINGS: The cardiomediastinal and hilar contours are
unchanged. Bilateral
small pleural effusions have slightly decreased. There has been
improved
aeration of the retrocardiac opacity with only minimal
atelectasis remaining.
No focal consolidation or pneumothorax. Sternotomy wires are
intact. Patient
is status post aortic valve replacement.
IMPRESSION: 1) Improved small bilateral pleural effusions with
associated
atelectasis. Improved aeration in the retrocardiac region.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: [**Doctor First Name **] [**2145-9-9**] 4:03 PM
Imaging Lab
Brief Hospital Course:
Mr. [**Known lastname 1617**] was admitted to the [**Hospital1 18**] on [**2145-9-6**] for surgical
management of his aortic valve disease. He was taken directly to
the operating room where he underwent an aortc valve replacement
using a tissue porcine prothesis. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Over the next several hours awoke neurologically
intact and was extubated. On postoperative day one, He was
transferred to the step down unit for further recovery. He was
gently diuresed toward his preop weight. Chest tubes and pacing
wires removed per protocol. Continued to make good progress and
was cleared for discharge to Newbridge on [**Hospital **] rehab on POD
#4. All f/u appts were advised.
Medications on Admission:
Remeron 15mg at bedtime
Ativan 0.5mg prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 1
weeks: hold for K+ > 4.5.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **]
Discharge Diagnosis:
Aortic stenosis/aortic insufficiency s/p AVR
Depression
Basal cell skin cancer
ocular migraines
mild hypothyroidism
mild memory loss
SVT
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**]
**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: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2145-9-30**] 1:15
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD on [**9-27**] at 10am
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] in [**3-29**] weeks [**Telephone/Fax (1) 2205**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32281**],[**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2145-10-11**] 1:00
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2145-9-10**]
|
[
"4241",
"42731",
"2724",
"2449",
"42789"
] |
Admission Date: [**2173-1-4**] Discharge Date: [**2173-1-11**]
Date of Birth: [**2110-10-7**] Sex: F
Service: MEDICINE
Allergies:
Prempro / Fiorinal / Erythromycin Base / Aleve
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 yo W w/h/o myasthenia [**Last Name (un) 2902**] on immunosuppression, htn,
hyperlipidemia, spinal compression fractures who initially
presented with tachycardia. ROS remarkable for intermittent
sinus pressure/HA, not unusual, no retroorbital pain, ear pain
or pressure, decreased hearing. On admission she was ruled out
for PE. Subsequently she developed a HA, N, V and was treated
with phenergan and lorazepam. Neurology felt symptoms could be
due to narcotic withdrawal and the pt was given Dilaudid 2x 1mg.
Subsequently she became obtunded and hypoxic.
Past Medical History:
1. Myasthenia [**Last Name (un) **]-first diagnosed in [**2163**], followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]
2. multiple spinal compression fractures s/p steroid use for MG
3. hypercholesterolemia
4. h/o migraines
5. seasonal allergies
6. HTN
7. osteoporosis
Social History:
Patient is single, lives alone. She is currently on disability.
She used to work as a histology tech a [**Hospital1 18**]. She denies
tobacco, illicit drugs, occ EToH but none since starting
narcotic medications.
Family History:
Mother: [**Name (NI) 77552**], first age 55, also CHF, deceased age 77; father
with rheumatic heart disease, deceased age 83 CVA; sister died
at age 5 of insulin dependent diabetes mellitus w/PNA.
.
Physical Exam:
VS: 102.4 120 140/85 100% on 50% FM
General: NAD, pleasant well-appering woman
HEENT: PERRL, EOMI without nystagmus, no proptosis, MMM, OP
clear, conj pink/sclera white, hirsuit
Neck: supple, no lad, JVP: 8cm, no bruits
Resp: CTA, scant left basilar crackels, no rhonchi or wheezes
CV: RRR, s1, s2 present, no murmurs, rubs, gallops
Abdomen: protuberant, soft, nontender, nondistended, +BS, no
masses, no HSM
Ext: trace edema, no c/c, 2+ radial, DP pulses bilaterally
Neuro: CN II-XII intact, A&Ox3, motor [**6-12**] UE/LE, lid lag not
tested because of photophobia, good coordination, reflexes
intact 2+ bilaterally
Pertinent Results:
[**2173-1-4**] 10:05PM CK(CPK)-27
[**2173-1-4**] 10:05PM CK-MB-NotDone cTropnT-<0.01 proBNP-<5
[**2173-1-4**] 10:05PM TSH-1.4
[**2173-1-4**] 10:05PM FREE T4-1.2
[**2173-1-4**] 10:05PM D-DIMER-783*
[**2173-1-4**] 01:40PM GLUCOSE-106* UREA N-26* CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2173-1-4**] 01:40PM estGFR-Using this
[**2173-1-4**] 01:40PM CK(CPK)-38
[**2173-1-4**] 01:40PM CK-MB-NotDone
[**2173-1-4**] 01:40PM CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-2.1
[**2173-1-4**] 01:40PM WBC-8.5# RBC-3.71* HGB-12.6 HCT-36.8 MCV-99*
MCH-34.0* MCHC-34.3 RDW-15.3
[**2173-1-4**] 01:40PM NEUTS-77.9* LYMPHS-16.6* MONOS-3.9 EOS-0.8
BASOS-0.9
[**2173-1-4**] 01:40PM POIKILOCY-1+ MACROCYT-2+
[**2173-1-4**] 01:40PM PLT COUNT-242#
[**2173-1-4**] 01:40PM PT-12.1 PTT-23.2 INR(PT)-1.0
Brief Hospital Course:
1. Hypoxia:
This developed in the setting of IV narcotics use; quick
development and rapid improvement was most suggestive of
aspiration in the context of sedation. Contributing could have
been chronic low ventilatory state in the context of OSA and MG,
although MG crisis thought to be unlikely given 5/5 strength
otherwise.
The patient never required intubation and did well after being
dosed with narcan. Overall, her respiratory status improved;
she was continued on BiPAP at night and NIFs/VCs were followed.
Her MG was treated as prior.
For the possible aspiration, initially treated with levo/flagyl,
then just levofloxacin. [**2173-1-12**] is day 7 of planned seven day
course.
2. Tachycardia:
Sinus, likley reactive. PE ruled out, TSH normal. Anemia
slightly worse then normal but not sufficient to explain
tachycardia. This was felt to be either related to beta-blocker
withdrawal or narcotic withdrawal. This resolved upon
resumption of narcotics (at home doses) and beta-blocker. Later
in the admission, the beta-blocker was again d/c'd as the
indication was unclear. Thereafter, the patient's HRs remained
<100.
3. [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]:
There was no evidence for current flare. Cellcept and
pyridostigmine were continued; neurology followed the patient.
4. Anemia:
Previous baseline hct mid 40's, over the last month decreased to
mid 30's. This was felt to be secondary to B12 deficiency with
the possible contribution of Cellcept. The B12 level was low
end of normal. MMA was checked and pending at d/c. Given that
the patient has no reason for nutritional deficiency, pernicious
anemia was entertained and IF antibody was sent (pending at
d/c).
5. Headache:
Thought to be secondary to possible migraine headache versus med
withdrawal headache.
Was treated with tylenol PRN.
6. Spinal compression fractures:
Narcotics were initially held, but restarted many of the
patient's symptoms were felt to be secondary to withdrawal.
7. Hypertension:
The patient's propranolol had recently been stopped prior to
admission. This was restarted, given the tachycardia. Later in
the admission, the patient was not hypertensive so the
beta-blocker was again held given the prior episodes of
hypotension. Her blood pressure and heart rate were normal on
discharge.
8. Hyperlipidemia:
Continued atorvastin.
Medications on Admission:
Pyridostigmine Bromide 30 mg PO Q8H
Atorvastatin 20 mg PO HS
Mycophenolate Mofetil 1000 mg PO BID
Raloxifene *NF* 60 mg Oral qd osteoporosis
Senna 1 TAB PO HS:PRN constipation
Heparin 5000 UNIT SC TID
Cyanocobalamin 1000 mcg PO DAILY
Docusate Sodium 100 mg PO HS
Calcium Carbonate [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN upset stomach
Dolasetron Mesylate 25 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/PR Q4-6H:PRN pain
Sodium Chloride Nasal [**2-10**] SPRY NU QID:PRN
Discharge Medications:
1. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO qd () as
needed for osteoporosis.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: [**2-10**] Tablet,
Chewables PO Q4H (every 4 hours) as needed for upset stomach.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-10**] Sprays Nasal
QID (4 times a day) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
13. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Sinus tachycardia
2. Narcotic withdrawal
3. Myasthenia [**Last Name (un) 2902**]
4. Anemia
5. Renal cysts
Secondary:
1. Hypertension
2. Hyperlipidemia
3. Osteoporosis
Discharge Condition:
Improved; in normal sinus rhythm.
Discharge Instructions:
You were admitted with elevated heart rates and possibly
withdrawal from narcotics. At this time, your heart rate is
normal and you do not have any symptoms of withdrawal.
If you experience worsening headaches, diarrhea, racing heart,
shortness of breath or have any other questions/concerns, please
call your PCP or go to the emergency room.
Followup Instructions:
You have the following appointments scheduled:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9899**], M.D. Phone:[**Telephone/Fax (1) 558**] Date/Time:[**2173-2-15**]
1:00
DR. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2173-2-23**]
8:00
Please be sure to schedule an appointment with your PCP to be
seen within 1-2 weeks: [**Last Name (LF) **],[**First Name3 (LF) 198**] W. [**Telephone/Fax (1) 250**]
|
[
"42789",
"51881",
"4019",
"2724"
] |
Admission Date: [**2167-4-9**] Discharge Date: [**2167-4-20**]
Service: MEDICINE
Allergies:
Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization, mechanical intubation, continuous
[**Last Name (un) **]-venous hemofiltration
History of Present Illness:
85 year old woman with hx of CAD s/p prior PTCA, pVD, DM2, htn,
chol and anemia presented to NWH on [**2167-4-8**] with unstable
angina. Her EKG was described as unchanged from prior. Her labs
were notable for Trop0.06. BNP 234. creat 1.3 on arrival
(baseline 1.2).
Her evaluation there was notable for cardiac enzymes as above.
She was felt to be in mild congestive heart failure after 1 unit
of pRBCS which she received for a Hct of 26. She received 2
doses of lasix. She was started on a heparin gtt (not listed in
discharge meds. She did have small amount of blood on her toilet
tissue thought secondary to hemorrhoidal bleed. She did receive
a 2nd unit of PRBCs. A TTE (prelim only) LAE, preserved LVEF,
mild MR/TR.
.
She describes her baseline at chronic stable angina with chest
pressure at similar level of exertion such as walking [**5-17**] block
of level ground. However over the past month she noted a
decreased threshhold for her discomfort now after only 1 flight
of stairs. On the day prior to her admission she had the similar
sensation of chest pressure while at rest. It lasted for ~2
hours and improved with nitroglycerin. She had recurrent event
at 1:30pm on the 25th so she presented to the hospital. She
states her weight has been stable. She has chronic venous stasis
and has had new lower extremity swelling over the past few
weeks. She has no orthopnea or PND.
.
On floor, patient was feeling short of breath with walking to
the bathroom but otherwise feeling well. She has no current
chest pain.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools. She has been having small amount of blood on the toilet
tissue over the past few weeks. She denies recent fevers, chills
or rigors. She has exertional leg pain at 4 blocks of walking.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope.
Past Medical History:
# s/p inferior wall NQWMI in [**2157**], s/p cardiac catheterization
in [**2157**] with PTCA of RCA (RCA mid-vessel total occlusion ->
PTCA with grade C dissection -> TIMI 3 flow, no stent);
complicated by dissection and pseudoaneurysm
#. Type 2 diabetes - HgA1C 7.3% [**2166-11-12**]
- complicated by neuropathy
#. Hypertension
#. Hyperlipidemia
#. Peripheral [**Year (4 digits) 1106**] disease
#. Asthma
#. Chronic kidney disease baseline 1.1-1.2
#. GERD
#. Hyperparathyroidism
#. Osteoarthritis
#. B12 deficiency anemia
#. Appendectomy
#. Bladder suspension
#. Right meniscectomy in [**2161-1-11**]
#. Excision of benign breast mass times two
Social History:
The patient currently lives in [**Location 107641**] with her [**Age over 90 **] year old
Husband. She has 1 son who lives in [**Name (NI) 701**]. At baseline she
walks with a cane, she is otherwise independent in all ADl
although looking to get an aid to help clean soon.
Tobacco: None
ETOH: None
Illicits: None
Family History:
Non-Contributory
Physical Exam:
VS: 98.7 148/62 74 20 93%3L
wt. 96kg
GENERAL: obese elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**3-20**] MR murmur. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles at left base
greater than right.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits. external
hemorrhoids. red blood (heme+) in rectal vault.
EXTREMITIES: No c/c/e. right femoral bruit.
SKIN: +stasis dermatitis. no ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP trace PT trace
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP trace PT trace
Neuro:
-MS a,ox3. coherent response to interview.
-CN II-XII intact (pupils reactive, EOMI, face symmetric,
palate/tongue midline)
-Motor moving all 4 extremities symmetrically
-[**Last Name (un) **] light touch intact to face/hands/feet
Pertinent Results:
[**2167-4-9**] 10:40PM GLUCOSE-141* UREA N-65* CREAT-1.6* SODIUM-142
POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-17
[**2167-4-9**] 10:40PM CK(CPK)-150*
[**2167-4-9**] 10:40PM CK-MB-6 cTropnT-0.07*
[**2167-4-9**] 10:40PM WBC-9.6# RBC-2.84* HGB-9.4* HCT-26.9* MCV-95
MCH-33.2* MCHC-35.1* RDW-14.6
[**2167-4-9**] 10:40PM PLT COUNT-220
[**2167-4-9**] 10:40PM PT-13.4 PTT-36.9* INR(PT)-1.1
.
STUDIES OF RELEVANCE IN CHRONOLOGICAL ORDER:
[**2167-4-9**] CXR:
Lungs clear, mild pulmonary engorgement and top normal heart
size suggest
borderline cardiac decompensation, but there is no edema or
appreciable
pleural effusion.
[**2167-4-10**] Card Cath:
COMMENTS:
1. Coronary angiography in this right-dominant system revealed:
--the LMCA had no angiographically apparent disease.
--the LAD had a proximal <50% stenosis.
--the LCX had no angiographically apparent disease.
--the RCA had an ostial >90% stenosis.
2. Limited resting hemodynamics revealed severely elevated
left-sided
filling pressures, with LVEDP 30 mmHg. There was mild systemic
arterial
systolic hypertension with SBP 149 mmHg. There was no gradient
across
the aortic valve upon pullback of the angled pigtail catheter
from LV to
ascending aorta.
3. Successful PTCA and stenting of the ostial RCA with two
overlapping
bare metal stents - Minivision (2.5x15mm distally; 2.5x12mm
proximally)
postdilated with a 2.75mm balloon. Final angiography
demonstrated no
angiographically apparent dissection, no residual stenosis and
TIMI III
flow throughout the vesel (See PTCA comments).
4. Successful closure of the right femoral arteriotomy site
with a 6F
Angioseal closure device.
FINAL DIAGNOSIS:
1. Significant one coronary artery disease.
2. Successful PTCA and stenting of the ostial RCA with two
overlapping
bare metal stents.
3. Successful clousre of the right femoral arteriotomy site
with a 6F
Angioseal closure device.
[**2167-4-11**] ECHO:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is mild regional left ventricular
systolic dysfunction with mild basal and mid-anterior septal
hypokinesis, distal septal akinesis and probable apical
hypokinesis. The remaining segments contract normally (LVEF =
40-45%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericar
dial effusion.
IMPRESSION: Normal right ventricular systolic function. Mild
regional left ventricular systolic dysfunction, c/w CAD.
Moderate mitral regurgitation. Mild pulmonary hypertension.
[**2167-4-11**]:
IMPRESSION: CT A and P
1. Multifocal consolidations may represent pneumonia, however
pulmonary
hemorrhage in the setting of hyperdense, and likely hemorrhagic,
effusions
should be considered.
2. Retained renal contrast with vicarious excretion via the
gallbladder, all
consistent with renal failure.
3. Fibroid uterus.
[**2167-4-13**] CT Chest:
Followup of a patient with bilateral pleural
effusion, consolidations, and known pneumothorax.
COMPARISON: CT abdomen from [**2167-4-11**] and multiple chest
radiographs
obtained in the interval between [**4-9**] and [**2167-4-13**].
TECHNIQUE: Unenhanced MDCT of the chest was obtained from
thoracic inlet to upper abdomen with subsequent 1.25- and 5-mm
collimation axial images reviewed in conjunction with coronal
and sagittal reformats.
FINDINGS:
Extensive widespread consolidations involve mostly the right
upper lobe, right middle lobe, and right lower lobe but also are
seen in left lower lobe and left apex. The consolidations are
relatively high in density (the left upper lobe consolidation is
about 57 Hounsfield units in density), as are the right middle
lobe and lower lobe consolidations (ranging up to 50 Hounsfield
units). The comparison of the lung bases with a recent CT
abdomen from [**2167-4-3**] demonstrates interval progression
of the consolidations in the right middle and right lower lobe.
The bilateral pleural effusion, although did not increase
significantly in size, is still of high density (up to 46
Hounsfield units) in the lower portions of the lungs suggesting
sedimentation effect.
The mediastinal lymph nodes are enlarged ranging up to 16 mm in
right lower paratracheal area and might be reactive. Extensive
coronary calcifications are noted. The heart size is mildly
enlarged. There is no significant pericardial effusion.
Minimal left pneumothorax is demonstrated, 2A:31, seen in the
anterior
mediastinum giving the patient's supine position and might
correspond to an apical pneumothorax demonstrated on the upright
chest radiograph obtained the same day earlier at 09:09 a.m.
Although the comparison between the chest CT and chest
radiograph is difficult, the size of the pneumothorax is most
likely unchanged and is small.
The imaged portion of the upper abdomen demonstrates fat density
left adrenal lesion, -19 Hounsfield units, consistent with
lipoma. The rest is
unremarkable within the limitations of this non-enhanced study.
Again note is made of the presence of contrast enhancement of
the kidneys consistent with known failure and retained excretion
of contrast. Contrast is also
demonstrated in the renal pelvis. The vicarious excretion of the
distended
gallbladder is again noted. The bladder is at least 5 cm in
diameter,
although no wall thickening or surrounding abnormalities are
seen.
There are no [**Year (4 digits) 500**] lesions worrisome for malignancy. Degenerative
changes are seen.
IMPRESSION:
1. Extensive bilateral consolidations, right more than left, of
high density that might be consistent with multifocal
hemorrhage. The differential diagnosis in the presence of renal
failure might include vasculitis. Hemorrhagic pneumonia might be
considered in appropriate clinical setup.
2. Small left apical pneumothorax, most likely unchanged
compared to prior
chest radiograph.
3. Bilateral grossly unchanged pleural effusions, high in
density that might also contain an element of hemorrhage.
4. Extensive coronary calcifications.
5. Still present contrast enhancement of kidneys and vicarious
excretion of contrast the gallbladder consistent with known
renal failure.
Brief Hospital Course:
85-year-old woman with a history of coronary artery disease s/p
BMS x 2 in RCA on [**2167-4-10**], with post-cath course complicated by
pulmonary edema, contrast-induced nephropathy requiring CCU stay
with transition to cardiac service.
1) Unstable angina/CAD: Patient's typical anginal pain was
occurring at rest and had ST depressions in V4-6. Given concern
for ongoing bleeding cath was deferred until [**4-10**]. Cardiac
catheterization demonstrated 90% occlusion of ostial RCA which
was stented with two overlapping bare metal stents. Her chest
pain occurred intermittently since the PCI with intermittent ST
depressions in V4-V6. Nitro gtt was temporarily started for the
pain, and she remained pain free after it was discontinued.
Cardiac markers were mildly elevated, likely demand ischemia
from anemia, and CK-MB was negative. She was treated with
aspirin, statin, and plavix. Patient's metoprolol was restarted
once she stabilized.
2) Acute on chronic diastolic heart failure: Felt to be
secondary to RBC transfusions at OSH. She had an ongoing O2
requirement and desatted to 85% RA on am of [**4-11**], for which she
was transferred to the CCU and lasix gtt was started. Fluid was
initially removed via CVVH (as below), although once UOP
improved, she was successfully diuresed with IV furosemide.
3) Acute on chronic CKD: FENa 6%, likely contrast nephropathy.
Her [**Last Name (un) **] was held. Renal was consulted for poor UOP while on
lasix drip and high dose diuril. Her creatinine rose and she was
started on CVVH via L IJ line. After a few days, her UOP picked
up and responded well to 40mg IV furosemide boluses, so the CVVH
line was removed.
4) Anemia: Given concern for RP bleed related to cath, she had
CT abd, which showed bilat ?hemothoraces, but no RP bleed. Other
source could be GI bleed from external hemorrhoids. She received
1 unit of pRBCs and her hematocrit remained stable.
5) Pneumonia: Patient had frequent coughing associated with
desaturations. CT chest was concerning for atypical pneumonia
vs. alveolar hemorrhage, although pulm consult favored the
former. ANCA and anti-GBM were negative. She received a 5 day
course of azithromycin and a brief course of prednisone for
possible diffuse alveolar hemorrhage (one day each at 60mg,
40mg, 20mg, 10mg). Her cough greatly improved.
6) Diabetes mellitus: Initially on glargine, although changed to
insulin gtt in the CCU due to highly elevated (300s) sugars in
the setting of steroids. She was transitioned back to glargine
as the steroids were rapidly tapered.
Medications on Admission:
Home Meds:
Amlodopine 5mg daily
atorvastatin 20 mg daily
furosemide 40mg [**Hospital1 **]
glimepiride 4 mg daily
humalog insulin sliding scale
imdur 60 mg [**Hospital1 **]
lidoderm patch [**Hospital1 **]
nitroglycerin spray prn
pentoxifylline SR 400 mg TID with meals
diovan 320 mg daily
aspirin 325 mg dialy
calcium +D 600/200 units [**Hospital1 **]
cyanocobalamin (unknown dose)
multivitamin daily
Omega 3 fatty acids 1000 mg daily
.
Meds on transfer:
amaryl 4 mg daily
calcium +d [**Hospital1 **]
centrum daily
diovan 160 mg daily
aspirin 325 mg daily
fish oil daily
isodil 40 mg q8hours
lasix 40 mg [**Hospital1 **]
lipitor 20 mg daily
lopressor 25 mg q6
nitrostat prn
norvasc 10 mg [**Hospital1 **]
protonix 40 mg IV daily
tylenol prn
vitamin b12 daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Lidoderm Topical
10. Nitroglycerin Sublingual
11. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO three times a day: with meals.
12. Calcium 600 with Vitamin D3 600 mg(1,500mg) -200 unit Tablet
Sig: One (1) Tablet PO twice a day.
13. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
once a day.
14. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease
Angina
Pulmonary Edema
Contrast Induced Nephropathy
Discharge Condition:
Good
Discharge Instructions:
You were admitted for cardiac catheterization and stent
placement in the setting of unstable angina. You required ICU
level care for pulmonary edema and contrast-induced nephropathy.
.
Please take all your medications as prescribed.
.
Please follow-up with your providors as below.
.
Please return if you have any further chest pain or shortness of
breath.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Followup Instructions:
#You will need to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] (your PCP) ([**Telephone/Fax (1) 250**])
within one week of discharge. Please call to make this
appointment. At that time, please bring-in your daily weights
and ask your doctor to determine if he feels your Lasix needs to
be restarted. You may note that we have just restarted your [**Last Name (un) **]
(Valsartan). You are no longer on Isosorbide Dinitrate s/p your
intervention.
.
#You will need to see Dr. [**Last Name (STitle) **] (your cardiologist) within
two week of discharge. Please call to make this appointment. Ask
him to review your blood pressure and medications.
.
#Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2167-4-27**] 9:00
.
#Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2167-4-27**] 10:00
.
#Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2167-5-4**]
9:30
Completed by:[**2167-5-18**]
|
[
"41401",
"5849",
"5180",
"486",
"4280",
"40390",
"2720",
"5859",
"49390",
"53081"
] |
Admission Date: [**2153-9-18**] Discharge Date: [**2153-10-4**]
Date of Birth: [**2079-3-29**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Codeine / Demerol / Nafcillin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Cellulitis, troponin leak
Major Surgical or Invasive Procedure:
Bedside debridement of eschar on right foot
History of Present Illness:
74 yo M with MM including PVD, DM, HTN, CAD, CRI transferred
from NWH for cellulitis/LE pain because pt's podiatric surgeon
is at [**Hospital1 18**]. Initally presented to NWH because of increasing
right foot pain and redness. At NWH, found to have EKG changes
with STD in V2-V4, though patient was asymptomatic and said he
never had chest pain. Unclear if he received abx from there per
records available. Patient was transferred here for further
management.
.
Of note, patient was recently hospitalized [**Date range (1) 91344**] in the ICU
at NWH when he was found at home unresponsive - was hypoglycemic
and in ARF. Patient states he does not remember 'anything' about
that hospital stay, the medications he was on or any events that
occurred then. Per report, he was discharged on lovenox for DVT
but when NWH ED was [**Name (NI) 653**], records there indicated that he
was started on Lovenox ppx because he was immobile and was
supposed to continue taking it until he was able to consistently
walk >100 feet. Unclear if patient has been administering the
lovenox himself as he stated that he no longer gives himself
insulin because 'it's just too complicated'.
.
On past hospitalization at NWH, also had a troponin has high as
8.8 thought be due to demand ischemia in the setting of
hypoglycemia. During that admission, he never had chest pain and
a stable percent MB fraction at 0.7. He was started on aspirin,
beta blocker and statin. An ACEi was held due to intolerance in
the past.
.
In the ED here VS: AF, hr:67, bp:130/70, rr:16 98% on RA.
Received fentanyl for pain, cards and vascular were c/s. Blood
cx were drawn. Vascular recommended vanc/zosyn given their
concern for osteo which he received. He received 50mg iv
fentanyl for pain.
.
Upon transfer to the floor, patient c/o of persistent right foot
pain. Denies fever or chills, CP, SOB, N/V/D, constipation, HA
or vision changes.
.
The patient is not a competent historian. 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 per HPI.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)HTN
2. CARDIAC HISTORY:
-CABG: [**2137**] LIMA->LAD. SVG->dRCA and SVG->D1/OM.
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2150**] (no report
available), [**2147**]: 3VD, patent LIMA-->LAD, patnet SVG--> dRCA and
D1/OM, severe native vessel disease
.
-PACING/ICD: None
.
3. OTHER PAST MEDICAL HISTORY: Per OMR notes, patient states he
does not know his full medical history
PVD
CAD s/p MI in '[**49**]
HTN
Hyperlipidemia
DM2 on Insulin
Diastolic CHF
CRI (baseline 1.8-2)
h/o GI bleed
Bladder carcinoma
Cervical stenosis
Anemia
Gastroparesis
.
PAST SURGICAL HISTORY:
- Debridement of osteomyelitis with L. 5th metatarsal head
resection [**2153-4-19**]
- L CFA to BK [**Doctor Last Name **] bypass with left arm vein [**9-27**]
- L4-5 laminectomies bilat w/ resection of large disk herniation
[**4-24**]
- R 2nd second toe amp [**5-24**]
- R CFA to AK [**Doctor Last Name **] bypass using [**Doctor Last Name 4726**]-Tex [**4-23**]
- L CEA [**2-/2140**], 4 vessel CABG [**1-/2138**]
- Aorta-bifemoral bypass at NWH in [**2147**]?
Social History:
HISTORY: Unwilling to give. Per prior records, married twice,
but recently separated. He has two children. H/o EtOH abuse in
AA 35 yrs; tobacco 45 pack year history
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=97.9 BP=140/60 HR=72 RR=20 O2 sat=93 on 2L%
GENERAL: elderly male lying in bed. Oriented x3. Mood
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. dry mmm. Poor
dentition
NECK: Supple. No JVD.
CARDIAC: RRR. s1/s2. III/VI systolic murmur heard best at LLSB.
LUNGS: clear anteriorly. patient unwilling to fully sit up for
posterior thorax exam, so limited. Heard scattered wheezes and
crackles at bases posteriorly.
ABDOMEN: Soft, NTND. +bs
EXTREMITIES: chronic venous statis changes bilaterlly. warm to
touch, DP pulses dopplerable.
RLE: 2 eshcars - one on medial aspect of foot and one on plantar
aspect of foot. Area of erythema on anterior/medial aspect of
foot with increased warmth. ?collection under foot?
SKIN: as above
Pertinent Results:
Admission laboratories:
COMPLETE BLOOD COUNT ([**9-18**]) WBC: 9.2 RBC: 3.45* Hgb: 8.3*#
Hct:27.6* MCV:80* MCH:23.9* MCHC:30.0* RDW:24.4* Plt Ct: 300
DIFFERENTIAL Neuts 87.1* Bands Lymphs 6.3* Monos 4.8 Eos 1.4
Baso 0.5
[**2153-9-18**] 07:01PM
BASIC COAGULATION (PT, PTT, PLT, INR) PT 15.0*PTT 41.8*Plt Ct
INR(PT)1.3*
Chemistry
RENAL & GLUCOSE Glucose 278* UreaN 69* Creat 2.0* Na 132* K 4.6
Cl 98 HCO3 22
EKG ([**9-20**]): Sinus rhythm. Right axis deviation. Incomplete right
bundle branch block. One to two millimeter downsloping ST
segment depression in the anterior leads extending from leads
V3-V6. Consider myocardial ischemia. Compared to the previous
tracing of [**2153-9-19**] the ST-T wave changes are pretty similar
except that the lead placement is slightly different.
