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Admission Date: [**2169-4-30**] Discharge Date: [**2169-5-5**]
Date of Birth: [**2123-11-17**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 45 year-old man wtih a
history of narcotic and benzodiazepine abuse status post
multiple attempts to detox who decided three days ago to stop
all of his narcotics and benzodiazepines, because he was
tired of being dependent on these medications. The patient
[**Hospital6 17459**] on [**4-28**] who
placed him on a combination of medications for withdraw. The
patient saw this physician again on the day of admission in
his office, checked a tox screen with a urine screen negative
for narcotic and gave him a test dose of Naltrexone by mouth
[**2-22**] of a 50 mg tablet at 1:00 p.m. Twenty minutes later the
patient became acutely confused, agitated, hypertensive,
without back pain and without headache. On further
questioning the patient admitted to taking one Percocet
earlier on the day of admission. In the Emergency Room the
patient's blood pressure was 220/100 with a pulse of 127,
respirations 28, very agitated and placed on four point
restraints. The patient received 8 mg of Ativan and 111 mg
of morphine over a several hour period with improvement in
his mental status and diminishment of his blood pressure to
166/110 and his pulse was diminished to 97.
SOCIAL HISTORY: One half pack per day of smoking times 17
years, occasional alcohol, history of intravenous drug abuse,
no cocaine. The patient was disabled with past profession as
a boxer. He lives with his fiance.
MEDICATIONS AT ADMISSION PRIOR TO [**4-28**]: The patient was
taking Percocet 7.5 mg tablets prn roughly 120 tablets per
month, Fentanyl patch 100 micrograms for the last seven
years, Xanax 1.5 mg b.i.d. for the last seven years, Prozac
and Tums. After seeing the withdraw specialist the patient
was on Neurontin 1600 mg q.i.d., Robaxin 750 mg t.i.d.,
Celebrex 200 mg q.d., Quinine 260 mg b.i.d., Baclofen 20 mg
b.i.d., Ambien 10 to 20 mg q.h.s., Librium 25 mg q.i.d.,
Valium 10 mg q.o.d., Risperdal 1 mg prn, Clonidine 0.1 mg
patch q week, Doxepin 100 mg q.h.s., Tizanidine 4 mg q.h.s.
PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 166/110.
Heart rate 97. The patient is [**Age over 90 **]% on room air. Pupils were
3 mm equal and reactive to light. Extraocular movements
intact. Oropharynx was clear. JVP was difficult to
evaluate. Neck was supple. The patient had a regular rate
and rhythm with no murmurs, rubs or gallops. Lungs were
clear to auscultation bilaterally. Abdomen was obese, well
healed midline scar, diffuse tenderness, no edema. 2+ pedal
pulses. The patient had a nonfocal cranial nerves examination
with cranial nerves II through XII intact.
HOSPITAL COURSE: The patient was initially observed in the
MICU for signs of acute withdraw and management of the
patient's hypertension. The patient was started on 60 mg of
intravenous morphine prn signs of withdraw q 6 hours. The
patient was also given up to 4 mg of po Ativan q 4 to 6
hours. The patient was weaned aggressively off these
narcotics and was followed by the toxicology service who
recommended keeping him on short acting agents for 72 hours
after his ingestion due to the 72 hour duration of
Spironolactone in the circulation. Therefore long acting
agents were discouraged and not used in this patient although
the patient did get one dose of methadone prior to this
decision being made. The patient was weaned off of his
intravenous medications and switched to oral. At the time of
discharge the patient was receiving 30 mg of MSIR q 6 hours
prn and 2 mg po Ativan q 6 hours prn. On the day prior to
discharge the patient got 10 mg total of po Ativan and
roughly 120 mg po of MSIR. The plan was to continue to wean
these medications completely off with acute inpatient detox
patient. The patient had been followed by social work,
psychiatry, toxicology and general medicine. All services
agreed that the patient would require inpatient
detoxification. An outpatient taper was discussed, however,
the patient's narcotic requirements were too high for any of
the physicians involved in his care to feel comfortable
prescribing him with medications. Also it was thought that
he should be receiving these medications and this
detoxification under an observed setting with administration
of these medications by a third party. The patient was
agitated throughout his hospitalization, but on the last 48
hours of his hospitalization showed no objective signs of
withdraw. The patient was normotensive. The patient had no
signs of tachycardia. The patient's pupils remained normal
with normal reactivity at the last day of admission. The
patient was afebrile throughout his hospitalization. The
patient was combative at times, but was never physically
aggressive or threatening.
PLEASE SEE OMR NOTE DATED [**2169-5-12**] BY DR. [**Last Name (STitle) **] FOR DETAILS
OF THE REMAINDER OF THIS HOSPITALIZATION.
DISCHARGE DIAGNOSES:
1. Acute narcotic withdraw.
2. Narcotic dependence.
3. Benzodiazepine dependence.
4. Depression.
5. Anxiety.
6. Complex regional pain syndrome.
7. Chronic low back pain.
8. Gastroesophageal reflux disease.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 7942**]
MEDQUIST36
D: [**2169-5-5**] 11:08
T: [**2169-5-5**] 11:18
JOB#: [**Job Number 17460**]
|
[
"4019",
"53081",
"3051"
] |
Admission Date: [**2138-2-11**] Discharge Date: [**2138-3-3**]
Date of Birth: [**2138-2-11**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 59275**] is a former 1.93
kg product of a 36 and 2/7 weeks gestation pregnancy, second
born of twin to a 42 year old G1, P0 woman.
Prenatal screens - blood type A positive, antibody negative,
rubella immune, RPR nonreactive, hepatitis B surface antigen
negative, group Beta strep status unknown. The pregnancy was
notable for in [**Last Name (un) 5153**] fertilization with diamniotic,
dichorionic twin. The pregnancy was otherwise uncomplicated.
The mother was delivered by cesarean section after
spontaneous rupture of membranes for known breech and
transverse lies. This twin, No. 2, emerged with Apgars of 8
at 1 minute, and 9 at 5 minutes. She was in good condition
and admitted to the Newborn nursery. At 17 hours of age she
was admitted to the Neonatal Intensive Care Unit for poor
feedings, bilious emesis and hypothermia.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, weight 1.93 kg, length 42.5 cm, head
circumference 30 cm, all 10th percentile for gestational age.
GENERAL: Sleepy, pink, preterm infant in no apparent
distress.
HEENT: Anterior fontanel soft and flat. Intact palate, poor
suck, positive red reflexes bilaterally.
CHEST: Lungs clear to auscultation. Equal breath sounds.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs. 2+
femoral pulses.
ABDOMEN: Full but soft and nontender. Positive bowel sounds.
GENITOURINARY: Normal female. Anus patent.
SPINE: Straight with normal sacrum.
EXTREMITIES: Hips stable. Fit and well perfused digits.
NEUROLOGIC: Tone and reflexes consistent with gestational
age.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LAB DATA:
RESPIRATORY: [**Known lastname **] was in room air for her entire Neonatal
Intensive Care Unit admission. She did not have any episodes
of spontaneous apnea during admission.
CARDIOVASCULAR: [**Known lastname **] has maintained normal heart rates and
blood pressures. No murmurs had been noted.
FLUIDS, ELECTROLYTES AND NUTRITION: [**Known lastname **] was made NPO upon
admission to the Neonatal Intensive Care Unit. Due to her
abdominal distention there was concern for possible
gastrointestinal obstruction. She had an upper
gastrointestinal series and a contrast enema performed at
[**Hospital3 1810**] on [**2138-2-11**], when she finally began to
pass stool on day of life No. 1. The abdominal distention
resolved and feedings were initiated on day of life No. 2.
She was gradually advanced to full volume without problems.
At the time of discharge she was taking breast milk or
Similac fortified to 24 calories per ounce of breast milk
with 4 calories of Similac powder. Weight on the day of
discharge is 2.335 kg with a length of 46 cm and head
circumference of 32 cm. Serum electrolytes were checked in
the first week of life and were within normal limits.
INFECTIOUS DISEASE: Due to the hypothermia, and the
abdominal distention, [**Known lastname **] was evaluated for sepsis upon
admission to the Neonatal Intensive Care Unit. Complete blood
count was within normal limits. Intravenous ampicillin and
gentamycin were started after procurement of blood culture.
Blood culture showed no growth at 48 hours and [**Known lastname 59278**]
clinical condition had improved and the antibiotics were
discontinued.
GASTROINTESTINAL: As previously noted, there was concern for
possible gastrointestinal obstruction. The upper
gastrointestinal series showed no bowel malrotation. The
contrast enema showed meconium plug which did not allow
contrast to pass beyond the sigmoid colon. She was returned
back to the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] from
[**Hospital3 1810**] Radiology Suite. She spontaneously passed
stool within the next 24 hours and the abdominal distention
resolved. She tolerated feeds well from that point on. She
also required treatment for unconjugated hyperbilirubinemia
with phototherapy. Her peak serum bilirubin occurred on day
of life No. 3 with a total of 10 mg/ dL over 0.3 mg per dL
direct. She received approximately 48 hours of phototherapy
with rebound bilirubin on day of life No. 6 was 5.8. Total
over 0.2 mg per dL direct.
NEUROLOGY: [**Known lastname **] has maintained a normal neurological
examination. During admission there are no neurological
concerns at the time of discharge.
SENSORY: Hearing screening was performed with automated
auditory brain stem responses. [**Known lastname **] passed in both ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 5279**] [**Last Name (NamePattern1) 43699**] Centre
Pediatric Associates, 10NE [**Location (un) **] Place, [**Apartment Address(1) 50442**],
[**Location (un) **], [**Numeric Identifier 59279**]. Phone No. [**Telephone/Fax (1) 43701**]. Fax No. [**Telephone/Fax (1) 59280**].
CARE RECOMMENDATIONS:
1. Feedings, ad lib breast feeding or bottle feeding Similar
24 calorie per ounce or expressed breast milk fortified to
24 calories per ounce with Similac powder.
2. No medications.
3. Car Seat Position Screening was performed. [**Known lastname **] was
observed for 90 minutes in her car seat without any
episodes of bradycardia or oxygen desaturations.
4. State Newborn Screens were sent on [**2-14**], and [**2138-2-25**]
with no notification of abnormal results to date.
5. Immunizations received: Hepatitis B vaccine was administered
on [**2138-2-19**].
6. 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:
A. Born at less than 32 weeks.
B. 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,
C. With chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for
household contacts and out of home caregivers.
Follow up appointments recommended:
Appontment with Dr. [**Last Name (STitle) 43699**], primary pediatrician within 2
days of discharge.
DISCHARGE DIAGNOSIS:
1. Prematurity at 36 and 2/7 weeks.
2. Twin No. 2 of twin gestation.
3. Suspicious for sepsis ruled out.
4. Suspicious for intestinal obstruction ruled out.
5. Meconium plug syndrome.
6. Unconjugated hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2138-3-2**] 22:56:05
T: [**2138-3-2**] 23:44:17
Job#: [**Job Number 59281**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2184-12-27**] Discharge Date: [**2185-1-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Gastrointestinal bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
HPI: [**Age over 90 **] y/o lady with CAD multiple PCI, chronic diastolic heart
failure, hypertension, hypothyroidism, chronic renal failure
presents after a syncopal episode and melena. Patient is a poor
historian with memory trouble per family. Most of the history
was obtained from grand daughter and daughter over the phone.
Patient daughter visited her this morning and found her to be in
usual health. Her grand daughter went during the evening and
patient was in bath room. She took her to the bedroom and
patient felt week. Patient slipped along her bed to the floor
but without trauma to the head or body. She had breif episodes
of loss of consciousness for 7-10secs and family decided to call
EMS. Patient was noted to be cold, clammy with stiffened
extremities during this episode. When they moved her, found to
have really dark stool. She also vomitted once, very dark
coloured vomit. Patient denied any chest pain or shortness of
breath.
In the ED vitals were: T 95.7 HR 71 BP 134/44 RR 19 100% in
RA. Patient received 80 mg IV pantoprozole. Patient was found
to have left retrocardiac opacity and was given 1 gm of IV
ceftriaxone and levofloxacin 750 mg IV.
On arrival to MICU her vitals were T 97.2 HR 73 BP 111/80 RR
18 100% in RA. Patient is asymptomatic. Patient and family
denied any recent fever, chills, nightsweats, cough, cold,
abdominal pain, diarrhea, constipation, dysuria, hematuria,
focal numbness or weakness.
Past Medical History:
CAD s/p multiple PCIs, stenting and restenting of LCx
Chronic diastolic heart failure
HTN
Hyperlipidemia
CRI: creatinine 2.0 on [**5-3**] (while reportedly on ACEi)
Hypothyroidism
Social History:
hx: Lives alone; former seamstress; widowed; Has children that
live close by and assist her with foodshopping; otherwise she is
totally independent. Never smoker, no ETOH
Family History:
NC
Physical Exam:
Vital: T 97.2 HR 73 BP 111/80 RR 18 100% in RA. Patient is
asymptomatic.
Gen: Alert and oriented to person and place. NAD. Pleasant
lady following commands.
HEENT: EOM-I, MM dry, JVP not elevated
Heart: S1S2 II/VI holosystolic murmur heard throughout the
precordium but best at RUSB.
Lungs: crackles at left base.
Abdomen: BS present, soft NTND.
Ext: WWP, no edema
Neuro: Following commands. CNII-XII grossly intact. Strength
[**5-31**] bilaterally.
Pertinent Results:
[**2184-12-27**] 08:10PM BLOOD WBC-14.4*# RBC-3.39* Hgb-10.8* Hct-31.6*
MCV-93 MCH-31.8 MCHC-34.1 RDW-13.2 Plt Ct-401#
[**2184-12-28**] 12:56AM BLOOD WBC-13.4* RBC-3.13* Hgb-10.1* Hct-28.7*
MCV-92 MCH-32.4* MCHC-35.3* RDW-13.3 Plt Ct-366
[**2184-12-27**] 08:10PM BLOOD Neuts-89.5* Lymphs-6.2* Monos-3.4 Eos-0.7
Baso-0.3
[**2184-12-27**] 08:10PM BLOOD PT-14.7* PTT-23.3 INR(PT)-1.3*
[**2184-12-27**] 08:10PM BLOOD Plt Ct-401#
[**2184-12-27**] 08:10PM BLOOD Glucose-176* UreaN-161* Creat-4.5*#
Na-137 K-5.2* Cl-99 HCO3-22 AnGap-21*
[**2184-12-28**] 12:56AM BLOOD Glucose-170* UreaN-162* Creat-4.6* Na-137
K-5.1 Cl-101 HCO3-22 AnGap-19
[**2184-12-27**] 08:10PM BLOOD CK(CPK)-50
[**2184-12-28**] 12:56AM BLOOD CK(CPK)-48
[**2184-12-27**] 08:10PM BLOOD CK-MB-NotDone
[**2184-12-27**] 08:10PM BLOOD cTropnT-0.07*
[**2184-12-27**] 08:10PM BLOOD Calcium-8.8 Phos-5.6* Mg-2.7*
[**2184-12-28**] 12:56AM BLOOD Calcium-8.4 Phos-5.5* Mg-2.5
[**2184-12-28**] 01:20AM URINE Hours-RANDOM UreaN-706 Creat-114 Na-10
[**2184-12-27**] 10:20PM URINE RBC-0-2 WBC-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2184-12-27**] 10:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR
.
Radiographic studies:
[**12-27**] CXR:
IMPRESSION: Increased left retrocardiac opacity suspicious for
pneumonia or aspiration. Correlate clinically.
.
EKG [**2184-12-27**]: sinus rhythm. rate 60s. PVC. Borderline left axis
deviation. Mildly prominent q waves in I and aVL with biphasix
T wave in I and TWI in aVL. No sig change since [**2184-12-13**].
.
EGD ([**12-28**]): Schatzki's ring
Medium hiatal hernia
Ulcers in the stomach body and antrum
Erosions in the fundus
Ulcers in the first part of the duodenum and second part of the
duodenum
Otherwise normal EGD to second part of the duodenum
.
[**2184-12-31**] 07:30AM BLOOD WBC-11.7* RBC-3.59* Hgb-11.1* Hct-32.6*
MCV-91 MCH-31.0 MCHC-34.1 RDW-14.7 Plt Ct-320
[**2184-12-31**] 07:30AM BLOOD Glucose-102 UreaN-118* Creat-3.7* Na-144
K-4.3 Cl-113* HCO3-18* AnGap-17
[**2184-12-31**] 07:30AM BLOOD CK(CPK)-62
[**2184-12-28**] 12:19 pm SEROLOGY/BLOOD Source: Venipuncture.
**FINAL REPORT [**2184-12-29**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2184-12-29**]):
POSITIVE BY EIA.
(Reference Range-Negative).
[**2184-12-31**] CXR
FINDINGS: In comparison with the study of [**12-27**], there is further
increase in
opacification at the left base with slight silhouetting of the
hemidiaphragm.
The appearance is suggestive of aspiration or pneumonia.
[**2185-1-2**] UA
SpecGr 1.013
pH 5.0
Urobil Neg
Bili Neg
Leuk Tr
Bld Neg
Nitr Neg
Prot Tr
Glu Neg
Ket Neg
RBC 1
WBC 7
Bact Few
Yeast None
Epi 1
Brief Hospital Course:
Assessment and Plan: [**Age over 90 **] yo F with CAD, chronic distolic heart
failure, hypertension, hypothyroidism, chronic renal failure
presents after a gastrointestinal bleeding, syncope and acute
renal failure.
.
1. GIB: Baseline HCT > 34. On admission 31 in the setting of
dehydration. Remained hemodynamically stable. Repeat hct of
26.2 prompted transfusion of 1U PRBCs. EGD on [**12-28**] showed
multiple gastric and duodenal ulcers, not actively bleeding. H
pylori was positive. Patient was started on [**Hospital1 **] PPI,
Clarithromycin, and Amoxicillin. HCT stable at 32 on discharge.
Aspirin and Plavix were held. GI recommended holding plavix for
total of 2 weeks, and Aspirin for 4-5 days. Restarted ASA on
discharge. Plavix to be resumed on [**1-11**]. Please monitor HCT.
Please continue PPI [**Hospital1 **] for total of 6 weeks (started [**12-28**]).
Patient was found to be H. pylori positive, and was started on
Amoxicillin and clarithromycin on [**2184-12-30**].
.
2. Left retrocardiac opacity: Crackles on exam and elevated
white count. T 96.6, has been low for several days, with HCO3 of
17. CXR [**12-31**] showed worsening infiltrate.
-continue amoxicillin and clarithromycin from H.pylori therapy
for pneumonia. Patient's GFR is 7.
.
3. Syncope: Thought to be secondary to GI bleed and dehydration.
EKG without any acute ischemic changes. Three sets of cardiac
enzymes negative.
.
4. Acute on chronic renal failure: Cr up to 4.5 but recent
baseline 1.7-2.2. However has been slowly trending up.
Nephrology was consulted. Thought to be prerenal. Seemed to be
improving on discharge, with creatinine down to 2.9 with IV
fluids. This will need continuous monitoring as an outpatient.
Continues to have good urine output. - send urine lytes
.
5. UTI: Developed urinary urgency and frequency, UA consistent
with UTI. Started on 7 day course of ciprofloxacin on [**1-3**].
6. CAD: Known CAD s/p multiple PCI. Inferior NSTEMI on
[**2184-12-11**]. Last PCI in [**2179**]. Held Asa and plavix in the
setting of GI bleed. Carvedilol was held briefly, and restarted
prior to discharge.
Medications on Admission:
Current Medications: Confirmed with family
Levothyroxine 75 mcg daily
Aspirin 325 mg daily
Nitroglycerin 0.3 mg prn
Atorvastatin 80 mg daily
Docusate Sodium 100 mg [**Hospital1 **] prn
Clopidogrel 75 mg daily
Carvedilol 12.5 mg [**Hospital1 **]
Furosemide 20 mg [**Hospital1 **]
Indomethacin 75 mg daily
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily) for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
7. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**] in [**Last Name (un) **] [**Doctor Last Name **]
Discharge Diagnosis:
Primary diagnosis:
1. Gastric and duodenal ulcers
2. H. pylori infection
3. Syncope
4. Acute renal failure
5. Urinary tract infection
6. Aspiration pneumonia
Secondary diagnosis:
Coronary artery disease
Chronic diastolic heart failure
Hypertension
Hyperlipidemia
Chronic kidney disease
Hypothyroidism
Discharge Condition:
Stable. HCT 32.6.
Discharge Instructions:
You were admitted because you were passing blood in your stool.
You had an endoscopy performed that showed ulcers in your
stomach. You are on a medication and several antibiotics to
treat this. You received several blood transfusions because your
blood count was low. We have stopped your plavix and Aspirin
temporarily because they can increase GI bleeding. Your
indomethacin was stopped, as this can worsen ulcers. Your
Carvedilol was stopped while you were in the hospital. Next time
you see Dr. [**Last Name (STitle) **], you can discuss restarting it.
Your kidneys weren't functioning well during your
hospitalization. We are closely monitoring your kidney function,
and this will need to be monitored in clinic as an outpatient.
If you have lightheadedness, fevers, bright red blood in your
stools, black stools, or vomiting blood, please call your
primary doctor or go to the emergenc room.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] Thursday [**1-6**]
at 3:15pm.
You will need to have some labs checked on Monday.
You have an appointment with Dr. [**Last Name (STitle) 80026**] on [**2-15**] at 1pm.
The clinic number is [**Telephone/Fax (1) 9557**].
Completed by:[**2185-1-3**]
|
[
"5849",
"2762",
"486",
"4280",
"40390",
"41401",
"2449"
] |
Admission Date: [**2189-9-24**] Discharge Date: [**2189-9-30**]
Date of Birth: [**2119-2-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Bronchopleural Fistula
Major Surgical or Invasive Procedure:
[**2189-9-25**] Rigid bronchoscopy using Dumon black bronchoscope.
Flexible bronchoscopy, Placement of covered metal stent [**95**] x 40
mm in the left main stem covering the left upper lobe bronchus,
Balloon dilation of the metal stent.