Rate PR QRS QT/QTc P QRS T
72 126 114 440/461 71 121 113
WOUND CULTURE (Final [**2153-9-25**]):
KLEBSIELLA OXYTOCA. SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**6-/2450**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| STAPH AUREUS COAG +
| |
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2153-9-24**]): NO ANAEROBES ISOLATED.
Imaging:
Xray of right foot ([**9-19**]):
IMPRESSION:
1. Erosive bony destructions at the first distal phalanx and at
the stump of the second proximal phalanx consistent with
osteomyelitis.
2. Severe degenerative changes in the tarsometatarsal joints and
fracture at the 3rd metatarsal, suggesting early Charcot joint
disease.
3. Significant small vessel disease.
2D-ECHOCARDIOGRAM ([**9-20**]): The left atrium is mildly dilated.
The right atrium is markedly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no left ventricular outflow
obstruction at rest or with Valsalva. The right ventricular
cavity is markedly dilated with moderate global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The ascending
aorta is moderately dilated. The aortic valve leaflets (3) are
mildly thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-22**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2151-12-16**],
the detected pulmonary hypertension has increased. There is no
change in the left ventricular systolic function.
ETT:
[**4-/2151**]:
This 72 yo man with IDDM, mild AS s/p multiple cadiac
interventions was referred to the lab for evaluation as a part
of the Spinal Cord Stimulation study. The patient exercised for
2.5 minutes on a modified [**Doctor First Name **] protocol and stopped due a
marked drop in systolic
blood pressure. This represents a very limited exercise
tolerance for
his age. The patient denied any neck, chest, arm or back
discomfort
throughout the study. In the setting of baseline abnormalities,
an
additional 0.5mm of ST segment depression was noted in V4-V5 at
peak
exercise. These changes returned to baseline by minute 3
post-exercise. The rhythm was sinus with a single VPB in late
recovery period. Marked drop in blood pressure with exercise
(136/60mmHg at rest to 98/50mmHg at peak). Post-exercise
hypertension was noted (172/60mmHg at 10 minutes of recovery).
.
IMPRESSION: Marked drop in blood pressure with exercise.
Non-specific EKG changes without anginal type symptoms.
.
CARDIAC CATH:
[**2147**]:
COMMENTS:
1. Coronary angiography of this right dominant circulation
revealed
severe native three vessel disease. The LMCA had a 30%
narrowing. The
LAD had diffuse luminal irregularities and a 70% proximal
stenosis. The mid vessel was diffusely diseased but the distal
vessel filled via a patent LIMA->dLAD. The LAD supplied a large
S2 that had an 80% lesion at its ostium. The LAD supplied two
moderate sized diagonal branches which had diffuse luminal
irregularities. The LCX tapered quickly and was totally occluded
in the proximal vessel after a small OM branch. The RCA was
diffusely diseased and totally occluded proximally.
2. Selective vein graft angiography revealed a widely patent
SVG->dRCA and a widely patent SVG->D1/OM.
3. Selective arterial conduit arteriography demonstrated a
widely patent LIMA->LAD.
4. Resting hemodynamics revealed markedly elevated right and
left
ventricular filling pressures with an LVEDP of 29 mmHg and a
mean PCW
pressure of 22 mmHg. In addition, there were V-waves to 50 mmHg
suggesting significant mitral regurgitation. There was evidence
of
moderate to severe pulmonary hypertension with PA pressures of
62/21/39 mmHg and a pulmonary vascular resistance of 209
dynes-sec/cm5. The cardiac output was preserved at 6.9 L/min.
Note was made of a 10 mmHg gradient across the aortic valve.
5. Left ventriculography was not performed due to the patient's
underlying renal insufficiency and recent non-invasive testing
documenting a preserved LV systolic function.
.
FINAL DIAGNOSIS:
1. Severe native three vessel disease.
2. Patent LIMA->LAD.
3. Patent SVG->dRCA and SVG->D1/OM.
4. Moderate to severe left ventricular diastolic dysfunction.
5. Moderate to severe pulmonary hypertension.
CT head ([**9-24**]):
IMPRESSION:
1. No acute intracranial process.
2. Sequelae of chronic infarction involving the left
parieto-occipital
region.
Renal U/S ([**9-27**]):
IMPRESSION:
Absent diastolic flow seen in the bilateral interlobar arteries
of the
kidneys. The findings are nonspecific, but indicate renal
parenchymal
disease. There is limited evaluation of the main renal arteries,
but there is no clear evidence of renal artery stenosis. There
is no hydronephrosis.
Brief Hospital Course:
Summary: 74 yo M transferred from NWH with EKG changes, trop
here to 0.87 (baseline 0.2) and RLE cellulitis, right foot
osteomyelitis, worsening acute on chronic renal failure
# Right lower extremity cellulitis and right foot osteomyelitis:
The patient presented with right lower extremity cellulitis and
was found to have osteomyelitis in the right foot. Vascular
surgery evaluated the patient and thought that treatment for the
infection and ischemia would be a below the knee amputation,
though given the patient's poor cardiac status, he would not be
a good candidate for surgery. The patient was empirically
started on Vancomycin and Zosyn. A wound culture grew Klebsiella
oxytoca and MRSA and continued on those antibiotics. Since
vascular surgery would be high risk, podiatry was consulted for
local debridement. They debrided the area locally, yet erythema
of the right foot existed. It remained unclear whether the
erythema was due to ischemia vs. a subcutaneous abscess, so they
recommended a MRI of the foot. The MRI was never performed
because after discussion with the family and primary care
physician, [**Name10 (NameIs) **] was decided for the patient to become CMO. His
antibiotics were withdrawn and wound care applied to the area.
# Acute on chronic renal failure: The patient presented with a
creatinine close to his baseline, however, after periods of
hypotension, likely due to a peri-septic state, his creatinine
starting to rise. He was given fluid boluses of 500 cc of normal
saline as needed because his urine lytes showed a FeUrea~20-25%.
Renal was consulted and thought his creatinine rise was likely
due to acute tubular necrosis secondary to a pre-renal state.
The patient was offered aluminium hydroxide for high phosphate
levels, but the patient refused it. A renal ultrasound showed no
hydronephrosis. The patient became progressively oliguric with
UOP less than 20 cc/hour. Renal thought his kidneys would
unlikely recover (his creatinine rose to 5.3 despite
interventions). The patient and his family felt that they did
not want to pursue dialysis as an option.
#Increased troponins: The patient was noted to have high
troponins and excentuated ST wave depressions in V3-V5.
Cardiology was consulted and recommended medical management with
a beta blocker, ACE inhibitor, statin, and aspirin. The patient
was started on these medications, though became persistently
hyperkalemic, and therefore, the ACEi was discontinued. Also,
his CK and LFTs were [**Last Name (LF) 28645**], [**First Name3 (LF) **] the statin dose of 80 mg was
lowered to 20 mg and eventually discontinued due to persistently
[**First Name3 (LF) 28645**] LFTs. An echocardiogram revealed no acute wall motion
abnormality, though it did show worsening tricuspid
regurgitation and increased pulmonary artery pressure.
Throughout his stay, the patient did not have any chest pain.
#Increased LFTs: The patient has a known history of alcohol
abuse and increased LFTs in the past. During his peri-septic
period, the patient was noted to have increased LFTs, likely
multifactorial due to low perfusion to the liver and also
congestion secondary to tricuspid regurgitation. The patient did
not have any complaints of abdominal pain, though, he had
hepatomegaly on exam.
#Gastrointestinal bleed: The patient has a history of a GI bleed
and was guiaic positive in the ER. In addition, he had a
persistently elevated PT/PTT, likely due to either underlying
liver or hematologic disease. The patient's hematocrit remained
stable until [**9-26**] when his hematocrit dropped from 29.0 to 25.6
and was noted to have melenic stools. He continued to have
melenic stools, so he was transfused one unit of blood and
transferred to the MICU. His aspirin was discontinued. His
hematocrit remained stable in the MICU and transferred to the
floors where there were no signs of any GI bleeding.
Altered mental status: The patient had periods where he had
altered mental status, mostly at night. His AMS was likely
multifactorial due to infection, pain and uremia. He had
significant altered mental status on one day when he appeared
more somnolent with respirations=10/min after a dose of Morphine
2mg IV. Narcane was given with some effect. A head CT showed no
acute pathology. He continued to have periods of delirium mostly
at night.
#Pruritis: The patient has been complaining of pruritis,
especially on his back, since admission. A variety of remedies
were tried for wound care. According to his son, the pruritis
has been long-standing. It might be exacerbated by his renal
failure. A side effect of Morphine is a possibility, but he
still had the itching even before the morphine. He is being
treated with skin care, sarna lotion, hydrocortisone and
doxepin.
Goals of care: The patient entered the hospital as full code.
After the renal and GI bleeding complications from his illness,
the patient and his family decided to become DNR/DNI. After a
meeting with the PCP and the family, they thought the best route
would be to become comfort measures only instead of pursuing
dialysis and being chronically cared for in a nursing home. At
first, it was thought that his beta blocker, aspirin, and
antibiotics would be continued, however, after further
conversation, these medications were discontinued and only
palliative measures for insomnia, anxiety, pain and constipation
were ordered.
Medications on Admission:
MEDICATIONS (from NWH D/C summary on [**9-11**])
acetaminophen 1 g q8hr
ASA 325 Daily
Erythropoietin 4000 units SC weekly
Ferrous sulfate 325 mg Daily
Furosemide 40 mg daily
Lovenox 30 mg SC daily until ambulatory
NPH (8 units before breakfast and dinner
Regular insulin (5 units before breakfast and dinner
Metoprolol 12.5 mg [**Hospital1 **]
MVT daily
Miralax 17 g Daily
Nystain triamcinolone cream topically twice daily
omeprazole 29 mg daily
Sarna lotion to affected area [**Hospital1 **]
senokot qHs
Sertraline 50 mg daily
simvastatin 20 mg daily
flomax 0.4 mg daily
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Morphine 10 mg/5 mL Solution Sig: [**4-29**] mL PO Q4H (every 4
hours) as needed for pain, respiratory distress.
9. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3
times a day) as needed for itching.
10. Doxepin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
12. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
six (6) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
Cape Code Nursing & Rehabilitation Center - [**Location (un) 10072**]
Discharge Diagnosis:
Primary
-cellulitis of lower extremity
-osteomyelitis
-coronary artery disease
.
Secondary
-Hypotension
-Type II diabetes Mellitus
Discharge Condition:
Stable. Patient breathing on room air.
Discharge Instructions:
You were transferred to the hospital with right foot cellulitis
and osteomyelitis. You were started on antibiotics. Vascular
surgery evaluated the foot and were cautious to pursue surgical
intervention because you have a poor cardiac reserve. Podiatry
evaluated you and they....
.
You should come back to the hospital or call your primary care
doctor if you have chest pain, shortness of breath, weight gain,
fevers/chills or increasing pain in your right foot.
Followup Instructions:
PRN
|
[
"5845",
"2851",
"2762",
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"5859",
"4280",
"V5861",
"2767",
"4168",
"V4581"
] |
Admission Date: [**2144-1-23**] Discharge Date: [**2144-1-30**]
Date of Birth: [**2090-4-28**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
OSH tx for UGIB
Major Surgical or Invasive Procedure:
Endoscopy with banding of esophageal varicies
History of Present Illness:
This is a 53 y/o female with a history of chronic hepatitis C,
cirrhosis, varices and portal hypertension who presents from
[**Hospital3 2737**] when she orginally presented with hematemesis.
Unclear what the patient's presenting Hct was. However she did
receive 3U of prbcs. While it is not entirely clear, it appears
that her hct improved to 32.8.
.
An EGD was performed and showed grade III varices. Blood and
clot present in the fundus. Question of small [**Doctor First Name **]-[**Doctor Last Name **]
tear. The patient remained hemodynamically stable. She was
transferred here for further mgmt.
Past Medical History:
1. Hep C Cirrhosis, most recent MELD 13 in [**9-24**]. Complicated by
esophageal varices, seen on [**1-23**] EGD with 3 cords of grade [**11-20**]
varices.
2. DM, poorly controlled, with A1c 11.9% in [**9-24**]
3. HTN
4. Aortic stenosis: seen by Dr. [**Last Name (STitle) **] in [**8-24**], [**Location (un) 109**] 1 cm, peak
grad 63, mean grad 34. Preserved EF (75-80%). Normal persantine
[**2-23**].
Social History:
used cocaine in past. moderate EtOH until [**2137**] then quit. lives
in [**Location (un) 2498**] with children and grandchildren. Has 5 kids. not
married.
Family History:
brother had lymphoma in his 20s. no liver disease. father had
CABG.
Physical Exam:
VITALS: 96.9 68 108/62 16 93% 2L nc
GEN: healthy appearing female in NAD, lying in bed, and
comfortable
HEENT: JVP flat, MMM
CARD: nl rate, S1S2, III/VI HSM heard best along RUSB radiating
to the carotids
PULM: CTA b/l no rrw
ABD: +BS, no guarding, no rebound tenderness, no shifting
dullness, no hsm, mild distention
EXT: wwp, 2+DP bilaterally
NEURO: A&O x3, MAE
Pertinent Results:
RADIOLOGY Final Report
DUPLEX DOP ABD/PEL LIMITED [**2144-1-24**] 12:57 PM
IMPRESSION:
1. No evidence of portal vein or hepatic vein thrombosis.
2. Nodular liver, consistent with cirrhosis.
3. Small ascites.
4. Gallbladder sludge.
.
.
.
.
.
.
................................................................
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2144-1-25**] 6:53 PM
HISTORY: 53-year-old woman with esophageal surgery, now with
shortness of breath. Evaluate for free air or fluid overload.
FINDINGS: Comparison is made to the previous study from [**7-7**], [**2141**].
.
.
.
.
.
.
.
.
................................................................
RADIOLOGY Final Report
CHEST (PA & LAT) [**2144-1-28**] 1:31 PM
IMPRESSION: No new evidence of pneumonic infiltrate. Plate
atelectases on bases similarly as existed on preceding study of
[**1-25**].
.
.
.
.
.
.
.
.
.
................................................................
RADIOLOGY Final Report
PARACENTESIS DIAG. OR THERAPEUTIC [**2144-1-28**] 8:27 AM
IMPRESSION:
1. Patient status post diagnostic paracentesis with drainage 700
cc of light brown/pink ascites.
.
.
.
.
.
.
.
.
................................................................
[**2144-1-30**] 11:15AM BLOOD WBC-2.6*# RBC-3.25* Hgb-9.7* Hct-28.1*
MCV-86 MCH-29.8 MCHC-34.6 RDW-17.3* Plt Ct-41*
[**2144-1-30**] 05:55AM BLOOD WBC-1.7* RBC-2.98* Hgb-8.8* Hct-25.6*
MCV-86 MCH-29.6 MCHC-34.5 RDW-17.1* Plt Ct-38*
[**2144-1-23**] 10:25PM BLOOD WBC-3.8*# RBC-3.42* Hgb-10.2* Hct-29.2*
MCV-85 MCH-29.9 MCHC-35.1* RDW-15.7* Plt Ct-42*
[**2144-1-29**] 06:45AM BLOOD Neuts-59.9 Lymphs-30.3 Monos-6.3 Eos-3.0
Baso-0.5
[**2144-1-30**] 11:15AM BLOOD Plt Ct-41*
[**2144-1-30**] 05:55AM BLOOD Plt Ct-38*
[**2144-1-30**] 05:55AM BLOOD PT-18.4* INR(PT)-1.7*
[**2144-1-30**] 05:55AM BLOOD Gran Ct-950*
[**2144-1-30**] 05:55AM BLOOD Glucose-102 UreaN-10 Creat-0.6 Na-134
K-4.0 Cl-104 HCO3-24 AnGap-10
[**2144-1-23**] 10:25PM BLOOD Glucose-99 UreaN-31* Creat-0.8 Na-143
K-3.8 Cl-117* HCO3-17* AnGap-13
[**2144-1-30**] 05:55AM BLOOD ALT-21 AST-33 AlkPhos-53 TotBili-1.0
[**2144-1-23**] 10:25PM BLOOD ALT-45* AST-50* AlkPhos-68 Amylase-10
TotBili-1.4
[**2144-1-24**] 03:21AM BLOOD Lipase-21
[**2144-1-23**] 10:25PM BLOOD Lipase-18
[**2144-1-30**] 05:55AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.8
Brief Hospital Course:
Patient was transferred from an outside hospital for treatment
of her upper GI bleed. She was admitted to the ICU and seen by
Hepatology. The following morning the pt. underwent EGD and
banding of her esophageal varicies that showed signs of recent
bleed. The next day the patient was transferred to the general
medical floor. There she was doing well. On [**1-25**] the pt.
developed abdominal pain, shortness of breath, and a low grade
fever. A chest x-ray was done, blood and urine cultures were
sent, and she was given tylenol. Over the next several days the
patients blood cultures were followed, she underwent pulmonary
toilet, and underwent a paracentesis. She did not have SBP and
gradually her fevers resolved. On HD 8 - the patient's blood
cultures were negative, her fevers had resolved, and her
hematocrit had been stable for several days, and she was ready
for discharge. She was to follow up with the gastroenterology
team and her primary care doctor. She was tolerating regular
food and was ready for discharge.
.
# New SOB: ~7pm [**1-25**] pt. c/o abdominal pain, right scapular pain,
SOB, spiked 101.3. Ua, u cx, bld cx, and repeat hct ordered ->
hct stable, CXR no free air/consolidation +atelectisis at bases
bilaterally, no overload
- [**1-26**]: Afebrile, O2sat 95 on 2L, diminished breath sounds at
bases.
- oxygen requirement at baseline this am, pt. no longer
complaining of shortness of breath
- encouraging ISS; encouraging ambulation
- [**1-27**] no longer c/o SOB -> enocouraging ISS, consider repeat
CXR
- persistant low grade temperatures -> repeat CXR PA and lat
today -> neg for pna
--> now only with dry cough
.
# Abdominal pain/diarrhea:
- [**1-28**] no further abdominal pain; minimal gas pain yesterday
that has resolved -> encouraging ambulation
- with persistant daily temps -> [**Last Name (un) **] guided paracentesis to eval
for XBP
- 7pm [**1-25**] pt c/o abdominal pain with SOB.
- Reverted diet to clears --> advanced to regualr [**1-26**] at patient
tolerating well
- slight 'gas' pain this am but overall much improved
- continue reg diet today
- titrate lactulose to [**1-21**] BMs a day
- checking stool cultures -> pending
- c.diff -> one negative
- started flagyl [**2144-1-28**]
.
# UGIB: Patient scoped at osh, no treatment performed. Study
showed blood and clots at the fundus. Patient remained HD stable
after received 3U PRBCS. She has 18,20,22 gauge for access. Hct
has been stable. IV PPI and octreotide for now. NOW s/p EGD at
[**Hospital1 18**] w/placement of 3 bands
- continue IV PPI and octreotide gtt -> d/c [**1-25**]
- continue to cycle hct --> has been stable
- consider restarting home meds if stable through night
- [**1-26**]: Hct trend demonstrated slow decrease; repeat p.m. hct.
VSS. Guaiac stool to assess for bleed. Pt not nauseous, no
emesis. Hold home regimen of nadolol and aldactone given hct
trend. Transfuse for hct<28 (currently 28.4)
- repeat hct [**1-26**] at 34 --> result of 28.4 likely not real -> 33
[**1-27**]
.
# Hx of cirrhosis: If BP and hct remain stable overnight can
restart nadolol and aldactone
- continue lactulose and ceftriaxone for sbp ppx
.
# Hx of diabetes: ISS
- elevated blood sugars despite home regimen of lantus -> will
follow today
- tighten sliding scale
.
# Anxiety: cont alprazolam
.
# Anemia: UGIB and [**Month/Year (2) 500**] marrow suppression from hep C
- continue to cycle hct -> has been stable -> consider qOD labs
if pt. stays
.
# Thrombocytopenia: decreased synthetic liver function; stable
.
# Non anion gap acidosis: secondary to ivf resuscitation and
diarrhea.
- following lytes
.
# FEN:
- Replete lytes
- pt. tolerating regualr diet
.
# PPX:
- pneumoboots given thrombocytopenia
- IV PPI
.
# Full code
.
# Dispo: pending stable hct, tolerating PO intake, and above.
Medications on Admission:
per OMR notes and OSH notes, patient is able to recall some
medications
Omeprazole 20mg daily
Spironolactone 100mg daily
Glipizide 15mg daily
Nadolol 20mg daily
Lactulose 30mg TID
Lasix 20mg daily
Lantus discrepancy between OMR (40 units qhs) and OSH records
(55 units qhs)
Ciprofloxacin 250mg daily
Xanax 0.5mg daily
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 12 days.
Disp:*36 Tablet(s)* Refills:*0*
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Glipizide 5 mg Tablet Sig: Three (3) Tablet PO once a day.
9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
upper GI bleed
esophageal varicies
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital and treated for your upper
gastrointestinal bleed. You were seen by the GI team and had an
endoscopy while here. You had three bands placed in your
esophagus to control the bleeding -> this worked well. You then
began spiking temperatures - you were maintained on the
ceftriaxone and added flagyl to your regimen for concern of a
stool infection. Cultures were sent and all have been negative.
You also underwent a sampling of fluid from your abdomen. This
was negative as well. You are now doing very well and ready for
discharge.
You will need to take all of your medication as prescribed.
You will need to keep all follow-up appointments as indicated.
Call your primary care doctor or return to the ED if T>101.5,
chills, nasuea, vomiting, chest pain, shortness of breath,
worsening abdominal pain, or any other concern.
Followup Instructions:
- you need to follow-up with your primary care doctor in the
next week.
- You need to follow-up with the hepatology team in [**12-22**] weeks
for a repeat endoscopy. Please call ([**Telephone/Fax (1) 2233**] to schedule
an appointment.
**You need to make sure you keep the following appointments**
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2144-2-5**] 1:40
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2144-2-5**] 3:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2144-2-18**] 10:20
|
[
"2762",
"2875",
"4241",
"4019"
] |
Admission Date: [**2163-4-20**] Discharge Date: [**2163-5-16**]
Date of Birth: [**2092-1-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Progressive dyspnea on exertion.
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 3 [**2163-4-22**].
Sternal rewiring [**2163-5-2**].
History of Present Illness:
This is a 71 yo male patient with known history coronary artery
disease who was previously turned down for a CABG in [**2143**] due to
obesity and was lost to follow-up.
He presented recently with complaints of worsening shortness of
breath with exertion and was referred for cath showing 3VD. At
that time he was transferred to the [**Hospital1 18**] for eval for CABG.
Past Medical History:
Coronary artery disease.
Hypertension.
Hyperlipidemia.
CVA in [**2148**].
Social History:
Lives in [**Hospital1 10478**] with his wife. Retired engineer. Not very
active secondary to severe shortness of breath. Reports that he
quit smoking 45 years ago afetr a 415 pack year history.
Reports very rare ETOH consumption.
Family History:
Father deceased at age 50 with MI.
Mother deceased at ago 72 with MI but [**Last Name (un) 27185**] MI in her 50s.
Pertinent Results:
[**2163-5-16**] 06:00AM BLOOD WBC-14.8* RBC-3.45* Hgb-10.1* Hct-30.7*
MCV-89 MCH-29.3 MCHC-33.0 RDW-14.1 Plt Ct-232
[**2163-5-16**] 06:00AM BLOOD Plt Ct-232
[**2163-5-7**] 09:55AM BLOOD PT-16.9* PTT-28.2 INR(PT)-1.9
[**2163-5-15**] 04:45AM BLOOD Glucose-80 UreaN-12 Creat-1.1 Na-140
K-4.1 Cl-103 HCO3-29 AnGap-12
[**2163-5-4**] 06:30AM BLOOD ALT-30 AST-19 AlkPhos-74 Amylase-18
TotBili-0.5
[**2163-5-8**] 04:10AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 32993**] was admitted from an OSH on [**2163-4-20**] pre-op for
CABG. Because of his severe 3VD he was started on heparin and
nitroglycerine drips for optimal control of his CAD. He
underwent pre-op workup including pre-op head CT (with hx of
CVA) and carotid ultrasound.
On [**2163-4-22**] he proceeded to the OR and underwent a CABG x 3 with
LIMA to the LAD, SVG to the OM, and SVG to the Ramus with patch
angioplasty and repair of ramus posterior rupture (subacute).
Please see OP note for full details.
He was successfully weened and extubated on his operative
evening.
On POD one he remained in the ICU for ongoing hemodynamic
monitoring and on POD two he was transferred to the in-patient
telemetry floor for ongoing care.
In the early morning hours on POD three, Mr. [**Name14 (STitle) 32994**] was
found to be talking non-sensically and trying to get out of bed.
A neuro consult, head CT and MRI were obtained for suspected
acute CVA. He was found to have small right parietal, left
cerebellar, and right cerebellar infarcts thought to be embolic
with new post-operative atrial fibrillation.
Over PODs four and five Mr. [**Known lastname 32993**] continued to wax and
waine; he was continued on his heparin and coumadin per neuro
recs.
On POD six his mental status was noted to be significantly
improved with neuro recs only for ongoing anticoagulation for
stroke prevention.
Also on POD six he was noted to have new sternal drainage. His
WBC bumped up to 18 (from 13) for which he was pan-cultured. He
had continued bursts of atrial fibrillation and was started on
amiodarone.
On POD seven his sternal drainage significantly increased; due
to his elevated INR, he was unable to return immediately to the
OR. On POD nine ([**5-2**]) his INR fell below 1.7 and he returned
to the OR for sternal rewiring.
On POD eleven he was found to be C. diff positive with multiple
loose stools and on POD thirteen he was noted to have guaiac
positive stools. An endoscopy showed bleeding ulcers in the
duodenal bulb accounting for the patient's GIB and hemostasis
was obtained. He was started on IV protonix with serial Hcts to
monitor progress. He was transfused as necessary and was taken
off of his anticoagulation. After two days in the ICU for close
hemodynamic monitoring in light of GIB, he was again transferred
to the inpatient floor on PODs 16 and 5.
He continued to work with the physical therapy team throughout
his stay but it was not felt that he was safe for home. He was
screened for rehabilitation.
On PODs 20 and 9, a new rash was noted on trunk and Mr.
[**Known lastname 32995**] antibiotics were discontinued. The rash resolved
and on PODs 24 and 13, it was decided that he was safe for
transfer to a rehabilitation facility for ongoing management,
treatment, and rehabilitation.
Final recommendations from the neurology service are for
coumadin as soon as cleared by GI with 325 mg aspirin daily
until then; to follow-up with primary neurologist. GI
recommends re-starting Coumadin 14 days post bleed: [**2163-5-10**].
Start coumadin at low dose and keep INR at low-end of
theraupetic.
Medications on Admission:
Aspirin 325 daily.
Multivitamin daily.
Lipitor 20 daily.
Nifidipine XL 30 daily.
Mirapex 1.5 [**Hospital1 **].
Reminyl 12 daily.
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Galantamine Hydrobromide 4 mg Tablet Sig: Three (3) Tablet PO
bid ().
9. Pramipexole Dihydrochloride 1 mg Tablet Sig: 1.5 Tablets PO
bid ().
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day.
11. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a
day for 7 days: To be followed by 200 mg daily dosing.
12. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
13. Metoprolol Tartrate 25 mg Tablet Sig: [**1-9**] Tablet PO twice a
day.
14. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
Coronary artery disease.
Cerebral vascular accident.
Sternal wound dehissence.
Gastrointestinal bleed.
Discharge Condition:
Stable.
Discharge Instructions:
Wash incisions daily with soap and water. Rinse well. Do not
apply any creams, lotions, powders, lotions, or ointments.
No lifting greater than 10 pounds.
Strict sternal precations.
[**Last Name (NamePattern4) 2138**]p Instructions:
Call to schedule appointment with Dr. [**Last Name (Prefixes) **] in 4 weeks.
Call to schedule appointment with Dr. [**Last Name (STitle) 32996**] in 2 weeks.
Call to schedule appointment with cardilogist in 2 weeks.
Call to schedule appointment with primary neurologist in [**2-11**]
weeks.
Please check Hct one week post-discharge from [**Hospital1 18**].
Low-dose Coumadin should be started [**2163-5-20**].
Completed by:[**2163-5-16**]
|
[
"41401",
"42731",
"4019",
"2720"
] |
Admission Date: [**2138-3-11**] Discharge Date: [**2138-8-25**]
Date of Birth: [**2079-8-15**] Sex: M
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 27294**] was admitted to [**Hospital1 1444**] on [**2138-3-11**], for
recurrent bleeding in his left pelvis. He had a hip
replacement done almost 20 years ago in [**Country 6171**] for a hip
infection he developed as a child. Mr. [**Known lastname 27294**] did well with
his original hip replacement until [**2134**] when he was seen at
[**Hospital1 69**], at which time he was
found to have a loose prosthesis with extensive osteolysis.
He attempted a reconstruction in [**2136-8-8**]. However,
he had extensive bone loss and reconstruction was not
possible. He was left with a resection arthroplasty.
Over the ensuing months Mr. [**Known lastname 27294**] had recurrent collections
of fluid of his left thigh. These were initially drained
successfully. He was also on Coumadin therapy for deep
venous thrombosis. He was seen at [**Hospital6 1130**] by Oncology Service for recurrent collection of
seroma in his left thigh. He was also seen by an orthopaedic
oncologist. Neither of these workups revealed any cause of
the recurrent left thigh collection.
HOSPITAL COURSE: On [**2138-3-20**], at [**Hospital1 190**], the patient had a left hip exploration with
placement of Hemovac. On [**2138-4-1**], he had a left hip
exploration and a femur resection. On [**4-21**] and [**2138-4-25**],
he went to Interventional Radiology to have embolization of two
vessels off the superficial femoral artery and embolization
of two distal branches of the deep femoral artery. On
[**2138-5-6**], he had a left hip disarticulation. On [**2138-5-30**], a Plastic Surgery consultation was obtained. They said
there was no role for flap. On [**2138-5-12**], a Vascular
Surgery consultation was obtained stating that bleeding was
most likely venous, and embolization had no further role. On
[**5-15**], a PICC line was placed. On [**5-15**], a Medication
consultation for tachycardia was obtained, and a beta blocker
was started. On [**5-21**], and echocardiogram revealed normal
left ventricular function and an ejection fraction of 55%.
From the period of [**5-27**] to [**7-7**], the patient had 12
incision and drainages of left thigh/groin wound. The
patient had chest pain on [**7-13**] and was ruled out for a
myocardial infarction. The patient had a spiral CT done on
[**7-13**] as well which revealed multiple emboli in the left
and right pulmonary arteries. At that time [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**]
filter was placed. A chest tube was also placed for
hemothorax which had an initial output of 1200 mL.
The patient was transferred to the floor on [**2138-7-18**].
Total parenteral nutrition was started on approximately
[**2138-7-20**]. The patient was transferred back to the
Surgical Intensive Care Unit in respiratory distress on
[**2138-7-29**]. At that point he was intubated, and the
chest tube had an output of 1 liter. Repeat embolizations
were attempted of the superior gluteal artery on [**2138-8-6**].
Throughout the admission, the patient received approximately
110 units of packed red blood cells. Two more dressing
changes were performed in [**2138-8-9**]. Consultations
obtained during admission were as follows: Pain Service.
Plastic Surgery revealed no role for flap.
Hematology/Oncology workup including factor VIII [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] factor bleeding time was completely normal.
Vascular Surgery consultation revealed that most likely the
bleeding was venous in nature. Interventional Radiology
performed embolization on several occasions. Medicine
consultation was obtained. Infectious Disease consultation
was also obtained. The patient had vancomycin-resistant
osteomyelitis, and candidal line infection. He was initially
started on ampicillin, ceftriaxone, and Flagyl. These were
discontinued. He was then placed on cefepime and vancomycin.
These were then discontinued, and he was started on
piperacillin and gentamicin, and these were discontinued. He
was then started on imipenem and linezolid which were both
discontinued on [**8-16**]. He was also started on Bactrim,
levofloxacin, and fluconazole. Blood cultures obtained on
[**8-14**] also showed stenotrophomonas mysophilia
bacteremia.
The patient was made comfort measures only on [**2138-8-25**]. This was done with the help of the Ethics Committee.
All other services including Hematology/Oncology,
Orthopaedic/Oncology, Pulmonary, Medicine, Vascular, Plastic,
and Surgical Intensive Care Unit team all agreed there were
no other medical actions which could be taken. The patient
deceased at 11:40 a.m. on [**2138-8-25**].
CAUSE OF DEATH: Respiratory failure, sepsis, pelvic
osteomyelitis, bleeding diathesis of unknown cause.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 27295**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2138-8-25**] 12:51
T: [**2138-8-29**] 13:54
JOB#: [**Job Number 27296**]
|
[
"42789"
] |
Admission Date: [**2181-2-2**] Discharge Date: [**2181-4-9**]
Service: [**Hospital Unit Name 196**]
Prior to this he was in the CCU. For [**Hospital **] hospital course
please see dictation by CCU intern.
HISTORY OF PRESENT ILLNESS: Briefly, patient is an
80-year-old male with a history of coronary artery disease,
hypertension, type 2 diabetes, gastroesophageal reflux
disease, subacute bacterial endocarditis who presented with
chest pain in the setting of taking Viagra. This was
associated with shortness of breath with no nausea, vomiting,
diaphoresis, palpitations, or lightheadedness.
Patient was found to have a new right bundle branch block
with Q-wave inversions in Lead III, aVF, and V1 through V4
with TWF in V5 through V6 and with no EKG to compare.
Patient underwent cardiac catheterization and had stent
placed to left anterior descending. The coronary angiography
revealed a right dominant system with LMCA that was normal,
left anterior descending with minor disease, left circumflex
with 80% lesion at D2 with TIMI 2 flow, right coronary artery
with 50% mid lesion.
Post catheterization patient was noted to have Mobitz II
rhythm on telemetry and hence underwent pacemaker placement
on [**2181-2-2**]. Subsequent to this patient was transferred to
the [**Hospital Unit Name 196**] service for further observation and care.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Gastroesophageal reflux disease.
3. Esophageal strictures.
4. Hypertension.
5. Type 2 diabetes.
6. Hepatitis C.
7. Subacute bacterial endocarditis 10 years ago.
8. Status post hernia repair.
9. Status post right wrist surgery with hardware placement.
MEDICATIONS ON TRANSFER:
1. Vancomycin 1 gram q. 12 hours times four doses.
2. Oxycodone p.r.n.
3. Captopril 12.5 mg one p.o. t.i.d.
4. Metoprolol 50 mg one p.o. b.i.d.
5. Celexa 20 mg one p.o. q.d.
6. Lorazepam 0.25 mg one p.o. q.d.
7. Senna p.r.n.
8. Docusate p.r.n.
9. Protonix 40 mg one p.o. q.d.
10. Regular insulin sliding scale.
11. Plavix 75 mg one p.o. q.d.
12. Aspirin 325 mg one p.o. q.d.
ALLERGIES: Patient has no known drug allergies.
SOCIAL HISTORY: He is a retired compositor. History of
intravenous drug use; none in the last six years. Prior
cocaine use; none in the last six years. Remote smoking
history; quit 60 years ago. History of heavy ETOH use but
none in the last six years. Lives alone. Separated from
second wife.
FAMILY HISTORY: Significant for father with cerebrovascular
accident at age 72. Son had myocardial infarction in 50s and
daughter had lung cancer.
PHYSICAL EXAMINATION: Vitals on admission to the [**Hospital Unit Name 196**]
service are blood pressure 170/86, pulse 68, respiratory rate
16, satting at 98% on room air. Patient is afebrile with
temperature 97.8. Generally, the patient is in no acute
distress, is alert and oriented times three. HEENT is
normocephalic, atraumatic. Extraocular muscles are intact.
Oropharynx is clear with moist mucous membranes. Neck is
supple with no jugular venous distention. Heart is regular
rate and rhythm. Pacemaker placement is clean, dry, and
intact with no evidence of oozing or hematoma. Lungs are
clear to auscultation bilaterally. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are free of any clubbing, cyanosis, or edema.
Neurologic exam: Cranial nerves II-XII are intact. Strength
is [**5-9**] and symmetric. Reflexes are intact and symmetric.
Toes are downgoing.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular: Patient was continued on aspirin,
Plavix, beta blocker, and Captopril with good blood pressure
control. His initial hypertension was felt to be secondary
to periprocedure stress. During his hospitalization on the
[**Hospital Unit Name 196**] service, however, his angiotensin-converting enzyme was
titrated up and his beta blocker was changed to t.i.d.
dosing.
2. For Mobitz II rhythm patient was status post pacemaker.
His pacemaker was interrogated on [**2181-2-3**]. Additionally,
a chest x-ray revealed proper placement. Patient received
four doses of Vancomycin and had no other abnormalities that
were noted.
3. For diabetes patient was continued on a regular insulin
sliding scale.
4. Gastrointestinal: Patient was maintained on a proton
pump inhibitor and bowel regimen.
5. Psychiatry: Patient was maintained on Celexa as well as
Lorazepam.
FINAL DIAGNOSES:
1. Coronary artery disease status post catheterization,
status post stent to left anterior descending, and status
post pacemaker placement.
2. Coronary artery disease.
3. Gastroesophageal reflux disease.
4. Hypertension.
DISCHARGE INSTRUCTIONS:
1. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N., [**Last Name (un) 4949**], R.N. at the [**Hospital Ward Name 23**] Cardiac Center
on [**2181-2-8**] at 3 p.m.
2. Audiology at the [**Hospital Ward Name **] Otolaryngology Building on
[**2181-2-21**] at 3 p.m.
3. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], R.N. at the [**Hospital Ward Name 23**] Dermatology Center on
[**2181-3-7**] at 2:20 p.m.
4. Patient is also to follow up in the Electrophysiology
Clinic at [**Telephone/Fax (1) 59**] on [**2181-2-8**].
5. The patient was advised that he is not to take a shower
for one week.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg one p.o. q.d.
2. Plavix 75 mg one p.o. q.d.
3. Pantoprazole 40 mg one p.o. q.d.
4. Citalopram 20 mg one p.o. q.d.
5. Captopril 25 mg one p.o. t.i.d.
6. Metoprolol 50 mg one p.o. t.i.d.
DISPOSITION: Home.
DISCHARGE CONDITION: Stable, stable on room air, is able to
ambulate without difficulty, is having no further ectopy on
telemetry, is tolerating a regular diet, has had no further
episodes of chest pain, palpitations, or other cardiovascular
complaints.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 5843**]
MEDQUIST36
D: [**2181-4-9**] 11:11
T: [**2181-4-12**] 09:20
JOB#: [**Job Number 50807**]
|
[
"9971",
"4019",
"53081"
] |
Admission Date: [**2131-8-29**] Discharge Date: [**2131-9-8**]
Date of Birth: [**2058-4-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2131-8-30**] Cardiac cath
[**2131-8-31**]: Urgent coronary artery bypass graft x3: Left internal
mammary artery to left anterior descending artery; saphenous
vein grafts to diagonal and obtuse marginal arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
Mr. [**Known lastname 11845**] is a 73 M with a history of CVD s/p left carotid stent
placement on [**2131-8-8**], HTN, HL, DM2 who presents following an
episode of dizziness followed by N/V/D and associated chest
pain. He reports that he has been feeling well since his prior
hospitalization with no recurrence of neurologic symptoms
(initially had some right hand numbness/weakness which came and
went). He felt well when he went to bed last night. On awakening
this morning and turning over in bed, he felt extremely dizzy
and like the room was spinning around. He turned back and his
symptoms resolved after about 10 seconds. He then got out of bed
and walked toward his kitchen to take his medications, but felt
the sudedn onset of nausea and rushed to the bathroom where he
proceeded to vomit for ~ one hour. He also had several episodes
of "soft stool" during this period though stool was not liquidy.
No blood in emesis or stool. He was diaphoretic during this
time, and after about an hour of dry heaving began to develop
chest pain located just above the manubrium to a severity of
~6.5/10. He also had an exacerbation of chronic left biceps pain
radiating to his hand to [**10-22**] severity and throbbing in
quality. At this time, his wife called EMS. He was ultimately
able to take his morning medications and reports that though he
had some dry heaving afterward he did not vomit his pills. The
chest pain began to resolve on its own and was down to 1/10
prior to EMS arrival. En route to the ED, he received a second
325 mg of aspirin and sublingual NG spray, following which the
CP fully resolved. He did have persistence of the left arm pain,
though less severe.
.
In the ED, initial VS were T 98.0, HR 130, BP 186/102 18 100% 4L
Nasal Cannula. His arm pain improved with one dose of 4 mg IV
morphine. Labwork was significant for WBC of 17.8 with
neutrophilic predominance on differential. CXR was notable for
possible early RLL pneumonia, for which he received 1 g IV vanco
and 750 mg levofloxacin for HAP given his recent
hospitalization. EKG was unremarkable. Vitals on transfer to the
floor were HR 122, BP 179/85, RR 18, O2 sat 97% on 2L. He was
admitted to medicine for treatment of pneumonia.
.
Upon transfer to the floor, he reported feeling significantly
improved. He has had no further vertigo, nausea, vomiting, or
diarrhea/loose stool since arriving in the ED. He does not feel
SOB and denies fever, chills, night sweats, shortness of breath,
cough, pleuritic chest pain or sputum production. No current CP
or arm pain.
Past Medical History:
- Hypertension (per record of home BPs, generally runs SBP
130s-140s, HR 80s-90s)
- Hypercholesterolemia
- Diabetes mellitus type II
- Hypothyroidism
- Cerebral [**Month/Year (2) 1106**] disease s/p stent placement to left carotid
[**2131-8-8**]
- Vertigo (likely BPPV) x several months (last episode > 1 month
ago)
- Lung cancer s/p surgical excision (left sided), no
chemo/radiation
- Left inguinal hernia repair
- Partial gastrectomy for ulcer ~40 years ago
- Multiple (~4) back surgeries for bone spurs (? additional
indications), no active back problems, ? hardware in place
- Accidental amputation of right thumb
- Rotator cuff surgery
Social History:
Married (second marriage) and lives with his wife. [**Name (NI) **] has one
stepson who lives nearby and two biological grown children who
live out of state. He was previously a heavy smoker (up to 4
packs per day) but quit 40 years ago. He drinks occasional beer
but keeps this to a minimum, because he continues to work as a
bus driver (cross-country charter buses) and takes jobs as they
come.
Family History:
Raised in an orphanage - does not know his biological family.
Physical Exam:
Admission Physical Exam:
GENERAL - Well-appearing elderly gentleman in NAD, comfortable,
appropriate, speaking in full sentences
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
upper and lower dentures in place, NC in place
NECK - Supple, no thyromegaly, no JVD, soft carotid bruits
appreciable bilaterally
LUNGS - No wheeze, rales, rhonchi. However, patient has
increased vocal fremitus at right base, as well as increased
sound transmission on assessment for egophony. No significant
dullness to percussion appreciated.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - No signifcant rashes or lesions. sebhorrheic keratoses on
the back
NEURO - Awake, A&Ox3, CNs II-XII grossly intact, strength/gait
not assessed
Pertinent Results:
CHEST (PORTABLE AP): [**2131-8-29**]
1. Suboptimal study, as the left costophrenic angle is not fully
included and a small left pleural effusion cannot be excluded.
Slightly increased right lower lobe opacity, early consolidation
not excluded. Suggest dedicated PA and lateral views for better
evaluation when patient able.
TTE: [**2131-8-31**]: PRE-BYPASS: No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
There is mild basal and mid-inferoseptal wall hypokinesis. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person
of the results at time of surgery.
POST-BYPASS: The patient is AV paced, on no inotropes. There is
moderate hypokinesis of the basal and mid-inferoseptal and
inferior wall of the left ventricle. Left ventricular systolic
function is unchanged. Right ventricular function is unchanged.
Mild aortic stenosis is unchanged. Mild (1+) aortic
regurgitation is unchanged. Moderate (2+) mitral regurgitation
is seen. The ascending aorta, aortic arch, and descending aorta
are intact.
.
Cardiac catheterization [**2131-8-30**]:
1) Coronary angiography of this right-dominant system
demonstrated significant left main and functional three vessel
coronary artery disease. The LMCA had 70% stenosis with severe
damping. The LAD had 60% distal stenosis with a D1 with 70%
proximal stenosis. The LCX had 70% stenosis at the origin. The
dominant RCA had 99% proximal stenosis, 99% mid stenosis, and
99% distal stenosis with left to right collaterals. 2) Limited
resting hemodynamics revealed systemic arterial hypertension
(161/72/113). 3) Left ventriculography was deferred.
.
Non-contrast Chest CT [**2131-8-30**]:
1. Moderate calcifications of the ascending aorta, the aortic
arch, the
descending aorta and the supra-aortic branches.
Moderate-to-severe coronary
calcifications. 2. Multiple non-characteristic, partly calcified
and partly non-calcified pulmonary nodules. Several sub 5-mm
ground-glass nodules. 3. Part solid and part non-solid pulmonary
nodule in the anterior aspects of the right lower lobe, with
retractile behavior with regard to the major fissure. This
nodule needs to be followed by CT in approximately six months
from now. 4. Minimal bilateral basal scarring, left more than
right, with a minimal left pleural effusion.
CXR [**2131-9-4**]: Upright PA and lateral views of the chest show a
decrease in the left pleural effusion. The abnormal contour is
likely due to pleuralthickening seen on previous examinations.
Unchanged small right pleural effusion. Heart size is large but
unchanged. Decrease in mediastinal size with no evidence for
active bleeding. Again seen are small calcified granulomas
within the right mid lung. No pneumothorax.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 11845**] presented to the ED with
dizziness and chest pain. He was admitted and worked up. A
repeat troponin on the evening of the day of admission ([**8-29**])
was elevated at 0.34 and CK-MB was 39. The patient was placed on
oxygen and administered a second dose of aspirin 325 mg. A
cardiology consult was called. He was placed on telemetry and
then transferred to the cardiology floor for cardiac
catheterization. Catheterization on [**2131-8-30**] demonstrated left
main and functional three vessel disease. He was continued on a
heparin drip, aspirin, clopidogrel, beta blocker, [**Last Name (un) **] and statin
in preparation for CABG. He was brought to the operating room on
[**2131-8-31**] where he underwent an urgent coronary artery bypass
graft x 3. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He was intubated
on propofol and Neo. He had increase bloody CT drainage
required multiple blood products, he ended up returning to the
OR for exploration. Venous bleed was found and repaired. He
returned to the ICU and was hemodynamically stable. He was
extubated that evening and was found to be alert and oriented
and breathing comfortably. The patient remained neurologically
intact and hemodynamically stable he weaned from vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed. The patient was transferred to the telemetry floor on
POD#1, his CT remained for continued drainage. His wires were
removed in timely fashion and wihtout difficulty. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. Patient has a history of vertigo
(likely BPPV), in the post-op period he was acutely dizzy and
very unsteady gait as a result, he was restarted on his
meclizine. He has a hx of carotid stenosis and was restarted on
Plavix. Due to his continued dizziness, he had carotid studies
done which showed 60-69% stenosis in right and patent left
carotid stent. He was evaluated by the neurology service who
felt that his dizziness was related his vertigo that has been
aggravated by his recent surgery and that it will improve with
time. He has remained hemodynamcically stable and remains in SR.
The wound was healing and his pain was controlled with oral
analgesics. In lgiht of his dizziness, unsteady gait and safety
concerns he was discharged to neuro rehab - [**Hospital 38**] rehab on
POD# 8.
Follow up instructions arranged [**9-6**]
Medications on Admission:
Ergocalciferol (vitamin D2) 50,000 unit Cap PO every other week
Simvastatin 80 mg PO mouth daily
Losartan 100 mg by mouth daily
Meclizine 25 mg PO up to three times per day for dizziness
Levoxyl 50 mcg PO daily
Enteric Coated Aspirin 325 mg Tab (E.C.) PO Daily
Plavix 75 mg PO daily
Metformin 850 mg PO BID
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. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO QID (4 times
a day).
10. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
11. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
12. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO DAILY (Daily) for 4 days.
13. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
- Hypertension
- Hypercholesterolemia
- Diabetes mellitus type II
- Hypothyroidism
- Cerebral [**Location (un) 1106**] disease s/p stent placement to left carotid
[**2131-8-8**]
- Vertigo (likely BPPV) x several months (last episode > 1 month
ago)
- Lung cancer s/p surgical excision (left sided), no
chemo/radiation
- Left inguinal hernia repair
- Partial gastrectomy for ulcer ~40 years ago
- Multiple (~4) back surgeries for bone spurs (? additional
indications), no active back problems, ? hardware in place
- Accidental amputation of right thumb
- Rotator cuff surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] on at [**Telephone/Fax (1) 170**] Date/Time:[**2131-10-8**]
1:00
Cardiologist: Dr. [**Last Name (STitle) **] on [**10-9**] @ 11am
Please call to schedule the following:
Primary Care: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD Phone:[**Telephone/Fax (1) 2205**]
Date/Time:[**2131-9-21**] 8:30
**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:[**2131-9-11**]
|
[
"41071",
"486",
"25000",
"41401",
"4019",
"2724",
"2720",
"2449",
"V1582"
] |
Admission Date: [**2121-8-8**] Discharge Date: [**2121-8-12**]
Date of Birth: [**2036-10-16**] Sex: F
Service: MEDICINE
Allergies:
lisinopril / morphine / Oxycodone
Attending:[**Last Name (un) 2888**]
Chief Complaint:
short of breath
Major Surgical or Invasive Procedure:
aortic valvuloplasty [**8-11**]
History of Present Illness:
REASON FOR TRANSFER: need for BiPAP
HISTORY OF PRESENTING ILLNESS:
84 yo with critical aortic stenosis, diastolic heart failure (EF
65%), CAD admitted to [**Hospital1 18**] for surgical evaluation of AS
transferred to CCU due to need for BiPAP.
Patient was initially admitted to [**Hospital1 **] [**Location (un) 620**] with respiratory
distress, thought to be secondary to flash pulmonary edema. She
was initially placed on BIPAP and diuresised with IV lasix.
Course at [**Location (un) 620**] was complicated by UTI with administration of
CTX. Her creatinine was 2.2 from 2.3 with diuresis. Her heart
rate was well controlled, and was continued on her home
metoprolol. She was transferred to [**Hospital1 18**] for surgical evaluation
for her aortic stenosis and possible balloon aortic
valvuloplasty.
On arrival to BIDNC discussion involving mgmt of AS ensued and
decision was made to precede with ballon angioplasty on [**8-11**]. On
[**8-10**] patient triggered twice for tachypnea. Initially patient
responded to 20mgIV lasix (received a total of 40mg IV) however
again became tachypneic and less responsive so discussion was
made to transfer to the CCU for initiation of BiPAP. Prior to
transfer patient received additional 20mg IV lasix and ipratrium
nebulizer.
Vitals on transfer were 130/50 80-90sAF RR: 24-28 98-100
3-4LNC.
On arrival to the CCU, patient minimally interactive and patient
started on BiPAP.
REVIEW OF SYSTEMS
On review of systems, s/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. S/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 of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
Critical aortic stenosis
Diastolic congestive heart failure (EF 65%)
Coronary artery disease s/p MI x 2
Atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
Myelodysplastic syndrome
Diabetes mellitus
Chronic kidney disease, baseline creatinine 1.7
Peripheral [**Month/Year (2) 1106**] disease
Peripheral neuropathy
Gout
Anemia of chronic disease
Bilateral carotid artery stenosis
Dementia
Peptic ulcer disease
Osteoarthritis
Depression
Anxiety
MEDICATIONS: (home)
Januvia 100 mg PO daily
Gabapentin 100 mg PO daily
Mirtazapine 30 mg PO daily
Carvedilol 25 mg PO BID
Torsemide 60 mg PO daily
Docusate 100 mg PO daily
Pravastatin 80 mg PO daily
Clopidogrel 75 mg PO daily
Vitamin B12 500 mg PO daily
Omeprazole 20 mg PO daily
Allopurinol 200 mg PO daily
Warfarin 2 mg daily alternating with 3 mg PO daily
Folic acid 1 mg PO daily
Trazodone 100 mg PO daily
ALLERGIES:
Lisinopril (hyperkalemia)
Social History:
Lives at home. Uses a walker. Quit smoking several years ago. No
alcohol or drug abuse.
Family History:
Non-contributory
Physical Exam:
VS: T= 97.8 BP=127/57 HR=85 Afib RR=20 O2 sat=100% on Bipap
GENERAL: Depressed affect, Bipap on
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. systolic ejection murmur in RUSB
LUNGS: Scan crackles in RLL, rhonchi over left
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting edema in bilateral lower extremities,
radial pulses 1+, DP pulses 1+. Patient mildly cool to touch,
small area of warmth and erythema over dorsal aspect of L shin
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Procedures: Coronary Angiography, RLHC, Balloon aortic
valvuloplasty
Indications: Critical aortic stenosis
Staff
Diagnostic Physician [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Fellow [**Name6 (MD) **] [**Name8 (MD) **], MD
Nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6185**], RN
Nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6692**], RN
Technologist [**Doctor First Name **] Hokinson, RTR
Technologist [**First Name8 (NamePattern2) 5335**] [**Last Name (NamePattern1) 5239**], EMT,RCIS
Technical
Anesthesia: Local
Specimens: None
Catheter placement via 5 French pulmonary artery catheter
Coronary angiography using 5 French JL3.5 JR4, Dual lumen
pigtail
Blood Oximetry Information
Baseline
Time Site Hgb(gm/dL) Sat (%) PO2 (mmHg) Content (ml per dl)
10:09 AM PA 7.80 63 6.68
10:16 AM AO 7.80 100 10.61
Cardiac Output Results
Phase Fick C.O.(l/min) Fick C.I. (l/min /m2) TD
CO (l/min) 3.30 2.11
Hemodynamic Measurements (mmHg) Baseline
Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR
PCW 30 22 30 65
AO 127 46 78 62
PA 75 34 55 62
ART 100 62
RV 77 16 25 58
RA 23 28 26 58
Baseline
Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR
LV 154 27 32 62
AO 137 47 81 59
Valve Results
Contrast Summary
Contrast Total (ml)
Omnipaque (300 mg/ml) 35
Radiation Dosage
Effective Equivalent Dose Index (mGy) 386
Radiology Summary
Total Runs
Total Fluoro Time (minutes) 15.7
Findings
ESTIMATED blood loss: < 25 cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: Moderate diffuse lumen irregularities up to 50%
LAD: Moderate diffuse lumen irregularities up to 50%
LCX: Moderate diffuse lumen irregularities up to 50%
RCA: Left dominant
Interventional details
The patient was placed under general anesthesia and the
procedure
was performed under TEE guidance. The left brachial artery was
exposed by surgical technique and coronary arteriography was
performed from the left brachial artery.
The aortic valve was then crossed with a 0.014 straight wire and
a pigtail catheter was placed in the left ventricle for
simultaneous pressure recordings.
A 0.035 Amplatz SuperStiff guidewire was placed in the left
ventricle and a single balloon inflation was performed using a
18
mm Tyshak II balloon.
Immediately after balloon deflation, the patient developed
marked
hypotension. There was no evidence of aortic regurgitation and
no evidence of pericardial fluid.
CPR was initiated but the left ventricular contractility
continued to worsen.
The patient expired at 11:11 AM.
The family was notified.
Assessment & Recommendations
1. Severe aortic stenosis
2. Non obstructive but diffuse coronary artery disease
3. Unsuccessful balloon aortic valvuloplasty resulting in death
______________________________________
Brief Hospital Course:
Ms [**Known lastname 32651**] is a 85 y/o F with PMHx of critical aortic stenosis,
CAD, DM2, transferred to the CCU for worsening respiratory
distress who underwent aortic valvuplasty with procedure
complicated by refractory hypotension and asystolic arrest.
# PUMP: Patient with known critical AS and transferred to CCU
for monitoring of heart failure symptoms prior to valvuloplasty.
She was on bipap briefly and then given lasix IV prn for
diuresis. Pt was stabilized for 48hrs prior to procedure. She
underwent elective valvuloplasty on [**8-12**]. Unfortunately
immediately after balloon deflation, the patient developed
marked hypotension. Per cath report there was no evidence of
aortic regurgitation and no evidence of pericardial fluid. CPR
was initiated but the left ventricular contractility continued
to worsen. Patient died on [**8-12**]. Family was notified.
#Anxiety: Patient had lots of anxiety leading up to procdure and
was treated with zyprexa.
#LLE Cellulitis. Treated with Vancomycin in house.
CHRONIC ISSUES
# Afib. Rate controlled in house. Coumadin was held on arrival
in plan for procedure.
# CAD, Patient with known occlusion of OM1 by CTA and
calcifications of widespread coronaries s/p MIx2. In house
contineud on home plavix 75mg, pravastatin 80 mg daily
# Diabetes mellitus type 2. Maintained on ISS + lantus in house
# Peripheral neuropathy. Continued on renally dosed Gabapentin
100 mg q 24 hrs
#PUD. Continued on Omeprazole 20 mg daily
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
2. Gabapentin 100 mg PO DAILY
3. Mirtazapine 30 mg PO HS
4. Carvedilol 25 mg PO BID
hold for sbp<95, hr<55
5. Torsemide 60 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY
7. Pravastatin 80 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Cyanocobalamin 500 mcg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Allopurinol 200 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Warfarin 2 mg PO DAILY16
14. traZODONE 100 mg PO HS:PRN insomnia
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Aortic Stenosis
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"25000",
"2724",
"412",
"42731",
"40390",
"5859",
"311",
"V1582",
"V5867",
"4241",
"5990",
"2762",
"5849",
"41401",
"4280"
] |
Admission Date: [**2110-8-17**] Discharge Date: [**2110-9-4**]
Date of Birth: [**2079-8-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Tracheostomy
PICC line placement
Bronchoscopy
History of Present Illness:
Patient is a 31 yo M with no significant PMHx who presented to
OSH with complaints of weakness developing acute respiratory
failure found to have a saddle PE started on heparin gtt
trasnferred to [**Hospital1 18**] for further management.