History of Present Illness:
Mr [**Known lastname 84248**] is a 70 year old man with a history of non-small cell
lung CA s/p R thoractomy with en bloc wedge resection in [**2184**],
who, on [**2189-7-28**] at [**Hospital6 8432**] Center, underwent left
thoracotomy, left upper lobectomy with wedge resection of left
lower lobe for two new lung lesions identified on surveillence
CT
chest in [**5-28**]. Post-operatively, the patient remained intubated
and had a mild elevation in his troponins which later trended
down. He underwent tracheostomy on [**2189-8-11**] and G-tube
placement.
He subsequently developed ventilator associated PNA (MSSA and
enterobacter) and has been treated with Zosyn and remained
ventilaor dependant. He eventualy recovered well but had a had a
persistant air leak and on his discharge to a [**Hospital 5442**] rehab
([**Hospital1 **]) his chest tube remained in place. The chest tube then
fell out at rehab and he was then transferred to [**Hospital3 **]
Medical Center for replacement and managament of the chest tube.
He underwent bronchoscopy and it was thought he had a
bronchopleural fistula. He was planned to undergo a Eloesser
procedure, but was felt to be too high risk and was transferred
to [**Hospital1 18**] for bronchoscopy and possible endobronchial glue to
treat likely bronchopleural fistula. Has been afebrile at [**Hospital3 84249**], WBC normalized. last BM today. Was complaining of
LLQ pain during admission, underwent Abd CT [**9-19**] that was
normal.
Past Medical History:
LULobectomy/LLlobe wedge for lung CA via L thoractomy [**2189-7-28**]
NSCL Ca [**2184**] s/p R thoracotomy, en bloc resection portions of
RUL/RLM/RLL
ETOH
GERD
Depression
L knee OA
h/o PE
Social History:
Lives in [**State 1727**]. Ex-smoker. + EtOH
Family History:
unknown
Physical Exam:
PHYSICAL EXAM:
T 97.5 HR 99 BP 131/69 RR 26 02 94% CMV 450x14 peep 5
GENERAL
[x] NAD [x] AAO to person
HEENT
[x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings: tracheostomy tube in place, no drainage
RESPIRATORY hyperesonent left chest, decreased BS right base,
no crackles
Left chest tube in place to WS, +airleak
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD
GI
Soft, ND, No mass/HSM, tender per patient w deep palpation, no
rebound or guarding. Peg in place, capped.
GU- foley in place, deep yellow urine in bag
EXT: warm, well-perfused, 2+ edema, RUE PICC line in place. no
erythema.
Pertinent Results:
[**2189-9-30**] 02:33AM BLOOD WBC-9.3 RBC-2.91* Hgb-7.4* Hct-23.8*
MCV-82 MCH-25.6* MCHC-31.3 RDW-19.1* Plt Ct-282
[**2189-9-30**] 02:33AM BLOOD Glucose-115* UreaN-16 Creat-0.5 Na-140
K-4.0 Cl-96 HCO3-39* AnGap-9
[**2189-9-30**] 03:45AM BLOOD Hct-24.1*
[**2189-9-30**] 09:17AM BLOOD Hct-26.0*
Brief Hospital Course:
Pt was admitted to SICU on [**2189-9-24**] and had CT Chest done which
demonstrated the following.
CT Chest with Contrast ([**2189-9-24**]):
1. Likely bronchopleural fistula from the left upper lobe stump.
2. Ground-glass opacification, peribronchial consolidation and
pleural
effusion, most consistent with multifocal pneumonia and mild
pulmonary edema.
3. Enlarged hyperdense paratracheal nodes that may relate to
patient's
diagnosis of NSCLC or be reactive.
4. Severe emphysema.
5. Pattern of interstitial disease suggestive of usual
interstitial pneumonia
which may be secondary to idiopathic pulmonary fibrosis,
collagen vascular
disease, or drug reaction.
6. Lung loculated effusion on the left with apparenelty
thickened consistent
with intection/inflammation.
7. Aortic and mild coronary artery calcification.
8. Defects the ribs on the right may be due to respiratory
motion or
fractures. Correlate clinically.
Patient underwent rigid bronchoscopy with stent placement on
[**2189-9-25**]. Plans were made to transfer him back to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1727**]
Medical Center for further surgical treatment ([**Last Name (un) 72968**]
procedure) with his thoracic surgeon there. After communication
with his thoracic surgeon it was determined that they were
unable to provide him with [**Location (un) **] transportation to his
facility. Plans were then made to transfer to him back to
[**Hospital **] Rehab with follow-up with his thoracic surgeon in [**State 1727**].
Medications on Admission:
Lopressor 25mg PO BID
Nexium 40 mg PO DAILY
Lorazepam 0.25mg PO q 8
Trazadone 50mg PO Daily
Colace 100mg PO BID
Fentanyl patch 50mcg topical q72hrs
Nicotine Patch 21mg topical DAILY
Zosyn 2.2.5mg IV q 6 Day #11 or 14
Tylenol 650 q 4 prn fever
albuterol nebs q 4 prn SOB
Dulcolax 10mg PO/PR prn Daily
Haldol 2mg PO q 4 prn agitation
Ativan 1 mg IV q 12 prn agitation
Morphine 2mg IV q12 prn pain
Morphine 1 mg IV q 2 prn severe pain
Zofran 4mg IV q 8 prn nausea
Oxycodone 10mg PO q 4 prn pain
Lovenox 40mg SC DAILY
ProMod w Fiber at 75cc/hr + 200cc free H20 down g-tube [**Hospital1 **]
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
2. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous Membrane [**Hospital1 **] (2 times a day).
4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Lung cancer with respiratory failure and bronchopleural fistula.
Discharge Condition:
Fair
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
Please follow up with your thoracic surgeon at [**State 48444**] Center in [**12-24**] weeks
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"2762",
"53081",
"496",
"311"
] |
Admission Date: [**2155-6-9**] Discharge Date: [**2155-6-13**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD through ostomy bag at [**Hospital **] Hospital with suture placed at
ostomy site at [**Location (un) **].
[**Hospital1 18**]: NG lavage and Ileoscopy through ostomy site [**2155-6-10**]
History of Present Illness:
[**Age over 90 **] year old man with history of PUD, recurrent diverticulitis
s/p illeostomy with history of illioconduit in [**2145**] then
colostomy in [**2152**], recent history of GI bleed 5 weeks ago
complicated by retained small bowel camera who presents with an
acute GI bleed. 3-5 days prior to admission he noticed blood
filling his ileostomy bag. The bag actually filled up with blood
three times over the past week. He and his wife tried to apply
pressure to the bleeding on the day of admission ([**2155-6-9**]), which
only temporarily helped. He denied any abdominal pain, nausea,
vomitting, chest pain, shortness of breath, fevers, chills. When
the bleeding did not stop, he decided to come to the ED.
.
He arrived at [**Hospital **] Hospital and underwent an EGD through the
ileostomy stoma which only revealed blood and no obvious source
of bleeding. He then underwent an a repeat EGD through the
ileostomy stoma that did not reveal the source of bleed. He did
get fent/versed and for unclear reasons sux/etom (although not
intubated) for sedation for this procedure. He also was given
phenylephrine and levoquin during the procedure. This procedure
also did not reveal the bleed. He had a suture placed at the
stoma entry site. He remained hemodynamically stable throughout
his stay and he was given 4 units of PRBCs, 2 units of FFP
during his hospital stay, and his HCT rose from 23 at 9am to 28
at 9pm on [**2155-6-9**]. He also was on protonix 40mg IV BID and an
ocreotide gtt. Because both scopes were unrevealing, he was
transferred to [**Hospital1 **] for unstable blood volume and evaluation for
IR guided intervention. His access was 2 #20 PIVs.
.
Of note, patient had a recent hospital stay for GI bleed at
[**Hospital **] Hospital with a small bowel camera retained in small
bowel from [**Date range (1) 89310**] for N/V and ?GI bleed c/b retention of
small bowel camera c/b SVT and fever. It is unclear if this
camera was ever removed.
Past Medical History:
1. Diverticulitis
2. Performated Meckel's diverticulum requiring surgery
3. S/p subtotal colectomy in [**2152**] for diverticulosis
4. S/p partial small bowel resection with ileostomy and ileal
conduit in [**2145**] for diverticulosis
5. CKD baseline Cr 1.5
6. H/o prosate CA s/p radiation in [**2134**]
7. PVD
8. Peripheral neuropathy
9. Macular degeneration of R eye
10. PUD
11. AS
12. S/p hemorrhoidectomy
13. Migraines
14. S/p cholecystectomy [**2151**]
15. Last echo EF 55%
Social History:
Lives with his wife in [**Name (NI) **], MA. He does not currently
smoke, drink, or use drugs.
Family History:
Noncontributory.
Physical Exam:
On admission:
GEN: Pale, confused, elderly man in NAD, AOx2
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no
jvd, no RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no r/g, 4+ crescendo/decrescendo SM, with
loss of S2, +pulsus parvus et tardus, not late peaking
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly,
ileostomy bag with active exsanguination and + clots that
resolved after 30m, stoma without any obvious bleeding lesions
with fresh suture in place
EXT: no c/c/e, trace LLE edema, none on RLE
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx2.
On discharge:
GEN: elderly gentleman in NAD, alert and oriented to person,
year (thinks he is in [**Hospital1 **] still; knows the year but thinks
it's [**Month (only) 958**])
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no
jvd, no RESP: CTA b/l with good air movement throughout
CV: S1 and S2, 4+ crescendo/decrescendo SEM, with loss of S2,
+pulsus parvus et tardus, not late peaking
ABD: (+)bowel sounds, ileostomy in place with 300cc of maroon
fluid, urostomy with light yellow urine; soft, nt, no masses or
hepatosplenomegaly, stoma without any obvious bleeding lesions
Pertinent Results:
ADMISSION LABS
[**2155-6-9**] 10:54PM BLOOD WBC-8.8 RBC-3.46* Hgb-10.1* Hct-28.2*
MCV-82 MCH-29.1 MCHC-35.7* RDW-16.1* Plt Ct-113*
[**2155-6-9**] 10:54PM BLOOD PT-13.4 PTT-27.6 INR(PT)-1.1
[**2155-6-9**] 10:54PM BLOOD Glucose-129* UreaN-25* Creat-1.0 Na-141
K-4.3 Cl-109* HCO3-23 AnGap-13
[**2155-6-10**] 03:05AM BLOOD ALT-9 AST-17 LD(LDH)-181 AlkPhos-60
TotBili-2.0*
[**2155-6-9**] 10:54PM BLOOD Calcium-7.1* Phos-4.3 Mg-1.6
DISCHARGE LABS
[**2155-6-13**] 07:50AM BLOOD WBC-4.4 RBC-3.36* Hgb-9.9* Hct-28.1*
MCV-84 MCH-29.5 MCHC-35.4* RDW-15.5 Plt Ct-163
[**2155-6-13**] 11:00AM BLOOD Hct-30.4*
[**2155-6-13**] 07:50AM BLOOD Glucose-87 UreaN-18 Creat-1.2 Na-138
K-3.6 Cl-107 HCO3-26 AnGap-9
[**2155-6-12**] 07:40AM BLOOD TotBili-0.6 DirBili-0.2 IndBili-0.4
[**2155-6-13**] 07:50AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.8
EKG [**2155-6-9**]
Sinus rhythm with premature ventricular complexes. Probable left
anterior
fascicular block with right bundle-branch block. Diffuse
baseline artifact
on the first half of the tracing marring interpretation of ST
segments for
ischemia but no gross abnormalities appreciated. No previous
tracing available for comparison.
CTA ABDOMEN/PELVIS [**2155-6-10**]
1. Multiple bowel surgeries, with right lower quadrant
ileostomy. No
evidence of vascular extravasation, obstruction, or leak.
2. Rectal Hartmann pouch, with apparent mild wall thickening
that could
reflect proctitis.
3. Ileal conduit and urostomy in the left lower quadrant. Renal
atrophy and
mild bilateral hydroureteronephrosis, likely reflecting chronic
reflux.
4. Cholecystectomy, with moderate intrahepatic and common
biliary ductal
dilation.
5. Emphysema and moderate bilateral pleural effusions.
CXR [**2155-6-10**]
1. Bibasilar opacities are likely atelectasis although pneumonia
or
aspiration pneumonitis cannot be excluded.
2. Pulmonary vascular congestion without evidence of pulmonary
edema.
3. Small left pleural effusion.
CXR [**2155-6-11**]
As compared to the previous radiograph, there is a progression
of
the pre-existing parenchymal opacities. The pattern and
distribution of the
changes suggest pulmonary edema of moderate severity. In
addition, the
pre-existing retrocardiac atelectasis and right basal
parenchymal opacity
persists
Ileoscopy [**2155-6-10**]
Normal mucosa in the ileum without blood.
Otherwise normal colonoscopy to ileum (20cm examined)
Brief Hospital Course:
BRIEF HOSPITAL COURSE
Mr. [**Known lastname 6632**] is a [**Age over 90 **]y/o gentleman with history of PUD, recurrent
diverticulitis s/p illeostomy with history of illioconduit in
[**2145**] then colostomy in [**2152**], recent history of GI bleed 5 weeks
ago complicated by retained small bowel camera who presented
with an acute GI bleed. This may have been due to a stomal
tear, which was repaired at the OSH. During this admission his
Hct was stable and he was discharged home.
.
1. Acute GI bleed: Resolved.
Lower GI source most likely given that he was briskly bleeding
with clots yet remaining hemodynamically stable. Possibly from a
stomal tear. At OSH a tear was visualized and he underwent
stoma revision. Since he has been here, he has had no active
bleeding. No clear source identified on CTA. He did require 3u
pRBCs and his Hct remained stable after that. GI scoped through
ileostomy with no clear source and given stability, Surgery
signed off. Next step would be capsule endoscopy, which Pt
declined due to his h/o obstruction from retained camera. He
was advised to follow up as an outpatient and to continue his
PPI. He was d/c'd home with PT and GI follow-up.
.
2. Hypoxia: Pulmonary edema, resolved.
Occurred while in ICU, most likely due to pulmonary edema from
volume resuscitation. He was diuresed with Lasix 20mg IV x1,
successfully. He was subsequently euvolemic.
.
3. [**Last Name (un) **] on CKD: Cr peaked at 1.4, was likely prerenal in the
setting of acute blood loss. Resolved quickly after blood
transfusions and his Cr returned to his baseline (1.2).
.
4. AS: Moderate to severe based on exam.
Unclear why not on diuretics or antihypertensives, although
fludricortisone suggests h/o orthostasis. He was set up with an
appointment to follow up with his Cardiologist.
.
5. Depression: Chronic.
He was continued on Celexa.
.
6. PVD: stable.
Unclear why not on aspirin or statin. He was told to follow up
with his Cardiologist.
.
Code Status: DNR/DNI
Medications on Admission:
1. Celexa 20mg PO daily
2. Rabeprazole 20mg PO daily
3. Fludrocortisone 0.1mg PO daily
4. Gabapentin unknown dose PO BID
5. Vitamin B12 600mcg PO daily
Discharge Medications:
1. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. rabeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis this admission: Gastrointestinal bleeding of
unclear source.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] from another hospital with bleeding
into your ostomy pouch. You received several blood tranfusions
to maintain your blood levels and the bleeding eventually slowed
down such that your blood levels were stable for several days.
Our gastroenterologists and surgeons felt comfortable
discharging you from the hospital given that you blood levels
were stable, and you did not want to have any further workup at
this time. Therefore, it is important for you to follow up
closely with the gastroenterologist doctors [**Name5 (PTitle) 7974**]. If you
notice any further bleeding, return to the hospital immediately.
We did not make any changes to your medications.
Followup Instructions:
PRIMARY CARE
Name: [**Doctor Last Name **],[**Last Name (un) 49339**] V. MD
Address: [**Street Address(2) 89311**]., [**Location **],[**Numeric Identifier 26374**]
Phone: [**Telephone/Fax (1) 13745**]
Appointment: Thursday [**2155-6-26**] 11:00am
CARDIOLOGY
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Address: [**Street Address(2) **] SUITE #4930, [**Location (un) **],[**Numeric Identifier 7023**]
Phone: [**Telephone/Fax (1) 89312**]
Appointment: Tuesday [**2155-7-1**] 11:20am
GASTROENTEROLOGY
[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 1437**] [**Name8 (MD) **], MD
S W Gastroenterological Assoc
[**State 89313**], SW Gastro Assoc
[**Location (un) **], [**Numeric Identifier 23881**]
Phone: ([**Telephone/Fax (1) 89314**]
We are working on a follow up appointment in Gastroenterology
with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 1437**] within 2 weeks. The office will contact
you at home with an appointment. If you have not heard within 2
business days or have any questions please call [**Telephone/Fax (1) 25843**].
|
[
"2851",
"5849",
"4241"
] |
Admission Date: [**2112-6-11**] Discharge Date: [**2112-6-15**]
Date of Birth: [**2062-5-23**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
You were initially intubated and admitted to the ICU during this
hospitalization.
History of Present Illness:
50 yoM found unaccompanied on a park bench by police/EMS
seizing. No sign of trauma at the scene. Fingerstick glucose at
the site was 142. En route to the ED, the patient was post-ictal
but able to tell EMS his name ([**Known firstname **]) and that he was a drinker.
.
In the ED, initial vs were: T 98.4 P 128 BP 145/77 R 24-30 O2
sat 99% on NRB. Upon arrival to the ED, the patient seized
again; he had 1 tonic-clonic seizure and received 1mg Ativan x2.
After his seizure in the ED, the patient remained non-responsive
and started the gurgle. He was intubated for protection of his
airway. CT scan of the head showed no acute ICH or acute
intracranial pathologic process. Encephalomalacia in the L
frontal lobe, and there was evidence of prior craniotomy. A
foley was placed with good uop and an OGT was also placed.
.
On the floor, the patient arrived intubated and sedated. Initial
VS were: T 37.7 P 101 BP 127/79 R 15 O2 Sat 97%; vent settings:
CMV/Assist, FiO2 100%, RR 14, TV 500, PEEP 5. He was finishing
his third liter of NS. An ABG was obtained on presentation to
the ICU.
.
Review of systems: Unable to obtain.
Past Medical History:
# EtOH abuse with hx of withdrawl seizures and DT's
# seizure disorder [**12-30**] traumatic brain injury
# hypertension
# Hyperlipidemia
# Essential tremor
Social History:
currently homeless
unemployed
incarcerated in the past
daily EtOH - [**11-29**] quart of vodka daily
hx of cocaine use
[**11-29**] PPD smoker
has daughter that lives in [**Name (NI) 1727**]
Family History:
pt denies any known family history
Physical Exam:
Admission Exam:
Vitals: T: 37.7 BP: 127/79 P: 101 R: 15 O2: 97% on vent.
General: Sedated, intubated.
HEENT: Sclera anicteric. Pinpoint pupils, minimally reactive to
light. ETT and OGT in place. Scar over the left frontal-temporal
area.
Neck: No LAD.
Lungs: Clear to auscultation bilaterally. No wheezes or
crackles.
CV: Regular rate and rhythm. Normal S1 + S2. No murmurs, rubs,
gallops
Abdomen: Soft, NT/ND. Bowel sounds +. No HSM.
GU: Foley in place.
Ext: WWP. 2+ DPs. No clubbing, cyanosis or edema
Skin: multiple tattoos with dry skin.
Neuro: Arousable to name. Able to squeeze right hand on command.
Unable to squeeze left hand on command.
Pertinent Results:
[**2112-6-11**] 11:45PM TYPE-ART TEMP-38.7 PO2-120* PCO2-43 PH-7.40
TOTAL CO2-28 BASE XS-1 COMMENTS-AXILLARY T
[**2112-6-11**] 11:45PM LACTATE-1.4
[**2112-6-11**] 08:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2112-6-11**] 08:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2112-6-11**] 08:15PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2112-6-11**] 08:15PM URINE HYALINE-3*
[**2112-6-11**] 08:15PM URINE MUCOUS-RARE
[**2112-6-11**] 07:33PM LACTATE-27.7*
[**2112-6-11**] 07:20PM GLUCOSE-150* UREA N-10 CREAT-1.0 SODIUM-145
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-8* ANION GAP-38*
[**2112-6-11**] 07:20PM ALT(SGPT)-84* AST(SGOT)-102* LD(LDH)-343*
CK(CPK)-550* ALK PHOS-97 TOT BILI-0.4
[**2112-6-11**] 07:20PM LIPASE-62*
[**2112-6-11**] 07:20PM ALBUMIN-5.0
[**2112-6-11**] 07:20PM WBC-9.9 RBC-4.46* HGB-14.4 HCT-45.6 MCV-102*
MCH-32.4* MCHC-31.6 RDW-14.6
[**2112-6-11**] 07:20PM NEUTS-47* BANDS-1 LYMPHS-32 MONOS-16* EOS-0
BASOS-0 ATYPS-4* METAS-0 MYELOS-0
[**2112-6-11**] 07:20PM PLT SMR-NORMAL PLT COUNT-266
Discharge labs:
[**2112-6-14**] 06:15AM BLOOD WBC-6.0 RBC-4.41* Hgb-14.5 Hct-41.5
MCV-94 MCH-32.8* MCHC-34.9 RDW-13.6 Plt Ct-247
[**2112-6-14**] 06:15AM BLOOD Glucose-114* UreaN-4* Creat-0.8 Na-136
K-3.7 Cl-100 HCO3-28 AnGap-12
[**2112-6-14**] 06:15AM BLOOD ALT-45* AST-35 LD(LDH)-200 CK(CPK)-176
AlkPhos-72 TotBili-0.5
[**2112-6-14**] 06:15AM BLOOD Albumin-3.8
Blood cultures ([**6-13**] and [**6-12**]): no growth to date, final results
pending.
Urine culture (([**6-12**]): no growth - FINAL.
MRSA screen ([**6-12**]): no MRSA - FINAL.
CT Head ([**6-11**]):
TECHNIQUE: Non-contrast MDCT images were acquired through the
brain.
Multiplanar reformatted images were obtained for evaluation.
FINDINGS: The study is slightly limited by patient's motion.