Patient initially presented to OSH ED with complaints of
weakness, that started 5 days prior to presentation. He was
initially seen in the ED, received 2L NS for hydration, and then
discharged. He represented with porfound weakness, requiring his
brother to help him to the [**Name (NI) **]. He had a headache and body aches.
He also noted fevers, chills, and sweats, along with n/v. Per
OSH H&P, the patient reported vomiting 10-15 times. The vomitus
was non-bloody. He denied abdominal pain or diarrhea at the time
of presentation. He denied recent travel or known sick contacts.
His friend reports that he had bowel and bladder incontinence.
He denied any sore throat.
At the OSH, the patient was initially able to provide history.
Upon presentation, his temperature was 99.3. He was thought to
have pulmoanry edema for which he received lasix. Because of his
weakness and observation that he had a sensory level at T8, he
was initially thought to have a transverse myelitis. However,
MRI of the head was negative; MRI of the cervical and thoracic
spine revealed no abnormalities. He underwent an LP at the OSH;
the LP showed WBC 550,00 with 15% polys, 19% lymphs, and 16%
monos. The patient was noted to be serologically positive for
Lyme disease as well as EBV virus. Lyme CSF was negative. He was
started on IV ceftriaxone for coverage of possible Lyme
meningitis. The patient also was given IV acyclovir prior to
presentation to [**Hospital1 18**] in case the patient's clinical picture
represented EBV encephalitis. The patient was noted to have an
acute hypoxic event on [**2110-8-11**], during this OSH
hospitalization. CTA at the OSH showed saddle PE wtih probably
lower lobe pulmoanry infarcts. LENI at OSH were negative fo DVT.
The patient was intubated and started on heparin gtt. TTE showed
dilated hypokinetic RV with flattened septum and well preserved
LV function. Cardiac surgery evaluated the patient for
thrombolectomy, who did not feel that thrombolectomy was acutely
indicated. CT abdomen/pelvis at the OSH showed normal kidney,
ureters, and bladder as well as hepatomegaly and trace ascites.
Bone windows were negative.
On arrival to the MICU, the patient is intubated and sedation.
Review of systems: Unable to obtain as patient is intubated and
sedated.
Past Medical History:
None per OSH records
Social History:
Unable to obtain as patient intuabted and sedated. [**Doctor Last Name **]. Former
Marine. Patient lives with his brother's family. He does not
drink EtOH. Smoker 1 pack cigarettes every 2 days.
Family History:
Per OSH recrods. Father died of stroke at age 69.
Physical Exam:
Admission Exam
Vitals: 98.6, 177/117, 112, 24, 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild bibasilar crackles
Abdomen: soft, exquisitely TTP, + guarding, + rebound
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact,
Discharge Exam
General: Awake and alert.
HEENT: Tracks to voice., answers to yes and no questions
Neck: Trach in place with no external blood
CV: RRR. No murmurs.
Lungs: Coarse breath sounds anteriorly. No crackles or wheezes.
Abd: BS+. Soft. NT/ND.
Ext: No clubbing, cyanosis, edema.
Neuro: Hand grip equal, [**4-14**] RUE flexion. Moving feet bilaterally
more vigorously as compared with yesterday. 1+ patellar reflexes
bilaterally. [**5-15**] plantarflexion b/l.
Pertinent Results:
[**2110-8-17**] 01:45PM BLOOD WBC-17.0* RBC-3.57* Hgb-10.5* Hct-33.4*
MCV-94 MCH-29.5 MCHC-31.6 RDW-12.8 Plt Ct-364
[**2110-8-23**] 03:44AM BLOOD WBC-11.5* RBC-3.80* Hgb-11.5* Hct-34.8*
MCV-92 MCH-30.3 MCHC-33.1 RDW-12.9 Plt Ct-571*
[**2110-8-29**] 04:38AM BLOOD WBC-11.7* RBC-3.42* Hgb-10.4* Hct-31.3*
MCV-92 MCH-30.4 MCHC-33.2 RDW-15.1 Plt Ct-435
[**2110-9-4**] 03:54AM BLOOD WBC-7.8# RBC-2.87* Hgb-9.1* Hct-24.7*
MCV-86 MCH-31.5 MCHC-36.7* RDW-15.7* Plt Ct-511*
[**2110-8-17**] 01:45PM BLOOD PT-14.0* PTT-66.0* INR(PT)-1.3*
[**2110-8-25**] 03:39AM BLOOD PT-13.1* PTT-27.3 INR(PT)-1.2*
[**2110-9-2**] 05:31AM BLOOD PT-17.6* PTT-36.6* INR(PT)-1.7*
[**2110-9-3**] 04:51AM BLOOD PT-19.2* PTT-39.0* INR(PT)-1.8*
[**2110-9-4**] 03:54AM BLOOD PT-18.6* PTT-41.0* INR(PT)-1.8*
[**2110-8-17**] 01:45PM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-142
K-4.2 Cl-101 HCO3-36* AnGap-9
[**2110-8-21**] 04:24AM BLOOD Glucose-186* UreaN-24* Creat-0.6 Na-145
K-4.7 Cl-103 HCO3-34* AnGap-13
[**2110-8-24**] 03:53AM BLOOD Glucose-126* UreaN-24* Creat-0.6 Na-139
K-4.4 Cl-100 HCO3-31 AnGap-12
[**2110-8-28**] 03:03AM BLOOD Glucose-86 UreaN-23* Creat-0.6 Na-139
K-4.6 Cl-101 HCO3-27 AnGap-16
[**2110-9-1**] 04:20AM BLOOD Glucose-124* UreaN-18 Creat-0.5 Na-134
K-4.3 Cl-96 HCO3-29 AnGap-13
[**2110-9-4**] 03:54AM BLOOD Glucose-87 UreaN-24* Creat-0.4* Na-139
K-4.4 Cl-100 HCO3-33* AnGap-10
[**2110-8-17**] 01:45PM BLOOD ALT-61* AST-40 LD(LDH)-319* AlkPhos-152*
TotBili-0.3
[**2110-8-22**] 02:58AM BLOOD ALT-150* AST-39 CK(CPK)-43* AlkPhos-110
TotBili-0.2
[**2110-8-27**] 04:01AM BLOOD ALT-93* AST-32 LD(LDH)-279* AlkPhos-92
TotBili-0.5
[**2110-9-1**] 04:20AM BLOOD ALT-92* AST-28
[**2110-9-4**] 03:54AM BLOOD ALT-82* AST-41* LD(LDH)-175 AlkPhos-88
TotBili-0.5
[**2110-8-28**] 03:03AM BLOOD Lipase-12
[**2110-9-4**] 03:54AM BLOOD Albumin-3.0* Calcium-9.5 Phos-4.5 Mg-2.0
[**2110-8-17**] 01:45PM BLOOD VitB12-1446*
[**2110-8-17**] 01:45PM BLOOD TSH-1.5
[**2110-8-20**] 04:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2110-8-17**] 07:50PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2110-8-28**] 03:03AM BLOOD IgG-1038 IgA-173 IgM-200
[**2110-8-17**] 01:45PM BLOOD PEP-NO SPECIFI
[**2110-8-20**] 04:15AM BLOOD HCV Ab-NEGATIVE
[**2110-8-18**] 02:53AM BLOOD LYME BY WESTERN BLOT-Test Name
[**2110-8-18**] 02:53AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG-Test
[**2110-8-18**] 02:53AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-Test
[**2110-8-18**] 02:53AM BLOOD BARTONELLA (ROCHALIMEA) HENSELAE
ANTIBODIES, IGG AND IGM-Test
[**2110-8-18**] 02:53AM BLOOD ARBOVIRUS ANTIBODY IGM AND IGG-Test Name
MRI Head ([**2110-8-17**])
Abnormal, multifocal, T2-signal hyperintensity throughout the
spinal cord, most severe in the cervical cord as above. Similar
abnormalities are present in the brain (that study is reported
separately). This appearance is not specific though would
favour viral infection, including that with West Nile virus.
Other infectious entities may have a similar appearance, such as
encephalomyelitis related to listeria, mycoplasma, or
campylobacter, amongst others (given the element of
rhomboencephalitis on the brain imaging).
Demyelinating processes such as MS, ADEM or neuromyelitis optica
and other
vatiants are also possibilities, as are other inflammatory
disorders such as [**Last Name (un) 39722**] encephalitis. Neoplastic or
vasculitic etiologies are less likely given the appearance,
short-interval change and extent of involvement.
MRI ([**2110-8-25**])
In comparison to [**2110-8-17**] exam, diffuse bilateral T2/FLAIR
hyperintensities have significantly progressed. Differential
considerations remain infectious or non-infectious
encephalitides, possibly a paraneoplastic process.
Demyelinating process such as ADEM is felt less likely given the
lack of
improvement despite reported treatment with steroids.
Neoplastic and
vasculitic etiologies are unlikely given appearance and
distribution.
Brief Hospital Course:
Patient is a 31 year old male with no significant PMHx who
presented to OSH with complaints of weakness developing acute
respiratory failure found to have a saddle PE started on heparin
gtt trasnferred to [**Hospital1 18**] for further management with MRI
findings suggestive of ADEM treated with IV steroids/IVIG, whose
mental status and neurological function improved.
# Respiratory failure: Multifactorial; etiologies include saddle
pulmonary embolism with infarction in combination with profound
weakness from ADEM. The patient was difficult to oxygenate at
times initially. Patient underwent trach and PEG placement in
light of prolonged intubation. Improving currently, he is
tolerating trach collar at times up to 30 minutes. Speech and
swallow are also working with him. Be sure to look for signs of
carbon dioxide retention if mental status worsens on PSV as
patient could tire out at times. He is usually arousable to
voice, alert and can nod to yes/no questions, oriented X3.
# ADEMS: Patient underwent head MRI as well as full spine MRI as
part of work-up of his clinical picture, and Neurology felt that
the findings were consistent with ADEM. He was treated with 5
days of IV steroids and five more days of IVIG. The patient's
exam improved along with repeat MRI imaging showed progression
of the lesions, but this was in the context of improved exam
clinically, and no further interventions were done. His
diaphgram has improved function with today's NIF of -43. He has
slowly regaining strength in his extremities with 3/5 UE and LE
strength (R > L). Please continue to ensure he has ongoing
physical therapy.
# Pulmonary embolism: Patient with saddle embolism at the OSH.
Patient was hemodynamically stable upon arrival to [**Hospital1 18**] with
SBP 130-140s. Patient was evaluated for thrombectomy at OSH and
it was felt that pulmonary embolectomy would be counter
productive. Patient was initially continued on heparin gtt, at
one point being transitioned Lovenox /coumadin which he
currently is on with INR of 1.8 on [**2110-9-4**], 1.8 [**9-3**], [**9-2**]
1.7. Coumadin was uptitrated to 12.5 mg from 10 mg daily on
[**9-2**]. If INR < 2.0 on [**2110-9-5**], please consider increasing
coumadin to 15 mg daily. Continue Lovenox bridge until
therapeutic INR.
# Pericarditis: He was noted to have diffuse ST elevations on
[**2110-9-3**]. He had not chest pain. They resolved with
ibuprofen 600 mg TID.
# Fevers of unknown etiology. Resolved for past few days.
Work-up at the OSH included: negative HIV; weakly positive Lyme
IgM, negative Lyme CSF, negative Monospot, Negative Babesia,
Negative anaplasma, positive EBV CSF serology. ID and neurology
were consulted upon patient's arrival. Repeat lumbar puncture
was done; culture data returned showing no growth and serologies
were negative. The patient was initially on broach spectrum
antibiotics upon ID recommendations, but with negative CSF
culture data, negative CSF data antiobiotics were then peeled
back. His fevers were attributed to ADEM and resolved week prior
to discharge
# Elevated LFTs: There was concern for viral hepatitis, though
viral serologies at [**Hospital1 18**] returned negative. RUQ ultrasound did
not show concerning findings. LFTs were trended through the
admission and remained stable.
Medications on Admission:
Medications HOME:
None
.
Medications on TRANSFER:
--Acyclovir 800mg ONCe
--Ceftriaxone 2grams IV daily
--Famotidine 20mg [**Hospital1 **]
--Heparin GTT
--Ipratropium/albuterol 6-8 puffs QID
--Propofol 1000mg GTT
--Acetaminophen 650mmh q4hours PRN PR
--Fentanyl 25mcg q1hours PRN pain
--Zofram 4mg IB q6hours PRN nausea
Discharge Medications:
1. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation.
3. Docusate Sodium (Liquid) 100 mg PO BID
hold for loose stools
4. Enoxaparin Sodium 100 mg SC Q12H
5. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID
6. Pantoprazole 40 mg IV Q24H
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 1 TAB PO BID:PRN constipation
9. Warfarin 12.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
ADEM
Saddle Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure to care for you at the hospital.
.
You were admitted for altered mental status and weakness. You
were found to have a encephalitis and lung blood clot. You
needed to be intubated during the admission and were cared for
in the ICU. You were treated for the encephalitis with IVIG and
are currently improving from a neurologic perspective. Your
respiratory status is also stable and slowly imroving.
.
Your physcial therapy and rehab. will continue at a specialized
facility.
Followup Instructions:
Please follow up with your primary care physician after
discharge
|
[
"2762",
"5180",
"51881",
"3051",
"2859"
] |
Admission Date: [**2135-11-12**] Discharge Date: [**2135-11-17**]
Date of Birth: [**2104-8-11**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
HD line removal ([**2135-11-12**])
Temporary HD line placement ([**2135-11-15**])
Post-pyloric feeding tube placement ([**2135-11-16**])
History of Present Illness:
31 y/o M with biliary atresia s/p liver [**Month/Day/Year **] at age 4
currently listed for liver/kidney [**Month/Day/Year **], ESRD on HD who was
transferred from OSH [**2135-11-12**] with fevers, tachycardia, and
abdominal pain. Patient reported diffuse abdominal pain, worse
in RUQ x 4 days that came on suddenly then radiated to right
chest. The day prior to transfer he had coffee-ground emesis and
black diarrhea. In the ED patient was tachycardic to 140-150s
with SBP 100's and spiked a fever to 102.4. Patient was
empirically started on vancomycin and zosyn. CXR demonstrated
bilateral effusions and no infiltrate. CTA torso demonstrated no
PE, but loculated ascites with mass effect, patent portal vein,
mod-large b/l pleural effusions and jejunal wall thickening of
unknown significance. Following 3L of IVFs patient remained
tachycardia and was consequently admitted to the MICU for
concern of sepsis.
.
During his MICU stay blood cultures returned positive for
klebsiella pneumoniae and consequently his HD line was removed.
Cultures were pan-sensitive consequently vanc/zosyn was narrowed
to ceftriaxone. Additional infectious work up included: negative
influenza, negative c. diff, negative SBP, negative urine
culture. Patient had no episodes of coffee ground emesis or
melena and HCT remained stable (hemoconcentrated on admission).
Tachycardia was an ongoing problem. The MICU team attempted
small boluses of fluid with only mild improvement in his HR.
Today 6 mg adenosine was given to investigate whether rhythm was
SVT but had no effect. During his admission the patient began
complaining of back pain and a MRI spine was ordered to rule out
epidural abscess prior to transfer.
.
Upon evaluation of the patient he states his abdominal pain has
completely resolved since admission. He denies any fevers,
chills, emesis or bloody bowel movements. He states his back
pain started on saturday ("after all the fluids") but has now
improved. The pain was [**4-3**] and non-localized ("my entire
back"). Patient describes difficulty ambulating due to lower
extremity edema only. No changes in his bowel movements (loose
at baseline). The patient is oriented x 3 and states he feels
much better than on admission.
.
Of note, patient was recently admitted [**10-3**] and diagnosed with
H1N1, SVT responsive to adenosine, multifocal PNA treated with
vancomycin, zosyn, and levofloxacin, possible sick euthyroid and
acute on chronic renal failure felt to be due to ATN requiring
HD and relisting for a kidney [**Month/Year (2) **].
.
Past Medical History:
-biliary Atresia s/p liver [**Month/Year (2) **] at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
-small bowel resection
Social History:
denies any tobacco, EtOH or illict drug use. Lives at home with
parents. Has one child with a prior girlfriend. Does not work.
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Current: 99.4, HR 127, BP 132/89, RR 22, SaO2 98%
Last 24 hours: T 97-100.2, Tm 100.2; BP 104-145/66-90. HR
119-137 (with episodes into the 140s); RR 19-22; O2 93-97% on
RA.
GENERAL: Cachectic, comfortable, NAD
HEENT: MM dry, no LAD, neck supple
CARDIAC: Tachycardic, regular, No MRG
LUNG: Decreased breath sounds in bases bilaterally, no crackles,
wheezes.
ABDOMEN: Moderately distended, not tense, BS+, no tenderness. No
rebound or gaurding. Midline and RUQ surgical scar. Multiple
excoriations on abdomen.
EXT: 3+ pitting edema in LE's bilaterally (R > L)
NEURO: CNII-XII intact. Motor [**3-29**] upper and lower.
.
DISCHARGE
Vitals: Current: 99.0, tmax 99.7, HR 109-111, BP 114-126/74-78
(10-20 mmHg higher than yesterday), RR 20-22, SaO2 97%
IO Last 8 --> i = 240 ; o = 200
Last 24 --> i = 490 ; o = 200 + 4BM
Ultrafiltration - 2Litres negative
GENERAL: Cachectic, NAD
HEENT: MM dry, no LAD, neck supple
CARDIAC: Tachycardic, regular, No MRG
LUNG: Decreased breath sounds in bases bilaterally, no crackles,
wheezes.
ABDOMEN: distended, not tense, BS+, no tenderness. No rebound or
gaurding. Midline and RUQ surgical scar. Multiple excoriations
on abdomen.
EXT: 3+ pitting edema in LE's bilaterally, excoriations on arms
NEURO: CNII-XII intact. Motor [**3-29**] upper and lower.
SKIN: blanching erythema over left flank
Pertinent Results:
Admission
[**2135-11-12**] 06:30AM BLOOD WBC-9.5 RBC-4.13* Hgb-12.0* Hct-37.9*#
MCV-92 MCH-29.0 MCHC-31.6 RDW-17.7* Plt Ct-203
[**2135-11-12**] 06:30AM BLOOD Neuts-82* Bands-14* Lymphs-1* Monos-0
Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2135-11-12**] 12:00PM BLOOD PT-15.2* PTT-32.7 INR(PT)-1.3*
[**2135-11-12**] 06:30PM BLOOD Glucose-108* UreaN-23* Creat-2.2* Na-133
K-4.1 Cl-107 HCO3-19* AnGap-11
[**2135-11-12**] 06:30AM BLOOD ALT-21 AST-63* CK(CPK)-84 AlkPhos-486*
TotBili-0.6
[**2135-11-12**] 06:25AM BLOOD Glucose-99 Lactate-2.2* Na-137 K-4.0
Cl-106
Discharge
[**2135-11-17**] 07:45AM BLOOD WBC-9.9 RBC-2.98* Hgb-8.4* Hct-26.8*
MCV-90 MCH-28.0 MCHC-31.2 RDW-17.9* Plt Ct-295
[**2135-11-17**] 08:45AM BLOOD PT-16.0* PTT-34.0 INR(PT)-1.4*
[**2135-11-17**] 04:45PM BLOOD Glucose-115* UreaN-10 Creat-1.4* Na-137
K-3.7 Cl-101 HCO3-30 AnGap-10
[**2135-11-17**] 04:45PM BLOOD Calcium-6.9* Phos-1.3* Mg-1.4*
[**2135-11-14**] 06:14AM BLOOD TSH-1.1
[**2135-11-14**] 06:14AM BLOOD Free T4-0.79*
[**2135-11-17**] 07:45AM BLOOD Vanco-17.0
[**2135-11-17**] 07:45AM BLOOD tacroFK-4.5*
Wound Culture
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Blood Culture
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CT ABD/PELVIS
1. Severely limited study due to technique and timing of
contrast, for
evaluation for pulmonary embolism. No evidence of pulmonary
embolism in the
main or primary branches of the pulmonary artery.
2. Increased intra-abdominal ascites, with loculation and mass
effect on the intra-abdominal organs. Cirrhosis. Patent portal
vein. Perisplenic varices, compatible with portal hypertension.
3. Pulmonary edema. Moderate-to-large bilateral pleural
effusions with
associated atelectasis.
4. Two enlarged right internal mammary lymph nodes and right
greater than
left gynecomastia.
5. Mild jejunal wall thickening of unclear etiology. Eneteritis
is a
consideration. Some of these loops are mildly dilated but there
is not
obstruction.
6. Stable pneumobilia and mild common bile duct dilatation
status post
choledocojejunostomy.
7. Stable enlarged mesenteric lymph nodes.
MRI L AND T
IMPRESSION:
1. No abnormal bone marrow signal to suggest acute fracture or
osteomyelitis.
2. Bilateral L5 spondylolysis associated with proliferative bony
changes
extending into the right posterior epidural space at L4-5 which
combines with additional degenerative changes to create severe
canal narrowing.
3. Small bilateral fluid clefts at the level of spondylolysis
without a
drainable collection. Early infection within the posterior soft
tissues
cannot be fully excluded and continued followup is recommended.
Brief Hospital Course:
31 yo M w/ ESRD, ESLD s/p liver [**Month/Day/Year **] presented with
abdominal pain and tachycardia, found to have klebsiella
pneumoniae bacteremia, MSSA line site infection vs colonization
and, later cellulitis. He received ultrafiltration, HD, a
rational antibiotic regimen and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-intestinal tube for
feeding
.
# Klebsiella pneumoniae bacteremia
Presumably from his [**Last Name (NamePattern4) 2286**] line. It was pulled and replaced.
Ultimately he was discharged on Cefazolin 2 g qHD.
.
# Likely MSSA Line infection vs colonization: Pt had low grade
temperatures after transfer from MICU. His line site culture
grew MSSA and it was thought that his temperatures were related
to an untreated gram positive infection. After initiation of
cefazolin and vancomycin (below) were started, his temperature
normalized, his HR declined and his BP rose. Discharged on
Cefazolin.
.
# Rash: Discovered on Hospital day 3 and considered a cellulitis
with a hospital acquired pathogen that emerged despite
ceftriaxone. Discharged on vanc
.
# Atrial Tachycardia: Fluid unresponsive, normal TSH,
unresponsive to adenosine. Improved over time. Patient
discharged on 12.5 [**Hospital1 **] Metoprolol
.
# Lower back pain: Prior to transfer MICU team ordered MRI to
r/o epidural abscess. Unlikely based on improving back pain,
non-tender to palpation along spine, pain non-localized. No
deficits on neuro exam. L-spine wit severe DJD. Discharged on
lidocaine patches and oxycodone
.
#Pleural effusions: Albumin is less than 1 and ascites present.
Likely hepatic hydrothorax. Patient is responding to Abx,
unlikely effusions are infectious source. Patient breathing
comfortably on room air.
.
#ESLD: MELD 24 on [**11-16**]. SBP work-up negative. Persistent
concern for chronic rejection. Elevated INR may be partly
nutritional. A dobhoff was placed and the patient was discharged
with tube feeds at 45cc/hr. He was given phosphorus and
instructions for the prevention of refeeding syndome
#ESRD: [**12-27**] post-infectious glomerulonephritis, was started on HD
last admission due to ATN. Continue HD
TO BE FOLLOWED
1) Pt asked to see PCP every [**Month/Day (2) **] for MELD labs
2) Pt asked to have basic chemistries checked for surveillance
of refeeding syndrome
Medications on Admission:
asix 20mg PO daily
Lactulose 30-60cc PO QID
Reglan
Sucralfate
Tacrolimus 0.5mg PO BID
Oxycodone
Buproprion
Caltrate D
.
On transfer:
Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
Adenosine 6 mg IV ONCE
Acetaminophen 500 mg PO/NG ONCE MR1
HYDROmorphone (Dilaudid) 0.2 mg IV Q6H:PRN pain
CeftriaXONE 1 gm IV Q24H
Tacrolimus 0.5 mg PO Q12H
Lidocaine 5% Patch 1 PTCH TD DAILY
OxycoDONE (Immediate Release) 5-10 mg PO/NG Q6H:PRN pain [**11-13**] @
Pantoprazole 40 mg PO Q12H
Sarna Lotion 1 Appl TP PRN Itching
Vitamin D 400 UNIT PO/NG DAILY
Calcium Carbonate 500 mg PO/NG DAILY
Sucralfate 1 gm PO QID
Metoclopramide 10 mg PO/IV QID:PRN nausea
Lactulose 30 mL PO/NG Q8H:PRN constipation
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO four times a
day as needed for constipation.
2. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
7. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) topical
application Topical four times a day as needed for itching.
8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One
(1) Patch Topical once a day: Leave on for 12 hours, off for 12
hours.
Disp:*30 Patches* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous QHD: To be given at every Hemodialysis.
12. Cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous
QHD: To be given at every Hemodialysis.
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Outpatient Lab Work
Every [**Month/Year (2) 766**]. Check PT/INR, Sodium, Creatinine, Albumin and
bilirubin. Fax results to [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 697**].
15. Phos-NaK 280-160-250 mg Powder in Packet Sig: Two (2)
Pakcets PO twice a day.
Disp:*120 Packets* Refills:*2*
16. Outpatient Lab Work
Please check Chem 10 on Saturday [**11-19**] at HD and fax
results to [**Telephone/Fax (1) 697**]. Thanks.
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary Diagnoses:
1. Klebsiella septicemia
2. MSSA cellulitis at former HD line site
3. Hospital-acquired cellulitis of the back
4. Tachycardia
5. Severe spinal DJD and canal narrowing at L4-5
.
Secondary Diagnoses:
- Cirrhosis / ESLD
- ESRD on HD
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to the MICU at [**Hospital1 18**] for abdominal pain, back
pain, bleeding, and sepsis, and you were found to have several
concurrent infections including Klebsiella bacteremia, MSSA
cellulitis from at the site of your hemodialysis catheter, and
back cellulitis that was thought to be hospital-acquired. You
were treated with IV Ceftriaxone for the Klebsiella bacteremia,
which was changed to Cefazolin with [**Hospital1 2286**], and then started
on Vancomycin with [**Hospital1 2286**] for treatment of your cellulitis.
You will continue to receive these medications for an additional
10 days, dosed each time at [**Hospital1 2286**]. Your hemodialysis line was
pulled and you were given a "line holiday" before it was
replaced. You received hemodialysis on your regular schedule, as
well as extra ultra-filtration given your fluid overload.
.
Given your bleeding your home Omeprazole was increased to twice
daily. You were also found to have severe degenerative joint
disease of the lumbar spine with severe spinal canal narrowing
on MRI that will need close follow-up of small bilateral fluid
clefts. You were started on a Lidoderm patch daily for control
of the back pain. Finally, your heart rate was found to be
elevated and you were started on a new medication called
Metoprolol to decrease the heart rate to the normal range.
.
MEDICATION CHANGES:
1. START Vancomycin 1gram IV at Hemodialysis x10 days
2. START Cefazolin 2grams IV at Hemodialysis x10 days
3. START Metoprolol 12.5mg by mouth twice daily
4. START Lidoderm patch daily for back pain
5. CHANGE Omeprazole to 40mg by mouth twice daily
.
Every [**Hospital1 766**] you must have labs drawn. You can do that here - at
the liver clinic - or at your PCP's office. Check PT/INR,
Sodium, Creatinine, Albumin and bilirubin. Fax results to
[**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 697**].
Followup Instructions:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2135-11-19**]
12:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2135-11-23**] 9:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2136-1-16**] 9:00
Completed by:[**2135-11-18**]
|
[
"5119",
"42789",
"49390"
] |
Admission Date: [**2106-11-3**] Discharge Date: [**2106-11-6**]
Date of Birth: [**2030-2-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD on [**2106-11-3**]
History of Present Illness:
This is a 76 yo M with ETOH cirrhosis, HCC, grade III varicies
who presented to the ED with 5-6 episodes of BRBPR followed by
black stools. Denied n/v. Denied abdominal pain. Had mild
lightheadedness with the stools but none after that.
.
In the ED, vital signs were intially T 98, BP 120/44, HR 59; RR
18; O2sat 100% RA. 2 large bore PIVs were placed and he was
given 1L IVF, IV pantoprazole. GI consult suggested octreotide
bolus and then gtt. No NG lavage given varicies.
.
He continues to deny pain, CP, SOB, abdominal pain, headache,
nausea or vomiting, weakness, lightheadedness, headache, vision
changes.
.
Past Medical History:
-ETOH cirrhosis- quit drinking in [**2106-4-4**]
-HCC s/p radiofrequency ablation
-grade III varicies
-portal vein thrombosis - occlusive; not on anticoagulation
given high grade varicies
-DM2
Social History:
Married and lives with son. Denies smoking, alcohol or drug use.
States last alcohol was in [**Month (only) 547**] of this year.
Family History:
No family history of liver disease
Physical Exam:
Vitals: BP 122/35, HR 85, RR 19, O2sat 100% RA
General: elderly male in NAD sitting up in bed
HEENT: pale conjunctiva, anicteric sclera, MMM, no JVD
CV: RRR, 2/6 systolic murmur
Lungs: crackles at left base; otherwise clear
Abdomen: +BS, soft, NT, distended with mild ascites, well healed
laproscopic incisions, occasional healing bruises across abdomen
Extremities: venous stasis changes to BLE; DP 1+ symmetric; no
edema; no asterixis
Pertinent Results:
Admission Labs:
[**2106-11-3**] 10:30AM PLT COUNT-210
[**2106-11-3**] 10:30AM NEUTS-57.8 LYMPHS-32.5 MONOS-6.6 EOS-2.1
BASOS-1.0
[**2106-11-3**] 10:30AM WBC-7.8 RBC-2.39* HGB-7.9* HCT-24.5* MCV-102*
MCH-33.0* MCHC-32.2 RDW-17.4*
[**2106-11-3**] 10:30AM ALBUMIN-3.3*
[**2106-11-3**] 10:30AM LIPASE-105*
[**2106-11-3**] 10:30AM ALT(SGPT)-42* AST(SGOT)-44* LD(LDH)-273* ALK
PHOS-167* AMYLASE-80 TOT BILI-0.7
[**2106-11-3**] 10:30AM estGFR-Using this
[**2106-11-3**] 10:30AM GLUCOSE-118* UREA N-47* CREAT-1.5* SODIUM-140
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2106-11-3**] 10:34AM HGB-8.2* calcHCT-25
[**2106-11-3**] 10:57AM PT-14.1* PTT-29.9 INR(PT)-1.3*
[**2106-11-3**] 02:28PM HGB-8.3* calcHCT-25
[**2106-11-3**] 05:06PM PT-13.6* PTT-31.2 INR(PT)-1.2*
[**2106-11-3**] 05:06PM PLT COUNT-130*
[**2106-11-3**] 05:06PM WBC-3.8*# RBC-2.04* HGB-6.6* HCT-20.8*
MCV-102* MCH-32.5* MCHC-31.9 RDW-17.3*
[**2106-11-3**] 05:06PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-2.0
[**2106-11-3**] 05:06PM GLUCOSE-102 UREA N-39* CREAT-1.3* SODIUM-143
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-20* ANION GAP-16
[**2106-11-3**] 10:29PM HCT-29.0*#
.
EGD: Findings: Esophagus:
Protruding Lesions 4 cords of grade III varices were seen
starting at 25 cm from the incisors in the lower third of the
esophagus and middle third of the esophagus. There were stigmata
of recent bleeding.
Stomach: Normal stomach.
Duodenum:
Excavated Lesions A single acute superficial non-bleeding 7mm
ulcer was found in the first part of the duodenum. Cold forceps
surveillance biopsy samples were retrieved from the stomach
Other procedures: 6 bands were successfully placed in the lower
third of the esophagus.
.
Liver US [**2106-11-3**]: IMPRESSION: Limited evaluation of cirrhotic
liver with partially occlusive thrombus of the main portal vein
redemonstrated. Evidence of portal hypertension including
splenomegaly and ascites.
.
CT Ab/Pelvis: IMPRESSION:
1. No evidence of enhancement in the region of patient's
previously seen left-sided hepatic mass lesion to suggest
residual tumor. No definite new enhancing lesions identified.
Atrophy of the left lobe of the liver distal to site of
radiofrequency ablation again seen.
2. Progression of patient's portal venous, splenic, and SMV
thrombosis. Interval increase in amount of free abdominal and
pelvic free fluid.
.
Discharge Labs:
[**2106-11-6**] 12:35PM BLOOD WBC-5.0 RBC-3.03* Hgb-9.7* Hct-29.0*
MCV-96 MCH-32.0 MCHC-33.4 RDW-18.9* Plt Ct-143*
[**2106-11-6**] 12:35PM BLOOD Glucose-175* UreaN-20 Creat-1.3* Na-135
K-3.7 Cl-103 HCO3-21* AnGap-15
[**2106-11-5**] 06:35AM BLOOD ALT-28 AST-27 LD(LDH)-209 AlkPhos-116
TotBili-1.2
[**2106-11-6**] 12:35PM BLOOD Calcium-8.2* Phos-3.5 Mg-2.1
[**2106-11-5**] 06:35AM BLOOD ALT-28 AST-27 LD(LDH)-209 AlkPhos-116
TotBili-1.2
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2106-11-5**]): POSITIVE BY
EIA.
Brief Hospital Course:
# GI bleeding: Patient was transferred from the ED to the MICU.
At that time he was transfused 2 units PRBC in total. Patient
received an EGD [**2106-11-3**] showing 4 cords of grade III varices
with three bands placed in lower third of esophagus. There was a
duodenal ulcer noted without biopsies taken. Patient had one
melanotic stool the day of transfer and one guaiac positive
without frank blood but remained hemodynamically stable. Patient
was placed on an octreotide gtt. Patient was kept at a goal HCT
of 25-27 to avoid increasing his portal pressures. He will
receive a total of 7 days ciprofloxacin for SBP prophylaxis. He
was restarted on nadolol on the day of transfer to medicine
floor. VS on transfer T 99 HR 61 BP 118/56 RR 19 O2sat 100%RA.
On day of discharge, patient was found to be H. pylori positive.
He is discharged with 2 weeks of antibiotics for treatment of
his infection. Prior to discharge, he was restarted on his
diuretics and remained hemodynamically stable.
.
# ETOH cirrhosis/Hepatocellular carcinoma: Known 3-4cm lesion
s/p radioablation in [**9-10**]. LFTs remained at baseline. CT of
abdomen demonstrating no new lesions or evidence of residual
tumor. Continued on diuretics and nadolol as above.
.
# Acute renal failure: Creatinine initially up to 1.5 on
admission with baseline around 1. Likely prerenal given bleeding
with elevated BUN as well. Improved to 1.3 at time of discharge.
.
# DM2: On ISS as inpatient. Restarted on outpatient glipizide
at time of discharge.
.
# Code: Full
.
# Communication: Son [**Name (NI) **] [**Telephone/Fax (1) 58057**]
Medications on Admission:
GLIPIZIDE 5 mg--1 tab(s) by mouth daily
LISINOPRIL 5 mg--2 tablet(s) by mouth daily
NADOLOL 20 mg--1 tablet(s) by mouth daily
PRILOSEC 20 mg--1 capsule(s) by mouth once a day
SPIRONOLACTONE 100 mg--1 tablet(s) by mouth daily
LASIX 20 mg--1 tablet (s) by mouth daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
5. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 26 doses.
Disp:*52 Tablet(s)* Refills:*0*
6. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 26 doses.
Disp:*104 Capsule(s)* Refills:*0*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 3 bowel movements daily.
Disp:*2700 ML(s)* Refills:*0*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: GI bleed
Secondary diagnoses: Alcoholic cirrhosis, Hepatocellular
carcinoma, grade III esophageal varices, portal venous
thrombosis, type II diabetes mellitus
Discharge Condition:
Stable
Discharge Instructions:
You were admitted after several episodes of bright red blood in
your stools. While you were here, you had an EGD that showed
severe varices and these were banded. In addition, you had an
ulcer in your duodenum. You were found to be positive for the
bacteria H. Pylori, and you are being treated for 2 weeks for
this infection.
If you develop any more bright red blood in your stools, dark
tarry stools, dizziness or lightheadedness, chest pain,
shortness of breath, vomiting blood, or any other symptom that
concerns you, please go to the nearest Emergency Department or
call your doctor as soon as possible.
Please take your medications as directed.
Followup Instructions:
It is very important that you keep the following appointments:
Provider: [**Name10 (NameIs) **] WEST,ROOM TWO GI ROOMS Date/Time:[**2106-11-11**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2106-11-11**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2106-11-17**]
11:20
|
[
"5849",
"2851",
"25000"
] |
Admission Date: [**2187-7-7**] Discharge Date: [**2187-7-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer to MICU for RP bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]yoW with h/o Afib on coumadin, remote right hip total
arthroplasty, severe aortic stenosis, SSS s/p pacer, presented
to OSH ED with one day right hip pain. He first noted aching
pain on rising from bed with inability to walk secondary to
pain. He denied any recent trauma or fall. He is s/p right hip
arthroplasty 10-15years ago. At the OSH HR 72 BP 140/77 RR 18.
He was found to have INR 19.3, raising concern for
intraarticular or retroperitoneal bleed. X-ray and CT abdomen
and pelvis were unremarkable. He was treated with 5mg SC and 5mg
po Vitamin K and 2units FFP prior to transfer to [**Hospital1 18**]. In [**Hospital1 18**]
ED T 97.8 HR 72 BP 169/89 RR 19 97%RA. CT right hip showed 7cm
hematoma extending from iliac [**Doctor First Name 362**] to level of right hip capsule
without evidence of hemarthrosis. CXR was consistent with CHF.
He was admitted to the floor where he remained hemodynamically
stable. His Hct, however, dropped from baseline 36 to 26 on
admission to 22 this morning with INR 3.4. He is admitted to the
MICU for further monitoring.
Past Medical History:
atrial fibrillation
s/p right total hip arthroplasty 10-15yrs ago
hypertension
dyslipidemia
h/o resected melanoma
sick sinus syndrome s/p pacer placement
mod AS; AV area 0.6cm2, AV gradient mean 30, peak 45
chronic Anemia (hct 35 in [**10/2186**])
Social History:
lives with his wife, half year in [**Name (NI) 6687**], half year in
[**State 108**]. retired from oil refineries
Denies tob use, illicits
Occasional alcohol
Family History:
non-contributory, MGF d. stroke at 42yrs
Physical Exam:
PE: T 97.0 HR 90 (78-90) BP 164/90 (138-164/70-90) RR 22 97%RA
GEN: comfortable, cooperative, except regarding foley placement,
oriented and alert, NAD
HEENT: PERRL, anicteric, MMM, OP clear
Neck: supple, no LAD, JVP 8-9cm
CV: RRR, III/VI SEM at RUSB
Resp: CTAB with one wheeze right apex, no crackles
Abd: +BS, soft, NT, ND, no masses, no HSM
Ext: pain right hip to palpation, no mass, no LE edema
Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout,
sensation intact grossly
Pertinent Results:
[**2187-7-7**] 09:51PM HCT-25.2*
[**2187-7-7**] 09:51PM PT-18.8* PTT-31.7 INR(PT)-1.8*
[**2187-7-7**] 06:51AM GLUCOSE-103 UREA N-18 CREAT-1.2 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
[**2187-7-7**] 06:51AM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.3
[**2187-7-7**] 06:51AM WBC-7.6 RBC-2.84* HGB-7.6* HCT-22.8* MCV-80*
MCH-26.6* MCHC-33.3 RDW-16.5*
[**2187-7-6**] 09:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-NEG
[**2187-7-6**] 09:19PM DIGOXIN-0.7*
Brief Hospital Course:
[**Age over 90 **] y/o man with h/o Afib, aortic stenosis, SSS s/p pacer, s/p
remote right total hip arthroplasty with right iliac crest
hematoma in setting of supratherapeutic INR (19).
.
1. Hematoma: He appears to have developed a retroperitoneal
bleed by CT scan read as a right iliacus muscle hematoma, which
most likely developed spontaneously in the setting of a
supratherapeutic INR. There did not appear to be any
hemarthrosis. He did not have any history of trauma to the hip
and his last surgery was 10-15 years ago. Vascular surgery was
consulted and followed Mr [**Known lastname 69679**] throughout his hospitalization.
He was transfused, in total, 4 units of FFP and 4 units of
pRBC, for a discharge Hct of 31.5. His coumadin was d/c on
admission, and he his INR subsequently decreased to 1.4 on
discharge. He was advised not to continue his coumadin until he
was seen by his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 2429**], and they would make a decision
together about whether or not the risks outweigh the benefits of
continuing his coumadin. We monitored his UOP and BUN/Cr for
any obstruction secondary to the hematoma. He had no issues in
regards to this.
.
# CHF: EF 60% with severe AS
The patient did have flash pulmonary in the ED with an initial
1L NS bolus, and was diuresed secondary to this. He was
monitored carefully during his blood transfusions for signs of
fluid overload, and he received Lasix after his units of blood
and FFP. He diuresed appropriately with good UOP, and did not
develop any shortness of breath during his transfusions.
.
# Agitation: The patient was intermittently confused and
agitated, especially at night. He required some Haldol for one
night, and subsequently only required a 1:1 sitter to keep him
safe. He was otherwise alert and oriented times three.
.
# Afib: Continue digoxin, which had a therapeutic level during
hospitalization; holding anticoagulation, V-paced.
.
# HTN: His amlodipine was held during his acute bleeding event
to prevent hypotension and to monitor the bleeding better. It
was restarted upon discharge.
.
# Hyperlipidemia: Atorvastatin was continued during the
hospitalization.
.
# Dementia: Aricept was continued throughout his
hospitalization.
.
# FEN: The patient was maintained NPO until he stabilized, when
he tolerated a regular diet well. His electrolytes were
repleted as needed.
.
# Insomnia: Benadryl prn as pt home regimen
.
# PPx: pneumoboots; bowel regimen given oxycodone pain control
.
# Communication: patient and his wife
wife: [**Name (NI) **] [**Name (NI) 69679**] [**Telephone/Fax (1) 69680**] (h), [**Telephone/Fax (1) 69681**] (c)
daughter: [**Name (NI) 17236**] [**Name (NI) 69679**] [**Telephone/Fax (1) 69682**]; [**Telephone/Fax (1) 69683**] (c)
daughter: [**Name (NI) **] [**Telephone/Fax (1) 69684**]
.
# Code: DNR/DNI -confirmed with patient with daughters present
Medications on Admission:
Coumadin 5mg, 2.5mg QOD
Lipitor 10mg daily
Norvasc 2.5mg daily
Digoxin 0.25mg daily
Lasix 40mg daily
Aricept 10mg daily
Discharge Medications:
Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Norvasc 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 65460**] [**Hospital **] Hospital Home Care
Discharge Diagnosis:
Primary: Retroperitoneal bleed
Secondary: Aortic stenosis
Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
Please do not continue to take coumadin or warfarin until
discussion with Dr. [**First Name (STitle) 2429**].
.
[**Name8 (MD) **] MD if you develop fever, chills, worsening pain in your
hip, dizziness, bleeding from nose, shortness of breath, or any
other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 22442**] Call to schedule
appointment within the next week. You should plan to have your
hematocrit and INR checked.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"42731",
"4280",
"4241",
"2851",
"V5861"
] |
Admission Date: [**2208-4-27**] Discharge Date: [**2208-4-30**]
Date of Birth: [**2147-7-28**] Sex: M
Service: MEDICINE
Allergies:
Abacavir / ritonavir / Lyrica
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Chief Complaint: AMS, fever, hypoxia, renal failure
Reason for MICU transfer: AMS requiring intubation
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
This is a 60 year old gentleman with a history of HIV last cd4
in [**1-25**] was 783 and VL undetectable who arrives with respiratory
distress, fevers x1day. Also having myoclonic jerks similar to
those seen on two previous admissions, for which no etiology was
found but presumed to be [**12-17**] metabolic derangements. Initial
hypoxic to 60-70's on RA, febrile to 101.8 (R). Labs show new
renal failure. During ED stay, patient remains febrile and
becomes increasingly altered/combative.
.
Of note, patient was most recently admitted for myoclonic jerks
and altered mental status from [**Date range (1) 96656**]. He was found to be
in renal failure, positive opioid tox screen. Renal hypothesized
ritonavir-induced nephrotoxicity was initial insult (ritonavir
crystals in urine), worsened by lisinopril and prerenal azotemia
in setting of insufficient PO intake and diarrhea. On discharge
all HAART was discontinued, as was Lyrica. Morphine and Lyrica
also held during hospitalization. Per OMR, Lyrica and Morphine
were re-prescribed on [**2208-4-7**]. There are no recent notes in OMR
documenting recent healthcare, and his wife could not be reached
by phone in the MICU.
.
In the ED, initial VS were: 101.0 124 124/63 16 74% RA. Initial
physical exam was significant for tremulousness and combative
behavior. Initial labs were signficant for cr 4.9 (baseline
1.2), K+ 4.2, CK 4619, MB 58 and MBI 1.3. LFTs were mildly
elevated with a normal t.bili and lipase. A serum tox screen was
negative and urine tox screen positive for opiates. A lactate
was 1.7. A UA was negative. An EKG demonstrated sinus
tachycardia. Given his elevated CK, MB and troponin (despite
flat MBI and presence of [**Last Name (un) **]), a heparin gtt was started for
empiric management of ACS. Cards recommends continuing to trend
enzymes. His oxygen saturations on arrival were in the 70s which
improved with a non-rebreather. A PE was entertained but could
not be addressed with a CTA [**12-17**] [**Last Name (un) **], thus heparin was further
pursued. A CXR revealed evidence of a pneumonia and given
hypoxia and h/o COPD, he was started on vancomycin and cefepime
for management of a pna and IV solumedrol and albuterol and
ipratropium nebs for a copd exacerbation. He became more
combative over time and the patient was ultimately intubated for
safety after ativan and haldol did not improve his mental
status. An initial ABG demonstrated 7.24/70/93 and subsequent
was 7.24/62/99. Vent settings on transfer were: Fio2 100% PEEP
5, TV 550. An LP was performed and results were pending at the
time of transfer. A CT head demosntrated no findings. He
received 4 L NS prior to transfer. Vitals on transfer: 134/97,
64, 22
.
On arrival to the MICU, vitals are: 98.0 144/105 22 100% (vent
settings: FiO2 50% PEEP 5 TV 550). Patient was agitated and
attempting to self-extubate so was bolused with fentanyl and
midazolam.
.
Review of systems: unable to obtain, patient intubated
Past Medical History:
- COPD: workup on [**11-23**] at [**Hospital1 **] with PFTs, which demonstrated
obstructive deficit with partial reversibility during
bronchodilator testing. FEV1 67% predicted value.
- HIV: diagnosed in [**2194**], no AIDS related complications (CD4 783
and VL undetectable in [**1-24**])
- Hepatitis C (viral load 6,270,000 IU/mL on [**2207-8-12**])
- History of IV drug use.
- Herpes zoster infection with postherpetic neuralgia, on
Morphine and Pregabalin.
- HTN
- Similar episode of myoclonic jerking in fall [**2205**], admitted to
[**Hospital 1263**] Hospital (etiology & treatment unknown), completely
resolved
Social History:
- Tobacco: active smoked w/ 30 pyh - now [**11-17**] cigg/day
- Alcohol: 1 40oz beer on weekends
- Illicits: remote history of polysubstance abuse including
heroin,
cocaine, marijuana, and alcohol
- Housing: lives w/ wife in [**Location (un) 686**]
- Employment: unemployed, preiovusly in contruction - no
asbestos exposure
Family History:
father and sister with asthma
Physical Exam:
On admission:
Vitals: 98.0 144/105 77 22 100% (vent settings: FiO2 50% PEEP 5
TV 550)
General: intubated, sedated, not responsive to painful stimuli
HEENT: Sclera slightly icteric, 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: Clear to auscultation bilaterally, 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: Pupils pinpoint, reactive bilaterally. Does not respond
to pain.
Pertinent Results:
On admission:
.
[**2208-4-27**] 12:20PM BLOOD WBC-7.8 RBC-4.49* Hgb-14.0 Hct-44.5
MCV-99* MCH-31.2 MCHC-31.5 RDW-12.7 Plt Ct-128*
[**2208-4-27**] 12:20PM BLOOD PT-10.9 PTT-28.6 INR(PT)-1.0
[**2208-4-27**] 12:20PM BLOOD Glucose-123* UreaN-28* Creat-4.2*# Na-133
K-4.2 Cl-96 HCO3-27 AnGap-14
[**2208-4-27**] 12:20PM BLOOD ALT-63* AST-212* CK(CPK)-4619* AlkPhos-54
TotBili-0.6
[**2208-4-27**] 12:20PM BLOOD CK-MB-58* MB Indx-1.3
[**2208-4-28**] 03:07AM BLOOD CK-MB-31* MB Indx-1.2 cTropnT-0.01
[**2208-4-27**] 12:20PM BLOOD Albumin-4.3 Calcium-7.9* Phos-4.5 Mg-2.1
[**2208-4-27**] 05:20PM BLOOD Type-ART pO2-93 pCO2-70* pH-7.24*
calTCO2-31* Base XS-0
.
lumbar puncture: unremarkable, hsv pcr negative
.
CXR:
IMPRESSION: Patchy new right basilar opacification, which would
perhaps be
compatible with atelectasis associated with persistent elevation
of the right
hemidiaphragm, but pneumonia could also be considered in the
appropriate
setting.
.
CT Head:
IMPRESSION: No acute intracranial process. Prominent mucosal
thickening of the
ethmoidal cells
.
EKG:
EKG ([**4-28**], 0005): sinus tach, no ST changes
EKG ([**4-28**], 0138): sinus rhythm, rate 73, no ST changes
.
Brief Hospital Course:
Hospitalization Summary:
60 year old gentleman with a history of HIV last cd4 in [**1-25**] was
783 and VL undetectable who arrives with respiratory distress
and altered mental status
.
# ALTERED MENTAL STATUS - Patient presented to the ER very
agitated. His wife explained that he had been confused for the
past day. He was intubated for safety after his agitation was
not affected by ativan/haldol administration. On HD#2, he was
extubated and as his renal function improved, he became more
oriented and conversant. His confusion was thought to be
secondary to morphine, lyrica, and other medications
accumulating in his acute renal failure. His Utox was + for
morphine. He had had a similar presentation over the past year.
LP was negative, Head CT negative, and HSV PCR negative.
.
# HYPOXIC HYPERCARBIC RESPIRATORY FAILURE: Patient was hypoxic
on arrival to the ER with O2 sats in the 60s-70s on RA. Initial
ABG (likely on significant O2 nc) showed 7.24/70/93 making
hypercarbic respiratory failure from accumulation of narcotics
in renal failure most likely. He was intubated in the ER for
safety and his hypercarbia and hypoxia improved. He was
extubated on HD#2 and weaned to 2L nc prior to being called-out.
Steroids and antibiotics were intiallly started for possible
COPD exacerbation but these were later discontinued. Home
nebulizers were continued.
.
# ACUTE RENAL FAILURE: Cr was 4.2 on arrival. Acute renal
failure was thought to be pre-renal and it improved dramatically
over 2 days with IVF to his baseline of 1.1. Other causes such
as tenofovir toxicity were also entertained. HAART medications
were initially held but were restarted as Cr returned to
baseline.
.
# TRANSAMINITIS: [**Month (only) 116**] be secondary to his known HCV with high
viral load. [**Month (only) 116**] be med-related: in particular, Raltegravir can
cause elevated LFTs (especially in patients with comorbid
HBV/HCV).
.
# CARDIAC ENZYME ELEVATIONS: Trop was initially elevated to 0.09
w/ MB of 58. These trended down. No concerning EKG changes were
seen.
.
# HTN: The patient was hypertensive on the day he was called out
of the ICU. Labetalol was uptitrated.
.
# HIV: ARVs were restarted as renal function improved - truvada,
raltegravir, and etravirine.
.
DVT prophylaxis was with subcutaneous heparin. Communication
with Wife [**Name (NI) **] [**Name (NI) 96657**] (HCP). [**Telephone/Fax (1) 96658**] or [**Telephone/Fax (1) 96659**].
Code status was Full Code.
Medications on Admission:
-Albuterol 90mcg HFA inhaler 1-2 puffs q4-6 hrs PRN wheeze
-Budesonide-formoterol 160mcg-4.5mcg inh 1 puff [**Hospital1 **]
-Emtricitabine-tenofovir (Truvada) 200mg-300mg tab PO daily
-Etravirine (Intelence) 200mg PO BID
-Isoniazid 300mg PO qHS
-Morphine 100mg PO BID
-Pregabalin (Lyrica) 150mg PO BID
-Raltegravir (Isentress) 400mg PO BID
-Pyridoxine 100mg PO daily
-Lisinopril (dose unknown)
-Cyclobenzaprine (dose unknown)
Discharge Medications:
1. Raltegravir 400 mg PO BID
2. Pyridoxine 100 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
hold for sbp < 100 or map <60
RX *lisinopril 10 mg 1 Tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*3
4. Isoniazid 300 mg PO HS
5. Etravirine 200 mg PO BID
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Morphine SR (MS Contin) 100 mg PO Q12H
hold for sedation or rr < 10
8. Albuterol Inhaler [**11-16**] PUFF IH Q6H:PRN cough/wheeze
9. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
10. Labetalol 300 mg PO BID
hold for SBP < 120
RX *labetalol 300 mg 1 Tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Hypercarbic respiratory failure
Acute renal failure
SECONDARY:
HIV
Hypertension
COPD
HIV neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 96657**],
You presented because of some jerking movements that you have
had in the past. You were admitted to the ICU with respiratory
and renal failure. You were intubated, stabilized, and then
extubated from the breathing machine. After you were given IV
fluids, your kidney fuction improved back to your baseline.
The cause of your jerking movements is not entirely clear; it is
possible that due to the kidney injury there was a buildup of
medications in your blood causing these symptoms. Currently,
this has resolved.
It is very important that you refrain from using unprescribed
medications and illicit drugs, as these can lead to serious
medical issues.
Note that while you were here you had very elevated blood
pressures; your blood pressure regimen was increased.
The following changes were made to your medications:
STOP LYRICA (pregabalin)
STOP CYCLOBENZAPRINE (flexeril)
INCREASE Labetalol to 300 mg twice daily for blood pressure
RESTART Lisinopril 10 mg once daily for blood pressure
Followup Instructions:
Please call Dr.[**Name (NI) 6767**] office at ([**Telephone/Fax (1) 6732**] to schedule an
appointment for within 1 week of discharge. At that visit, you
should have labs checked to ensure that your kidney function is
still fine.
Completed by:[**2208-5-6**]
|
[
"51881",
"2762",
"5849",
"4019"
] |
Admission Date: [**2126-8-19**] Discharge Date: [**2126-8-23**]
Date of Birth: [**2059-9-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2126-8-19**] Four Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending
artery, with saphenous vein grafts to diagonal, obtuse marginal
and PDA
History of Present Illness:
This is a 66 year old gentleman with history of coronary disease
and myocardial infarction s/p PTCA to RCA in [**2118**]. Has been
followed by Dr. [**Last Name (STitle) 29070**] and recently had episode of chest pain
while sleeping. He ruled out for myocardial infarction but
underwent cardiac cath which revealed 50% left main disease, LAD
and LCX disease. Along with 100% occluded RCA. Also underwent
stress ETT which was positive for EKG changes and myocardial
perfusion defect. He is now referred for coronary artery bypass
surgery.
Past Medical History:
Coronary Artery Disease - Myocardial Infarction [**2108**], PTCA of
RCA
Hyperlipidemia
Hypertension
Gastroesophageal Reflux disease
Obstructive sleep apnea on CPAP
Glaucoma
Traumatic injury after falling from ladder (Bilateral arm
fractures)
s/p Eye surgery
s/p Bilateral arm surgery for above injury (implants- rod, pins)
s/p Laparoscopic Abdominal surgery for ?Meckel's diverticulum
last yr
s/p Hernia repair in 20's
s/p Tonsillectomy as child
Social History:
Occupation: Driver and maintenance work for auto dealership
Last Dental Exam: 1.5 months ago
Lives with: Wife
[**Name (NI) **]: Caucasian
Tobacco: Denies
ETOH: Occasional
Family History:
Brother with history of MI in early 60's. Died at 64.
Physical Exam:
Pulse: 68 Resp: 16
B/P Right: 140/80
Height: 5'6" Weight: 175lbs
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema: Trace
Varicosities: None [X]
Neuro: Grossly intact, Alert and oriented x 3
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2126-8-19**] Intraop TEE:
PRE-BYPASS: No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). 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. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced.
1. Biventricular function is unchanged.
2. Aorta appears intact post decannulation.
3. Other findings are unchanged
[**2126-8-23**] 05:30AM BLOOD WBC-8.9 RBC-2.76* Hgb-8.4* Hct-24.5*
MCV-89 MCH-30.2 MCHC-34.1 RDW-13.8 Plt Ct-196
[**2126-8-22**] 05:12AM BLOOD WBC-10.7 RBC-2.77* Hgb-8.3* Hct-24.8*
MCV-90 MCH-30.1 MCHC-33.5 RDW-13.7 Plt Ct-149*
[**2126-8-22**] 05:12AM BLOOD Glucose-130* UreaN-25* Creat-1.1 Na-137
K-4.0 Cl-104 HCO3-28 AnGap-9
[**2126-8-23**] 05:30AM BLOOD UreaN-24* Creat-1.1 K-4.0
[**2126-8-23**] 05:30AM BLOOD Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 56758**] was admitted and underwent coronary artery
bypass grafting surgery by Dr. [**Last Name (STitle) **]. Please see operative
note for surgical details. Following the operation, he was
brought to the CVICU for invasive monitoring. Within 24 hours,
he awoke neurologically intact and was extubated without
incident. Chest tubes and pacing wires were discontinued
without complication. The patient was transferred to the
telemetry floor on POD 1 for further recovery. Postop course
was uneventful. Physical therapy evaluated the patient and
cleared him for discharge to home. Beta blocker was initiated
and the patient was gently diuresed toward his preoperative
weight. By the time of discharge on POD 4, the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. He was discharged to home with VNA and
appropriate follow-up instructions.