Allowing for
the limitations, there is encephalomalacia in the left frontal
lobe, with
adjacent old left frontotemporal craniotomy, compatible with
prior injury with
surgical intervention. There is otherwise no acute intracranial
hemorrhage,
edema, mass effect or major vascular territorial infarct. Apart
from the ex
vacuo effect from the left frontal encephalomalacia, there is no
shift of
normally midline structures. The ventricles and sulci are
prominent,
representing age-advanced global atrophy. There is no evidence
of acute
fracture. Scattered anterior ethmoidal opacification is noted
with minimal
aerosolized fluid in the right maxillary sinus. The remaining
visualized
paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Evidence of old left frontotemporal craniotomy, with severe
left frontal
encephalomalacia, compatible with old injury with surgical
intervention.
Recommend clinical correlation.
2. No evidence of acute intracranial pathologic process.
Specifically, no
intracranial hemorrhage.
Brief Hospital Course:
40yoM with no known significant PMHx with a known history of
EtOH use found by police/EMS seizing and who had one
tonic-clonic seizure in the ED.
#seizure disorder: The patient was intubated for airway
protection after seizure in the ED and admitted to the ICU. The
patient did well in the ICU and was extubated the following
morning and transferred to the regular medical floor. He has a
known history of seizure disorder due to traumatic brain injury
several years prior and also has a history of EtOH withdrawl
seizures. He admits to being non-compliant with his outpatient
regimen of Keppra and has been non-compliant with [**Hospital 878**]
Clinic follow-up at [**Hospital1 2177**] as well. Following transfer to the
floor, he was kept on oral standing and PRN benzos for EtOH
withdrawl and then seen by Neurology Consult regarding the
etiology and treatment of his seizures. Neurology Consult felt
that the most likely etiology of his seizures is his underlying
epilepsy due to prior TBI. They recommended restarting him on
his Keppra, and he received an IV Keppra load and was started on
maintenance Keppra as an antiepileptic. At this time, the
patient is amenable to restarting anti-seizure medications and
states he will continue the medication and follow-up with
[**Hospital 878**] Clinic at [**Hospital1 2177**] in 2 days.
#EtOH depedence: The patient has a long-standing history of
EtOH abuse and has been through treatment programs multiple
times. On this admission, he was initially placed on IV benzos
standing in the ICU, then transitioned to standing and PRN PO
benzos, then PRN PO benzos only. He has not required any benzos
in the past 24 hours and remains stable and without signs and
symptoms of withdrawl. After discussion with Social Work, he
has indicated that he is not interested in EtOH cessation at
this time. He was started on multi-vitamin, thiamine and
folate, and will be discharged with these prescriptions as well.
#Code status: Full code
#Pending lab work: Pt's blood cultures drawn during this
admission are negative thus far, but final results still
pending.
Medications on Admission:
none
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure disorder, epilepsy.
EtOH dependence.
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted to the hospital after presenting via ambulance
with seizures. You were initially admitted to the ICU, after
being intubated and connected to a ventilator machine. You did
well in the ICU and was then transferred to the floor after
being removed from the ventilator and breathing on your own.
You were seen by the Neurology Consult service given your
history of seizures and restarted on your prior anti-epileptic
medication (Keppra).
Please continue to take your medications as prescribed and
please follow-up with your outpatient [**Hospital 878**] Clinic
appointment.
Your blood cultures drawn during this admission are negative
thus far, but final results are still pending.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] --Neurology
Address: Dept of Neurology-[**Hospital1 2177**], [**First Name8 (NamePattern2) **] [**Hospital Ward Name 23**] Bldg, Ste
7B, [**Location (un) 86**], [**Numeric Identifier 89923**]
Phone: [**Telephone/Fax (1) 25666**]
Appt: [**6-17**] at 10am
NOTE: If you are unable to keep this appt, please give 24 hours
notice.
|
[
"2762",
"4019",
"2724",
"2859"
] |
Admission Date: [**2123-8-21**] Discharge Date: [**2123-8-25**]
Date of Birth: [**2076-3-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Hematochezia, Abdominal Distension
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Colonoscopy with biopsies
Ultrasound guided paracentesis
History of Present Illness:
47F with PMH of chronic depression, hemorrhoids x 20+ years
presents with BRBPR for past 2 weeks. Patient states that 2
weeks ago, she drank tap water, which she normally does not do,
and began to have diarrhea. Since then, she has been going to
the bathroom every hour, with small amounts of loose stool,
until two days ago, when she became more constipated. She has
noticed her hemorrhoids more recently, in the sense that when
she uses the bathroom, she can feel them popping out from her
sphincter, and finds blood on the toilet paper when she wipes.
There is no pain associated with her hemorrhoids. At the same
time, she has noticed worsened abdominal distension and her
clothes no longer fit. She denies abdominal pain, nausea, or
vomiting. Yesterday, she had a fever of 100F with some sweats,
but has not noticed any fevers since. She was also complaining
of reflux symptoms over the past three days for which she had
been taking an over the counter anti-acid.
In the ED, initial vs were: 98.8, 106, 116/80, 18, 100% RA.
Labs were notable for an HCT of 24.5 with an MCV of 122, Plt of
109, AP of 204, t-bili of 3, AST of 62, ALT of 18, amylase of
219, lipase of 123, INR of 1.7 and negative serum/urine tox
screens. A CT of her abdomen/pelvis with contrast was notable
for a thickened colonic wall consistent with colitis and a
moderate amount of free fluid in the pelvis/paracolic gutters.
She was given levofloxacin, with plans to start flagyl but did
not receive this in the ER. She was given 4g of Mg and 40meq of
potassium. GI was consulted with possible plans for a
colonoscopy on Monday, she had two 18 gauge IV's placed but was
not transfused any PRBC's in the ER. She was admitted to the
ICU for frequent HCT monitoring. VS on transfer were: T 98.4,
BP 118/86, RR 17, O2 sat 100% RA.
On arrival to the ICU her initial VS were: T98, Hr99, BP129/88,
RR20, Sat 100% (RA). She looks comfortable with no abdominal
pain, nausea/vomiting. She does feel somewhat lightheaded, but
no chest pain or SOB.
Review of Systems:
Positive per HPI. Other review checked and unremarkable.
Past Medical History:
Hemorrhoids
Depression (hx of SI, insomnia)
ETOH abuse, in remission (last drink > 1 year ago, last heavy
use approximately 4 years ago)
anemia secondary to folate deficiency
asthma
Hyperthyroidism s/p ablation, now hypothyroid
HTN
Low back pain secondary to DJD
s/p tubal ligation
s/p fibroidectomy
Social History:
unemployed, social support from mother but serious financial
limitations
- Tobacco: 1 pack/day for 20 years
- Alcohol: former alcohol abuse (up to [**1-3**] pink whisky/night),
quit using alcohol last year, reports much less alcohol over the
past four years
- Illicits: none
Family History:
Diabetes mellitus and cancer in members. No inflammatory bowel
disease she knows about.
Physical Exam:
Admission Physical Exam:
Vitals: T:98 BP:129/88 P:99 R:20 O2:100%(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,
ronchi
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: +BS, very distended, liver edge 4cm below costophrenic
margin, tympanic to percussion, no tenderness to palpation
GU: no foley
Ext: warm, well perfused, no edema
Discharge Physical Exam:
All vital signs stable and within normal limits. Pt appeared
comfortable. Mild jaundice. Heart and lung exam within normal
limits. Abdominal exam notable for significantly diminished
distension after U/S guided paracentesis. Abdomen nontender and
liver edge no appreciated. Bowel sounds positive. No masses.
Otherwise exam notable for no asterixis.
Pertinent Results:
===================
LABORATORY RESULTS
===================
Admission Labs:
WBC-6.0 RBC-2.02*# HGB-8.4*# HCT-24.5*# MCV-122*# RDW-15.2 PLT
COUNT-109*
--NEUTS-75.5* LYMPHS-15.1* MONOS-8.3 EOS-0.7 BASOS-0.4
PT-18.6* PTT-32.7 INR(PT)-1.7*
GLUCOSE-92 UREA N-5* CREAT-0.7 SODIUM-139 POTASSIUM3.0*
CHLORIDE-98 TOTAL CO2-29
ALT(SGPT)-18 AST(SGOT)-62* LD(LDH)-204 CK(CPK)-103 ALK PHOS-204*
AMYLASE-219* TOT BILI-3.0*
ALBUMIN-3.8 CALCIUM-8.7 PHOSPHATE-2.7 MAGNESIUM-1.3*
LIPASE-123*
cTropnT-<0.01 CK-MB-2
Serum Tox: ASA-NEG ACETMNPHN-NEG ETHANOL-NEG
UCG neg, UA: BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG
KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-SM RBC-1 WBC-3
BACTERIA-FEW YEAST-NONE EPI-33
Urine Tox: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
Discharge Labs:
WBC-7.9 RBC-2.52* Hgb-9.8* Hct-29.0* MCV-115* RDW-18.3* Plt
Ct-85*
PT-18.8* PTT-36.2* INR(PT)-1.7*
Glucose-83 UreaN-2* Creat-0.6 Na-133 K-3.6 Cl-101 HCO3-23
Other Important Labs
calTIBC-221* Ferritn-176* TRF-170*
VitB12-1123* Folate-7.4
TSH-33*
HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE HCV
Ab-NEGATIVE
Anti Smooth Muscle Antibody- POSITIVE *
[**Doctor First Name **]-NEGATIVE
Paracentesis:
WBC-270* RBC-25* Polys-3* Lymphs-16* Monos-73* Mesothe-8*
TotPro-3.1 Albumin-1.8
==============
MICROBIOLOGY
==============
Urine Culture [**2123-8-21**]: No growth
Stool Culture and C diff toxin assay: negative
Peritoneal Fluid culture [**8-24**]:
GRAM STAIN (Final [**2123-8-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
==============
OTHER STUDIES
==============
ECG [**2123-8-21**]:
Sinus rhythm. Poor R wave progression with low QRS voltage in
the precordial leads and the limb leads. Compared to the
previous tracing of [**2112-8-9**] the QRS voltage has decreased and
there is poor R wave progression.
CT Abdomen and Pelvis W/ Contrast [**2123-8-21**]:
IMPRESSION:
1. Heterogeneously enhancing liver with a gastroesophageal varix
and ascites; consider an acute inflammatory process of the
liver. Correlate for clinical presence of hepatitis.
2. Thickened right colonic wall, with lesser thickening of the
left colon wall and transverse colon sparing; this finding may
be nonspecific in the setting of ascites; another consideration
is colitis (infectious versus inflammatory etiologies).
Liver/ GB U/S [**2123-8-22**]:
IMPRESSION:
1. Heterogeneous liver with patchy areas of increased
echogenicity, finding
suggestive of steatosis or possibly acute inflammation. No
definite hepatic
lesion is identified.
2. Diffuse gallbladder wall edema, likely secondary to edema
and/or
underlying liver disease. No signs of acute cholecystitis.
3. No intra- or extra-hepatic biliary ductal dilatation.
4. Moderate ascites, largest pocket in the right lower quadrant.
Brief Hospital Course:
47F with PMH of chronic depression, hypothyroidism, and alcohol
abuse presenting with hematochezia and abdominal distension and
signs of acute liver injury with secondary portal
hypertension/ascites.
1) Portal hypertension complicated by ascites due to acute or
chronic hepatitis: Pt presented with thromobocytopenia,
increased transaminases with AST>ALT, elevated bilirubin, and
elevated INR that did not normalize with vitamin K. She also
had ascites that was eventually revealed to have a SAAG of 1.3
suggestive of being due to portal hypertension. Imaging
revealed heterogeneous liver. Overall picture is somewhat
confusing. Possible patient has chronic portal hypertension due
to cirrhosis (most likely due to previous alcohol abuse) but
imaging not strictly typical and though SAAG met criteria for
being due to portal hypertension ascites albumin was relatively
high. Other possibility would be an acute hepatitis causing
acute portal hypertension. Most likely etiology of this would
be alcoholic hepatitis but patient vehemently denies continued
alcohol use to multiple individuals. Extensive work up for
causes of liver disease was unremarkable except for positive low
titre anti-smooth antibody but with negative [**Doctor First Name **]. She remained
with an elevated bili, INR, and low platelets suggesting chronic
cirrhosis but given she was otherwise stable she was discharged
to follow up in liver clinic for further management and work up.
She was cautioned about other manifestations of decompensated
cirrhosis (i.e. encephalopathy) and warned to have a low
threshold to seek medical care. She was started on 20 mg PO
lasix daily at time of discharge to help control ascites.
2) Hematochezia: On presentation patient had bright red blood
per rectum with major concern being for a hemorrhoidal bleed vs
diverticular bleed vs bleeding from colitis (as CT seemed to
suggest inflammation). Never had large volume of blood and
never with dark blood suggesting more likely from a lower GI
source.
The patient's Hct on presentation was 24.5 and increased to
around 30 after transfusion of one unit with stability
thereafter. Upper and lower endoscopy failed to reveal a clear
source of bleeding though there were hemorrhoids, which could
certainly explain blood that was seen. To complete work up
should get a capsule endoscopy to evaluate for small bowel AVMs.
GI elected to arrange this as an outpatient. At time of
discharge Hct stable >48 hrs w/o any transfusion.
3) ? Fevers: Pt reported low grade fevers prior to presentation.
ED CT scan concerning for colitis so she was started on
cipro/metronidazole though never febrile here. Colonoscopy did
not show any colitis and C diff negative so metronidazole
stopped. SBP was also entertained as a source of fever but by
time of paracentesis (deferred due to bedside procedure being
technically infeasible and the deferred for endoscopies) she had
received four days of antibiotics. Therefore she completed five
days of ciprofloxacin for possible SBP. No prophylaxis was
started as diagnosis never confirmed and seemed unlikely.
4) Anemia. Patient has hx of anemia from folate deficiency.
Hct on presentation at 24.5 likely reflects baseline anemia with
component of GI bleeding. Labs suggested no current
deficiencies. Possible some degree of sequestration due to
portal hypertension. She felt considerably better after
transfusion and with higher Hct. She will follow up for Hct
rechecks.
5) Hypothyroidism: Pt acknowledged taking levothyroxine
irregularly at best. TSH 33 suggestive of very poor adherence.
Levothyroxine restarted in hospital. She will follow up with
PCP for TSH rechecks.
6) Depression. pt with significant history of depression and had
not been taking meds regularly. She was restarted on fluoxetine
and aripiprazole in house.
7) Poor adherence: Discussed with social work and largely due to
very limited income and large debts for housing. Patient
discussed and reassured her that the infrastructure at [**Hospital **] Clinic where she plans to be seen should be very helpful
in working with financial issues and helping to make sure she
does not miss care. Patient was reassured. Need for close
follow up, particularly for hepatic issues was repeatedly
emphasized.
Transitional Issues:
-Pt will follow up with PCP to assess for signs of dehydration,
tolerance of daily furosemide regime
-Pt will follow up with PCP and liver to assess resolution of
ascites
-Pt will follow up with liver to discuss further work up of
liver disease, trend labs, and discuss need for biopsy
-Pt will follow up with PCP to recheck anemia and trend as well
as platelet count
-Final ascites culture results and serum ceruloplasmin pending
at time of discharge.
Medications on Admission:
Levothyroxine 200mcg daily - not taking everyday
Metoprolol 100mg daily - not taking
HCTZ 50mg daily
Amlodipine 5mg daily
Fluoxetine 60mg daily - not taking regularly
Abilify 20mg daily - not taking everyday but thinks she should
be
calcium 1000mg
Vitamin D
Iron
Melatonin 3mg
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*1*
2. aripiprazole 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Acute decompensated cirrhosis complicated by ascites
Acute GI bleed (source unclear)
Secondary Diagnoses:
Depression
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with GI bleeding and swelling of your abdomen.
We think the swelling in the abdomen was due to liver disease,
likely due to your previous heavy alcohol use (we have excluded
viruses and some other common causes though the liver doctor you
follow up might perform other investigations). Despite using a
camera to look at significant portions of your upper and lower
GI tract we did not pinpoint a source of bleeding.
Nevertheless, the bleeding resolved on its own and it is likely
a slow source so GI feels it can be worked up as an outpatient.
Your medications have been changed. You have been started on an
acid blocking medication to help prevent further episodes of
bleeding. Your blood pressure medicines have been held as your
blood pressure is normal without them. Finally, you have been
started on a diuretic called furosemide (lasix) to help you get
rid of excess fluid on the body.
Followup Instructions:
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
When: THURSDAY [**2123-9-2**] at 9:00 AM
With: Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NOTE: This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up
Department: LIVER CENTER
When: THURSDAY [**2123-9-9**] at 10:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"2875",
"2851",
"2449",
"4019"
] |
Admission Date: [**2132-12-14**] Discharge Date: [**2132-12-30**]
Date of Birth: [**2066-5-26**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Augmentin
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
dyspnea, anemia
Major Surgical or Invasive Procedure:
EGD
Colonscopy
Capsule endoscopy
History of Present Illness:
Mrs [**Known lastname 103573**] is a pleasant 66F with history of COPD, afib, mitral
valve replacement presenting from group home with worsening
dyspnea on exertion x 3 days. She denies chest pain, cough,
shortness of breath, lower extremity swelling, headache, nausea,
vomiting, or fever. She has orthopnea at rest and sleeps with 2
pillows at baseline, this has not worsened recently.
.
In the ED, she was noted to be hypotensive to the 70s, however
manual BP was 100/70 and pt was mentating well. Physical exam
was notable for loud murmur not previously documented. EKG was
done and notable for hypertrophy and ST depressions, unchanged
from prior. Labs were notable for mildly elevated lactate of
2.4, hyponatremia to 132, elevated creatinine to 2.4 (baseline
2.0), mildly elevated BNP, and crit of 21.5, down from a
baseline of 30. Pt was guiac negative on exam. CXR showed
retrocardiac opacity, possibly pleural effussion.
.
On the floor, pt is comfortable without any complaints. She
states that she feels improved since she arrived in the
hospital, with improvement in her weakness.
.
Review of systems:
(+) Per HPI. Pt states she has 1 BM daily, no blood recently
however did have blood in stools 1 wk prior which she attributed
to her hemorrhoids. + lightheadedness.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
-Rheumatic heart disease s/p mitral & aortic valve replacement
-COPD
-Asthma
-Hypothyroid
-CRI, baseline creatinine 2.0
-urinary incontinence
-Anxiety
-Depression
-Afib
-psychoaffective disorder
-hx ascending aortic anuerysm 5.4x 4.9 cm [**6-/2132**], appropriate
for resection
Social History:
Lives in group home. No tobacco/No Etoh, very unstable family
life according to PCP
Family History:
Mother and father with CAD, dad died of MI
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T:98.2 BP:100/46 P:63 R:17 O2:98%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, conjunctiva
pale
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregular rate, 2/6 SEM, mechanical s1, s2
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: aaox3, CNs [**3-22**] intact, strength and sensation grossly
nl.
.
DISCHARGE PHYSICAL EXAM
VS: 97.3, 77, 103/52, 16, 96% on RA
GEN: A&OX3
HEENT: MM dry, oropharynx clear, anicteric conjunctiva
NECK: supple, JVP not elevated, no LAD
HEART: irregularly irregular rhythm, high pitched S1, S2, [**3-16**]
systolic murmur best heart at LUSB
LUNG: CTA Bl
ABD: soft, NT/ND, positive BS, no rebound/guarding
EXT: warm, no pitting edema, nontender over left MTP
Pertinent Results:
ADMISSION LABS
[**2132-12-14**] 02:50PM WBC-9.5 RBC-2.34*# HGB-6.9*# HCT-21.5*#
MCV-92# MCH-29.6 MCHC-32.2 RDW-20.5*
[**2132-12-14**] 02:50PM NEUTS-84.1* BANDS-0 LYMPHS-9.8* MONOS-5.3
EOS-0.7 BASOS-0.1
[**2132-12-14**] 02:50PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-OCCASIONAL
STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
[**2132-12-14**] 02:50PM PLT SMR-NORMAL PLT COUNT-273
[**2132-12-14**] 02:50PM PT-33.2* PTT-77.7* INR(PT)-3.3*
[**2132-12-14**] 02:50PM proBNP-2838*
[**2132-12-14**] 02:50PM GLUCOSE-100 UREA N-69* CREAT-2.4* SODIUM-132*
POTASSIUM-3.5 CHLORIDE-91* TOTAL CO2-28 ANION GAP-17
[**2132-12-14**] 02:50PM cTropnT-0.02*
[**2132-12-14**] 03:00PM LACTATE-2.4* K+-3.5
[**2132-12-14**] 05:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2132-12-14**] 05:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2132-12-14**] 11:34PM HCT-23.3*
[**2132-12-14**] 11:34PM CK-MB-2 cTropnT-0.01
[**2132-12-14**] 11:34PM CK(CPK)-24*
.
DISCHARGE LABS
[**2132-12-30**] 07:05AM BLOOD WBC-2.9* RBC-3.06* Hgb-8.8* Hct-27.1*
MCV-89 MCH-28.9 MCHC-32.6 RDW-17.0* Plt Ct-146*
[**2132-12-30**] 07:05AM BLOOD PT-28.0* INR(PT)-2.7*
[**2132-12-30**] 07:05AM BLOOD Glucose-96 UreaN-13 Creat-1.4* Na-141
K-4.2 Cl-105 HCO3-28 AnGap-12
[**2132-12-30**] 07:05AM BLOOD ALT-31 AST-24 AlkPhos-21* TotBili-0.4
[**2132-12-30**] 07:05AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.1
.
PERTINENT LABS
[**2132-12-14**] 02:50PM BLOOD proBNP-2838*
[**2132-12-15**] 04:52AM BLOOD calTIBC-369 Hapto-33 Ferritn-23 TRF-284
[**2132-12-19**] 07:25AM BLOOD VitB12-455 Folate-19.4
.
Beta-2-Glycoprotein 1 Antibodies IgG
Test Result Reference
Range/Units
B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU
.
[**2132-12-16**] 07:30AM BLOOD tTG-IgA 1
[**2132-12-20**] 07:00AM BLOOD Inh Screening POS
[**2132-12-20**] 07:00AM BLOOD Lupus anti-coagulant POS
[**2132-12-22**] 07:05AM BLOOD ACA IgG-2.2 ACA IgM-7.2
Anticardiolipin Antibody IgG 2.2 0 - 15 GPL
0-15 GPL: NEGATIVE;15-20 GPL: INDETERMINATE; >20 GPL: POSITIVE
Anticardiolipin Antibody IgM 7.2 0 - 12.5 MPL
.
PERTINENT STUDIES
[**12-14**] CT chest/abd/pelvis
IMPRESSION:
1. Stable appearance of thoracic aortic aneurysm without
evidence of hematoma in the chest, abdomen, or pelvis, as
questioned.
2. Splenomegaly and prominence of the left hepatic lobe,
findings that
suggest the possibility of background liver disease. Correlation
with LFTs is recommended.
3. Biapical and left lower lobe nodular pulmonary densities, for
which
followup with chest CT is recommended in one year if there are
risk factors for lung cancer.
4. Aortic and mitral valve replacement with biatrial enlargement
and findings again consistent with pulmonary artery
hypertension.
5. Fat-containing umbilical and left inguinal hernias.
.
[**12-16**] EGD
[**Doctor First Name **]-[**Doctor Last Name **] tear
Blood in the body of stomach
Erythema in the stomach
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
.
[**12-16**] Colonoscopy
Melanosis coli in the colon
Polyp in the colon
.
[**12-16**] Duodenal biopsy
Duodenum, biopsy (A): Duodenal mucosa within normal limits.
.
[**12-24**] CXR
FINDINGS: In comparison with the study of [**12-14**], there is
continued
enlargement of the cardiac silhouette in a patient with aortic
and mitral
valve replacement and CABG procedure. Opacification at the base
posteriorly is consistent with pleural effusion, more prominent
on the left. Volume loss is again seen in the region of the left
lower lobe. No evidence of acute focal pneumonia.
.
[**12-26**] single ballon enteroscopy
Normal esophagus.
Normal stomach.
Normal duodenum.
There was one small area with active bleeding seen in the
proximal jejunum. The base of the bleeding was not able to be
well visualized because of the active bleeding and clots. It is
suspicious for AVM or Dieulafoy lesion. It was first treated
with cauterization with a gold probe. Then it was injected with
1:10,000 epinephrine. Three hemoclips were placed successfully
with good hemostasis.
SPOT tattoo was applied on either side of the bleeding area for
future localization
.
[**12-29**] KUB
IMPRESSION: Single focally dilated loop of small bowel with wall
thickening and two clips within the lumen, which likely
represents a focal ileus in the area of the recent AVM clipping.
Brief Hospital Course:
66 yo woman with h/o rheumatoid heart disease s/p MVR and AVR,
A-fib on coumadin, admitted for DOE, found to have new anemia.
.
ACTIVE ISSUES:
# Jejunal AVM: Pt presented with 10 pt crit drop. There was no
evidence of hemolysis or BM suppression. She was treated with
PPI gtt. Her EGD revealed [**Doctor First Name 329**] [**Doctor Last Name **] tear, but no active
source of bleeding. Her colonoscopy showed benign polyp and
melanosis coli . However, capsule endoscopy showed jejunal AVM.
Pt was treated medically with blood transfusion, while awaiting
optimization of anticoagulation status. She received endoscopic
cauterization on [**12-26**]. She was hemodynamically stable
afterwards. We discontinued her aspirin given she is already on
warfarin. WE continued her homedose omeprazole given there is
no evidence gastric ulcer disease.
.
# Coagulation abnormality: Pt has chronically elevated PTT.
Current workup is notable for positive mixing test, inhibitor
screening, and lupus anticoagulant. The test was done > 48 hrs
after cessation of heparin, therefore unlikely false positive
from presence of heparin. Her anti-cardiolipin and
beta2-glycoprotein were negative. The clinical suspicion for
anti-phospholipid syndrome was high, however, pt does not
formally meet the diagnostic criteria for antiphospholipid
syndrome, and she is already on anti-coagulation treatment. A
FOLLOW UP APPOINTMENT WITH HEMATOLOGY ON [**2132-3-6**] WITH DR. [**First Name (STitle) **]
HAS BEEN MADE FOR FURTHER WORKUP AND MANAGEMENT.
.
# Ileus: Pt complained of abdominal bloating and mild discomfort
on the last few days of this admission. She tolerated food
intake well with no nausea/vomiting. Her abdominal exam was
always reassuring. She did not have bowel movement for three
days. KUB showed evidence of ileus likely in the location of
AVM clipping.
.
# Hx prosthetic valve: Pt has documented h/o MVR and AVR
secondary to rheumatic heart disease. We kept her INR at goal
of 2.5 - 3.5 with heparin gtt for procedure. No thromboembolic
events were observed during this admission. She was discharged
with INR 2.7.
.
# Gout: Pt developed left MTP pain. The location and nature of
pain is concerning for gout. She was empirically treated with
low dose colchicine once, and her symptoms improved
significantly in the following days.
.
# [**Last Name (un) **]: Pt presented with acute kidney injury in the setting of
significant GIB. Her creatinine improved after correcting her
anemia.
.
# CHF: Pt has a documented history of diastolic CHF. We held
her diuretics temporarily in the setting of hypovolemia. An the
time of discharge, pt tolerated half dose of her lasix well. We
recommend restarting spiralactone and half dose of her potassium
supplement, and titrating up as tolerated.
.
CHRONIC ISSUES
# A-fib: Pt has documented a-fib. She was in a-fib rhythm
throughout this hospitalization. We started her diltiazem after
the procedure, and she tolerated well. Pt was anticoagulated
throughout this hospitalization.
.
# Psychoaffective disorder/depression: We continued her home
medication.
.
# COPD: Pt has documented history of COPD. She did well on her
home medication Spiriva and Advair.
.
# Hyperlipidemia: We continued her home dose statin.
.
TRANSITIONAL ISSUES
# CODE STATUS: Full code
# COMMUNICATION: [**Doctor First Name **] at group home [**Telephone/Fax (1) 103574**] (pt
designated person of contact), daugher is official HCP, but not
in [**Name (NI) 86**].
# PENDING STUDIES AT DISCHARGE: none
# MEDICATION CHANGES:
- STOPPED aspirin in the setting of GIB. Will consider
restarting after stabilization, as there are evidence that
aspirin and coumadin is superior than coumadin monotherapy in
mortality of patients with mechanical valves.
- RESTARTED furosemide at half dose.
- STOPPED Metolazone.
- CONTINUED at home dose with alternating 5 mg and 4.5 mg.
- RESTARTED half dose of potassium supplement
# FOLLOWUP:
- Will need early follow-up with PCP/Cardiology
- Recommend follow-up with hematology
- Recommend maintenance treatment for gout as outpatient.
Medications on Admission:
Priloesec 20 mg qam
diltiazem 240 mg q am
spiriva 1 cap inh qhs
aspirin 81 mg daily
pramipexole 1 mg PO qhs
bupropion 150 mg po qam
zocor 10 mg po qhs
iron sulfate 325 po q am
aldactone 25 mg po qam
nephrocaps 1 cap po q day
advair 5/500 puff inh [**Hospital1 **]
senna 2 tabs PO bid
colace 100 mg PO BID
albuterol nebs 1 vial neb q 4hr prn sob
tylenol 650 mg po q 6h
procrit 40,000 un sc q month, hold for hgb 12
levothyroxine 125 mcg po qam
zaroxolyn 1 tab 2.5 po mon/wed/fri 1/2 hr prior to lasix
kcl 20 mcg po bid
lasix 40 mg PO bid
coumadin 4.5 alternating with 5 mg
MoM 30 mL po prn constipation
Discharge Medications:
1. pramipexole 1 mg Tablet Sig: One (1) Tablet PO qHS ().
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Diltia XT 240 mg Capsule,Ext Release Degradable Sig: One (1)
Capsule,Ext Release Degradable PO once a day.
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. albuterol sulfate 2.5 mg/0.5 mL Solution for Nebulization
Sig: One (1) neb treatment Inhalation q4h prn as needed for
shortness of breath or wheezing.
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. Procrit 40,000 unit/mL Solution Sig: One (1) injection
Injection once a month: Hold for Hgb > 12.
15. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: alternate 4.5mg and 5mg doses every other day.
17. FerrouSul 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO
once a day.
18. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) cc
PO once a day as needed for constipation.
19. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
20. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
21. potassium chloride 20 mEq Packet Sig: One (1) PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2251**] Nursing and Rehabilitation - [**Location (un) 2251**]
Discharge Diagnosis:
Primary Diagnosis
- A-V malformation in jejunum
Secondary Diagnosis
- Atrial fibrillation
- Asthma
- anti-phospholipid syndrome (high suspicion)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 103573**],
You came to our hospital for shortness of breath, and was found
to have a significant drop in blood count, concerning for
bleeding from your gut. You were initially treated in the MICU,
and received multiple units of blood products. You underwent
upper and lower endoscopy, as well as a capsule endoscopy. We
found that you have a large malformed vessel in your small
intestine. Our gastroenterologist corrected that bleeding
vessel through endoscopy. During this hospitalization, we also
found that you have an unusual blood clotting pattern, that will
require further followup. You had a small gout flare, that has
largely resolved.
.
Please note that the following medication has changed:
- Please STOP taking aspirin, until further instruction by your
PCP.
[**Name Initial (NameIs) **] Please TAKE a reduced dose of furosemide at 20 mg tablet, one
tablet by mouth twice a day. Please remind your doctor that
this is half of your previous dose, and should be increased if
needed.
- Please STOP taking Metolazone until further notice by your
PCP.
[**Name Initial (NameIs) **] Please CONTINUE to take warfarin 5 mg daily and have your INR
checked regularly.
- There is no further changes to your medication.
INR monitoring will be extremely important moving forward due to
the propensity of your blood to clot.
We have arranged followup with your PCP/Cardiologist Dr. [**Last Name (STitle) **],
and with our hematologist. Please make sure that you make to
these appointments.
It has been a pleasure taking care of you here at [**Hospital1 18**]. We
wish you a speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) 7726**],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE/CARDIOLOGY
Address: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 7728**]
Appointment: THURSDAY [**1-29**] AT 2PM
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2133-3-6**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], 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
|
[
"5849",
"2761",
"2851",
"4280",
"42731",
"5859",
"2449",
"53081",
"311"
] |
Admission Date: [**2127-10-9**] Discharge Date: [**2127-11-5**]
Date of Birth: [**2094-10-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
Central Line Placement
History of Present Illness:
32 Year-old male with h/o asthma was under his usual status of
health until the end of [**Month (only) 216**] when he developed sore throat.
He had intermittent sore throat and running nose and fatigue
since the end of [**Month (only) 216**]. He denied fever, chill, rash, blurry
vision, dizzy, CP, cough, and SOB. In the morning of [**2127-10-8**],
he suddenly felt discomfort in his LUQ which was not pain. He
made urgent appointment with his PCP who checked his CBC. his
CBC showed significant increase WBC counts. He was called to ED
yesterday. He denied Abd pain, n/v, BRBPR, melena, or diarrhea.
In [**Name (NI) **], pt's VS: T 99.9 P 89 BP 155/88 R 20 SaO2 100. He
received one dose of Allopurinol 100mg
ROS: no fever, chill, dizzy, CP, SOB, cough, wheezing, dysuria,
urgency, dysphagia, odynophagia, Abd pain, reflux, diarrhea,
constipation, BRBPR, or melena, no N/V. no weakness, numbness.
rash. He gain 7 lps.
Past Medical History:
asthma
ERECTILE DYSFUNCTION
Hypertriglyceridemia
Seasonal allergies
PSH:
none
Social History:
He is smoking one to two cigarettes a day. He is unclear if
this hurts his asthma. He works in a financial company. He has
no pets. Unmarried. No regular alcohol.
Family History:
father died from RCC in his 40s, maternal grandmother had
melanoma, his mother is healthy. He has 2 half siblings (from
his
father side) that he doesn't know about their health status.
Physical Exam:
Vitals: T 98.6 BP 124/79 P 78 RR 18 O2 Sat 100%
General: Alert, oriented, no acute distress. Pleasant.
HEENT: Sclera anicteric, MMM, oropharynx clear no lesions or
thrush.
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+O x 3, CN grossly intact, upper and lower extremity
strength 5/5, sensory intact, normal gait.
Cerebellar Function: Rapid hand movements, finger to nose wnl,
heel to shin wnl, normal gait.
Pertinent Results:
ADMISSION LABS:
[**2127-10-9**] 03:00AM URINE HOURS-RANDOM
[**2127-10-9**] 03:00AM URINE GR HOLD-HOLD
[**2127-10-9**] 03:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2127-10-9**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2127-10-9**] 02:31AM PT-13.1 PTT-24.5 INR(PT)-1.1
[**2127-10-9**] 02:31AM FIBRINOGE-377
[**2127-10-9**] 02:28AM D-DIMER-583*
[**2127-10-9**] 12:21AM LACTATE-1.1
[**2127-10-9**] 12:10AM GLUCOSE-106* UREA N-21* CREAT-1.4* SODIUM-142
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
[**2127-10-9**] 12:10AM ALT(SGPT)-31 AST(SGOT)-33 LD(LDH)-900* ALK
PHOS-83 TOT BILI-0.5
[**2127-10-9**] 12:10AM ALBUMIN-5.1 URIC ACID-9.8*
[**2127-10-9**] 12:10AM WBC-55.6* RBC-4.08* HGB-13.3* HCT-36.1*
MCV-89 MCH-32.7* MCHC-36.9* RDW-15.3
[**2127-10-9**] 12:10AM NEUTS-6* BANDS-0 LYMPHS-22 MONOS-34* EOS-2
BASOS-1 ATYPS-5* METAS-0 MYELOS-0 OTHER-30*
[**2127-10-9**] 12:10AM I-HOS-AVAILABLE
[**2127-10-9**] 12:10AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL
[**2127-10-9**] 12:10AM PLT COUNT-54*
[**2127-10-8**] 04:45PM WBC-57.1*# RBC-3.98*# HGB-13.0* HCT-35.8*#
MCV-90 MCH-32.6*# MCHC-36.3*# RDW-14.1
[**2127-10-8**] 04:45PM NEUTS-4* BANDS-0 LYMPHS-23 MONOS-44* EOS-4
BASOS-4* ATYPS-3* METAS-0 MYELOS-0 OTHER-18*
[**2127-10-8**] 04:45PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2127-10-8**] 04:45PM PLT SMR-VERY LOW PLT COUNT-56*#
.
DISCHARGE LABS:
[**2127-11-5**] 05:25AM BLOOD WBC-5.3 RBC-3.80* Hgb-12.1* Hct-31.7*
MCV-84 MCH-31.8 MCHC-38.0* RDW-14.1 Plt Ct-711*
[**2127-11-5**] 05:25AM BLOOD Neuts-23* Bands-1 Lymphs-30 Monos-19*
Eos-0 Baso-0 Atyps-2* Metas-5* Myelos-15* Promyel-1* Blasts-4*
NRBC-3* Other-0
[**2127-11-5**] 05:25AM BLOOD Plt Smr-VERY HIGH Plt Ct-711*
[**2127-11-5**] 05:25AM BLOOD Gran Ct-2931
[**2127-11-5**] 05:25AM BLOOD Glucose-83 UreaN-14 Creat-1.1 Na-140
K-4.9 Cl-102 HCO3-31 AnGap-12
[**2127-11-5**] 05:25AM BLOOD ALT-59* AST-30 LD(LDH)-286* AlkPhos-85
TotBili-0.3
[**2127-11-5**] 05:25AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.3
Brief Hospital Course:
Mr. [**Known lastname 27628**] is a 32y/o gentleman with new diagnosis of AML who
has recently undergone 7+3 therapy.
.
#AML: The patient was diagnosed with AML on BMB, and has
tolerated 7+3 therapy without complaint. Patient was started on
an aggressive hydration regimen with bicarbonate as well as
hydroxyurea and allopurinol in order to bring down the WBC
burden as well as prevent tumor lysis syndrome. Bone Maroow
Biopsy at Day 14 showed a clean bone marrow. Patient's counts
began to slowly recover around Day 20 and was discharged on Day
+ 27.
.
#Hypoxia: On [**10-11**] pt spiked a fever and had need for
supplemental O2 to maintain sats. On [**10-12**] he continued to have
fevers and had increase in oxygen demand requiring a
non-rebreather in order to keep sats in the 90s and was
accordingly transfered to the [**Hospital Unit Name 153**] for hypoxia. His CXR at the
time showed moderate-severe new pulmonary edema. Pt was given 2
doses of 20mg IV lasix with good urine response. Vancomycin and
cefepime had been started (see below) and levofloxacin was
started to cover atypicals. Pt was supported in the evening on a
non-rebreather but then O2 was tapered as pt showed improvement
in saturations. CXR on [**10-13**] showed significant improvement in
pulmonary edema s/p lasix diuresis. Another 20mg IV lasix was
given with good response and pt transferred back to floor on 2L
NC. ECHO was perfomred to look for signs of cardiotoxicty and
decrased EF [**2-25**] chemotherapy, but was unrevealing; inital
concerns about an ASD were put to rest after a ubble study was
negative for ASD.
.
# Neutropenic Fever: When pt spiked initial fever Cefepime was
started although not technically neutropenic at the time. Vanco
had been added as well at time of ICU transfer. Levofloxacin was
started to cover possible atypical PNA organisms. ID was
consulted, and he completed 5 days of coverage with Levofloxacin
for atypical organisms. Vancomycin was subsequently DC'ed, and
the patient continued on Cefepime, Acyclovir, and fluconazole.
Patient subsequently began to have 4 consecutive days of low
grade fever to 99-100. He was restarted on IV Vancomycin. CT
Scan of the chest showed several lung nodules that may represent
new area of infection. As his ANC increased, his fevers began
to fade. He was transitioned to PO Levofloxacin for 7 days on
discharge to cover the likely infection in his lungs.
.
# [**Last Name (un) **]: Creatinine was slightly elevated upon admission, and rose
even further prior to tranfser tot he ICU. It has since
normalized [**2-25**] diuresis both within the ICU and on the floor.
.
# Anemia: Patient has become transfusion dependent for both RBC
and plts during admission, and was supported with multiple
transfusions.
.
# ? Aneurysm: Patient had an MRI head with contrast to explore
possible CNS involvement of the AML as he was having 2 days
worth of headaches. The headaches subsequently faded and
decision was made to not to an LP. The MRI showed a possible
anueurysm in the internal carotid artery; however, the read was
that it was a likely artifact. MRA was done, which showed the
finding was an artifact from the tourtuous nature of the
internal carotid artery.
Medications on Admission:
ProAir HFA 90 mcg/Actuation Aerosol Inhaler 2 Puffs(s) inhaled Q
4 hr as needed for sob or wheezing
Loratadine 10 mg Tab 1 Tablet(s) by mouth once a day allergies
Fluticasone 50 mcg/Actuation Nasal Spray, Susp [**1-25**] sprays(s)
each nostril daily as needed for allergy season
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
AML
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for high-dose chemotherapy to
treat your leukemia.
.
We made the following changes to your medications:
1. ADDED Levofloxacin 500 mg daily for 5 days
2. ADDED Acyclovir 400 mg three times a day
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2127-11-7**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2127-11-7**] 10:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], RN, [**Name8 (MD) 16569**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1579**]
Date/Time:[**2127-11-10**] 10:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
|
[
"5849",
"49390",
"3051"
] |
Admission Date: [**2173-8-7**] Discharge Date: [**2173-8-7**]
Date of Birth: [**2117-2-1**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 13489**]
Chief Complaint:
swollen lips
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 56 y.o male with h.o HTN, DM who presents with
L.maxillary Lip swelling and pruritis below the L.eye. Pt states
that swelling began around 1hr after eating chinese
food/vegetable lomain (~1130pm), which he has eaten before
without difficulty. At that time, pt took 25mg of benedryl. PT
denies tongue swelling, dyspnea, SOB, dysphagia, odynophagia,
inability to handle secretions, difficulty speaking, hives, or
rash. He took 25mg of benedryl at 2345 without relief.
.
Pt reports that an episode similiar to this, but with
predominately itching rather than swelling occurred 23yrs ago
after eating an apple, but resolved at home within 5 days. Pt
states this episode was predominately swelling. He denies any
other history of this occurrance or any other anaphylactoid type
reaction. He denies any new medications, has taken lisinopril
for ~8yrs and ASA for 3yrs.
Denies f/c/headache/LH/blurred
vision/ST/cough/URI/CP/palp/SOB/abd
pain/n/v/d/c/brbpr/melena/dysuria/hematuria/skin rash/joint
pain.
.
In the ED, initial vs were-01:49 T98 HR59 BP127/80 RR14 sat100.
Pt was given solumedrol 125, pepcid 20mg and benedryl 50mg IV.
1L of NS,
Last vitals-97.5 65 119/80 16 98%.
.
Currently, pt feels that swelling has improved.
Past Medical History:
DM2
HTN
R.knee pain
Social History:
WOrks for NSTAR, lives at home with his 29 y.o daughter. Denies
smoking, ETOH or drug use.
Family History:
denies allergic rxns
Physical Exam:
Vitals: HR 66, BP 115/74, RR 14, sat 99% on RA
General: Alert, oriented, no acute distress, speaking in full
sentences.
HEENT: NC/AT, perrla, EOMI, Sclera anicteric, MMM, prominent
L.maxillary swelling and in the nasolabial fold. No rash. Minor
swelling present on the R.side.
Neck: supple, JVP not elevated, no LAD, no stridor.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no rash
neuro: AAOx3
Pertinent Results:
[**2173-8-7**] 05:15AM BLOOD WBC-8.9 RBC-4.66 Hgb-15.1 Hct-44.1 MCV-95
MCH-32.3* MCHC-34.1 RDW-12.6 Plt Ct-232
[**2173-8-7**] 05:15AM BLOOD Plt Ct-232
[**2173-8-7**] 05:15AM BLOOD Glucose-147* UreaN-17 Creat-1.0 Na-140
K-4.2 Cl-109* HCO3-22 AnGap-13
.
CXR:
The heart is not enlarged. The aorta is minimally unfolded. No
CHF, focal
infiltrate or effusion. Within the limits of plain film
radiography, no hilar or mediastinal lymphadenopathy is
identified. No focal infiltrate, effusion, CHF, or pneumothorax
identified.
IMPRESSION:
No acute pulmonary process identified.