Medications on Admission:
Lopressor 50mg [**Hospital1 **], Zantac 150mg [**Hospital1 **], Isosorbide 10mg qd,
Simvastatin 20mg qd, Felodipine 5mg qd, Aspirin 162mg qd,
Sublingual Nitro prn, Tylenol prn, Fish oil qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Hypertension
Dyslipidemia
Prior Myocardial Infarction [**2108**]
Sleep Apnea
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**5-12**] weeks, call for appt
Dr. [**Last Name (STitle) 29070**] in [**3-12**] weeks, call for appt
Dr. [**Last Name (STitle) 32668**] in [**3-12**] weeks, call for appt
Completed by:[**2126-8-23**]
|
[
"41401",
"2724",
"4019",
"53081",
"32723",
"412",
"V4582"
] |
Admission Date: [**2203-11-18**] Discharge Date: [**2203-12-3**]
Date of Birth: [**2143-10-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1242**]
Chief Complaint:
1. Hyperglycemia
2. Hypothermia
Major Surgical or Invasive Procedure:
Intubation
Dialysis
Endoscopy
History of Present Illness:
60F w seizure hx and diabetes was found down today in fetal
position and brought to ED by EMS. She was noted to be
hypothermic and hyperglycemic. Unclear how long she was down.
There was no evidence of trauma.
In the ED, she was found to have blood in her mouth, she was
intubated for airway protection and had a central line placed.
She required phenylephrine briefly during intubation, but
otherwise did not require any pressors. She was sedated with
fent/midaz. Because of the blood in her mouth and OG was placed
with return of coffee ground. She was started on a PPI gtt.
Her initial serum glucose was 900 and she was started on an
insulin drip.
For her hypothermia she was given warm saline, warm air through
the ED tube and a bear hugger. A CT scan was done which showed
pancreatic stranding around the head and gallbladder sludge. AN
ECG was note to have some QRS widening (120) comparred to prior
(100)
Upon review of previous notes in OMR, the patient intermitantly
threatens noncompliance with her insulin therapy and has a
length history of impulse control problems, for which she sees
psychiatry. Seizure disorder history is unclear and unproven,
but was prescribed Tegretol. Most recent HbA1c was 7.9. Her
last note indicates that she did agree to taking all of her
prescribed medications, including her Tegretol and insulin. She
inappropriately and frequently calls her providers and it has
been difficult in the past to get her to agree to medications
that will control her chronic issues, with threatened section
12's to get her into the hospital for appropriate treatment.
Past Medical History:
- Mild mental retardation
- DM, onset age 51
(poorly controlled, does not check FS; A1c [**10-18**] 9.7%)
- neuropathy
- dysphagia
- hx of [**Doctor Last Name **] with spontaneous remission
- PVD, angioplasty of R femoral in [**2198**]
- Seizure disorder (per pt focal, partial)
- Lower Back pain s/p fall, followed in chronic pain clinic
- posterior mediastinal mass since [**2182**], stable (likely
neurofibroma).
- Hyperlipidemia
- Urinary Incontinance
- Pneumonia ([**2198**])
- ? gastroparesis- normal gastric emptying, no reflux in [**1-/2200**]
Endoscopy with ? [**Last Name (un) **]; biopsy negative.
.
Surgical History
- Angioplasty as above ([**2198**])
- Appendectomy
.
Psychiatric History:
Patient reports growing up in state care. She has a history of
an impulse control disorder. She reports that she is not
currently not seeing any psychiatrists. She has discontinued her
use of amitriptyline.
Social History:
The patient lives alone. She is disabled and on [**Social Security Number 105858**]social security.
DMR caseworker [**Doctor First Name **] (Phone #[**Telephone/Fax (1) 105853**]) . Sister [**Name (NI) 717**]
[**Telephone/Fax (1) 105854**]. Gets Home services from [**Location (un) 1465**] Elder
Services through Case Worker [**Doctor First Name **] [**Telephone/Fax (1) 105855**]
Tobacco: Smoker since the age of 3, 2 packs per day. Quit [**2198**]
Etoh/Drugs: None
Family History:
Ovarian Cancer, Diabetes in mother and grandmother
Physical Exam:
On Admission:
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: Clear to auscultation bilaterally, 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
Pertinent Results:
[**2203-11-19**] 04:00PM BLOOD WBC-11.7* RBC-4.07* Hgb-12.0 Hct-33.0*
MCV-81* MCH-29.4 MCHC-36.3* RDW-14.0 Plt Ct-137*
[**2203-11-19**] 03:58AM BLOOD WBC-9.9# RBC-4.51 Hgb-13.0 Hct-37.9
MCV-84 MCH-28.8 MCHC-34.4 RDW-13.4 Plt Ct-156
[**2203-11-18**] 09:15PM BLOOD WBC-26.6* RBC-4.61 Hgb-13.3 Hct-40.6
MCV-88 MCH-28.7 MCHC-32.7 RDW-13.1 Plt Ct-249
[**2203-11-18**] 12:44PM BLOOD WBC-30.0* RBC-4.88 Hgb-14.6 Hct-46.0
MCV-94 MCH-29.9 MCHC-31.7 RDW-12.6 Plt Ct-236
[**2203-11-18**] 09:15PM BLOOD Neuts-83* Bands-2 Lymphs-11* Monos-1*
Eos-0 Baso-2 Atyps-0 Metas-1* Myelos-0
[**2203-11-19**] 04:00PM BLOOD Plt Ct-137*
[**2203-11-19**] 03:58AM BLOOD Plt Ct-156
[**2203-11-19**] 03:58AM BLOOD PT-10.5 PTT-29.6 INR(PT)-1.0
[**2203-11-18**] 12:44PM BLOOD PT-10.1 PTT-30.8 INR(PT)-0.9
[**2203-11-19**] 03:58AM BLOOD Fibrino-158*
[**2203-11-19**] 04:00PM BLOOD Glucose-124* UreaN-38* Creat-2.6* Na-142
K-4.0 Cl-111* HCO3-16* AnGap-19
[**2203-11-19**] 10:30AM BLOOD Glucose-316* UreaN-38* Creat-2.5* Na-141
K-3.5 Cl-113* HCO3-16* AnGap-16
[**2203-11-19**] 07:22AM BLOOD Glucose-274* UreaN-40* Creat-2.4* Na-141
K-4.1 Cl-116* HCO3-12* AnGap-17
[**2203-11-19**] 03:58AM BLOOD Glucose-249* UreaN-42* Creat-2.4* Na-142
K-3.6 Cl-117* HCO3-9* AnGap-20
[**2203-11-19**] 12:19AM BLOOD Glucose-357* UreaN-42* Creat-2.4* Na-143
K-4.0 Cl-115* HCO3-8* AnGap-24*
[**2203-11-18**] 12:44PM BLOOD Glucose-900* UreaN-48* Creat-2.2* Na-133
K-5.3* Cl-93* HCO3-LESS THAN
[**2203-11-19**] 10:30AM BLOOD ALT-29 AST-49* LD(LDH)-242 AlkPhos-80
TotBili-0.3
[**2203-11-19**] 03:58AM BLOOD ALT-30 AST-52* LD(LDH)-256* AlkPhos-109*
TotBili-0.3
[**2203-11-19**] 12:19AM BLOOD LD(LDH)-253* CK(CPK)-378*
[**2203-11-18**] 07:00PM BLOOD ALT-28 AST-58* LD(LDH)-299* CK(CPK)-461*
AlkPhos-153* TotBili-0.4
[**2203-11-18**] 12:44PM BLOOD CK(CPK)-381*
[**2203-11-19**] 04:00PM BLOOD Calcium-8.0* Phos-2.8# Mg-1.9
[**2203-11-19**] 10:30AM BLOOD Calcium-6.9* Phos-0.4* Mg-2.2
[**2203-11-19**] 07:22AM BLOOD Calcium-7.1* Phos-1.1* Mg-2.4
[**2203-11-19**] 12:19AM BLOOD Triglyc-272*
[**2203-11-19**] 12:19AM BLOOD Osmolal-337*
[**2203-11-19**] 12:19AM BLOOD TSH-1.6
[**2203-11-19**] 12:07PM BLOOD Cortsol-77.3*
[**2203-11-19**] 11:35AM BLOOD Cortsol-79.7*
[**2203-11-19**] 10:30AM BLOOD Cortsol-83.2*
[**2203-11-19**] 03:58AM BLOOD Cortsol-91.7*
[**2203-11-19**] 10:30AM BLOOD Carbamz-1.8*
[**2203-11-18**] 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2203-11-19**] 04:15PM BLOOD Type-ART Temp-38.8 Rates-26/6 Tidal V-500
PEEP-8 FiO2-50 pO2-74* pCO2-29* pH-7.36 calTCO2-17* Base XS--7
Intubat-INTUBATED Vent-CONTROLLED
Studies:
.
[**11-18**] CT Spine - IMPRESSION: 1. No acute fracture or subluxation
of the cervical spine. Moderate narrowing of the central canal
at C5-6 is noted, and if there are myelopathic symptoms, these
could be better evaluated with MRI. 2. Soft tissue within
pharynx and hypopharynx consistent with history of hemorrhage. A
mucosal or submucosal pharyngeal/hypopharyngeal mass is not
excluded, which could be clarified by direct visualization. 3.
Intubated patient, with the tip of endotracheal tube projecting
1 cm from the level of the carina, this should be withdrawn for
appropriate positioning vs re-evaluated with chest radiograph.
.
[**11-18**] CT Head - IMPRESSION: 1. No acute intracranial injury.
There is stable age-appropriate atrophy. 2. Air-fluid levels
within multiple paranasal sinuses.
.
[**11-18**] CT Abdomen/Pelvis - IMPRESSION: 1. Stranding of the
retroperitoneal fat in the region of the pancreatic head, second
and third portions of the duodenum, extending to the region of
the gallbladder fossa. Differential diagnosis includes
gallbladder pathology, pancreatitis, and duodenitis, which might
be clarified with laboratory analysis. 2. Bibasilar atelectasis.
A well-circumscribed stable mass is seen in the left paraspinal
location, benign.
.
[**11-19**] ECHO - IMPRESSION: Mild symmetric left ventricular
hypertrophy with normal regional and global systolic function.
Mild right ventricular cavity enlargement with low normal free
wall motion. Increased PCWP.
.
[**12-1**] Endoscopy - Impression: (dilation, biopsy) Abnormal mucosa
in the lower third of the esophagus (biopsy) Blood in the fundus
Polyp in the fundus (polypectomy)Granularity and friability with
shallow ulceration in the duodenal bulb (biopsy)Medium hiatal
hernia Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
60F with lengthy psychiatric history with impulse control and
difficult to control t2DM, now presenting with hypothermia,
extreme hyperglycemia, and severe metabolic acidosis.
.
# Severe metabolic acidosis: The patient was found down prior
to admission with markedly elevated serum glucose (900). pH on
admission was 6.84 with a minimal osmolar gap. With mild
ketones in the urine and an undetectable bicarbonate level in
the serum, this appeared to be a combination of a hyperglycemic
hyperosmolar state and a diabetic ketoacidosis. However, it was
felt that even with both of these processes at play, they likely
still could not explain the degree of acidosis. Initial thought
was given to emergent dialysis, but the acidosis corrected with
fluid boluses of D5-1/2NS + 3 amps of bicarbonate. She was also
aggressively volume resuscitated for what was presumed to be
extreme hypovolemia and kept on an insulin gtt, with refractory
glucoses requiring a gtt to up to 40 units per hour.
Toxicology screens and cultures were unrevealing in finding a
cause for her extreme acidosis.
# Respiratory failure: She was intubated in the setting of
hypothermia and visible blood in the nares. Intubation was done
mostly for airway protection. Due to persistent respiratory
alkalosis, occasional difficulty with oxygenations, and volume
overload after fluid resuscitation, she was slow to be
extubated. She was covered broadly for pulmonary processes.
Her dead space fraction was calculated at 68%. Sputum cultures
grew out MRSA. To address the anxiety component of extubation
and her home dosing of clonazepam TID, she was started on
dexmedetomidine (Precedex) to help transition to her home
benzodiazepines. Upon fluid mobilization s/p CVVH and anxiety
control, she was extubated successfully after 1 week and
continued to do quite well, with a slow improvement in her O2
dependence.
# Septic shock: Complicated by hypothermia, hyperglycemia, and
acidosis. Initially found to be hypothermic and covered broadly
for sepsis with antibiotics and administered warm NS and Bair
hugger, resulting in improving temperatures within days of
admission. When her first course of antibiotics was nearly
complete, her CXRs began to show suspicious findings for
developing infiltrates, prompting a switch in her antibiotic
course (Vanc/Zosyn --> Vanc/Cefepime). We also covered for ?C.
difficile with Flagyl and PO Vancomycin, but toxins were
negative and this course was stopped a few days later. Her
pressor requirement was slowly weaned as her fluid was mobilized
>1 week into her hospitalization. Her leukocytosis has waxed
and waned, with peak on admission of 30 and a nadir of 5.5.
# Acute kidney injury: The first few days of her admission saw
an acute rise in her creatinine from baseline and oliguria to
anuria. The Renal service was consulted and spun the urine,
noting some muddy brown casts consistent with ATN. Given her
poor urine output, minimally responsive to furosemide, and her
continued respiratory requirements, a femoral dialysis line was
placed (C-collar was still in place, preventing IJ placement)
and she was started on CVVH. Volume was aggressively
ultrafiltrated with the goal of extubation. She continued to
have oliguria and was given a brief dialysis holiday while her
femoral line was pulled. Though she continued to be responsive
to furosemide and may have some residual kidney function, it is
still too soon to predict if her renal function will return to
her prior baseline. The patient was transferred to the floor
where a temporary dialysis line was placed. She went for HD once
with removal of fluid. The patient's Cr continued to rise on the
subsequent days as did her UOP. Given rising UOP, further
dialysis was held until Cr peaked on [**2203-12-1**]. The temporary
dialysis line was removed on [**2203-12-2**] and the patient will
follow-up with nephrology for further evaluation.
# Glucose control: Inciting event leading to severe
hyperglycemia unclear. After her initial insulin resistance
with high-dose insulin drip, her blood glucose seemed to be
better controlled with close monitoring. Prior to her discharge
from the ICU, she had been started on an insulin regimen closely
resembling her home regimen with resulting hypoglycemia with
minimal symptoms. Her insulin regimen was adjusted such that
she was placed on long acting with sliding scale only. This
worked well until the patient began to eat normally on the
medicine floor. At that time her insulin dose was steadily
adjusted upwards towards her home dosing. She will be discharged
on her pre-admission dose as she is eating well and her kidney
function is improving.
# Dysphagia - The patient has a long history of dysphagia. Prior
to this admission, plan had been for EGD. While the patient was
here and EGD was done. Expected strictures were not seen
although there was abnormal mucosa in the lower third of the
esophagus, blood in the fundus, polyp in the fundus and
granularity and friability with shallow ulceration in the
duodenal bulb. The patient was dilated. PPI uptitrated.
Following this procedure the patient reported being able to eat
very well. Diet returned to baseline.
# ?unstable neck: [**Location (un) 2848**] J-collar was initially in place until
the patient was extubated and able to verbalize her lack of pain
was palpation of the C-spine. She was radiographically cleared
within a day or two of admission, but the collar was finally
removed after she was extubated >1 week later.
# Coffee grounds from OG tube: Likely epistaxis or facial trauma
given blood seen on nares. GI bleed was treated initially with
IV PPI [**Hospital1 **], but this was felt to be less likely and hematocrit
were trended and stable. She did not require any transfusion.
# CT findings - Pancreatic stranding and gallbladder sludge:
Non-specific finding with normal lipase. ?relation to
dehydration and initial hyperglycemia. Unclear if other
ingestions such as alcohol were related to the inciting event.
# ?Seizure disorder: EEG negative. She was continued on her
home AEDs (carbamazepine) with therapeutic levels on admission.
# Goals of care / HCP proxy information: She has a confusing
chain of important people in her life that help her with medical
decision making. She is a FULL code and relies on her friend
[**Name (NI) 11894**] [**Name (NI) 105858**] (cell # [**Telephone/Fax (1) 105859**] - former case worker, now
good friend) and her sister for assistance. Both have been
heavily involved in her care. Her health care is mostly
coordinated by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (NP) and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (MD), who
follows her closely.
# Transitional Issues:
1) Continue to actively encourage good glucose control
2) No need for HD. Will follow-up with renal
3) Follow-up on results of Bx from EGD
Medications on Admission:
CARBAMAZEPINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day
CLONAZEPAM 0.5mg TID
GABAPENTIN 200mg [**Hospital1 **]
INSULIN ASPART [NOVOLOG FLEXPEN] - (Prescribed by Other
Provider; Dose adjustment - no new Rx) - 100 unit/mL Insulin Pen
- 12 units with meals three times a day
INSULIN DETEMIR [LEVEMIR FLEXPEN] - 100 unit/mL (3 mL) Insulin
Pen - 24 units sq qam - No Substitution
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - one
patch qd 12 hours on and 12 hours off prn back pain
LORATADINE - 10 mg daily
MELOXICAM - 7.5 mg [**Hospital1 **]
OMEPRAZOLE [PRILOSEC] - 20 mg daily
SIMVASTATIN [ZOCOR] - 40 mg daily
TRAZODONE - 50 mg qhs PRN insomnia
Medications - OTC
CARBAMIDE PEROXIDE - 6.5 % Drops - 4 drops left ear twice a day
for ear wax blockage
GLUCERNA - Liquid - 1 can by mouth twice a day
Discharge Medications:
1. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-12**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a
day.
8. insulin aspart 100 unit/mL Solution Sig: Twelve (12) Units
Subcutaneous With Meals.
9. insulin detemir 100 unit/mL Solution Sig: Twenty Four (24)
Units Subcutaneous once a day.
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day: Apply to back
.
11. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. meloxicam 7.5 mg Tablet Sig: One (1) Tablet PO twice a day.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
16. Carbamoxide Ear Drops 6.5 % Drops Sig: Four (4) Drops Otic
twice a day as needed for ear blockage.
17. Glucerna Liquid Sig: One (1) Can PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital for Continuing Medical Care
Discharge Diagnosis:
Diabetic coma, 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:
It was a pleasure taking care of you at [**Hospital1 18**]!
You initially came to this hospital severely ill in a diabetic
coma. You were in the intensive care unit for over a week. In
the hospital we have treated your diabetic coma and a number of
associated complications. You are now ready for discharge to a
rehabilitation facility
See below for changes to your home medication regimen:
1) Please INCREASE Omeprazole dosing to 40mg twice daily
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2203-12-13**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 105860**] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2203-12-20**] at 10:00 AM
With: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2203-12-27**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 105860**] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Nephrology
With: Dr. [**Last Name (STitle) 4090**]
When: [**2203-1-5**] at 1:00pm
|
[
"0389",
"5845",
"51881",
"5070",
"78552",
"2875",
"99592",
"2724"
] |
Admission Date: [**2136-2-12**] Discharge Date: [**2136-2-22**]
Date of Birth: [**2056-8-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo F w/ unknown PMH who lives with elder brothers was brought
to [**Hospital1 18**] ED by EMS after being found at home by niece to be
unfed wearing clothes soiled with urine. Per family report, she
had been increasingly lethargic over the last week. Family not
present at time of MICU admission. ED note statues pt's brother
reported 1 week h/o decreased PO intake. EMS notes state niece
reported she "believes elderly brother unable to care for her
now, may not be feeding her." EMS also notes h/o "fall" 2-3 days
ago. ED notes say that patient's brother denied h/o patient
falling, but report her sliding to floor. EMS notes also state
that patient's bed found to have large urine stains. There was a
question of elder abuse raised in the ED.
.
In the ED, her triage VS were T=95 HR=94 BP=89/61 RR=16 96=RA.
Initally, she was given 1400cc. Also started on D5 1/2NS for
hypernatremia (Na=154). CXR and UA unremarkable. CT c-spine
negative for fracture. CT head negative for bleed, but showed
prominent ventricles. Admission to medicine service was planned.
After it was noticed that she made no UOP to the inital IVF, she
was then given an additional 6L NS (total 7L NS). SBP remained
relatively low in the 90's, so she was admitted to the MICU for
further management. A dose of vanco and zosyn were ordered in
the ED prior to transfer. Vancomycin 1gm IV x1 was given. Blood
cultures not done in ED.
.
On arrival to MICU, BP initially 88/52, but improved to 128/57
without intervention. Denies all complaints, including CP, SOB,
diarrhea, abd pain; but pt clearly confused, only A&Ox1.
.
In the MICU, the patient was treated with Zosyn x 1 day and
Vanco for 2 days. Found to have RLE DVT. Started on heparin
drip. Guaic negative prior to heparin.
Past Medical History:
- PNA, [**2134**]
- Dementia, began approx 5 years ago
Social History:
Previously a school teacher - 1st grade. Never married. No
children. She is one of 9 children. Lives with younger brother
in [**Name (NI) **]. No EtOH or tobacco in 15 years, but was a social
user of alcohol/tobacco. Brother does shopping, cooking,
cleaning, laundry. During the day, she watches television and
sleeps.
Family History:
[**Name (NI) 2481**] - sister, passed at age 75
Father passed at age 76y, mother passed at age 73y of natural
causes
Physical Exam:
PHYSICAL EXAM on TRANSFER from MICU:
VS: Tm: 98.7, Tc: 97.7; HR: 78; BP: 101/51; RR 17; O2 97% RA
I/Os: [**Telephone/Fax (1) 71085**], LOS +10L
GEN: elderly woman, lying in bed, NAD, pleasant, awake
HEENT: PERRL bilat, EOMI bilat, anicteric, dry MM, OP clear
NECK: JVP not elevated, no carotid bruits
CV: RRR, distant HS, no S3, ?S4 vs systolic murmur heard best at
apex
CHEST: CTA bilat. no crackles/wheezes.
ABD: NABS, soft, ND, NT, no masses
EXT: ++ firm edema RLE, approx 2x LLE, 1+ DP pulses
SKIN: erythematous rash w/ some excoriations on buttocks and
sacrum, no skin breakdown.
NEURO: A&O x person and city only, not hospital or year; CN 2-12
grossly intact
Pertinent Results:
[**2136-2-11**] 09:45PM PT-15.7* PTT-38.8* INR(PT)-1.4*
[**2136-2-11**] 09:45PM WBC-13.6* RBC-4.58 HGB-15.1 HCT-45.4 MCV-99*
MCH-33.0* MCHC-33.2 RDW-14.9
[**2136-2-11**] 09:45PM LIPASE-31
[**2136-2-11**] 09:45PM ALT(SGPT)-23 AST(SGOT)-29 ALK PHOS-45
AMYLASE-48 TOT BILI-1.5
[**2136-2-11**] 09:45PM UREA N-45* CREAT-1.4* SODIUM-154*
POTASSIUM-3.5 CHLORIDE-122* TOTAL CO2-23 ANION GAP-13
[**2136-2-11**] 10:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-RARE
EPI-0-2
[**2136-2-11**] 10:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-TR
[**2136-2-11**] 10:43PM LACTATE-3.0*
[**2136-2-12**] 02:20AM LACTATE-2.1*
.
IMAGING:
[**2136-2-11**] PORTABLE CXR:
Mild right lower lobe atelectasis and elevation of the right
hemidiaphragm
.
[**2136-2-11**] CT HEAD:
1. Prominence of the ventricular system without obstructing
lesion
identified. No definite evidence of acute dilation. Please
correlate clinically to exclude normal pressure hydrocephalus.
2. No evidence of intracranial hemorrhage or fracture.
.
[**2136-2-11**] CT C-SPINE:
No fracture or malalignment; facet degenerative changes; minor
scarring at the lung apices; minor polypoid mucosal thickening
in the left maxillary sinus.
.
[**2136-2-13**] LE DOPPLER U/S: Positive study for DVT in the right
lower extremity. Occlusive thrombus is present in the distal
superficial femoral vein and popliteal vein. Non-occlusive
thrombus is present in the mid superficial femoral vein. Right
common femoral and proximal superficial femoral veins are
patent.
Brief Hospital Course:
Ms. [**Known lastname 71086**] is a 79 year old female with past medical history
significant for dementia who presented with failure to thrive
and sub-acute decline in mental status. She also demonstrated
signs of failure to thrive. Full neurologic work up was
performed and there was no clear explanation for her recent
decline. Per discussion with Neurology, NPH was considered as a
possible cause of worsening dementia. However, given the
chronicity of her illness, the likelihood of clinical benefit
from shunt placement was considered to be quite low, especially
in light of the known potential morbidity associated with shunt
placement. Therefore, the decision was made to not pursue this
diagnositic workup further.
.
The patient continued to have poor oral intake of both food and
liquid during her stay. Per the patient's brother, who is also
the [**Hospital 228**] Health Care Proxy, the family was not interested
in nutrition support via JPEG or TPN. Her HCP expressed his wish
that the patient receive comfort measures only.
Medications on Admission:
None.
Discharge Medications:
1. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical TID (3 times a day).
2. Bisacodyl 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. dementia
Discharge Condition:
Stable. Afebrile. Not taking PO. Patient is comfort measures
only.
Discharge Instructions:
Ms. [**Known lastname 71086**] was admitted to the hospital for altered mental
status. The change in mental status was likely related to
dementia. Primary focus is comfort measures. Further care per
nursing home medical director, ideally patient should be do not
hospitalization.
Followup Instructions:
None.
|
[
"2760",
"2762"
] |
Admission Date: [**2150-9-17**] Discharge Date: [**2150-9-17**]
Date of Birth: [**2074-1-11**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Serax
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypoxia and Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 76-yo woman w/ MMP incl DM2, Afib, ESRD on HD, CAD
s/p MI / CABG, CHF, sarcoidosis, COPD, p/w hypotension on the
way to dialysis. She was on her way from home at her long term
care facility to HD, when the ambulance noted that her SBP was
70s, so she was taken straight to the nearest ED instead. There
she also was hypoxic to the 60s. She was started on peripheral
Levophed and a facemask, given a dose of Vancomycin, and
transferred to [**Hospital1 18**] ED. On arrival here, her SBP dropped from
110 to 52, so she was started on Neosynephrine in addition to
the Levophed, and these were run in to her HD line due to the
inability to gain adequate other CVL access. She also became
more hypoxic, requiring a NRB. She was noted to have a waxing
and [**Doctor Last Name 688**] mental status. CT Head was unremarkable, but CT Torso
showed significant findings c/w pneumonia, sarcoidosis vs.
malignancy, and pulmonary congestion. She was given CTX and
Levo. Her VS - afebrile, BP 125/29, HR 80, R 22, O2-sat 97% NRB.
Her DNR/DNI status was confirmed. She was admitted to the MICU.
On arrival to the MICU, the patient appeared quite distressed,
and remained hypoxic at 85% on 100% NRB + 6L O2 NC. Her SBPs
were holding in the 120s. She was in severe respiratory
distress, so she was given 0.5mg Morphine IV, with reasonable
effect. The family was notified, and DNR/DNI was confirmed. The
possibility of BiPAP was raised, which the family declined. The
family decided to come in for further discussion regarding her
care and anticipation of moving towards Comfort Measures.
Past Medical History:
Diabetes mellitus Type 2
Hypothyroidism
Hyperlipidemia
Hypertension
CAD s/p MI x2, s/p CABG
PVD
A-fib - wide complex a-fib w/ RVR, Amio for rate control
CHF - tx w/HD in past
ESRD on HD
Nephrogenic systemic fibrosis
Sarcoidosis
COPD
Centrilobular emphysema
h/o Breast Ca s/p left mastectomy, no chemo/XRT
h/o Colon polyps
Pleural effusions
Social History:
Lives w/ husband in [**Name (NI) **]. She is dependent with her ADLs and
wheelchair-bound at home. Has [**Name (NI) 269**] and husband to care for her.
Tobacco: 25 50 pack year smoking history, quit [**2124**]. No EtOH.
Family History:
FAMILY HISTORY: One sister had lung cancer, one brother had
lung cancer and leukemia, five of the patient's six siblings
have diabetes. Father died of myocardial infarction at age 66.
There is a strong family history of hypertension.
Physical Exam:
VS - Afeb, HR 70s, SBP 120s, O2-sat 85% on NRB+6L NC
Gen - ill-appearing elderly woman
Heart - RRR, no MRG
Lungs - coarse crackles and rhonchi throughout
Abdomen - soft/NT/ND, no rebound/guarding
Extrem - cool, no c/c/e
Pertinent Results:
[**2150-9-17**] 01:20AM GLUCOSE-106* UREA N-39* CREAT-4.1*#
SODIUM-136 POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-24 ANION GAP-20
[**2150-9-17**] 01:20AM estGFR-Using this
[**2150-9-17**] 01:20AM CK(CPK)-28
[**2150-9-17**] 01:20AM cTropnT-0.12*
[**2150-9-17**] 01:20AM CK-MB-NotDone
[**2150-9-17**] 01:20AM CALCIUM-8.4 PHOSPHATE-6.8*# MAGNESIUM-2.9*
[**2150-9-17**] 01:20AM NEUTS-79.9* LYMPHS-12.5* MONOS-6.8 EOS-0.4
BASOS-0.4
[**2150-9-17**] 01:20AM NEUTS-79.9* LYMPHS-12.5* MONOS-6.8 EOS-0.4
BASOS-0.4
[**2150-9-17**] 01:20AM PLT COUNT-226
[**2150-9-17**] 01:20AM PT-57.7* PTT-99.2* INR(PT)-6.8*
Brief Hospital Course:
ASSESSMENT AND PLAN: 76-F w/ MMP incl DM2, Afib, ESRD on HD, CAD
s/p MI / CABG, NSF, CHF, sarcoidosis, COPD, p/w hypotension and
hypoxia.