Brief Hospital Course:
Pt is a 56 y.o male with h.o DM, HTN who presents with facial
itching and lip swelling after dinner.
.
#eye itching/lip swelling-likely secondary to an allergic rxn.
Pt denied any SOB/difficulty swallowing/throat swelling. Pt
denied any h.o anaphylaxis. ACEI started 8 yrs ago, ASA 3 yrs
ago. Pt received 125mg solumedrol, famotidine and benedryl in
the ED. Pt reports improvement in swelling. We continued
solumedrol and famotidine while on the floor, and then
transitioned him to PO prednisone, with dose of 40 mg x3 days,
20 mg x3 days, then 10 mg x3 days. He will also complete 7 days
of prevacid. He was advised not to eat chinese food and stop
his acei and aspirin. Allergy was called and the case was
discussed with plan for outpatient follow up. He was
hemodynamically stable throughout and had no airway compromise.
He was discharged home with an epi pen.
.
#HTN- stable off the lisinopril, he should follow up as
outpatient to have BP checked and see if new [**Doctor Last Name 360**] needs to be
added.
.
#DM- held metformin while inpatient, did sliding scale;
restarted on discharge.
.
Prophylaxis: Subutaneous heparin, pneumoboots
Access: peripheralsx2
Code: Full
Medications on Admission:
Calcium 600 + D(3) 600 mg-400 unit Tab-[**Hospital1 **]
ASA 81mg
Lisinopril 30 mg Tab daily
Metformin 1,000 mg Tab [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Prednisone 10 mg Tablet Sig: 1-4 Tablets PO once a day for 7
days: please take 4 tabs (for total of 40 mg) for 2 days; then
take 2 tabs (for a total of 20 mg) for 3 days; then take 1 tab
(10 mg) for 3 days; then stop.
Disp:*17 Tablet(s)* Refills:*0*
3. Pepcid 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
4. Benadryl 25 mg Capsule Sig: [**1-8**] Capsules PO every eight (8)
hours: as needed for itching.
5. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) pen
Intramuscular once: as needed for shortness of breath and
wheezing in setting of allergic reaction.
Disp:*1 pen* Refills:*2*
6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Angioedema
2. Hypertension
Discharge Condition:
stable, unobstructed airway, no stridor, swollen upper lip
Discharge Instructions:
You were admitted to the hospital with swelling of your lips
after eating chinese food. The swelling is likely an allergic
reaction either from the food you ate, or possibly from either
your lisinopril or aspirin. You should stop taking both
lisinopril and aspirin until you have allergy testing. You
should also avoid chinese food and apples until you have allergy
testing.
.
Please continue all your other medications. We have added a
week of prednisone and pepcid to treat the swelling. The
prednisone will be tapered. Starting tomorrow, take 4 tabs
daily for 2 days; then 2 tabs daily for 3 days; then 1 tab daily
for 3 days and then stop. You can also take benadryl as needed
for comfort.
.
Please also get an epipen from the pharmacy. You can use this
if you get short of breath and are feel like your throat is
closing up.
.
Please return to the hospital for any shortness of breath,
increased swelling, tongue swelling, feeling like your throat is
closing up, or any other concerns.
Followup Instructions:
Please follow up with the allergy clinic. Please call
[**Telephone/Fax (1) 9316**]
on Monday morning to make an appointment. They will be
expecting your call.
Please follow up with your primary care doctor. Please call Dr. [**Name (NI) 13490**] office on Monday morning at [**Telephone/Fax (1) 7976**]. You will
have to have your blood pressure rechecked and maybe have some
new medications in place of your lisinopril.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13491**] MD, [**MD Number(3) 13492**]
Completed by:[**2173-8-7**]
|
[
"4019",
"25000"
] |
Admission Date: [**2122-2-16**] Discharge Date: [**2122-2-28**]
Date of Birth: [**2087-6-23**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
1. Gastric pacer placement
2. Jejunostomy tube placement
3. PICC placement
History of Present Illness:
This is a 34 y/o M w /h/o diabetes, on insulin pump,
gastroparesis, peptic ulcer disease, who is transferred from OSH
([**Hospital 794**] Hospital, [**Hospital1 789**] RI), after 6 week stay for nausea,
vomiting and abdominal pain, for gastric pacemaker placement.
In brief, the patient reports ongoing pain symptoms for the past
one year, with difficulty tolerating POs and constant nausea.
This most recent admission resulted after he had several
episodes of vomiting and acute mid-epigastric abdominal pain not
relieved with outpatient pain meds. The pain ranges from [**2124-6-8**]
to [**11-13**] in intensity. It is similar to prior pain episodes. No
radiation to the flank or back. No associated fever, chills,
night sweats, brbpr or melanotic stools.
For the past two months he had been only taking in only limited
POs and had been on chronic TPN. TPN discontinued at OSH and
started on J tube with tube feedings. Pain controlled with IV
dilaudid. Attempt to wean over last week from 4mg q3 to 3mg q3
to 1.5mg q3, however have had difficulty weaning due to rebound
abdominal pain, nausea. Plan to transfer for evaluation of
gastric pacmeaker.
Of note, hospital course complicated by PICC infection with coag
neg staph ([**4-6**], last positive [**2-12**]) treated with 14 days of
vanco.
On arrival, patient tearful, complaining of [**11-13**] mid-epigastric
pain, nausea. No fever, chills, chest pain, shortness of breath.
ROS: as per hpi, otherwise negative
Past Medical History:
diabetesI- on subcutaneous insulin pump
peptic ulcer disease
h/o shingles
anxiety
depression
?h/o celiac sprue
GERD
gastroparesis
h/o seizure
asthma
Social History:
denies tobacco or ETOH. lives at home.
Family History:
mother with dm, gastroparesis, breast ca. brother, sister with
bipolar disorder
Physical Exam:
vitals- afebrile, VSS
gen- awake, NAD
heent- eomi, op clear, sclera non-icteric
neck- supple
pulm- cta b/l. no r/r/w
cv- rrr. normal s1/s2. no m/r/g
abd- benign
ext- no c/c/e. warm, 2+ dp
neuro- alert and oriented x 3. CNII-XII intact
skin- normal
Pertinent Results:
[**2122-2-17**] 05:00AM BLOOD Glucose-309* UreaN-13 Creat-0.7 Na-132*
K-4.8 Cl-95* HCO3-29 AnGap-13
[**2122-2-18**] 03:06AM BLOOD Glucose-126* UreaN-11 Creat-0.7 Na-133
K-3.9 Cl-95* HCO3-30 AnGap-12
[**2122-2-20**] 06:36PM BLOOD Glucose-445* UreaN-15 Creat-0.9 Na-133
K-4.9 Cl-97 HCO3-14* AnGap-27*
[**2122-2-21**] 04:24AM BLOOD Glucose-42* UreaN-12 Creat-0.8 Na-138
K-3.3 Cl-108 HCO3-23 AnGap-10
.
[**2122-2-17**] 05:00AM BLOOD ALT-17 AST-21 AlkPhos-89 Amylase-22
TotBili-0.5
[**2122-2-17**] 05:00AM BLOOD Albumin-4.0 Calcium-9.6 Phos-5.0* Mg-1.6
.
[**2122-2-20**] 05:30AM BLOOD Acetone-MODERATE
.
[**2122-2-20**] 06:50PM BLOOD Type-ART pO2-213* pCO2-28* pH-7.26*
calTCO2-13* Base XS--12
[**2122-2-20**] 11:36AM BLOOD Lactate-1.1
.
[**2122-2-17**] 05:00AM BLOOD WBC-9.7 RBC-4.12* Hgb-12.4* Hct-35.7*
MCV-87 MCH-30.2 MCHC-34.8 RDW-12.9 Plt Ct-322
[**2122-2-17**] 05:00AM BLOOD PT-12.6 PTT-27.0 INR(PT)-1.1
[**2122-2-17**] 05:00AM BLOOD Plt Ct-322
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There is minimal
dependent atelectasis in the left lower lobe. The imaged portion
of the heart and pericardium appears unremarkable. In the
subcutaneous tissues of the right upper abdominal wall, a
metallic structure is consistent with the implanted gastric
pacemaker. The pacemaker lead the enters the peritoneum via a
right upper abdominal approach, and courses anteriorly adjacent
to the abdominal wall before diving to terminate at the greater
curvature of the stomach. There is a small amount of free
intraperitoneal air adjacent to the pacemaker lead just deep to
the pacer pocket (2:42), a finding that could be associated with
surgical introduction of the lead. A jejunal feeding tube is in
place via a left paramedian approach terminating in the left
mid-abdomen. The large and small bowel loops are normal in
caliber. No intra-abdominal abscesses are identified. The liver,
spleen, gallbladder, and adrenal glands appear unremarkable. The
pancreas is atrophic. No renal masses are identified, and there
is no hydronephrosis. The abdominal aorta is normal in caliber.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The appendix is
normal. The bladder, distal ureters, rectum and sigmoid colon,
prostate and seminal vesicles appear unremarkable. There are no
pathologically enlarged pelvic or inguinal lymph nodes.
BONE WINDOWS: Bone windows show no lesions worrisome for osseous
metastatic disease.
IMPRESSION:
1. Status post placement of a gastric pacemaker with a small
amount of free intraperitoneal air, a nonspecific finding that
could relate to postsurgical state .
2. No evidence of abscess or bowel obstruction.
Discharge Labs:
[**2122-2-28**] 05:27AM BLOOD WBC-10.6 RBC-3.71* Hgb-10.9* Hct-33.4*
MCV-90 MCH-29.4 MCHC-32.7 RDW-13.7 Plt Ct-380
[**2122-2-25**] 05:16AM BLOOD PT-12.1 PTT-29.0 INR(PT)-1.0
[**2122-2-28**] 05:27AM BLOOD Glucose-163* UreaN-25* Creat-0.7 Na-139
K-4.2 Cl-98 HCO3-33* AnGap-12
[**2122-2-28**] 05:27AM BLOOD ALT-51* AST-81* AlkPhos-76 TotBili-0.2
[**2122-2-28**] 05:27AM BLOOD Albumin-3.8 Calcium-9.9 Phos-5.4* Mg-1.9
Brief Hospital Course:
A/P: This is a 34 y/o M w /h/o diabetes I, on insulin pump,
gastroparesis, peptic ulcer disease, who was transferred to the
[**Hospital1 18**] from an OSH ([**Hospital 794**] Hospital, [**Hospital1 789**] RI), after a 6
week stay for nausea, vomiting and abdominal pain, for gastric
pacemaker placement.
.
# gastroparesis- acute on chronic abdominal pain, felt secondary
to gastroparesis. Gastroenterology consulted and recommended
gastric pacer placement given duration of symptoms and failure
of medical therapy. Gastric pacer placed by Dr. [**Last Name (STitle) **] on
[**2122-2-18**]. Post-operatively he went to the hospitalist service
for recovery and further management. However, on the hospitalist
service, attempts had been made to control his hyperglycemia
with boluses from the patient's insulin pump as well as SC
insulin on a scale. Unfortunately despite intensive efforts this
was not successful in lowering the glucose and narrowing the
anion gap, and the patient remained in DKA.
.
MICU course:
The patient was transferred to the [**Hospital Ward Name 332**] ICU in DKA, where he
was put on an insulin drip, and his glucose came under control
overnight, and his anion gap narrowed to within normal limits.
He continued to have significant pain which was treated with a
hydromorphone PCA. He received tube feeds and was transitioned
to subcutaneous insulin scale. He was transferred back to the
hospitalist service.
Post-MICU course:
The patient's diet was advanced, while tube feeds were
continued, for his malnutrition. The patient's pain significant
improved and his hydromorphone PCA was rapidly tapered over 3
days. A plan was made that the patient would not continue any
opioids on discharge. He was instructed to remain on J-tube
feeds until further evaluation by his gastroenterologist.
Medications on Admission:
reglan 10mg qid
trazadone 75mg qhs
protonix 40mg [**Hospital1 **]
dilaudid 1.5mg q3 hours prn
promethazine 25mg q4 prn
[**Last Name (un) **] 0.125mg q4hours
atenolol 12.5mg [**Hospital1 **]
claritin 10mg qhs
insulin pump 1unit per hour with boluses durin meals
dronabinol 10mg 3x/d AC
ativan 1mg q6prn
meat tenderizer (adolphs) 2xday prn
ondansetron 4mg IV q6prn
suralfate 1g 3x/day
Discharge Medications:
1. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
Disp:*120 Tablet, Sublingual(s)* Refills:*1*
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*1*
3. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) for 1 weeks.
Disp:*qs * Refills:*0*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*1*
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*180 Capsule(s)* Refills:*1*
7. Insulin
by pump as previously ordered.
Discharge Disposition:
Home With Service
Facility:
OptionCare
Discharge Diagnosis:
1. Type 1 diabetes mellitus with gastroparesis with placement of
gastric pacer
2. Chronic abdominal pain
3. Gastroesophageal reflux disease and peptic ulcer disease
4. Depression with anxiety
5. Hypertension
6. Diabetic ketoacidosis, resolved
7. Chronic asthma
8. History of shingles
Discharge Condition:
Stable, tolerating diabetic diet
Discharge Instructions:
Please contact your primary care physician if you develop
worsening abdominal pain, nausea, vomiting, or fevers, sweats
and chills.
Followup Instructions:
You will need a follow up appointment with your primary care
physician [**Last Name (NamePattern4) **] [**2-4**] weeks, with LFT check at that time.
Please arrange follow up with Dr. [**Last Name (STitle) 10689**] at [**Telephone/Fax (1) 17075**] in [**5-10**]
weeks.
Readdress tube feed duration with your gastroenterologist at the
next appointment.
|
[
"49390",
"53081",
"V5867"
] |
Admission Date: [**2124-10-10**] Discharge Date: [**2124-10-14**]
Date of Birth: [**2085-2-11**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 39-year-old state
trooper, who was diagnosed with squamous cell carcinoma of
the left neck, which was resected. She did well for
approximately a year and about nine months started developing
progressive sensory symptoms over the left neck and jaw.
Initially started with some numbness over the left earlobe
above the surgical site followed by burning sensation in the
jaw. She then noticed when she brushed her hair behind her
ear, it felt raw. Pain that went down the neck to the chest
and shoulder area. For the past month, these symptoms have
been relatively stable without progression.
On direct questioning, she and her husband, who is here with
her cooberates some difficulty with short-term memory which
has worsened in the past year or so. A MRI scan of the head
shows a third ventricle hyperintense lesion in T1 weighted
images, which does not enhance causing mild-to-moderate
increased size in the lateral ventricles. There is no
significant transependymal fluid noted on T2 weighted images,
and the cerebellar tonsils are a little bit low lying, but
just at the level of the foramen magnum. The fourth
ventricle was normal in size and the corporis callosum is
thin throughout relatively uniformly.
PHYSICAL EXAMINATION: On physical exam, she is awake, alert,
and fully oriented. Speech is normal and fluent. Cranial
nerves are normal. Strength is normal throughout. Gait is
normal. Sensory examination reveals some decreased touch
sensation over the left neck posterior to the ear and the
occipital areas as well as along the neck to the upper part
of the anterior chest. Left neck neuropathic symptoms
concerning for a perineural invasion.
On MRI scan of the head, the third ventricles tumor is an
incidental finding. Dr. [**First Name (STitle) **] felt that this was most likely a
colloid cyst, and the patient was given an option for VP
shunt and watching colloid cyst or drainage. Patient opted
for resection of the colloid cyst.
Patient underwent transcallosal resection of the third
ventricle colloid cyst without intraoperative complication.
Postoperatively, the patient was monitored in the ICU without
complication. Postoperatively, she was monitored in the
Surgical ICU. There were no intraoperative complications.
Postoperatively, patient was alert, awake, oriented,
following commands. Motor strength is [**5-15**] in all muscle
groups. Face is symmetric. Pupils are equal, round, and
reactive to light. EOMs were full. Tongue was midline, good
language skills. Patient had ventricular drain in place that
was level 10 meters about the tragus draining 45 cc to 10 cc
over postoperative day #2. Head CT was performed on
[**2124-10-11**].
CT scan showed no hemorrhages, showed good size of ventricles
with decompression of the ventricles. The vent drain was
removed on [**2124-10-13**], and the patient after having it
clamped which showed no evidence of hydrocephalus, the
patient was transferred to the regular floor on [**2124-10-13**].
She remained neurologically stable.
The patient was discharged home on [**2124-10-14**] for followup
with staple removal on postoperative day #10 and follow up in
the Brain [**Hospital 341**] Clinic in two weeks.
MEDICATIONS AT TIME OF DISCHARGE:
1. Nicotine patch once a day.
2. Percocet 1-2 tablets p.o. q.4h. prn for pain.
3. Dilantin 100 mg p.o. t.i.d. for seven days and then
discontinue.
CONDITION ON DISCHARGE: Stable at the time of discharge.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2124-12-20**] 11:18
T: [**2124-12-22**] 11:01
JOB#: [**Job Number 51200**]
|
[
"496",
"3051"
] |
Admission Date: [**2131-5-24**] Discharge Date: [**2131-6-2**]
Date of Birth: [**2073-8-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
[**5-28**] Exam under anesthesia, control of internal hemorrhoidectomy
bleeding
History of Present Illness:
57F with rectal bleeding pod 13 from hemorrhoidectomy for
bleeding internal hemorrhoids by Dr. [**Last Name (STitle) 1120**]. She said the week
after her surgery she was fine. However this last week she has
had increasing spotting and bleeding with bms. Earlier this
week
her inr was 4.5. Her goal is 2.5 - 3.5. This last day it has
been fairly constant and she has to keep changing pads. She
feels occasionally lightheaded.
Past Medical History:
Significant for alcohol abuse
Status post AVR and MVR in [**2123**] (due to rheumatic HD)
Migraines
Depression
Hepatitis C
Status post hysterectomy
Hypertension
Anemia with a baseline hematocrit in the low 30s to mid 30s
Social History:
Works in a multidisciplinary clinic on [**Hospital Ward Name **] for patients
with melanoma. Married, no children.
- Tobacco: 1 pack per week
- EtOH: Couple of drinks every night but hasn't drank in a week,
has been in detox in the past
- Illicits: Denies
Family History:
Mom had breast cancer in her 50s. No h/o abdominal/GI diseases.
Family h/o DM.
Physical Exam:
On Admission:
98.2 94 117/68 16 100
NAD
RRR
CTAB
Abd soft
Rectal - no external hemorrhoids, small amount of bleeding from
anus, unable to pass an anoscope due to patient discomfort.
Ext - no edema
Pertinent Results:
[**2131-5-25**] 02:09AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.3*
[**2131-5-29**] 10:33PM BLOOD Calcium-7.8* Phos-3.9 Mg-1.2*
[**2131-5-24**] 04:00AM BLOOD Glucose-210* UreaN-15 Creat-1.5* Na-141
K-3.6 Cl-108 HCO3-23 AnGap-14
[**2131-5-29**] 10:33PM BLOOD Glucose-107* UreaN-6 Creat-0.8 Na-139
K-3.3 Cl-107 HCO3-26 AnGap-9
[**2131-5-24**] 04:00AM BLOOD PT-92.5* PTT-50.0* INR(PT)-11.4*
[**2131-5-24**] 04:00AM BLOOD Plt Ct-336
[**2131-5-24**] 11:08AM BLOOD PT-34.9* PTT-46.4* INR(PT)-3.6*
[**2131-5-24**] 11:08AM BLOOD Plt Ct-186
[**2131-5-24**] 01:52PM BLOOD PT-21.1* INR(PT)-2.0*
[**2131-5-24**] 05:15PM BLOOD PT-19.6* INR(PT)-1.8*
[**2131-5-25**] 02:09AM BLOOD PT-15.5* PTT-67.5* INR(PT)-1.4*
[**2131-5-25**] 02:09AM BLOOD PT-15.5* PTT-67.5* INR(PT)-1.4*
[**2131-5-25**] 02:09AM BLOOD Plt Ct-125*
[**2131-5-25**] 08:36AM BLOOD PT-13.4 PTT-52.2* INR(PT)-1.1
[**2131-5-25**] 03:08PM BLOOD Plt Ct-178
[**2131-5-25**] 03:20PM BLOOD PT-13.0 PTT-59.2* INR(PT)-1.1
[**2131-5-25**] 10:00PM BLOOD PTT-73.1*
[**2131-5-26**] 04:00AM BLOOD PT-13.9* PTT-62.2* INR(PT)-1.2*
[**2131-5-26**] 05:20PM BLOOD PT-13.6* PTT-56.8* INR(PT)-1.2*
[**2131-5-27**] 02:06AM BLOOD PT-14.5* PTT-82.2* INR(PT)-1.3*
[**2131-5-27**] 08:40AM BLOOD PT-14.3* PTT-41.2* INR(PT)-1.2*
[**2131-5-27**] 09:15PM BLOOD PTT-82.2*
[**2131-5-28**] 04:30AM BLOOD PT-15.7* PTT-67.0* INR(PT)-1.4*
[**2131-5-28**] 04:30AM BLOOD Plt Ct-161
[**2131-5-28**] 10:20AM BLOOD PTT-37.8*
[**2131-5-29**] 09:22AM BLOOD PT-14.7* PTT-33.5 INR(PT)-1.3*
[**2131-5-29**] 10:33PM BLOOD PTT-97.3*
[**2131-5-30**] 07:00AM BLOOD PT-14.2* PTT-46.2* INR(PT)-1.2*
[**2131-5-30**] 03:30PM BLOOD PTT-150*
[**2131-5-30**] 09:47PM BLOOD PTT-40.8*
[**2131-5-30**] 09:47PM BLOOD PTT-40.8*
[**2131-5-31**] 05:53AM BLOOD PT-17.6* PTT-108.9* INR(PT)-1.6*
[**2131-5-31**] 06:57AM BLOOD PT-17.4* PTT-86.4* INR(PT)-1.6*
[**2131-5-31**] 01:24PM BLOOD PTT-119.6*
[**2131-5-31**] 09:40PM BLOOD PTT-75.0*
[**2131-6-1**] 06:16AM BLOOD PT-20.2* PTT-61.1* INR(PT)-1.9*
[**2131-5-24**] 04:00AM BLOOD WBC-8.0# RBC-2.62* Hgb-7.5* Hct-23.9*
MCV-91 MCH-28.5 MCHC-31.3 RDW-17.2* Plt Ct-336
[**2131-5-24**] 11:08AM BLOOD WBC-8.0 RBC-2.00* Hgb-6.1* Hct-18.0*
MCV-90 MCH-30.7 MCHC-34.1 RDW-16.9* Plt Ct-186
[**2131-5-24**] 01:52PM BLOOD Hct-28.4*#
[**2131-5-24**] 05:15PM BLOOD Hct-28.1*
[**2131-5-25**] 02:09AM BLOOD WBC-5.6 RBC-3.18*# Hgb-9.5*# Hct-26.9*
MCV-85 MCH-29.8 MCHC-35.2* RDW-16.5* Plt Ct-125*
[**2131-5-25**] 08:36AM BLOOD Hct-26.7*
[**2131-5-25**] 03:08PM BLOOD WBC-6.7 RBC-3.71* Hgb-10.8* Hct-32.3*
MCV-87 MCH-29.0 MCHC-33.3 RDW-16.6* Plt Ct-178
[**2131-5-25**] 10:00PM BLOOD Hct-29.3*
[**2131-5-26**] 04:00AM BLOOD WBC-5.7 RBC-3.10* Hgb-9.3* Hct-27.2*
MCV-88 MCH-29.9 MCHC-34.1 RDW-15.6* Plt Ct-155
[**2131-5-26**] 03:10PM BLOOD Hct-28.0*
[**2131-5-27**] 02:06AM BLOOD Hct-26.5*
[**2131-5-27**] 08:40AM BLOOD Hct-27.2*
[**2131-5-27**] 05:00PM BLOOD WBC-4.8 RBC-2.89* Hgb-8.5* Hct-25.5*
MCV-88 MCH-29.5 MCHC-33.4 RDW-15.8* Plt Ct-174
[**2131-5-28**] 04:30AM BLOOD WBC-4.4 RBC-2.48* Hgb-7.4* Hct-21.9*
MCV-89 MCH-29.7 MCHC-33.5 RDW-15.6* Plt Ct-161
[**2131-5-28**] 04:30AM BLOOD WBC-4.4 RBC-2.48* Hgb-7.4* Hct-21.9*
MCV-89 MCH-29.7 MCHC-33.5 RDW-15.6* Plt Ct-161
[**2131-5-28**] 03:30PM BLOOD Hct-28.9*#
[**2131-5-28**] 09:35PM BLOOD Hct-28.6*
[**2131-5-29**] 03:30AM BLOOD Hct-26.6*
[**2131-5-29**] 09:55AM BLOOD Hct-28.5*
[**2131-5-29**] 10:33PM BLOOD Hct-25.6*
[**2131-5-30**] 06:54AM BLOOD Hct-28.7*
Brief Hospital Course:
[**2131-5-24**] - Admitted to SICU for rectal bleeding, decreased
hematocrit and elevated INR.; Foley catheter, A-line placed,
transfused 3 units of PRBC's and 1U FFP, surgi-cel rectal tampon
placed, ICU consent obtained. Hct stable, INR decreased to <2,
heparin gtt initiated.
[**2131-5-25**] - Low electrolytes, repleated per sliding scale,
Serial hematocrits were checked and coumadin was held.
Patient was transferred to the floor after Hct, BP, UOP and
coagulopathy were stabilized.
[**5-28**] patient underwent exam under anesthesia control of internal
hemorrhoidectomy bleeding
[**5-29**] coumadin restarted and hematocrits continued to be checked
and stable in mid to upper 20's. heparin drip continued to
bridge patient to warfarin given the AVR and MVR.
[**6-2**] INR was therapeutic at 2.7
By time of discharge the INR was therapeutic and the patient's
Hct was stable.
Medications on Admission:
amlodipine 2.5', fioricet q6 prn, premarin cream, anusol supp'',
lisinopril 80', metoprolol 100'', mirtazapine 45', percocet prn,
trazodone 200 qhs, coumadin as dir.
Discharge Medications:
1. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
3. Trazodone 50 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime) as needed for insomnia.
4. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: AFTER your dose tonight, and your dose Sunday, you are to
GO TO [**Hospital Ward Name **] ONE ON MONDAY MORNING [**2131-6-4**] FOR an INR Draw.
Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
rectal bleeding from internal hemorrhoidectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call if you notice further rectal bleeding. Call if
fevers >101. Call if light headed, dizzy, bleeding, chest pain,
change in mental status, sudden weakness or slurring of speech.
Call with any concerns or questions.
You were admitted to the hospital due to rectal bleeding and
elevated INR. On [**5-28**] you had an exam under anesthesia with
control of internal hemorrhoidectomy bleeding. After bleeding
was adequately controlled you were restarted on coumadin and
heparin drip as a bridge to coumadin. Your therapeutic goal INR
is 2.5 to 3.5. It is very important that you follow up in
coumadin clinic for frequent INR checks and appropriate
adjustmenjt of your coumadin.
Followup Instructions:
On Monday MORNING you are to go to [**Hospital Ward Name **] 1 for a blood draw
and INR check, at which your comadin dose will be adjusted by
the doctor on-call. Then later that week, we ask that you
please follow-up with Dr. [**First Name (STitle) **] for INR checks and coumadin
dose adjustment. Phone: [**Telephone/Fax (1) 250**]
Please call Dr. [**Last Name (STitle) 1120**] to schedule follow up in [**2-3**] weeks
|
[
"4019",
"V5861",
"2859"
] |
Admission Date: [**2140-11-15**] Discharge Date:[**2140-11-18**]
Date of Birth: [**2140-11-15**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] was the 3.145
kg product of a 39 and [**6-5**] week gestation, admitted for
evaluation of prenatally diagnosed hydrocephalus, absence of
corpus callosum and hydronephrosis. Infant was born to a 31
year-old, Gravida III, Para I now II woman. Prenatal screens:
0 positive, antibody negative, RPR nonreactive, rubella
immune, hepatitis surface antigen negative, GBS negative, CF
negative, quad screen normal. Pregnancy complicated by fetal
ultrasound with agenesis corpus callosum, colpocephaly, mild
bilateral ventricular dilatation, tear dropped shape frontal
[**Doctor Last Name 534**] and mild bilateral hydronephrosis with renal pelvic
dilatation. The remainder of fetal survey, including cardiac
anomaly, was normal. Fetal MRI of the brain confirmed the
findings. A fetal echocardiogram was normal. Care
transferred from [**Hospital 1474**] Hospital to [**Hospital3 **] with these
findings on ultrasound. AFCC consultation with Drs. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36469**] and Dr. [**First Name4 (NamePattern1) 622**] [**Last Name (NamePattern1) 36467**]. They
also met with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**], neonatology. Amniocentesis
was declined.
Induced vaginal delivery with epidural anesthesia. Apgars
were 9 and 9.
FAMILY HISTORY: Paternal first cousin with autism and mental
retardation.
SOCIAL HISTORY: Parents are married. Two year old healthy
sister.
PHYSICAL EXAMINATION: Weight 3.145 kg, 25th to 50th
percentile. Length 54 cm, greater than 90th percentile.
Head circumference 35.5 cm, 90th percentile. Anterior and
posterior fontanel soft, flat, positive molding. Sutures are
closed. Eyes: Slightly close set. Ears with mild posterior
rotation but normally set. Mild retrognathia. Intact palate.
Red reflex not done. Clear breath sounds. S2 over 6 systolic
murmur in the left lower sternal border. Normal pulses. Soft
abdomen. 3 vessel cord. No hepatosplenomegaly. No masses.
Bilateral undescended testes. Normal penis. Patent anus. No
hip click, no sacral dimple, warm and well perfused. Skin
peeling on hands and feet. Active normal tone. Symmetric
moro on response to exam.
HOSPITAL COURSE: Respiratory: [**Doctor First Name **] has been stable in
room air throughout his initial hospital stay in the NICU. He
was transferred to the Newborn Nursery on the night of [**11-16**]. He
initially did well by report with slow feeding. On theearly
morning of [**11-18**] he was transferred back to NICU for persistent
hypothermia reqiring warming lights and lethargy. Weight was 9%
below BW at the time of NICU readmission. This
Cardiovascular: [**Doctor First Name **] was noted to have an audible murmur
after birth. Prenatal echocardiogram was within normal limits.
He was seen by cardiology because of the murmur. His CXR showed
normal herat size and configuration. His four extremity BPs were
normal. . His pre and post ductal saturation were 98-100% in RA.
Echo done [**11-18**] showed muscular VSD and ASD., Aortic arch said to
be at lower normal of size. No restriction seen. PDA closed.
Cardiology team to follow.
Fluids, electrolytes and nutrition: Birth weight was 3.145
kg. Infant has been ad lib breast feeding and taking in
adequate amounts. Started on IV D10w on morning of [**11-18**] after
receiving NS bolus for MBP 39. Subsequent BPs normal. BS 49 this
am. Subsewquently in 100-150 range on IVF. Na 147 with NaHCO# 12
noted on lytes done [**11-17**]. This am noted to be hyperventilating.
Repeat CBG and lytes showed pH 7.44 HCO3 7. Given NaHCO3 2 meq/kg
and begun on NaHCO3 drip at 1 meq/k/h. Following drip for several
hours serum HCO3 increased to 17 then 21.
A serum ammonia from this morning was 540, however there was a
delay in processing fo this specimen for several hours. A repeat
specimen that was promptly run showed NH3 of 240. A serum lactae
was 2.4. AHs been seen by Metabolism team from CH. Newborn
screening specimen has been sent and received by State lab.
Director there has been contact[**Name (NI) **] by Metabolism team. A urine
organic aa screen has been sent to CH lab. Lactate/Pyruvate sent
here.
Endocrine: He was seen and evaluated by the endocrine team
because of bilateral undescended testes. He had TSH 14 T4 10.7
Cortisol 11.6. 11 DOC and 17 OHP pending.
Gastrointestinal: No issues. His bilirubin prior to discharge
was 9.6/1.6. DIRECT FRACTION HAS INCREASED FROM 1.2 EALIER IN
DAY. ALT 24. AST 87. AP 188.
Genitourinary/renal: An abdominal ultrasound was obtained on
[**11-16**], demonstrating normal kidneys with no
hydronephrosis, no testes in canal or scrotal sac. No female
inetrnal genitalai noted. Urology was consulted, they plan
outpatient followup.
Infectious disease: Was restarted on AMpicillin and gentamicin
this morning after repeat BC was obtained.
Neuro: Head ultrasound was obtained on admission to the
Neonatal Intensive Care Unit and the findings include:
Complete agenesis of corpus callosum. Mild accompanying
colpocephaly, left greater than right. The degree of
occipital [**Doctor Last Name 534**] dilatation is quite modest. No other
structural abnormalities evident. In particular, the
posterior fossa is normal appearing with no evidence of
arachnoid cyst or Dandy-Walker spectrum of abnormality.
Extra axial fluid spaces are normal. Neonatal neurology was
consulted, Dr. [**Last Name (STitle) 36469**], was consulted prenatally and
postnatally. Recommended follow-up with the neonatal
neurology program after discharge.
Genetics: Genetics was consulted because of the bilaterally
undesended testes. They would like to follow-up with the patient
after his neurology follow-up. Opthalmology consult has been
requested but not completed at this time.
Sensory: Audiology: Hearing screening has not [**Female First Name (un) **] been
performed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], telephone number [**Telephone/Fax (1) 69092**].
FOLLOW UP CARE AND RECOMMENDATIONS from previous evaluations
2) Day of life # 10 he should have testosterone, LH, and FSH
levels drawn.
3) He should follow up with [**Hospital3 1810**] Endocrinology one
month of life. Please call [**Telephone/Fax (1) 69093**] to arrange appointment.
Should endocrine questions arise, please page Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 53567**] pager id [**Pager number **].
4) His neurology appointment is scheduled for [**2140-12-21**]
at 8 am. The appointment is at [**Hospital3 1810**] [**Last Name (un) 9795**] 8.
Please plan to arrive 15-20 minute prior to appointment.
Telephone number is [**Telephone/Fax (1) 36468**].
5) He needs to have an MRI prior to the neurology appointment.
Please call [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 69094**] to arrange appointment [**Telephone/Fax (1) 36468**].
6) He will need follow up with genetics Dr. [**Last Name (un) 69095**] [**Name (STitle) **]. Please
call [**Telephone/Fax (1) 37200**].
FEEDS AT DISCHARGE: Ad lib breast feeding.
MEDICATIONS: None.
STATE NEWBORN SCREENING: .
IMMUNIZATIONS: He hjas not received his Hep B vaccine.
DISCHARGE DIAGNOSES:
1. Absence of corpus callosum, mild dilatation of occipital
[**Doctor Last Name 534**].
2. Bilaterally undescended testes.
3. Cardiac murmur.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2140-11-17**] 02:53:33
T: [**2140-11-17**] 05:24:36
Job#: [**Job Number 69096**]
|
[
"V053"
] |
Admission Date: [**2172-10-9**] Discharge Date:
Date of Birth: [**2132-4-12**] Sex: M
Service:
CHIEF COMPLAINT: Increased seizures and fever.
HISTORY OF PRESENT ILLNESS: This is a 48-year-old male with
a history of tuberous sclerosis, mental retardation, and
seizure disorder. The patient was in his usual state of
health on [**2172-10-8**], when he received a flu shot at
his outpatient physician's office. He was also okay on the
morning of [**10-9**], and then at his group home had a
seizure, and this seizure repeated later in the day.
Emergency Medical Service was called. They noted
tonic-clonic motions and gave 5 mg of Valium intravenously
with cessation of the seizure. The patient has been
unresponsive after the seizure. He was taken to
[**Hospital3 1196**] Emergency Room where a urine
culture was done, and the patient was started on
ciprofloxacin 400 mg intravenously when the urinalysis was
positive. He was than transferred to [**Hospital1 190**] because of lack of bed space and because he
has received his prior care here.
Emergency Medical Service noted in the field that the
patient's oxygen saturation was 99%. He had a slightly low
blood pressure of 92/60. His pulse was 107.
In the [**Hospital1 69**] Emergency Room
temperature was 102. He was covered empirically for
meningitis with ampicillin and ceftriaxone. A systolic blood
pressure of 72 was noted. The patient was given intravenous
fluids and treated briefly with dopamine. This was titrated
up to 7.5 and then weaned off as soon as he got to the
Medical Intensive Care Unit on the [**Hospital Ward Name **]. In the
Emergency Room, however, his abdomen was noted to "rigid."
Therefore, an abdominal CT was performed, and this showed
intussusception of the duodenum into the jejunum without
local mass and without obstruction as contrast reached the
colon. Therefore, Surgery got involved and recommended
nasogastric tube and a follow-up CT. The patient received a
total of 4.5 liters of fluid in the Emergency Room. He
reportedly denied fever, chills, cough, sputum, change in
mental status, headache, and nausea, and vomiting. Head CT
was negative. Lumbar puncture was negative.
The patient had a couple of episodes of diarrhea while in the
Medical Intensive Care Unit. These were Clostridium
difficile colitis negative. His temperature maximum while in
the Medical Intensive Care Unit was 100.3. The patient's
antibiotics were trimmed to ceftriaxone only secondary to the
negative cerebrospinal fluid samples, and this was continued
for his urinary tract infection. Also, while in the Medical
Intensive Care Unit, he was continued on his anti-seizure
medications and decreased hematocrit and platelets were
noted. He had no seizures while in the Medical Intensive
Care Unit.
PAST MEDICAL HISTORY:
1. Tuberous sclerosis with angiomyolipomas of the kidney,
eye, and brain.
2. Hypertension.
3. Depression.
4. History of increased NH4.
5. Seizure disorder with a baseline of one to two seizures
per week, up to every other day.
6. Violent behavior toward nursing in the past, throwing
food at them, attributed to Lamictal.
7. Questionable history of gastritis per past discharge
summaries.
8. Mental retardation.
SOCIAL HISTORY: The patient lives at a group home. His
contact there is [**Name (NI) **] and that number is [**Telephone/Fax (1) 94768**].
Reportedly, the patient wonders at the group home at
baseline, speaks a few words of Portuguese and Spanish,
sometimes English, and some made up words. He draws pictures
and eats on his home. Per his outpatient neurologist, his
functional status is poor. He has refused to wear a helmet,
and therefore he has had large amounts of anti-seizure
medications which have produced some sedation. The patient
also has multifocal seizures, and therefore surgery is not an
option. The patient's guardian is his brother. Phone number
for the brother is [**Telephone/Fax (1) 94769**] and [**Telephone/Fax (1) 94770**]. The
patient's father can be reached at [**Telephone/Fax (1) 94771**]. His primary
care physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**], and his primary
neurologist is Dr. [**Last Name (STitle) 851**].
FAMILY HISTORY: Not able to be obtained.
MEDICATIONS ON ADMISSION: Valproic acid 750 mg p.o. t.i.d.,
Trileptal 600 mg p.o. b.i.d. (it was increased to 765 mg p.o.
b.i.d. in the Intensive Care Unit), Topamax 200 mg p.o.
b.i.d., Prozac 20 mg p.o. q.d., folate, and multivitamin,
Tums 750 mg p.o. b.i.d., Miacalcin 1 spray q.d. alternating
nostrils, Ensure supplement p.r.n.
MEDICATIONS ON TRANSFER: On transfer to the floor, the
patient was also receiving Ativan 1 mg p.o. q.8h., and
ceftriaxone 1 g q.24h., as well as Protonix 40 mg
intravenously q.d., and normal saline, and potassium
chloride 40 mEq.
ALLERGIES: LAMICTAL causes agitation, NEURONTIN causes
"toxicity."
REVIEW OF SYSTEMS: Review of systems was not able to be
obtained.
LABORATORY DATA ON PRESENTATION: Laboratories on admission
at the outside hospital were white blood cell count 18.8,
hematocrit 38.6, platelets of 135. Depakote level was 146.8.
Differential of 67 neutrophils, 13 bands, 2 lymphocytes,
21 monocytes. Urinalysis showed 115 ketones, was negative
for nitrites but showed 313 white blood cells in clumps.
Laboratories also notable for a sodium of 134, a potassium
of 3.3, bicarbonate of 23, BUN of 13, creatinine of 1.
RADIOLOGY/IMAGING: The CT in the Emergency Department
showed intussusception of the duodenum into the jejunum in
the left upper quadrant as well as angiomyolipomas in
multiple sites, atelectasis of the lung bases versus early
pneumonia, and a left adrenal mass 3.5 cm in dimension.
Chest x-ray showed no free air and no infiltrate in the
lungs.
HOSPITAL COURSE BY SYSTEM: On transfer to the floor, the
patient was hemodynamically stable and had a stable
hematocrit and platelet count.
1. INFECTIOUS DISEASE: The patient was continued on his
ceftriaxone intravenously. Repeat urinalysis showed marked
decrease in white cells to 3 from an initial greater than 50,
and repeat urine culture was negative. The outside hospital
urine culture results, however, showed a Pseudomonas
aeruginosa sensitive to all antibiotics tested except for
cefotaxime. The patient was therefore switched to
ciprofloxacin before discharge, and he was to complete a
10-day course of this antibiotic. Note that the one dose of
ciprofloxacin the patient received as an outpatient
apparently caused substantial reduction of his urine white
cells, resolution of all fevers, and decline in his white
count, and this course should be sufficient to cover
Pseudomonas.
2. GASTROINTESTINAL: After the patient's abdominal rigidity
resulted in his abdominal CT he was followed by Surgery and
Medicine clinically given the intussusception shown on CT.
The patient had a soft abdomen throughout, although he would
periodically tense when palpate. He tolerated p.o.
throughout his stay, especially after Ativan was
discontinued, and he had increased alertness. At discharge
he was tolerating p.o. well.
Another concern was a low hematocrit in the setting of a
questionable history of gastritis. However, his hematocrit
was stable throughout. He never had any episodes of bright
red blood per rectum or melena, and his initial decline in
hematocrit seemed to be related to a large amount of fluid
administration in the Emergency Room.
At one point, the patient's father indicated he thought his
son might be having some odynophagia; however, the patient
was tolerating p.o. well enough that the team did not feel it
was necessary to pursue this pain with
esophagogastroduodenoscopy or barium swallow.
3. HEMATOLOGY: Throughout his stay, the patient had a low
hematocrit and low platelet count; however, these were
stable. Consideration was made for DIC; however,
laboratories for this were negative. Hemolysis laboratories
were also negative. Iron studies showed an anemia of chronic
disease pattern. Consideration was also given to bone marrow
suppression related to his antiepileptics; however, he had
been on all of these for a long time, and it was thought that
none of them were causing acute bone marrow suppression. In
review of his past counts, it seemed that his hematocrit had
been declining rather slowly since [**2171-6-8**], and that his
platelets had done the same and are now remaining stable.
Therefore, a workup was deferred as an outpatient. A B12 and
folate were sent which were still pending. The patient
requires outpatient Hematology/Oncology follow up to evaluate
his depressed counts. Also of note, his white blood cell
count declined from the 20s to a normal range of 5 during his
stay, consistent with resolution of infection.
4. NEUROLOGY: Per Neurology curbside opinion, his Trileptal
was increased from 600 mg b.i.d. to 675 mg b.i.d. He was
also covered through the acute febrile phase of his illness
with Ativan 1 mg p.o. q.8h. which was discontinued after this
illness had largely resolved. The patient had no seizures
while on the floor or while in the Medical Intensive Care
Unit, and no changes were contemplated for his antiseizure
regimen.
5. MUSCULOSKELETAL: The patient's father indicated he
thought his son might have right shoulder pain; however, on
examination, the patient had full range of motion of both
shoulders, and while he did grimace while the right shoulder
was manipulated, he grimaced to nearly any physical
examination intervention. Therefore, this was only followed
clinically. If there is further evidence that something is
going on in the right shoulder, this should be worked up as
an outpatient.
6. LABORATORY: Laboratory results were notable for a
decline of white count from 20.3 to 5.1 with treatment of his
infection. Hemoglobin and hematocrit have remained stable in
the range of 10.4 and 31 throughout his stay, and were
actually improved on the day of discharge. Platelet count
was 116 at discharge which represented an improvement.