.
#. Hypotension: The etiology of her hypotension is unclear, the
differential includes sepsis vs. cardiogenic vs. combined. Pt
arrived on 2 pressors with SBPs in 120s through HD line. Now
broadly covered with Vanc / CTX / Levo, although adequate
coverage would include Vanc / Zosyn. Other possibility is severe
congestive heart failure, but pt is anuric and unable to benefit
from HD at this time given her inability to sustain BPs. Family
was aware of situation and preferred to continue pt on multiple
pressors until all family was able to visit prior to
transitioning to Comfort Measures.
.
#. Hypoxia: Also of unclear etiology, DDx includes pneumonia,
aspiration, congestive heart failure, and massive burden of
sarcoidosis vs. recurrent metastatic cancer. Pt appears in
severe respiratory distress, with an oxygen saturation of 85% on
100% NRB + 6L NC. Patient's code status was DNR/DNI, which was
confirmed with family. Family also declined BiPAP, which would
have been a temporizing measure for at least the overlying fluid
congestion. Family was aware as above, preferred continuing
current treatment with O2 until all family was able to visit
prior to transitioning to Comfort Measures. see below
.
#. Goals of Care: Pt and family were aware of situation re: pt's
hypotension and hypoxia. Initially, pt was continued on
admitting treatment of antibiotics and pressors without
escalation. Family came in to see pt today, and after a family
meeting, the decision was made to transition to comfort focused
care. At this point, antibiotics and pressors were
discontinued, and morphine was used for comfort for respiratory
distress. Over several hours, the patient gradually became
increasingly hypotensive and bradycardic, and developed agonal
respirations. At 19:46 on [**2150-9-17**], the patient died. The
family requested a postmortem exam, and the paperwork for the
death and postmortem was completed.
.
Medications on Admission:
Tylenol #3 PO Q6hrs PRN pain
Amiodarone 100mg PO daily
Nexium 40mg PO daily
Lunesta 1mg PO QHS PRN
Glargine 5units SQ QAM
Lactulose 15ml PO daily PRN constipation
Levothyroxine 300mcg PO QOD, alternating with 200mcg PO QOD
Midodrine 5mg PO prior to HD
Sevelamer 400mg PO TID
Simvastatin 20mg PO QHS
Warfarin 2mg PO QAM
ASA 81mg PO daily
Beneprotein 1 tablespoon TID
Cranberry extract
RISS
Glucerna 4oz PO daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Arrest
Respiratory Failure
Chronic Obstructive Pulmonary Disease
Congestive Heart Failure
End Stage Renal Disease
Sarcoidosis
Nephrogenic Systemic Fibrosis
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"51881",
"40391",
"4280",
"42789",
"42731",
"25000",
"V4581",
"412"
] |
Admission Date: [**2140-11-11**] Discharge Date: [**2140-11-16**]
Date of Birth: [**2082-7-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
vomitting
Major Surgical or Invasive Procedure:
right and left heart catheterization
blood transfusion
History of Present Illness:
Ms. [**Known lastname 13537**] is a 58 year old Female with DM, CAD, pulm. HTN
(minimally responsive to inhaled NO on cath [**9-/2136**]), presents
with a 3 day history of Nausea Vomitting and chest pain,
subjective fevers and sore throat. Unable to tolerate liquids.
ED course notable for initial BP 88/54, improved with fluids.
ECG concerning for changes, started on NTG and heparin gtt, with
resultant hypotension. Remained hypotensive, and eventually
started on pressors. Mildly elevated TnT of .12. CTA negative
for PE. Areas of mild patchy opacity in RML, which may
represent atypical inf vs inf changes.
ECG: TWI v1-v6 (old), III (new). TWF in I, II, III, F.
Past Medical History:
pulm HTN (primary vs. rheum condition vs undiagnosed cardiac
dz). Seen in [**Hospital **] clinic in [**2135**] ([**Doctor Last Name **]). PFTs 11, [**2135**]:
Reduced FVC suggests a restrictive ventilatory defect, however
the TLC was within normal limits when measured on [**2136-6-13**].
FVC 1.78 2.48 72
FEV1 1.38 1.85 75
MMF 0.90 2.61 34
FEV1/FVC 78 75 104
DMII
CAD. Cath [**9-/2136**] severe LM with 50% ostial stension. other Cs
without sig lesion. No intervention. PA syst 80, with elevated
R-sided pressures (RV 80/15), though nl L-sided, minimal
response to inhaled NO. EF 65%.
hypothyroid. MIBI in [**2136**] with no perfusion defects, but
dilated RV.
?pan-hypo pit: partially empty sella on MR [**2131**], though has not
required hormone replacement.
?small ASD. TEE in [**2135**] with no ASD or anomalous venous return.
bedside ECHO: nl LV function, TR grad 66, dilated RV, no flow
across mobile intraatrial septum.
anticardiolipin IgM
anemia
Social History:
lives with husband, has children
Family History:
noncontributory
Physical Exam:
Vitals: T 97.3, HR 66 RR BP 118/60, HR 66 PAP 82/25 PCWP 45
(40's to 50's), CO 6.3, CI 3.33 (fick and thermodilution), CVP
13, SVR 863
Gen: pleasant and cooperative
HEENT:MMM PERRLA
Pulm: CTAB no crackles
Cor: RRR no murmurs
Abd: soft NT ND
Ext: WWP DP 2+ bilaterally
Neuro/Psych: A+O x 3 moving all 4 extremities
Pertinent Results:
[**2140-11-11**] 11:56PM CK(CPK)-98
[**2140-11-11**] 11:56PM CK-MB-NotDone cTropnT-0.18*
[**2140-11-11**] 11:56PM PT-15.6* PTT->150* INR(PT)-1.5
[**2140-11-11**] 07:19PM cTropnT-0.12*
[**2140-11-11**] 07:19PM CK(CPK)-82
[**2140-11-11**] 01:00PM ALT(SGPT)-13 AST(SGOT)-26 CK(CPK)-85 ALK
PHOS-37* AMYLASE-23
[**2140-11-11**] 01:00PM GLUCOSE-160* UREA N-26* CREAT-1.3* SODIUM-136
POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-25 ANION GAP-18
[**2140-11-11**] 01:00PM LIPASE-18
[**2140-11-11**] 01:00PM ACETONE-SMALL
[**2140-11-11**] 01:00PM TSH-0.18*
[**2140-11-11**] 01:00PM WBC-10.4# RBC-4.09* HGB-11.2* HCT-33.4*
MCV-82 MCH-27.5 MCHC-33.7 RDW-13.7
ECG: Sinus rhythm, Ventricular premature complex, Right axis
deviation, Probable right ventricular hypertrophy, Inferior and
precordial ST-T wave abnormalities - may be due to right,
ventricular hypertrophy but cannot exclude in part ischemia,
Clinical correlation is suggested, Since previous tracing of
[**2140-11-12**], precordial lead ST-T wave abnormalities
decreased
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 188 100 422/450.57 80 110 -18
Cardiac Cath: COMMENTS: 1. Selective coronary angiography
of this right dominant system revealed no flow limiting coronary
disease. The LMCA contained a 40% ostial lesion but was
otherwise widely patent. The LAD contained a proximal 40%
lesion just before the takeoff of a large first diagonal branch.
The apical LAD was small in caliber. The LCX contained diffuse
plaquing with a 40% lesion after OM2. THe RCA had diffuse mild
plaquing with slow washout of contast consistent with the
patient's RV pressure elevation.
2. Resting hemodynamics revealed evidence of severe pulmonary
hypertension at baseline with mean PA pressure of 41 mm Hg, a
PVR of 605,
and a cardiac index of 2.2 l/min/m2 (Fick). With 100% oxygen
therapy, the mean PA remained approximately the same at 40mmHg,
but the PVR dropped to 385 and the cardiac index rose to 2.98
l/min/m2. Little further improvement was seen with Nitric
Oxide: the mean PA dropped slightly to 39mmHg, the PVR rose
slightly to 415, and the cardiac index fell slightly to 2.8
l/min/m2. In summary, neither oxygen nor nitric oxide
significantly dropped the mean PA pressure, but both therapies
resulted in a modest increase in CO which drove a fall in PVR
compared to baseline.
3. Left ventriculography was not performed.
FINAL DIAGNOSIS:
1. No flow limitng coronary artery disease.
2. Mild LV diastolic dysfunction.
3. Severe primary pulmonary hypertension.
4. No change in mean PA pressures with 100% oxygen or Nitric
Oxide.
Brief Hospital Course:
Ms. [**Known lastname 13537**] is a 58 year old woman with pulmonary hypertension
who presented with a likely viral gastroenteritis which quickly
resolved. She responded to NO in past on cath [**2135**]. A swan was
attempted on [**2140-11-12**] and was unsuccessful but one was placed at
cardiac cath. She had a right and left heart cath on [**2140-11-14**]
which showed no change from previous. She started sildafenil
after catheterization and was observed. It appeared to have an
effect of 30% or more improvement on her cardiac output but her
pulmonary artery pressures only seemed to decrease transiently.
It was decided that she would benefit from the sildafenil and
was discharged with a prescription and follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
In the emergency department the patient had been transiently
hypotensive in ED secondary to nitroglycerin as the patient is
preload dependent. It quickly resolved.
In terms of her CAD, Ms. [**Known lastname 13537**] had 50% LMCA stenosis,
otherwise clean Cs. Her aspirin and statin were continued and
she was restarted on bblocker. TNT elevation was thought likely
secondary to RH strain but not to ACS.
Regarding her acute renal failure, the patient's Cr is 0.8 at
baseline, and 1.3 on admit. This was thought to be prerenal and
resolved with rehydration.
Ms. [**Known lastname 13537**] was anemic with a hct drop 32 to 26 after line
placement. There was no evidence of bleed. She received a unit
of prbcs and following that her hct remained stable. She was
guaiac negative.
The patient has a history of hypothyroidism for which
levothyroxine was continued. She was discharged in her usual
state of health.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 100 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Disp:*30 Tablet(s)* Refills:*0*
8. Bosentan 62.5 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 weeks. Disp:*56 Tablet(s)* Refills:*0*
9. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2*
10. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day). Disp:*90 Tablet(s)* Refills:*2*
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 100 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
8. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Sildenafil Citrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Hypertension
CAD
Discharge Condition:
good
Discharge Instructions:
Please return to the hospital if you experience worsening chest
pain and shortness of breath, fevers, dizzyness, or any other
severe symptoms. Please call your doctor if you have any
questions about your symptoms.
Please start 2 new medications: metoprolol which is good for
your heart and sildafenil which is good for your lungs.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one week for your
pulmonary hypertension. [**Hospital1 18**] - Division of Pulmonary and
Critical Care, [**Location (un) 830**], KSB-23
[**Location (un) 86**], [**Numeric Identifier 718**], Phone: [**Telephone/Fax (1) 612**]
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Hospital1 7975**] INTERNAL MEDICINE Where: OFF
CAMPUS [**Hospital1 7975**] INTERNAL MEDICINE Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2140-12-7**] 2:00
|
[
"4168",
"5849",
"2449",
"25000",
"41401",
"2859"
] |
Admission Date: [**2170-3-25**] Discharge Date: [**2170-3-31**]
Date of Birth: [**2112-6-24**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Morphine / Iodine; Iodine Containing / Keflex /
Wellbutrin Sr / Simvastatin
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Right IJ central venous catheter placement, removed [**3-28**].
lumbar puncture
History of Present Illness:
57 year old woman with history of Crohns (chronic steroids),
peripheral neuropathy, hypertension, obesity presenting with
fever and altered mental status. She was started on cipro for a
UTI on [**2170-3-12**] however her UCx grew cipro resistant e. coli then
was switched to macrobid. She had persistent dysuria on [**2170-3-16**]
and was started on ceftin. Yesterday she was at home and
developed onset of headache and shaking chills. She stated that
bright lights hurt as well as loud noises. She denied cough,
shortness of breath, dysuria, flank pain, diarrhea, or increase
in abdominal pain. Family was concerned with her mental status
and called EMS. Upon arrival EMS found her somnolent but
arousable with small pupils. She was given 1 dose of narcan
with no change in mental status.
In the ED her initial vital signs were 102 135 151/81 20 95%RA.
She had a CT head that was unremarkable. She had an LP but was
too agitated to adequately measure an opening pressure. Her
initial lactate was 5 which triggered the sepsis protocol and
RIJ central line was placed without complication. She received
ceftriaxone 2g, vancomycin 1g, decadron 10 mg all times one
dose. She received 3 liters of saline. She was transfered to
the [**Hospital Unit Name 153**].
Past Medical History:
Crohns disease since age 16 (chronic prednisone 15 mg daily)
Obseity
Peripheral neuropathy
hypertension
depression
osteoporosis
hypercholesterolemia
Social History:
Occupation: former nurse
Drugs: none
Tobacco: none
Alcohol: none
Other: lives alone. many friends and family nearby.
Family History:
Brother and father with [**Name (NI) 4522**] disease as well as neuropathy
and
diabetes. Her father also had coronary artery disease and
diabetes, he died of CHF.
Physical Exam:
Afebrile, VSS
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : anteriorly and
posteriorly)
Abdominal: Soft, Non-tender, Bowel sounds present, lower abd
midline surgical scar
Musculoskeletal: No Muscle wasting
Skin: Warm, no rashes, no splinter
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Not Sedated, Tone: Normal,
CNII-XII intact. moving all extremites symmetrically. no neck
stiffness or photophobia
Pertinent Results:
CSF:
GRAM STAIN (Final [**2170-3-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
CRYPTOCOCCAL ANTIGEN (Final [**2170-3-26**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
Results should be evaluated in light of culture results
and clinical
presentation.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Herpes Simplex Virus, Type 1 & 2 DNA, Real-Time PCR
HSV 1 DNA Not Detected Not
Detected
HSV 2 DNA Not Detected Not
Detected
[**2170-3-26**] 5:59 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal aspirate.
Rapid Respiratory Viral Antigen Test (Final [**2170-3-27**]):
Respiratory viral antigens not detected.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
This kit is not FDA approved for direct detection of
parainfluenza
virus in specimens; interpret parainfluenza results with
caution.
VIRAL CULTURE (Preliminary): No Virus isolated so far
[**2170-3-25**] 10:55PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-1
Lymphs-79 Monos-20
[**2170-3-25**] 10:55PM CEREBROSPINAL FLUID (CSF) TotProt-43 Glucose-88
[**2170-3-25**] 11:49PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-negative
CT HEAD WITHOUT CONTRAST: No intracranial hemorrhage, mass
effect, shift of normally midline structures, or major vascular
territorial infarct is apparent. The density values of the brain
parenchyma are preserved. There is mild prominence of the
frontal extraaxial space bilaterally, consistent with atrophic
changes. There is mucosal thickening of multiple ethmoid air
cells. Visualized paranasal sinuses and mastoid air cells are
clear. Bony structures and surrounding soft tissue structures
are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial pathology.
2. Mild bifrontal brain atrophy.
[**2170-3-25**] 09:11PM BLOOD WBC-8.9 RBC-4.69 Hgb-10.8* Hct-34.0*
MCV-73* MCH-23.0* MCHC-31.7 RDW-15.5 Plt Ct-262#
[**2170-3-25**] 09:11PM BLOOD Neuts-94.6* Bands-0 Lymphs-2.7*
Monos-1.5* Eos-1.1 Baso-0.1
[**2170-3-25**] 09:11PM BLOOD PT-12.5 PTT-22.3 INR(PT)-1.1
[**2170-3-25**] 09:11PM BLOOD Glucose-128* UreaN-14 Creat-1.0 Na-138
K-3.4 Cl-98 HCO3-27 AnGap-16
[**2170-3-25**] 09:11PM BLOOD ALT-26 AST-25 AlkPhos-64 TotBili-0.4
[**2170-3-28**] 03:50AM BLOOD LD(LDH)-194 TotBili-0.2 DirBili-0.1
IndBili-0.1
[**2170-3-25**] 09:11PM BLOOD Lipase-136*
[**2170-3-25**] 09:11PM BLOOD Albumin-3.6
[**2170-3-26**] 10:55AM BLOOD Iron-14*
[**2170-3-26**] 10:55AM BLOOD calTIBC-324 Ferritn-115 TRF-249
[**2170-3-28**] 03:50AM BLOOD Hapto-281*
[**2170-3-25**] 09:11PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-3-25**] 09:13PM BLOOD Lactate-5.0*
[**2170-3-25**] 11:59PM BLOOD Lactate-4.2*
[**2170-3-26**] 11:19AM BLOOD Lactate-3.0*
[**2170-3-25**] 10:55PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-1
Lymphs-79 Monos-20
[**2170-3-25**] 10:55PM CEREBROSPINAL FLUID (CSF) TotProt-43 Glucose-88
Brief Hospital Course:
57 year old woman with history of Crohns disease on chronic
steroids admitted with fever, altered mental status, and lactic
acidosis with initial concern for meningitis.
.
Fever: leading sources included CNS, urine, lung, abd or skin.
of these leading concern would be for CNS infection although
mental status now markedly improved and CSF underwhelming. with
underlying immune suppressed state would be at risk for HSV or
listeria which could be more consistent with atypical
infections, however CSF with no growth and HSV PCR negative.
also chest xray normal and recent UA negative as well. Patient
received empiric abx vanc/ceftriaxone/ampicillin for 48 hours
and given negative gram stain and cell count these were
discontinued. Patient's headache and fever resolved. Possible
viral etiology causing her symptoms. Afebrile throughout the
remainder of her stay.
.
Altered Mental status: appears to be markedly improved compared
to pre-admission eval. no focal neurologic deficits nor
inability to switch sets. CT head negative. At baseline at
discharge.
.
Anemia: Baseline 25, initially 34 on admission in setting of
volume depletion. Patient has history of iron deficiency anemia.
% saturation less than 10, ferritin 125 in setting stress
response. Patient refused PO iron due to GI complaints. Received
2 units packed red cells on [**3-28**] to replete iron stores. Hct
stable prior to discharge.
.
Lactic acidosis: not likely systemic hypoperfusing given normal
to elevated blood pressure. no abdominal pain to suggest
ischemic bowel. home use of metformin may have contributed.
Lactate improved, metformin discontinued and glyburide
initiated. Patient unintentionally took 10 mg po once of
glyburide prior to discharge (was prescribed 2.5 mg po BID and
had been given four tabs to avoid having to go to pharmacy over
the weekend). Her blood glucose was monitored for six hours
prior to discharge and it remained >170 mg/dL. She was advised
to eat small snacks in addition to her meals for the next day,
hold her PM dose of glyburide the day of discharge, and check
her glucose QAC/QHS in addition to when she had hypoglycemic
symptoms. She was educated on symptoms and management of
hypoglycemia at home.
Crohns: no current evidence of flare of abdominal symptoms.
Continue steroids.
Medications on Admission:
celebrex 200-400 mg daily
celexa 80 mg daily
clonazepam 1 mg TID:prn
vitamin b12 IM qmonth
vitamin D [**Numeric Identifier 1871**] units twice weekly
folic acid 1 mg daily
gabapentin 600 mg QID
hydromorphone 4-12 mg TID:prn
lisinopril 5 mg daily
loperamide 2-4 mg q4:prn
metformin 500 mg [**Hospital1 **]
concerta 36 mg SR daily
oxycodone 30-60 mg TID:prn
pravastatin 10 mg daily
prednisone 5 mg tablets 1-4 tablets daily
prednisone 1 mg tablets 1-5 tablets daily
trazodone 200 mg daily
verapamin SR 120 mg daily
calcium carbonate 1200 mg daily
omperazole 20 mg daily
vitamin E 800 units daily
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
4. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Calcium Carbonate 1,177 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
8. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Oxycodone 5 mg Tablet Sig: Six (6) Tablet PO TID (3 times a
day) as needed for pain.
10. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
13. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. CONCERTA 36 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
16. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO twice
weekly.
17. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
18. Vitamin E 800 unit Capsule Sig: One (1) Capsule PO once a
day.
19. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
20. Glucometer
dispense one
check blood glucose QAC, QHS
21. Glucometer strips
dispense 100
refills 2
Discharge Disposition:
Home
Discharge Diagnosis:
1. lactic acidosis
2. altered mental status
3. diabetes mellitus
4. chronic steroid use/adrenal insufficiency
5. chronic pain
Discharge Condition:
stable, afebrile, ambulating.
Discharge Instructions:
You were hospitalized with altered mental status, which may have
been related to a viral illness, medications, or adrenal
insufficiency from chronic steroid use. Please call your
primary care physician with any questions or concern. Return to
the emergency department with any fever greater than 101,
chills, altered mental status, or other alarming symptoms.
Do not resume your metformin.
Followup Instructions:
Please call your primary physician, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4775**],
for follow up as soon as possible (preferably within the next
two weeks).
|
[
"0389",
"2762",
"2720",
"4019",
"2859"
] |
Admission Date: [**2124-7-2**] Discharge Date: [**2124-7-21**]
Date of Birth: [**2073-1-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Compazine / Penicillins / Metformin / Heparin Agents
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
51 year old gentleman with COPD on home O2 and several
admissions for COPD flare requiring intubation, smoking,
diabetes type II, s/p IVC filter for DVT, and recent admission
for cellulitis presents from a nursing home with respiratory
failure. Noted at nursing home to be hypoxic to 70's, treated
with duonebs with O2 to 92% afterwards. Taken to emergency
department. In [**Name (NI) **], pt in respiratory distress on
presentation--placed on NRB and given continuous nebulizers, O2
sats began to trend to high 80's and pt became unresponsive. ABG
at that time pH 7.35 pCO2 99 pO2 69 HCO3 57, pt intubated at
that time. Of note, the respiratory therapist removed a large
mucus plug shortly after intubation. Hemodynamically the pt was
tachycardic in the 110's with SBP in the 150 systolic range.
Also given ceftriaxone. Pt was already on vancomycin and
ciprofloxacin for cellulitis for which he was admitted on [**6-30**].
Past Medical History:
DM2 on RISS
COPD on oxygen + prednisone
CHF
osteoporosis w/ related thoracic fracture
h/o MRSA (but cleared by ID at OSH)
h/o DVT s/p filter
hepatitis B
Social History:
Shx:currently lives at the [**Doctor First Name **] [**Doctor First Name **] rehab since the
vertebrate fracture; extensive smoking history, but still smokes
[**2-12**] cig/day; extensive alcohol abuse in the past, but now sober.
Has used IV drugs before, but also quit. Not married, but has
children. His HCP is mother living at [**State 2748**].
Family History:
Fhx: non-contributory
Physical Exam:
Gen: Cushingoid
Neck: old trach wound
Chest: Decreased air movement bilaterally, insp and exp wheezes
Cor: RRR, no M/R/G
Abd: Obese, soft, NT, ND, minimal bowel sounds.
Ext: Mild erythema bilaterally in ankles about [**1-12**] way up shin
extr: erythema b/l starting above the anles to upper leg area,
temp same as temp of other parts of leg although a bit colder
than temp of [**Last Name (un) **] extr, tender to palpation, distal pulses 2+, 2+
edema b/l
Neurol: No focal deficits
Back: kyphoscoliosis
Pertinent Results:
[**2124-7-2**]
TYPE-ART TEMP-36.7 PO2-289* PCO2-91* PH-7.35 TOTAL CO2-52* BASE
XS-19
LACTATE-1.3, O2 SAT-100, freeCa-1.20
TEMP-36.6 PO2-257* PCO2-87* PH-7.39 TOTAL CO2-55* BASE XS-22
LACTATE-2.1*
O2 SAT-99
TYPE-ART RATES-/24 O2 FLOW-10 PO2-69* PCO2-99* PH-7.35 TOTAL
CO2-57* BASE XS-22 INTUBATED-NOT INTUBA
GLUCOSE-150* LACTATE-2.5* NA+-139 K+-3.6 CL--80* TCO2-48*
GLUCOSE-139* UREA N-13 CREAT-0.7 SODIUM-140 POTASSIUM-3.4
CHLORIDE-87* TOTAL CO2-49* ANION GAP-7*
CK(CPK)-111
CK-MB-12* MB INDX-10.8* cTropnT-0.06* proBNP-28
WBC-17.5* RBC-4.71 HGB-13.5* HCT-39.3* MCV-83 MCH-28.7 MCHC-34.4
RDW-13.3
NEUTS-74.9* LYMPHS-16.5* MONOS-7.2 EOS-1.1 BASOS-0.3
PLT COUNT-294
.
([**2124-7-21**])
BLOOD WBC-14.1* RBC-4.19* Hgb-11.6* Hct-36.3* MCV-87 MCH-27.8
MCHC-32.0 RDW-13.6 Plt Ct-248
PT-11.1 PTT-27.1 INR(PT)-0.9
Glucose-136* UreaN-11 Creat-0.5 Na-138 K-4.7 Cl-90* HCO3-42*
AnGap-11
Albumin-3.7 Calcium-9.4 Phos-4.6*# Mg-2.2
Type-ART pO2-94 pCO2-72* pH-7.43 calTCO2-49* Base XS-18
.
LIVER ULTRASOUND
IMPRESSION:
1. Unremarkable liver.
2. No ascites.
3. No hydronephrosis. Caliceal diverticulum with crystals in
lower pole of left kidney
([**2124-7-19**]) CT Trachea
IMPRESSION:
1. Marked tracheobronchomalacia, demonstrated by near collapse
of the central airways on expiration.
2. Moderate subglottic tracheal stenosis; irregularity of the
wall suggests prior therapy by dilatation.
3. Persistent near-collapse of the right middle and lower lobes.
4. Similar focal skeletal deformity centered at T7, unchanged
over one month. However, earlier studies are not available to
confirm stability. Correlation with prior imaging if available,
any clinical factors suggesting recent or prior infection, and
consideration of MR are suggested to evaluate further. Discussed
with Dr. [**Last Name (STitle) 111595**] on [**2124-7-21**].
Brief Hospital Course:
Upon admission, the patient was on a prednisone taper for COPD
flare and finishing his course of antibiotics for bilateral
lower extremity cellulitis (the reason why he had been admitted
a few days prior)
During this admission, we addressed the following issues:
.
1) Hypoxic respiratory failure--from mucus plug/pneumonia. The
patient was intubated in the MICU. Suctioning and bronchoscopy
were successfull removing large mucus plug. Pneumonia was
treated with cefepime and vancomycin. He was initially on
solumedrol 125 TID. He was extubated on day and transferred to
the floor for continuous management of his COPD flare and
secretions. On the floor, he transitioned quickly from face mask
to nasal cannula 4 Liters. Initially on solumedrol 80 TID, then
by day 2 started on prednisone taper.
MICU Course: Breathing difficulty continued however and
bronchoscopy was performed, and a severe stenosis secondary to
fibrous tissue was found. Patient was again transfered to MICU
for airway monitoring. Patient continued to have increased work
of breathing and required ET intubation. Interventional
Pulmonary was able to re-perform tracheotomy and secure the
airway using a T-piece device. Patient had an uneventful and
rapid recovery and was only requiring supplemental O2 by time of
discharge.
.
2) Hypercarbia, at one point the pt had Co2>100, which is very
above his baseline of 60-70. This was accompanied by marked
alkalosis >60. Both parameters improved steadily. Initially
lasix was decreased to once a day, later discontinued altogether
without worsening of the patient's volume status and marked
improvement in his alkalosis.
.
After above procedure, hypercarbia improved and blood gases
returned to baseline of pCO2 near 70.
.
3) COPD. Exacerbation was managed with steroids, albuterol and
atrovent nebulizers, as well as saline nebs.
.
After airway procedure, predinsone taper was begun and patient
continued to improve.
.
6) DM : Due to steroid induced hyperglycemia, the patient was
kept on a humalog sliding scale thorughout admission, including
MICU course.
.
7) Smoking, on going: received smoking cessation counseling,
kept on nicotine patch
Medications on Admission:
Fluticasone-Salmeterol 250-50 mcg/Dose Disk Inhalation [**Hospital1 **].
2. Spironolactone 25 mg PO DAILY.
3. Lasix 60 mg PO twice a day.
4. Cholecalciferol (Vitamin D3) 400 unit PO BID (2 times a day).
5. Omeprazole 20 mg PO once a day.
6. Hexavitamin PO DAILY (Daily).
7. Insulin Regular Sliding Scale.
8. Docusate Sodium 100 mg PO BID.
9. Senna 8.6 mg PO BID as needed.
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days.
11. Terbinafine 1 % [**Hospital1 **].
12. Ipratropium Bromide 0.02 % One Inhalation Q6H.
13. Prednisone taper 60 mg PO once a day, was on taper
14. Albuterol Sulfate 0.083 % Inhalation Q2H (every 2 hours) as
needed.
15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
TID (3 times a day) as needed.
17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
18. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q3H (every 3 hours).
19. Vancomycin 1 g Intravenous Q 12H (Every 12 Hours) for 11
days.
20. Oxycodone 5 mg, 1-2 Tablets PO PRN pain
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4H
(every 4 hours) as needed for breakthrough.
10. Ipratropium Bromide Inhalation
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours)
as needed for low back pain.
13. Lorazepam 0.5-2 mg IV Q4H:PRN
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
15. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
TID (3 times a day) as needed.
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
19. Guaifenesin 100 mg/5 mL Syrup Sig: Twenty (20) ML PO Q6H
(every 6 hours).
20. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): [**7-17**] and 10.
21. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days: [**7-19**] and 12.
22. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: [**7-21**] and 14.
23. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
From [**7-23**] on.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
COPD exacerbation
CHF
Metabolic Alkalosis
Discharge Condition:
Good. At baseline oxygen (3 Liters)
Discharge Instructions:
Admitted for shortness of breath. Initially you were in the MICU
intubated, then transitioned to the floor for steroid taper and
continued management of your shortness of breath.
Please take your medications as directed. Take the prednisone as
indicated in the taper. Continue your breathing exercises as
well. Don't miss any doctor's appointments.
Followup Instructions:
With your primary care doctor within 1 week of discharge
|
[
"51881",
"5180",
"4280",
"486",
"2762",
"3051",
"4168",
"2720"
] |
Admission Date: [**2182-8-7**] Discharge Date: [**2182-8-14**]
Date of Birth: [**2109-9-3**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 72-year-old patient,
who has a [**2-15**] year history of chest discomfort with exertion,
which resolves with rest. He had an abnormal EKG and was
referred for stress testing. His stress test was positive
for ST depression inferiorly and laterally, which improved
with rest and he was referred for cardiac catheterization.
PAST MEDICAL HISTORY: Hypercholesterolemia.
He is a 50-pack-year smoker.
Thalassemia trait with anemia.
Claudication.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Toprol XL 50 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Imdur 30 mg p.o. q.d.
PREOPERATIVE LABORATORY DATA: Significant for a creatinine
of 1.5.
HOSPITAL COURSE: Patient was admitted to [**Hospital1 346**] on [**2182-8-7**] and underwent
cardiac catheterization. He was found to have an ejection
fraction of 60 percent, LVEDP of 14, 80 percent heavily
calcified left main coronary artery, 80 percent diffuse
proximal LAD lesion with a distal LAD lesion at 70-80
percent. An 80 percent origin of left circumflex, 90 percent
proximal left circumflex, and a totally occluded RCA with
collaterals to RDL.
Ba[**Last Name (STitle) 57772**] the results of the catheterization, it was
determined that the patient would be admitted to the hospital
and be taken for revascularization. Patient was placed on a
Heparin drip. He had ultrasound evaluation of his carotid
arteries, which showed a less than 40 percent lesion on the
right and no stenosis on the left. He had lower arterial
Doppler studies done, which showed normal flow to the left
leg with significant aortoiliac disease on the right, and
patient was taken to the operating room on [**8-9**] with
Dr. [**Last Name (Prefixes) **], where he underwent a CABG x4 LIMA to LAD,
SVG to OM-1 and OM-2, and SVG to PDA. Total cardiopulmonary
bypass time 133 minutes. Cross-clamp time 95 minutes.
Patient was transported to the Intensive Care Unit in stable
condition. Please see operative note for full details.
Patient was weaned and extubated from mechanical ventilation
on his first postoperative afternoon. On postoperative day
one, the patient was started on Lasix for diuresis and beta
blockers, and on postoperative day number one, the patient
was transferred from the Intensive Care Unit to the regular
part of the hospital. Patient began ambulating with Physical
Therapy, had continued diuresis. By postoperative day number
five, the patient had completed level 5 of Physical Therapy.
Had appropriately diuresed and was cleared for discharge to
home.
CONDITION ON DISCHARGE: T max 99.4. Pulse 64 in sinus
rhythm. Blood pressure 114/54. Respiratory rate is 18. On
room air oxygen is 94 percent. Neurologically: He is awake,
alert, and oriented times three and no obvious deficit.
Heart: Regular rate and rhythm without rub or murmur.
Respiratory: Breath sounds are clear bilaterally. GI:
Positive bowel sounds, soft, nontender, nondistended, and
tolerating a regular diet. Sternal incision is clean, dry,
and intact. Sternum is stable. Steri-Strips open to air.
Vein harvest site is clean, dry, and intact. There is no
erythema and there is no drainage.
Chest x-ray on [**8-14**] showed small bilateral pleural
effusions without any evidence of CHF, no pneumothorax.
LABORATORY DATA: Sodium 143, potassium 4.7, chloride 109,
bicarb 25, BUN 24, creatinine 1.5, glucose 79.
DISPOSITION: The patient is to be discharged to home in
stable condition.
DISCHARGE MEDICATIONS:
1. Percocet 5/325 mg 1-2 tablets p.o. q.4-6h prn.
2. Plavix 75 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Norvasc 5 mg p.o. q.d.
6. Lasix 20 mg p.o. q.d. x7 days.
7. Potassium chloride 20 mEq p.o. q.d. x7 days.
8. Toprol XL 50 mg p.o. q.d.
DISCHARGE DIAGNOSES: Coronary artery disease.
Status post coronary artery bypass graft.
Right aortoiliac disease.
FO[**Last Name (STitle) 996**]P: The patient should follow up with his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57773**] in [**1-15**] weeks. He should
follow up with Dr. [**Last Name (STitle) 1911**], his cardiologist in [**2-14**]
weeks, and he should follow up with Dr. [**Last Name (Prefixes) **] in four
weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2182-8-14**] 13:01:36
T: [**2182-8-15**] 05:12:55
Job#: [**Job Number 57774**]
|
[
"41401",
"2720"
] |
Admission Date: [**2175-5-16**] Discharge Date:
Date of Birth: [**2110-8-10**] Sex: F
Service: O-MED
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
lady with locally advanced non-small cell cancer that was
initially presented as superior vena cava syndrome more than
one year ago and recently diagnosed subsegmental PE who
initially presented to the Emergency Department on [**2175-5-16**] with nausea, vomiting, and abdominal pain.
She was subsequently found to have a large PE with a
tamponade physiology. She had a pericardial window placed on
[**2175-5-18**] without any complications. She had remained
hemodynamically stable since. Her chronic anticoagulation
for a history of superior vena cava syndrome and PE was
initially reversed to enable the pericardial placement.
Postoperatively, the decision was made to re-initiate
anticoagulation given her hypercoagulable state, but the
therapeutic INR range was decreased to 1.5 to 2. She was
also started on an intravenous heparin drip with a goal
partial thromboplastin time of 60 to 70 while her INR was
subtherapeutic.
She was called out of the Medical Intensive Care Unit to the
East Oncology/Medicine Service as she was clinically stable.
While she was in the Medical Intensive Care Unit, she also
had a barium swallowing study done to evaluate a questionable
small amount of air behind the esophagus on her admission
chest computed tomography. The barium swallowing study was
normal. Her stay int he Medical Intensive Care Unit was also
notable for episodes of psychosis which were attributable to
opioids side effects.
PAST MEDICAL HISTORY:
1. Non-small cell cancer diagnosed in [**2173-1-18**] after
the patient presented with superior vena cava syndrome.
Status post chemotherapy with carboplatin, Taxol, and
gemcitabine, and radiation therapy.
2. Hypertension.
3. Type 2 diabetes mellitus.
4. Gastroesophageal reflux disease.
5. Chronic low back pain.
6. Depression.
7. Chronic abdominal pain.
8. Esophageal strictures; status post dilatation.
9. In [**2175-1-18**], pancreatic divisum with chronic
hyperamylasemia due to macroamylasemia.
10. Status post sphincterectomy in [**2171**].
11. Subsegmental PE diagnosed in [**2175-4-18**].
12. Congestive heart failure (with an ejection fraction of
40%).
ALLERGIES: PENICILLIN and SULFA (which cause a rash) and
CODEINE.
MEDICATIONS ON TRANSFER: (To the East Oncology/Medicine
Service)
1. Warfarin 2 mg p.o. q.h.s.
2. Paxil 20 mg p.o. q.h.s.
3. Protonix 40 mg p.o. once per day.
4. Fentanyl patch 50 mcg per hour transdermally q.72h.
5. Senna one tablet p.o. twice per day.
6. Colace 100 mg p.o. twice per day.
7. Ibuprofen 600 mg p.o. three times per day (with meals).
8. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed.
9. Zofran 2 mg to 4 mg intravenously q.4-6h. as needed.
10. Seroquel 25 mg to 50 mg p.o. q.h.s. as needed.
11. Heparin drip (with a goal partial thromboplastin time of
60 to 70).
12. Regular insulin sliding-scale.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on transfer to the East Oncology/Medicine Service revealed
temperature was 96.5, blood pressure was 114/64, heart rate
was 102, respiratory rate was 14, and oxygen saturation was
99% on 2 liters. In general, a pleasant elderly woman
sitting up in bed, in no acute distress. Head and neck
examination revealed sclerae were anicteric. Mucous
membranes were moist. The oropharynx was clear. The neck
was supple. Extraocular movements were intact. Pupils were
equal, round, and reactive to light. Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. Positive for rubs.
The lungs revealed bilateral basilar crackles. The abdomen
was soft. Normal active bowel sounds. Diffusely tender
especially at the epigastric region where the window was
done. The back revealed no costovertebral angle tenderness.
No spinal tenderness. Extremity examination revealed trace
edema but warm to touch. Distal pulses were 2+. Skin
revealed no rashes, and no lesions. Neurologic examination
revealed awake, alert and oriented times three. A nonfocal
examination.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
transfer to the Oncology/Medicine Service revealed white
blood cell count was 13.6, hematocrit was 25.5, and platelets
were 485. Prothrombin time was 13.6, partial thromboplastin
time was 46.6, and INR was 1.2. Sodium was 140, potassium
was 3.5, chloride was 109, bicarbonate was 18, blood urea
nitrogen was 13, creatinine was 0.8, and blood glucose was
142. Calcium was 8.7, magnesium was 2.2, and phosphate was
3.7.
HOSPITAL COURSE: During her stay on the Oncology/Medicine
Service she remained hemodynamically stable. She continued
to require ibuprofen, Tylenol, and occasional oxycodone for
her pain around the pericardial window site.
She was continued on anticoagulation without any
complications. Her Coumadin dose was increased to 3 mg p.o.
q.h.s., and her INR reached the therapeutic range. Her
hematocrit had slowly been trending down throughout her
hospital stay, which was thought most likely secondary to her
chronic disease. She received 2 units of packed red blood
cells, and her hematocrit responded nicely to the
transfusion.
Since the patient complained of recurrent dysphagia, she went
for another esophageal dilatation. The procedure itself was
not complicated. However, in the Postanesthesia Care Unit
she acute respiratory decompensation with oxygen saturations
down to 70s on room air. She was thought to have
methemoglobinemia with a methemoglobin level of up to 17, for
which she was treated with methylene blue. However, after
methemoglobinemia was resolved with methylene blue she was
also noted to have acute mental status changes with the
inability to speak. Since her mental status and neurologic
deficits resolved spontaneously, it was thought she had acute
metabolic encephalopathy due to analgesics which she received
perioperatively. However, the Neurology Service recommended
a lumbar puncture to rule out meningeal carcinomatosis. The
decision was made not to pursue lumbar puncture since the
patient was not a candidate for intrathecal chemotherapy.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to rehabilitation.
DISCHARGE DIAGNOSES:
1. Cardiac tamponade with pericardial effusion; status post
pericardial window placement.
2. Esophageal stricture; status post dilatation.
3. Delirium psychosis.
4. Metabolic encephalopathy.
5. Pulmonary emboli.
6. Type 2 diabetes mellitus.
7. Metastatic non-small cell lung cancer.
MEDICATIONS ON DISCHARGE:
1. Coumadin 3 mg p.o. q.h.s.
2. Paxil 20 mg p.o. once per day.
3. Protonix 40 mg p.o. once per day.
4. Fentanyl patch 50 mcg per hour transdermally q.72h.
5. Seroquel 25 mg p.o. q.h.s. as needed.
6. Colace 100 mg p.o. twice per day.
7. Dulcolax 10 mg p.o./p.r. once per day as needed.
8. Senna one to two tablets p.o. once per day as needed.
9. Regular insulin sliding-scale.
10. Motrin 800 mg p.o. three times per day as needed.
11. Tylenol 500 mg to 1000 mg p.o. q.4-6h. as needed (with a
maximum dose of 4000 mg p.o. once per day).
12. Lidocaine Viscous 1 cc to 2 cc p.o. q.4-6h. as needed
(for pain).
13. Oxycodone 5 mg p.o. q.4-6h. as needed (avoid this if
possible).
14. Zofran 4 mg p.o. q.4-6h. as needed.
15. Compazine 10 mg p.o. q.6-8h. as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. Please check the patient's INR twice per week until it is
stabilized in a therapeutic range of 1.5 to 2.
2. Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] office with any
questions.
[**Name (STitle) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3282**]
Dictated By:[**Last Name (NamePattern1) 225**]
MEDQUIST36
D: [**2175-5-26**] 22:57
T: [**2175-5-26**] 23:49
JOB#: [**Job Number 9354**]
|
[
"4280",
"53081",
"311",
"25000",
"4019",
"V5861"
] |
Admission Date: [**2111-1-11**] Discharge Date: [**2111-1-13**]
Date of Birth: [**2048-8-13**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Metformin
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Inferior STEMI
Major Surgical or Invasive Procedure:
[**2111-1-11**] Catheterization and stent of distal RCA
History of Present Illness:
The patient is a 62 year old female with a medical history that
includes diabetes and hypertension who presents from home with
chest pain. She was in her normal state of health (chest pain
free, able to ambulate up three flights of stairs in home w/out
symptoms) until one week ago when she started to develop
epigastric and substernal chest pain. She describes it as
[**2109-5-24**], constant, radiating to left shoulder and jaw, and
associated with nausea. It was not worse w/ activity. She
initially attributed it to acid reflux although it did not
improve with antacids. She felt that it was getting
progressively worse so she presented to [**Hospital1 **] [**Location (un) 620**].
.
In [**Location (un) 620**] ED, initial vitals were 97 BP: 171/81 (168/70 right
arm, 162/73 left arm) Resp: 18 O(2)Sat: 100. Exam was
unremarkable. EKG per report showed sinus rhythm, rate 94, 2mm
ST elevation II, III, AVF with 1mm ST depression in AVL. Initial
labs notable for WBC count 13, creatinine 2.1, troponin-T 1.62.
She was given 2SLNG with resolution of chest pain. CXR per
report with no acute process. She was given aspirin 325mg,
plavix 600mg, and heparin bolus and gtt, and sent to [**Hospital1 18**] for
urgent cardiac catheterization.
.
In the Catheterization lab at [**Hospital1 18**], she was found to have
complete occlusion of the distal RCA, 80% disease of OM1 and 70%
disease of the proximal LAD. The distal RCA lesion was believed
to be the culprit and she received one DES with good
angiographic result. She was given bivalrudin. Got 230cc of dye.
.
In the CCU, she denies chest pain, shortness of breath. Feels
some tightness in back of throat.
.
On review of systems, s/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. S/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 of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:
+Diabetes
+Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
-GERD
Social History:
- works as administrative assistant
- lives in [**Location 1439**] with husband, no children
- Tobacco history: remote, quit 40 years ago
- ETOH: denies
- Illicit drugs: denies
Family History:
- Mother: alive, 87 years old, multiple PCI 10 years ago
- Father: died 40s, Hodgkins disease
- several uncles with myocardial infarction
Physical Exam:
Admission Exam:
VS: afebrile, 135/51 HR: 65 95% room air
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. I/VI systolic murmur apex
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. R radial TR band in
place
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+
Discharge Exam:
VS: 100.3, 98.8, 126/65 (108-126/47-65), 64 (54-68), 20, 98%RA
Weight: 99.1kg
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis, erythema of the oral mucosa. No
xanthalesma.
NECK: Supple with JVP of 8cm, unchanged.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. II/VI early systolic murmur apex. No
rubs or gallops noted
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 abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. R radial cath site
without tenderness, erythema or hematoma. Dressing c/d/i.
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:
OSH labs:
WBC count 13, creatinine 2.1, troponin-T 1.62
Admission Labs:
[**2111-1-12**] 12:51AM BLOOD WBC-9.6# RBC-3.34* Hgb-9.3* Hct-28.3*
MCV-85 MCH-27.9 MCHC-32.9 RDW-13.8 Plt Ct-162
[**2111-1-12**] 12:51AM BLOOD PT-12.3 PTT-125.6* INR(PT)-1.1
[**2111-1-12**] 12:51AM BLOOD Glucose-224* UreaN-38* Creat-1.8* Na-136
K-4.7 Cl-106 HCO3-22 AnGap-13
[**2111-1-12**] 12:51AM BLOOD ALT-22 AST-87* LD(LDH)-382* AlkPhos-64
TotBili-0.2
[**2111-1-12**] 12:51AM BLOOD CK-MB-32* cTropnT-3.81*
[**2111-1-12**] 09:12AM BLOOD CK-MB-15* cTropnT-2.95*
[**2111-1-12**] 12:51AM BLOOD Calcium-9.7 Phos-2.8 Mg-1.6 Iron-20*
Cholest-133
[**2111-1-12**] 12:51AM BLOOD calTIBC-278 Hapto-196 Ferritn-70 TRF-214
[**2111-1-12**] 12:51AM BLOOD Triglyc-135 HDL-41 CHOL/HD-3.2 LDLcalc-65
Discharge Labs:
[**2111-1-13**] 07:20AM BLOOD WBC-7.0 RBC-3.17* Hgb-8.9* Hct-27.3*
MCV-86 MCH-28.0 MCHC-32.5 RDW-13.7 Plt Ct-154
[**2111-1-13**] 07:20AM BLOOD PT-11.9 PTT-29.9 INR(PT)-1.1
[**2111-1-13**] 07:20AM BLOOD Glucose-179* UreaN-46* Creat-2.5* Na-137
K-4.3 Cl-107 HCO3-23 AnGap-11
[**2111-1-13**] 07:20AM BLOOD Calcium-10.4* Phos-3.3 Mg-2.5
[**2111-1-11**] Catheterization:
1. Selective angiography of this right dominant system
demonstrated 3
vessel coronary artery disease. The RCA had a 100% distal
occlusion
that was thought to be the culprit lesion for the patient's
inferior
STEMI. The RCA gave off a small PDA and a large network of
RPLs. The
LMCA was without angiographically significant coronary artery
disease.
The proximal LAD appeared aneurysmal with a long, ulcerated 70%
lesion,
but the remainder of the LAD was free of angiographically
significant
stenoses. The LCX had a focal 80% lesion in the OM1, but was
otherwise
free of angiographically significant coronary artery disease.
2. Limited resting hemodynamics revealed a normal systemic
arterial
blood pressure with a central aortic pressure of 138/68.
3. Successful PTCA and stenting of the distal RCA with a
2.5x23mm PROMUS
RX stent which was postdilated to 2.5mm. Final angiography
demonstrated
no residual stensis, no angigoraphically apparent dissection and
TIMI
III flow (see PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PTCA and stenting of the distal RCA with a DES.
3. Normal systemic arterial blood pressure.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 62 year old female with a medical history of
hypertension and diabetes who presents from home with one week
of symptoms concerning for angina, found to have inferior ST
elevation myocardial infarction, taken for urgent
catheterization and found multivessel coronary artery disease
with complete occlusion of distal RCA, which was intervened on
with one drug eluting stent with good angiographic result,
transferred to CCU post-cath.
.
# INFERIOR STEMI: Patient found to have ST elevation in inferior
leads with III > II and reciprocal depression in AVL suggesting
RCA as the culprit vessel. She also had ST depression in V1,
which may have represented contiguous infero-basal involvement.
Likely this is a late presentation of her myocardial infarction
given her symptoms have been going on for days and troponin-T
was positive to 1.6 at [**Location (un) 620**], peak troponin was 3.81 at
admission to the CCU. She was found to have complete occlusion
of distal RCA on cardiac catheterization. She was also found to
have left circumflex and anterior descending disease on
catheterization. It is not clear if these lesions are resulting
in symptomatic ischemic heart disease and less likely that
either is causative of her current presentation. She remained
chest pain free after the catheterization. Her LCx and LAD
disease will be medically managed at discharge. She was started
on aspirin, Plavix, metoprolol, and atorvastatin. On the
morning of discharge, she had some mild chest pain when lying
flat. ECG suggested some pericarditis. Pain resolved when
sitting upright. She was advised to not take NSAIDs at this time
given her acute kidney injury. She will contact her PCP should
her pain worsen. She will follow-up with cardiology regarding
future management options: CABG vs repeat PCI vs medical
management. She will also have an echocardiogram at this time
to assess her LV function.
.
# ELEVATED CREATININE: Patient without known history of renal
insufficiency with last creatinine recorded being 1.2 ([**2106**]),
found to have elevated creatinine of 2.1 at admission of unclear
[**Name2 (NI) 105600**]/duration. Given concern for contrast induced nephropathy
after her cardiac cath, her lisinopril was held. At discharge,
her creatinine was acutely worse at 2.5, likely a result of the
dye load during catheterization. Her lisinopril and metformin
were held on discharge and patient was scheduled with close
follow up ([**1-15**]) with her PCP, [**Name10 (NameIs) **] was instructed to have labs
drawn the day prior to her appointment to ensure her Creatinine
improves. SHe was also advised to avoid NSAIDs at this time.
.
#DIABETES: We held her metformin given elevated creatinine with
large dye load during PCI. She was started on an insulin
sliding scale. Her A1c during this admission was pending at
discharge. She is only on metformin at home currently, which
was not continued on discharge given her acute kidney injury.
She will have close follow up with her PCP ([**1-15**]), and provided
her Creatinine improves, can restart the metformin a few days
s/p discharge.
.
#HYPERTENSION: Blood pressure remained well controlled during
this admission. Her lisinopril was held, as discussed above, and
she was started on metoprolol.
.
#CODE STATUS: FULL
#Transitional issues
-Will require Plavix for one year and aspirin 325mg for one
month followed by 81mg daily given [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]
-Has been started on atorvastatin and metoprolol during this
admission
-Consider restarting lisinopril if creatinine improves
-Restart metformin provided creatinine improves
-Will follow up with PCP on [**1-15**].
-Will follow-up with Dr. [**Last Name (STitle) 171**] after discharge regarding
management of her CAD, she will have a repeat echo at this time
([**2-16**])
Medications on Admission:
-lisinopril 20mg daily
-metformin 1000mg [**Hospital1 **]
-aspirin 81mg daily
-folic acid 1mg daily
-calcium 600mg and vitamin D
Discharge Medications:
1. aspirin 325 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).
3. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. Outpatient Lab Work
Please draw a basic chemisty panel on [**2111-1-14**] and fax results
to Dr. [**Last Name (STitle) **], [**First Name3 (LF) 1158**] R. (Office #[**Telephone/Fax (1) 9347**], Fax
#[**Telephone/Fax (1) 12540**]).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Inferior wall STEMI
Secondary Diagnosis:
Diabetes
Hypertension
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the Coronary Care Unit (CCU) at [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for management of your chest pain. You
were found to have a heart attack and went to the cardiac
catheterization lab urgently where we placed a drug-eluting
stent in one of your heart arteries. You were given
anti-platelet medications after your procedure. Your chest pain
resolved and you were monitored without any additional events.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
-Aspirin 325mg by mouth daily for one month. Following this,
you
should take 81mg by mouth daily.
-Plavix (Clopidogrel) 75mg by mouth daily for 1 year
-Metoprolol extended release 50mg by mouth daily
-Atorvastatin 80mg by mouth daily
-Docusate sodium 100mg by mouth as needed for constipation
.
You should STOP:
Lisinopril
Metformin
* These medications have been stopped because of your acutely
worsened kidney function. Your primary care doctor can decide
to restart them at your appointment on [**1-15**] if your blood
work comes back improved. Please have your blood work drawn on
[**1-14**].
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
You will need a follow up Cardiac echo prior to your cardiology
appointment. You should also get blood work drawn prior the day
prior to your appointment with DR. [**Last Name (STitle) 10531**].
Followup Instructions:
Name: [**Last Name (LF) 10531**],[**First Name3 (LF) **] R.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Street Address(2) 10534**], [**Location (un) **],[**Numeric Identifier 12541**]
Phone: [**Telephone/Fax (1) 9347**]
Appointment: Thursday [**2111-1-15**] 11:00am
*Please discuss with your doctor about an echocardiogram prior
to your cardiology follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**].
Department: CARDIAC SERVICES
When: MONDAY [**2111-2-16**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2111-2-16**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"41401",
"4019",
"25000"
] |
Admission Date: [**2197-4-10**] Discharge Date: [**2197-4-19**]
Date of Birth: [**2197-4-10**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] is 31/1 weeks
gestation female weighing 1350 gm at birth, who was admitted
to the Neonatal Intensive Care Unit from OR for prematurity.
At the time of transfer to [**Hospital3 2783**] she is 9 days
old and corrected gestation of 32+3 weeks. Mother is a
33-year-old gravida 4, para 1, now 2 mom with past medical
history notable for chronic hyperreninemic hypertension since
[**11**] years of age and has been on Hydralazine, Labetalol,
Nifedipine, Catapres and potassium supplement.
OBSTETRIC HISTORY: Significant for previous 30 week infant
born by cesarean section in [**2194**] after pregnancy was
complicated by severe hypertension. Her prenatal screens
were A+, antibody negative, RPR non reactive, rubella immune
and GBS unknown. The current pregnancy, expected date of
delivery was [**2197-6-4**] based on 6 and 9 weeks ultrasound. The
current pregnancy was complicated by acute on chronic
hypertension.
She completed a course of Betamethasone on [**4-6**], following
which she developed insulin dependent gestational diabetes
mellitus. Repeat cesarean section was performed for
worsening PIH under epidural and spinal anesthetic. No
intrapartum fever or fetal tachycardia. No antibiotics
administered to mom. Rupture of membranes at the time of
delivery yielding clear amniotic fluid.
DELIVERY DETAILS: The infant emerged with good tone and weak
cry, was given some tactile stim and oral and nasal bulb
suctioning. Mild central cyanosis was noted. Apgars were
[**5-22**] and she was transferred to NICU uneventfully.
PHYSICAL EXAMINATION: On admission the weight was 1350 gm
which is between 25th and 50th percentile. Head
circumference of 27 cm, between 10th and 25th percentile and
length of 38.5 cm which is between 10th and 25th percentile.
Heart rate was 142, respiratory rate 46, temperature 96.9,
blood pressure mean of 39, saturation of 93% in room air.
Physical examination revealed anterior fontanels flat and
opened, non dysmorphic, intact palate, moderate nasal
flaring, mouth and neck normal. Chest showed mild
retractions with initial grunting respirations which were
resolved pretty soon after few scattered crackles.
Cardiovascular, well perfused, no murmur. Abdomen soft, non
distended, no organomegaly, no masses, bowel sounds active,
anus patent, normal female external genitalia, active and
responsive to stim, normal spine length, hips and clavicles.
IMPRESSION: 31+1 week gestation female with mild respiratory
distress, improving within an hour of life and low risk for
infection.
HOSPITAL COURSE:
Respiratory: She has been in room air since birth, was
loaded with caffeine for shallow breathing and has stayed on
caffeine. Is currently on 6 mg/kg/day of caffeine citrate
which is 8 mg po/PG q d. Has not had any spells and is
stable in room air.
Cardiovascular: No issues. Blood pressures have been
stable.
Fluids, Electrolytes & Nutrition: Was initially started
on D10W at 80 cc per/kilo/day. Subsequently was started on
feeds on day #2 of life, at 20 cc/kilo which were advanced
and now is on full feeds of breast milk 22. Today the
calories were advanced to 24cal/oz of breast milk at 150
cc/kilo/day. The last set of electrolytes were sodium of 142,
potassium 4.6, chloride 111 and total CO2 of 20 which was on
[**4-14**]. Blood sugar has been stable at 86 which was done on
[**4-17**].
GI: The child has been on tube feeds, tolerating breast
milk 22, given PG.
ID: Was started on Amp and Gent for rule out which were
discontinued after 48 hours once the blood cultures came back
negative.
Heme/Bili: She has been on single phototherapy,
highest bilirubin being 11.2/.3 on day #3 which is [**4-13**]. The
latest bilirubin was 5.9/.2 on [**4-18**] and is still under one
phototherapy. The last hematocrit was 58.9 on [**4-13**].
6. Neuro: Head ultrasound on [**4-19**] showed choroid plexus cysts
bilateral otherwise normal.
7. Sensory: Hearing screen is pending. Eye exam is also
pending.
CONDITION ON DISCHARGE: Stable, growing preterm infant who
needs to start feeding po and grow and that is why she is
transferred to [**Hospital3 **]. The primary pediatrician
is Dr. [**Last Name (STitle) **] [**Name (STitle) 36391**] from [**Location (un) 5028**].
Newborn screen was sent on [**4-13**], hepatitis B immunization is
pending.
CURRENT CARE RECOMMENDATIONS: The child is on 150
cc/kilo/day of breast milk 24 and plan is to continue going up
on calories, is on caffeine with the dose of 8 mg po PG q
daily. Today Ferinsol 0.1cc pg qd and vitamin E 5 IU were
added. She is also under single phototherapy. Car seat
position screening is pending. Immunizations are pending.
Immunizations recommended
i.Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**].
DISCHARGE DIAGNOSIS: 1. Prematurity. 2. Hyperbilirubinemia.
3. Rule out sepsis.
4. Shallow breathing.
5. Choroid plexus cysts on head ultrasound scan
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Doctor Last Name 42588**]
MEDQUIST36
D: [**2197-4-18**] 16:16
T: [**2197-4-18**] 16:29
JOB#: [**Job Number 42589**]
|
[
"7742",
"V290"
] |
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