Coagulation studies were sent with a question of DIC given
his decline in hematocrit and platelets; these were normal
with a PT of 13, a PTT of 34.9, and an INR of 1.2. D-dimer
was sent, and this was 500 to 1000 which represented a
minimal elevation. Fibrinogen was sent; this was 611, which
was elevated and inconsistent with DIC. A reticulocyte count
was low at 0.8. Urinalyses were nitrite negative. Large
blood was noted after the patient self discontinued his Foley
catheter with the balloon inflated; however, the white count
in his urine declined from 50 to 3 with treatment.
Cerebrospinal fluid showed 0 white blood cells, 0 red blood
cells. Culture was negative. Chemistry was remarkable only
for slightly low potassium which was repleted, and a mild
anion gap acidosis with a bicarbonate of 15 and anion gap of
15, which resolved with feeding. At discharge, anion gap was
10 and bicarbonate was 20. LDH was 231. For unclear
reasons, the patient was ruled out for myocardial infarction
while in the Medical Intensive Care Unit. Troponin and
creatine kinases were 0.3 to 0.8 and 109 to 159,
respectively. Calcium was 8.5 and 7.9 on the day before
discharge. Iron was 32. B12 and folate were pending. TIBC
was 202. Haptoglobin was 140. Ferritin was 299.
Transferrin was 155. Repeat valproic acid level was 82.
Initial urine culture was negative. Repeat urine culture was
pending. Clostridium difficile assay was negative. Sputum
culture showed oral contamination only. Blood cultures were
no growth to date.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE FOLLOWUP: Follow up with the patient's primary
care physician within one week; arranged at his group home.
Followup should be initiated with Hematology to evaluate his
low hematocrit and platelets, and B12 and folate levels sent
here should be reviewed. His questionable odynophagia and
right shoulder pain should be followed as an outpatient.
DISCHARGE DIAGNOSES:
1. Pseudomonas urinary tract infection.
2. Tuberous sclerosis.
3. Mental retardation.
4. Depression.
5. Anemia.
6. Thrombocytopenia.
7. Seizure disorder.
8. Intussusception.
MEDICATIONS ON DISCHARGE:
1. Depakote 750 mg p.o. t.i.d.
2. Topamax 200 mg p.o. b.i.d.
3. Trileptal 675 mg p.o. b.i.d.
4. Calcitonin nasal spray 1 spray q.d. alternating
nostrils.
5. Prozac 20 mg p.o. q.d.
6. Multivitamin p.o. q.d.
7. Tums 750 mg p.o. b.i.d.
8. Folate 1 mg p.o. q.d.
9. Tylenol 650 mg p.o. q.4-6h. p.r.n. for pain.
10. Ensure dietary supplements p.r.n.
11. Zantac 150 mg p.o. b.i.d.
12. Ciprofloxacin 500 mg p.o. b.i.d. times 10 days (nursing
should alert physicians if the patient is not taking this
medication as it is required to treat his Pseudomonas urinary
tract infection).
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2172-10-13**] 13:41
T: [**2172-10-13**] 14:43
JOB#: [**Job Number 94772**]
(cclist)
|
[
"5990"
] |
Admission Date: [**2126-12-6**] Discharge Date: [**2126-12-8**]
Date of Birth: [**2075-3-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. [**Known lastname 74626**] is a 51 year old gentleman with stage IIa
esophageal adenocarcinoma s/p chemoradiation, HCV with
?cirrhosis, and EtOH abuse who presented to the [**Hospital1 18**] ED for
abdominal pain and distension now transferred to the [**Hospital Unit Name 153**] for
hyperbilirubinemia and SBP. The patient reports that he has had
worsening jaundice over the past several weeks with an
increasing hyperbilirubinemia measured at an outside hospital
who presented to the ED today for progressively worsening
abdominal pain and distension. Per the patient's wife, the
patient had a CTAP performed at [**Hospital1 1474**] over the past 2 weeks,
and was originally scheduled for ERCP at [**Hospital 1474**] Hospital
today. The patient's wife states that over the past 2 weeks, his
bilirubin has increased from 9 two weeks ago to 20 5 days ago,
to 40 on initial presentation to the ED. Per the patient's wife,
he has not had any f/c/s, diarrhea, or recent medication
changes.
.
With regard to the patient's oncologic history, he was diagnosed
with stage IIa esophageal adenocarcinoma in [**5-30**] and underwent
5-FU chemoradiation completed on [**2126-10-10**]. He has been followed
by Dr. [**First Name (STitle) **] of Oncology here at [**Hospital1 18**].
.
In the [**Hospital1 18**] ED, initial VS 140 210/120 28 99%. He had a CXR
and KUB that were unremarkable. A RUQ U/S was performed with
interpretation pending at the time of transfer. A diagnostic and
therapeutic paracentesis was performed with 3L removed, with a
white count of 19k with diff pending. He received 1L IVF,
pip/tazo, vanco, and he was admitted to the [**Hospital Unit Name 153**] for further
management.
.
Currently, the patient is confused and in severe abdominal pain.
.
ROS: As above, otherwise negative.
Past Medical History:
ONCOLOGIC HISTORY:
[**2126-6-14**] EGD showed a 1.5 cm GE junction mass, biopsy positive
for poorly differentiated adenocarcinoma with signet ring cells
(stage IIA
(T3 N0 M0)
[**2126-7-2**] endoscopic ultrasound at [**Hospital1 **] by Dr.
[**Last Name (STitle) **], which revealed a 3-cm mass of malignant appearance at
the GE junction, staged as T3 by US criteria. No lymph node was
noted in the peri-esophageal mediastinum. He was deemed to not
be a surgical candidate due to his poor functional status,
ongoing alcohol and tobacco use, and history of chronic
hepatitis C.
[**2126-7-22**]: Planned to start chemotherapy concurrent with
radiation with cisplatin and 5-FU. Thrombocytopenia was noted
on
[**2126-7-22**], only 5-FU and radiation was started. 5-FU and
radiation were discontinued on [**2126-7-24**] for a platelet count
of
42. Workup for thrombocytopenia revealed no reversible causes,
with likely contributions from his liver disease and
splenomegaly.
[**2124-1-21**]: Received 4500 cGy with photons, followed
by boost of [**2095**] cGy in 11 fractions. Total radiation
administered with 6480 cGy from [**2126-7-22**] to [**2126-10-10**], given
over a total of 80 days, with treatment interruptions due to the
patient not showing up.
.
PAST MEDICAL HISTORY:
1. Chronic hepatitis C, diagnosed 30 years ago; [**7-9**] viral
load:
3,890,000, stable
2. Alcoholism.
3. Right above the knee amputation status post motor vehicle
accident at the age of 17, stable.
4. Bullet fragment in the left foot as a result of an accident
that the patient does not wish to elaborate upon.
5. Chronic lower extremity edema in left leg, stable
6. Umbilical hernia, stable
7. Chronic neck and back pain presumably due to degenerative
joint disease, stable
8. Narcotic dependence.
9. Splenomegaly.
Social History:
He previously worked as a landscaper, but has not been working
since [**2122**] secondary to poor fitting prosthesis and not being
able to ambulate. He is married and has one son who is in the
military. He continues to smoke one pack per day of cigarettes
since about [**2110**]. He previously was drinking 10 to 15 beers per
day, and briefly stopped drinking, but he reports that he
currently drinks one day per week, about six or seven beers per
session.
Family History:
NC
Physical Exam:
VS: 97.8 118 117/63 13 92%6L nc
Gen: Splinting in severe abdominal pain, rapid shallow breathing
HEENT: Jaundiced, +scleral icterus. MM dry
CV: Tachy S1 + S2
Pulm: Low lung volumes, CTAB
ABD: Distended, tense. -BS.
Ext: Chronic stasis dermatitis.
Neuro: Oriented to person. otherwise non-focal. -asterixis.
Pertinent Results:
[**2126-12-8**] 04:51AM BLOOD WBC-22.7*# RBC-3.37* Hgb-11.9* Hct-35.4*
MCV-105* MCH-35.4* MCHC-33.7 RDW-17.9* Plt Ct-106*
[**2126-12-7**] 04:15PM BLOOD WBC-11.3*# RBC-3.56* Hgb-12.4* Hct-35.6*
MCV-100* MCH-35.0* MCHC-34.9 RDW-17.9* Plt Ct-72*
[**2126-12-7**] 03:42AM BLOOD WBC-3.1* RBC-3.83* Hgb-13.5* Hct-37.9*
MCV-99* MCH-35.3* MCHC-35.7* RDW-17.4* Plt Ct-68*
[**2126-12-6**] 09:28PM BLOOD WBC-2.3* RBC-3.84* Hgb-13.6* Hct-39.1*
MCV-102* MCH-35.3* MCHC-34.7 RDW-17.0* Plt Ct-68*
[**2126-12-6**] 12:50PM BLOOD WBC-3.1*# RBC-4.39*# Hgb-15.3# Hct-44.1#
MCV-100*# MCH-34.9* MCHC-34.8 RDW-17.3* Plt Ct-79*#
[**2126-12-6**] 12:50PM BLOOD Neuts-85* Bands-8* Lymphs-2* Monos-4
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2126-12-6**] 12:50PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL
[**2126-12-8**] 04:51AM BLOOD PT-33.5* PTT-55.0* INR(PT)-3.4*
[**2126-12-7**] 04:15PM BLOOD PT-27.2* PTT-56.7* INR(PT)-2.6*
[**2126-12-7**] 03:42AM BLOOD PT-22.7* PTT-45.6* INR(PT)-2.1*
[**2126-12-6**] 09:28PM BLOOD PT-22.7* PTT-49.8* INR(PT)-2.1*
[**2126-12-6**] 12:50PM BLOOD PT-19.6* PTT-40.9* INR(PT)-1.8*
[**2126-12-8**] 04:51AM BLOOD Glucose-86 UreaN-29* Creat-2.1* Na-137
K-4.7 Cl-104 HCO3-19* AnGap-19
[**2126-12-7**] 04:15PM BLOOD Glucose-59* UreaN-26* Creat-1.8* Na-138
K-4.2 Cl-109* HCO3-15* AnGap-18
[**2126-12-7**] 03:42AM BLOOD Glucose-73 UreaN-19 Creat-1.4* Na-138
K-3.6 Cl-105 HCO3-17* AnGap-20
[**2126-12-6**] 09:28PM BLOOD Glucose-88 UreaN-15 Creat-1.2 Na-135
K-2.7* Cl-100 HCO3-18* AnGap-20
[**2126-12-6**] 12:50PM BLOOD UreaN-14 Creat-0.9
[**2126-12-8**] 04:51AM BLOOD ALT-60* AST-202* LD(LDH)-422* AlkPhos-47
TotBili-31.4*
[**2126-12-7**] 03:42AM BLOOD ALT-38 AST-83* LD(LDH)-141 AlkPhos-81
TotBili-33.0*
[**2126-12-6**] 09:28PM BLOOD ALT-38 AST-78* LD(LDH)-149 AlkPhos-94
TotBili-33.9* DirBili-24.6* IndBili-9.3
[**2126-12-6**] 12:50PM BLOOD ALT-44* AST-92* LD(LDH)-210 AlkPhos-135*
TotBili-41.7* DirBili-29.4* IndBili-12.3
[**2126-12-6**] 12:50PM BLOOD Lipase-25
[**2126-12-8**] 04:51AM BLOOD Albumin-3.5 Calcium-7.9* Phos-8.1*#
Mg-2.8*
[**2126-12-7**] 03:42AM BLOOD Albumin-2.5* Calcium-7.9* Phos-4.2 Mg-2.5
[**2126-12-6**] 09:28PM BLOOD Hapto-12*
[**2126-12-6**] 12:55PM BLOOD Ammonia-96*
[**2126-12-6**] 12:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2126-12-8**] 05:27AM BLOOD Type-ART Temp-37.8 Rates-14/2 Tidal V-500
PEEP-20 FiO2-80 pO2-108* pCO2-74* pH-7.00* calTCO2-20* Base
XS--14 AADO2-392 REQ O2-69 Intubat-INTUBATED
[**2126-12-8**] 01:18AM BLOOD Type-ART Temp-37.8 Tidal V-500 PEEP-20
FiO2-80 pO2-75* pCO2-77* pH-6.96* calTCO2-19* Base XS--17
AADO2-422 REQ O2-73 Intubat-INTUBATED
[**2126-12-7**] 10:41PM BLOOD Type-ART Temp-38.3 Rates-14/12 Tidal
V-500 PEEP-20 FiO2-80 pO2-81* pCO2-63* pH-7.02* calTCO2-17* Base
XS--16 AADO2-430 REQ O2-74 -ASSIST/CON Intubat-INTUBATED
[**2126-12-7**] 08:23PM BLOOD Type-ART Temp-37.6 Rates-14/10 Tidal
V-550 PEEP-10 FiO2-80 pO2-69* pCO2-45 pH-7.11* calTCO2-15* Base
XS--15 AADO2-460 REQ O2-78 -ASSIST/CON Intubat-INTUBATED
[**2126-12-7**] 06:33PM BLOOD Type-ART Temp-38.1 Rates-/24 Tidal V-550
PEEP-10 FiO2-80 pO2-86 pCO2-40 pH-7.16* calTCO2-15* Base XS--13
AADO2-463 REQ O2-76 -ASSIST/CON Intubat-INTUBATED
[**2126-12-7**] 04:22PM BLOOD Type-ART pO2-141* pCO2-39 pH-7.22*
calTCO2-17* Base XS--11
[**2126-12-7**] 01:11PM BLOOD Type-ART Temp-37.6 PEEP-10 pO2-106*
pCO2-41 pH-7.19* calTCO2-16* Base XS--11 -ASSIST/CON
Intubat-INTUBATED
[**2126-12-6**] 09:33PM BLOOD Type-ART pO2-89 pCO2-33* pH-7.36
calTCO2-19* Base XS--5
[**2126-12-8**] 05:27AM BLOOD Lactate-6.6*
[**2126-12-8**] 01:18AM BLOOD Lactate-7.0*
[**2126-12-7**] 10:41PM BLOOD Lactate-7.4*
[**2126-12-7**] 08:23PM BLOOD Lactate-7.9*
[**2126-12-7**] 04:22PM BLOOD Lactate-6.3*
[**2126-12-7**] 01:11PM BLOOD Lactate-7.3*
[**2126-12-7**] 04:10AM BLOOD Lactate-6.0*
[**2126-12-6**] 09:33PM BLOOD Lactate-7.3*
[**2126-12-6**] 12:57PM BLOOD Glucose-90 Lactate-4.1* Na-135 K-3.4*
Cl-97* calHCO3-24
[**2126-12-7**] 04:22PM BLOOD freeCa-1.09*
[**2126-12-7**] 01:11PM BLOOD freeCa-1.10*
[**2126-12-6**] 12:57PM BLOOD freeCa-1.05*
[**2126-12-6**] 03:20PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-LG Urobiln-4* pH-7.0 Leuks-NEG
[**2126-12-6**] 03:20PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2126-12-6**] 03:20PM URINE CastGr-[**2-22**]* CastHy-0-2
[**2126-12-7**] 10:10AM URINE Hours-RANDOM UreaN-70 Creat-99 Na-94 K-30
Cl-90
[**2126-12-7**] 10:10AM URINE Osmolal-303
[**2126-12-6**] 03:29PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2126-12-6**] 03:13PM ASCITES WBC-[**Numeric Identifier 24587**]* RBC-5000* Polys-93* Bands-2*
Lymphs-0 Monos-5*
[**2126-12-6**] 03:13PM ASCITES TotPro-0.8 Glucose-0 LD(LDH)-110
Amylase-25 Albumin-LESS THAN
[**2126-12-6**] 12:50 pm BLOOD CULTURE SET#1.
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
AMIKACIN-------------- S
AMPICILLIN------------ S
AMPICILLIN/SULBACTAM-- S
CEFEPIME-------------- S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- R
GENTAMICIN------------ S
MEROPENEM------------- S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ S
Aerobic Bottle Gram Stain (Final [**2126-12-7**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 6:08A [**2126-12-7**].
GRAM NEGATIVE RODS.
Anaerobic Bottle Gram Stain (Final [**2126-12-7**]): GRAM
NEGATIVE RODS.
[**2126-12-6**] 3:13 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2126-12-6**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 85252**] ON [**2126-12-3**] AT [**2115**].
FLUID CULTURE (Preliminary):
ESCHERICHIA COLI. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Abd u/s IMPRESSION: No free intraperitoneal air or evidence of
small bowel obstruction.
RUQ u/s IMPRESSION:
Limited evaluation of the right upper quadrant due to patient's
inability to cooperate with the study.
1. No focal hepatic lesions. Patent main portal vein with
hepatopetal flow. 2. Minimal ascites not amenable to
paracentesis.
3. Splenomegaly
CTAP
IMPRESSION:
1. Extensive intrahepatic biliary dilatation and irregularity
involving the right lobe of the liver of uncertain etiology for
which differential includes infection (ascending cholangitis
with pericholangitic phlegmon), primary neoplasm such as
cholangiocarcinoma, or metastasis. Overall MRCP/ERCP is
recommended for further evaluation.
2. Distended gallbladder without other CT evidence of acute
cholecystitis. Clinical correlation to this site is recommended
and if acute cholecystitis is of clinical concern, HIDA can be
considered.
3. Small amount of intra-abdominal ascites in the setting of a
cirrhotic
liver with sequela of portal hypertension including splenomegaly
and varices.
4. Likely bibasilar atelectasis of the lungs, though pneumonia
is not
excluded.
Brief Hospital Course:
Mr. [**Known lastname 74626**] is a 51 year old gentleman with stage IIa
esophageal adenocarcinoma s/p chemoradiation, HCV cirrhosis, and
EtOH abuse who presented to the [**Hospital1 18**] ED for abdominal pain and
distension now transferred to the [**Hospital Unit Name 153**] for hyperbilirubinemia
and SBP.
The pt was found to have Ecoli in his peritoneal fluid, with
fluid analysis consistent with SBP, and GNR's in his blood. He
was started on Zosyn and given albumin. ERCP, Hepatology, and
Transplant surgery were consulted. However, pt began to
clinically decompensate very rapidly and was intubated. He had
CTAP to evaluate for secondary source of infection, i.e. ?
ascending cholangitis, however by this time was becoming anuric
with worsening renal function, WBC count was rising, becoming
more coagulopathic, liver enzymes rising, and becoming very
acidemic with elevated lactate. Consulting services evaluated
the pt and felt him far too sick to survive any intervention and
gave him a grim prognosis. He was bolused IVF's and eventually
started on pressors, however his BP's continued to fall despite
3 pressors at max doses, and FiO2 100% with 20 PEEP to maintain
sats in the 80's.
Initial discussion with pt's ex-wife, who was present through
this course, was to continue pressors and mechanical
ventilation, but not escalate care, and he was initially made
DNR. Eventually he was made CMO given futility of further
medical management. He passed away in the am of [**2126-12-8**].
Medications on Admission:
Ativan 1 mg po tid prn
Oxycodone 30 mg QID prn
Ambien 10 mg qhs prn
Colace
Omeprazole 20 mg daily
Discharge Medications:
N/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
Completed by:[**2126-12-8**]
|
[
"51881",
"5849",
"2762",
"2875",
"99592"
] |
Admission Date: [**2155-7-16**] Discharge Date: [**2155-7-25**]
Date of Birth: [**2081-10-8**] Sex: F
Service:
CHIEF COMPLAINT: Disabling leg claudication, left greater
than right.
HISTORY OF THE PRESENT ILLNESS: The patient is a 73-year-old
nondiabetic white female with hypertension,
hypercholesterolemia, mesenteric ischemia, status post
mesenteric artery bypass in [**2154-7-8**] complicated by
respiratory failure, pleural effusions, esophageal
Candidiasis, and gallbladder disease requiring gallbladder
decompression and anorexia requiring the placement of a PEG,
complained of severe, disabling bilateral claudication and
left foot rest pain.
The patient had outpatient arteriogram which showed
aortoiliac disease. However, because of the patient's
pulmonary disease and recent postoperative complications
following mesenteric artery bypass an axillobifemoral bypass
graft was recommended. The patient had no ulcerations on her
feet.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Mesenteric ischemia.
4. Gastritis.
5. Migraines.
6. GERD.
7. Esophageal Candidiasis during hospitalization in [**2154-7-8**].
8. Postoperative respiratory failure requiring reintubation
in [**2154-7-8**].
9. Left pleural effusion, status post thoracentesis times
two in [**2154-8-8**].
10. Gallbladder disease requiring percutaneous cholecystotomy
for gallbladder decompression.
11. Anorexia requiring the placement of a PEG in [**2154-8-8**] hospitalization.
PAST SURGICAL HISTORY:
1. Mesenteric artery bypass graft on [**2154-8-6**] by Dr.
[**Last Name (STitle) **].
2. Left thoracentesis on [**2154-8-15**] and [**2154-8-17**].
3. Percutaneous cholecystotomy.
4. PEG placed on [**2154-9-3**].
5. Tonsillectomy at age 6.
ALLERGIES:
1. Penicillin causes red blotching, rash.
2. Erythromycin base: Reaction unknown.
ADMISSION MEDICATIONS:
1. Metoprolol 50 mg p.o. b.i.d.
2. Aspirin 81 mg p.o. q.d.
3. Lasix 20 mg p.o. q.d.
4. Pravachol 20 mg p.o. b.i.d.
5. Folic acid 1 mg p.o. q.d.
6. Senokot C two tablets q.d.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is a former cigarette smoker,
does not drink alcohol. She lives with an elderly female
roommate. She ambulates independently.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Pulse 85,
blood pressure 184/85, height 5' 2", weight 132 pounds.
General: The patient was an alert, cooperative, frail white
female, mildly dyspneic on ambulation to examination room.
HEENT: The pupils were equal and round. The sclerae were
anicteric. Neck: Range of motion was within normal limits.
No lymphadenopathy or thyromegaly. Chest: Lungs were clear
bilaterally. Heart: Regular rate and rhythm without murmur.
Abdomen: Bowel sounds present. Mild tenderness in the
epigastric area at the proximal pole of the surgical incision
with some hypertrophy and puckering noted. Rectal:
Deferred. Extremities: No ankle edema. Right first toenail
absent. Left foot ruborous without ulceration. Pulse
examination: Femoral pulses diminished bilaterally. Distal
pulses nonpalpable. Neurologic: Nonfocal.
LABORATORY/RADIOLOGIC DATA: On [**2155-7-8**], WBC 11.6,
hemoglobin 12.5, hematocrit 39.2, platelets 360,000. PT
12.7, PTT 24.8, INR 1.1. Sodium 147, potassium 4.0, chloride
107, bicarbonate 20, BUN 29, creatinine 1.2, glucose 96.
EKG showed a normal sinus rhythm at a rate of 70. Normal
tracing compared to previous tracing of [**2154-9-17**].
Chest x-ray showed no acute pulmonary disease.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2155-7-16**] following an uneventful right axillary artery to
right common femoral bypass and right femoral to left common
femoral bypass with PTFE graft. At the end of surgery, the
patient had warm feet with Dopplerable right pedal pulses and
no Doppler signals in the left pedal pulse initially but
within several hours Doppler signals were found.
On postoperative day number one, the patient was transferred
from the VICU to a floor bed. Later that same evening, the
patient had two episodes of nausea and vomiting. She
complained of epigastric pain. EKGs were normal. She was
kept n.p.o. Her heart rate was approximately 115 and was
treated with IV Lopressor. The patient's hematocrit was
found to be 26 after having been 32 on postoperative day
number one. She was transfused 2 units of packed red blood
cells. She was started on IV heparin and IV nitroglycerin.
Her second set of cardiac isoenzymes were positive and she
was transferred to the SICU for treatment of her evolving
myocardial infarction.
The Cardiology Service started the patient on Imdur,
Lopressor, and hydralazine which was then changed to an ACE
inhibitor. The goal heart rate was 60 and goal systolic
blood pressure was 115-125. The patient was continued on
heparin. The patient continued to have several more episodes
of nausea and vomiting without any EKG changes. This was
thought to be continued demand ischemia. Persantine MIBI
study was planned; however, because of repeated episodes of
nausea, the patient was taken for a cardiac catheterization
on [**2155-7-21**]. Catheterization showed one vessel coronary
artery disease, preserved ventricular function with an
ejection fraction of 55%, a successful PTCA/drug eluding
stent of the midcircumflex was placed and a PTCA of OM1.
Cardiology also recommended starting Zestril 5 mg q.d. if the
patient's systolic blood pressure continued to be higher than
130 on Lopressor, Captopril, and Imdur.
The patient's left hand became somewhat cooler following
cardiac catheterization and revealed the left brachial
artery. Heparin was continued to prevent thrombosis during
arterial vasospasm. The arm was also edematous since the
patient had gained 10 kilograms postoperatively in fluid.
The patient's hematocrit was noted to be 28 and she was
transfused 1 more unit of packed red blood cells. The
patient returned to [**Hospital Ward Name **] 9 from the Postcatheterization Unit
on [**2155-7-23**]. Her hand was somewhat warmer. She had a
triphasic left ulnar pulse and a biphasic left radial pulse.
The IV heparin was stopped.
Physical Therapy consult was requested for full weightbearing
ambulation. Short-term cardiac rehabilitation was
recommended.
At the time of dictation, the patient's incisions are clean,
dry, and intact. She has Doppler signals of her axillo and
femoral-femoral grafts. Her pedal pulses are all
Dopplerable. She will follow-up with Dr. [**Last Name (STitle) **], covering
for Dr. [**Last Name (STitle) **], in one weeks time or per further
instructions at the time of discharge.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q.d.; nine months following PTCA/stent
placement.
2. Aspirin 325 mg p.o. q.d.
3. Lopressor 50 mg p.o. t.i.d.
4. Lasix 20 mg p.o. q.d.
5. Pravastatin 20 mg p.o. b.i.d.
6. Folic acid 1 mg p.o. q.d.
7. Isordil 10 mg p.o. t.i.d.
8. Protonix 40 mg p.o. q.d.
9. Colace 100 mg p.o. b.i.d.
10. Senna tablet one p.o. b.i.d. p.r.n.
11. Dulcolax suppository, one per rectum q.d. p.r.n.
12. Milk of magnesia 30 cc p.o. q. six hours p.r.n.
13. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n.
14. Hydromorphone 2-4 mg p.o. q. four hours p.r.n. pain.
15. Ambien 5 mg p.o. q.h.s.
DISPOSITION: To [**Hospital **] Rehabilitation, possibly cardiac
rehabilitation.
CONDITION ON DISCHARGE: Satisfactory.
PRIMARY DIAGNOSIS:
1. Severe disabling claudication, left greater than right.
2. Axillobifemoral bypass graft on [**2155-7-16**].
SECONDARY DIAGNOSIS:
1. Postoperative myocardial infarction.
2. Left arm arterial vasospasm, resolved.
3. Blood loss anemia, status post transfusions.
4. Postoperative fluid retention, treated with IV Lasix.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2155-7-24**] 03:22
T: [**2155-7-24**] 19:05
JOB#: [**Job Number 42960**]
|
[
"9971",
"2851",
"496"
] |
Admission Date: [**2124-10-2**] Discharge Date: [**2124-10-3**]
Date of Birth: [**2068-5-18**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Vomiting coffe ground like stuff
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Ms. [**Known firstname 553**] [**Known lastname 23957**] is a 56 year old woman with a history of ITP s/p
splenectomy and recently diagnosed DM2 who presents from her PCP
office with new onset coffee ground emesis.
.
Ms. [**Known lastname 23957**] describes waking up this morning and feeling unwell
while running errands. On return back to the house she felt
extremely fatigued and lightheaded after walking up the four
stairs from her driveway to the front door and had to sit down.
She described the sensation of sudden fevers and chills. She
reports having sudden sharp substernal chest pain while seated
that lasted a few minutes. She was concerned that this chest
pain might be a heart attack so she went inside to take aspirin.
On the way to the kitchen she vomited dark brown coffee
grounds. She took two baby aspirin and called her spouse. She
did not want to go to the Emergency Department so her spouse
called her PCP who instructed her to come in. On her walk into
the office she had another episode of coffee ground emesis. In
clinic she was found to be tachycardic and was instructed to go
immediately to the Emergency Department for concern for a GI
bleed.
.
In the ED, initial vs were: T 96.4 P 111 BP 115/73 R 18 O2 sat
100% RA. NG lavage was positive for coffee grounds. Her rectal
exam revealed melanotic guaiac positive stools. EKG showed sinus
tachycardia with [**Street Address(2) 4793**] depression I and aVL. CXR was negative
for an acute process. Her initial hct returned at 36 down from
recent 43 on [**2124-9-13**]. Repeat hct, however, fell to 26. GI
services was consulted. During her evaluation she had one
transient episode of hypotension to 79/54 which quickly
responded to IV fluids. Patient received protonix bolus and
continuous drip, 2 u pRBC, and 3 L IV NS prior to transfer to
the ICU.
.
On the floor, patient reports feeling much better since
receiving her blood transfusions in the Emergency Department.
She is no longer light headed and fatigued. She reports only
having two episodes of coffee ground emesis which both occured
prior to arrival to the ED. On further questioning she admits
to one day of dark tarry stools but has not had any further
bowel movements since her arrival. She denies any history of GI
bleeding or ulcers. She denies use of alcohol or
anticoagulation. She denies recent GI illness or repeated
emesis or heaving. When asked about NSAID use she does report a
significant increase in her NSAID use after a recent dental
procedure. She describes taking 3 Advil tablets at time up to
every four hours. She states she probably averages 12 pills per
day over the last two weeks. She also reports starting a
prescription strength NSAID that she took in addition to the
Advil after her dental procedure. She was also given a
prescription for Percocet and often alternated her Advil doses
with 2 extra strength Tylenol. Patient reports taking up to 8
extra strength Tylenol each day (4 grams).
Past Medical History:
1) Hypertension: Toprol XL 50mg.
2) High cholesterol/triglycerides: Zocor
3) Irritable Bowel Syndrome: with constipation alternating with
diarrhea and lower abdominal pain.
4) Migraine headaches: several times monthly
5) ITP s/p laparoscopic splenectomy ([**12/2112**]): initially relapsed
following splenectomy but has had stable, normal platelet levels
for last 10 years.
6) Diabetes Mellitus Type 2: last hemoglobin A1C of 8.3
[**2124-9-13**]. started metformin.
7) Serologies: neg hepatitis w/u '[**11**], neg [**Doctor First Name **], RF '[**13**]
Social History:
Social History: Patient lives with her spouse. She is
unemployed.
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
.
Family History:
Family History: Mother - cerebral aneurysm
Physical Exam:
Physical Exam:
Vitals: T: 98.5 BP: 141/85 P: 109 R: 16 O2: 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,
ronchi
CV: Tachycardic and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no hepatomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
.
Pertinent Results:
[**2124-10-2**] 02:47PM BLOOD WBC-9.6 RBC-3.74* Hgb-11.4* Hct-36.1
MCV-97 MCH-30.6 MCHC-31.7 RDW-12.8 Plt Ct-338
[**2124-10-2**] 05:55PM BLOOD WBC-8.1 RBC-2.74*# Hgb-8.7* Hct-25.8*#
MCV-94 MCH-31.7 MCHC-33.6 RDW-12.7 Plt Ct-245
[**2124-10-3**] 04:42AM BLOOD WBC-10.6 RBC-3.74*# Hgb-11.2*# Hct-34.1*
MCV-91 MCH-29.9 MCHC-32.8 RDW-14.9 Plt Ct-207
[**2124-10-2**] 02:47PM BLOOD Neuts-64.4 Lymphs-30.5 Monos-3.6 Eos-0.6
Baso-0.9
[**2124-10-3**] 04:42AM BLOOD PT-12.4 PTT-22.2 INR(PT)-1.0
[**2124-10-2**] 02:47PM BLOOD Glucose-178* UreaN-38* Creat-0.6 Na-137
K-4.6 Cl-103 HCO3-24 AnGap-15
[**2124-10-3**] 04:42AM BLOOD Glucose-84 UreaN-15 Creat-0.5 Na-142
K-3.4 Cl-113* HCO3-21* AnGap-11
[**2124-10-3**] 04:42AM BLOOD ALT-47* AST-35 CK(CPK)-91 AlkPhos-50
TotBili-0.9
[**2124-10-3**] 04:42AM BLOOD CK-MB-2 cTropnT-<0.01
[**2124-10-3**] 02:04PM BLOOD CK-MB-2 cTropnT-<0.01
[**2124-10-3**] 04:42AM BLOOD Phos-2.4* Mg-1.9
[**2124-10-2**] 02:52PM BLOOD Glucose-179* Lactate-2.9* K-4.4
Brief Hospital Course:
#GI Bleed: Patient with hematocrit drop 17 pts (43-->26) since
PCP [**Name Initial (PRE) **] [**2124-9-13**]. She had two witnessed episodes of coffee
ground emesis on the day of admission as well as one of day of
dark tarry bowel movements. In the ED she was noted to have no
known history of GI bleeding or PUD. She denies history of
recent GI illness, upper endoscopy, or liver disease. She has a
history of ITP which has been in remission for 10 years and
presents today with normal platelet count. Patient does admit
to significant increase in NSAID use due to recent dental
procedures. She is not able to quantify the exact amount of
NSAIDs but reports taking 3 Advil tablets at one time multiple
times each day over the last two weeks. She also states she was
started on a prescription strength NSAID that she took in
addition to the Advil over the last two weeks. She was without
hemodynamic compromise. Since her transfusion in the ED, her
lightheadedness, shortness of breath, or sharp chest pain
resolved. Pt Hct was stable overnight and EGD did not show any
areas of active bleeding. She was on a pantoprazole drip, and
was switched to PO BID. She remained asymptomatic throughout
the day and her diet was advanced from NPO to regular. Pt
tolerated her diet and was ready for discharge to home. She was
instructed to avoid NSAIDs for at least the next 6-8 weeks as
well as to not get an MRI for one month. She was given tramadol
for 1 month and her outpatient physician said he would manage
her pain thereafter.
.
# Chest pain: Clinical history is unlikely to represent ACS with
unstable plaque. Given her active bleed this may represent
demand ischemia. The sharp sudden nature of the pain is more
consistent with GI or musculoskeletal pain. Her chest discomfort
may be related to gastritis or ulcer. No evidence of mediatinal
widening to suggest esophageal perforation. Repeat EKG showed no
concerning findings. Her cardiac enzymes were negative x2. Her
aspirin was held in the setting of GI bleed. The patient was
advised to follow up with a cardiologist for an exercise stress
test.
.
#Transaminitis: AST/ALT mildly elevated. Unclear etiology.
Negative hepatitis work-up in the past. Slightly more elevated
than expected for NASH. She does admit to taking acetaminophen
1 gram q4 hours in addition to Perocet over the last two weeks.
LFTs were trended and they were trending back to normal at the
time of discharge.
.
#Diabetes Mellitus Type 2: Hold metformin while inpatient. Pt
was put on an insulin sliding scale during her admission and was
discharged to home on her oral hypoglycemics.
# Hypertension: Blood pressure currently well controlled. Hold
home antihypertensives.
.
Pt was discharged to home with instructions to follow up with
her PCP [**Last Name (NamePattern4) **] 6 weeks or [**Name (NI) 23958**] if she had any change in clinical
status or any medical concerns that needed to be addressed.
Medications on Admission:
Metformin
Toprol XL 50mg,
Zocor 40mg,
Vitamin D
Levsin (Hyoscyamine) prn
Maxalt (Rizatriptan) prn
Hydrocortisone 2.5 %
Ibuprofen 200 mg three daily
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. ketoconazole 2 % Cream Sig: One (1) Topical PRN as needed
for Rash.
6. hydrocortisone valerate 0.2 % Ointment Sig: One (1) Topical
once a day.
7. hydrocortisone 2 % Lotion Sig: One (1) Topical once a day.
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*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Upper Gastrointestinal Bleed
Secondary Diagnosis:
Hypertension
High cholesterol/triglycerides
Irritable Bowel Syndrome.
Migraine headaches: several times monthly
ITP s/p laparoscopic splenectomy
Diabetes Mellitus Type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are being discharged from [**Hospital1 18**]. You were admitted to the
hospital because you woke up feeling unwell. You were
lightheaded, weak, had fevers/chills, tachycardia and vomited
coffe ground color vomit two times before seeing your Primary
Care Physician. [**Name10 (NameIs) **] sent you straight to the hospital as you
physician was concerned about bleeding from your stomach or in
that area. You presented to the emergency department and you
had a drop in your red blood cells compared to previously. You
were transfused 2 units of packed red blood cells and given
fluids. Your blood levels stabilized after those two
transfusions and further transfusions were not required. It is
believed that the bleeding occurred because of the NSAID's that
you were taking. It seems that you were taking a lot of advil
and ot her anti-inflammatories that aggrevate the stomach lining
and can cause it to bleed. It is important that you do not take
NSAIDs in the next 6-8 weeks and try to avoid them in the
future. You should follow up with Dr. [**First Name (STitle) 679**] regarding pain
management. Do not have an MRI done for 1 month after being
discharged from the hospital.
The following medication was added:
Omeprazole 40mg by mouth daily.
Tramadol every 6 hours as needed for pain.
The following medications were stopped:
Ibuprofen 200 mg three daily
Other NSAID's
Followup Instructions:
Please call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 682**]. You should follow up with
Dr. [**First Name (STitle) 679**] 6 weeks after leaving the hospital.
NO MRI FOR ONE MONTH.
DISCUSS WITH DR. [**First Name (STitle) **] ABOUT FOLLOWING UP FOR A CARDIAC STRESS
TEST.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"4019",
"2724",
"25000"
] |
Admission Date: [**2114-7-20**] Discharge Date: [**2114-8-7**]
Date of Birth: [**2038-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / aspirin / Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Progressive lower extremity edema
Major Surgical or Invasive Procedure:
[**2114-7-30**] Mitral Valve Replacement ([**First Name8 (NamePattern2) 11599**] [**Male First Name (un) 923**] Tissue)
History of Present Illness:
76 year old female with a past medical history pertinent for
Rheumatic heart disease with mitral valve stenosis and severe
pulmonary hypertension, atrial fibrillation-on Coumadin, type II
Diabetes Mellitus,Hypertension, hyperlipidemia, COPD, Transient
ischemic attack, A-V malformation with recurrent GI bleeds, who
was admitted to an outside hospital for exacerabation of hear
failure, worsening lower extremity edema, shortness of breath
and hyponatremia.
Past Medical History:
anemia secondary to arterio-venous Malformation, bleed 2'
Coumadin use, congestive heart failure, Atrial fibrillation,
type 2 diabetes mellitus, depression, hypertension,
hypothyroidism, peripheral neuropathy, hyponatremia, glaucoma,
chronic obstructive pulmonary disease, vascular disease-s/p
carotid endarterectomy, obstructive sleep apnea-sleep
study x2-does not use recommended CPAP at home, irritable bowel
syndrome w/ chronic constipation/diarrhea
Social History:
Lives with:her daughter
[**Name (NI) 1139**]: intermittent tobacco x 60yr, [**7-17**] cigs/day x last 2
months -pt states last cigarette prior to admission at OSH
ETOH:+2 beers/day:pt states last beer ~ 1mo ago
Family History:
non-contributory
Physical Exam:
Pulse:75, Resp: 18, O2 sat: 98%
B/P 125/60
Height:148 Weight:63.5"
General:A&Ox 3, NAD
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: CTA
Heart: RRR [] Irregular [x] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema
Varicosities:superficial varicosities None []
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:1+ Left:1+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none Right: 2+ Left:2+
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: 65% >= 55%
Left Ventricle - Stroke Volume: 91 ml/beat
Left Ventricle - Cardiac Output: 6.01 L/min
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 29
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - Mean Gradient: 7 mm Hg
Mitral Valve - E Wave: 2.0 m/sec
Mitral Valve - E Wave deceleration time: *300 ms 140-250 ms
TR Gradient (+ RA = PASP): *68 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing wire is seen in the RA and extending into the
RV.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient.
RIGHT VENTRICLE: RV hypertrophy. Mildly dilated RV cavity. RV
function depressed. Abnormal systolic septal motion/position
consistent with RV pressure overload.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta.
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.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve supporting structures. No TS. Mild to moderate
[[**2-11**]+] TR. Severe PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF 65%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with depressed free wall
contractility. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. 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. There is severe pulmonary artery
systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
Transferred in from outside hospital after presenting with
increased edema and shortness of breath for re evaluation for
surgical intervention. She was on heparin for atrial
fibrillation and underwent preoperative evaluation. Hepatology
was consulted, she had abdominal ultrasound that revealed normal
liver and spleen, and she was cleared for surgery. Additional
preoperative workup included dental, pulmonary function test and
echocardiogram. She had discomfort at her catheterization site
and had vascular ultrasound that revealed no hematoma or
pseudoaneurysm. She was brought to the operating room on [**7-25**]
for surgery however due to increased tenderness at the
catheterization site her surgery was cancelled and she was
started on ancef for potential cellulitis. Vascular surgery was
consulted and felt there was no evidence of infection or
vascular issues. However her creatinine increased to 1.6, her
ace inhibitor and lasix were stopped and the ancef was
discontinued. Additionally her digoxin was stopped due to
increased creatinine and bradycardia. Over the next few days her
creatinine trended down to baseline 1.1-1.3. She developed
diarrhea which resolved within twenty four hours with WBC
remaining normal.
On [**2114-7-30**] she was brought to the operating room and underwent
mitral valve replacement. See operative report for further
details. She received vancomycin for perioperative antibiotics
and was transferred to the intensive care unit for post
operative management. That evening, she was weaned from
sedation, awoke neurologically intact, and was extubated without
complications. However later she was noted to have increasing
pulmonary and systolic pressures with no response to milirone,
nipride, and nicardipine. Her medications were adjusted and on
post operative day one she was started on diuretics, ace
inhibitor, and beta blocker. On post operative day two her
pulmonary catheter was removed and she remained in the intensive
care unit for hemodynamic management. Her epicardial wires and
chest tubes were removed per protocol. She continued to have
betablockers adjusted for heart rate management and lasix for
diuresis. Additionally she was treated for hyponatremia with
free water restriction and sodium tablets. She was restarted on
coumadin for atrial fibrillation and then on post operative day
four was transferred to the floor for the remainder of her care.
Physical therapy worked with her on strength and mobility. On
post operative day eight she was ready for discharge to rehab -
[**Hospital3 **] in [**Hospital1 **] [**Location (un) **].
Medications on Admission:
Coumadin 2.5 mg Fri-Wed/5 mg Thurs
Digoxin 0.125mg daily
Glucophage 500 mg [**Hospital1 **]
Lasix 80 mg daily
Omeprazole 20 mg daily
Synthroid 150 mcg daily
Zocor 20 mg daily
Lisinopril 20 mg daily
B-12 injections
Ambien 5 mg HS
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day:
received 4 mg on [**8-7**] - to have INR checked [**8-8**] for further
dosing - see coumadin referral form for dosing and INR .
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
give with lasix daily .
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
15. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
puffs Inhalation every six (6) hours.
16. amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): 7.5 mg daily .
17. Lantus 100 unit/mL Solution Sig: Twelve (12) untis
units Subcutaneous at bedtime: 12 units at bedtime .
18. Insulin Sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 2 Units 2 Units 2 Units 2 Units
160-199 mg/dL 4 Units 4 Units 4 Units 4 Units
200-239 mg/dL 6 Units 6 Units 6 Units 6 Units
240-279 mg/dL 8 Units 8 Units 8 Units 8 Units
Also note to receive lantus at bedtime
19. potassium chloride 10 mEq Capsule, Extended Release Sig: [**2-11**]
Capsule, Extended Releases PO once a day.
20. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication: Atrial Fibrillation
Goal INR 2.0-2.5
First draw [**2114-8-8**]
Please check PT/INR Monday, Wednesday, and Friday for two weeks
then decrease as instructed by physician
Coumadin to be managed by rehab physician then please arrange
for follow up with PCP when discharged from rehab
21. Outpatient Lab Work
Please check Chem 7 to evaluate once a week due to
lasix/zaroxlyn/lisinopril/potassium
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Mitral valve stenosis s/p MVR
Atrial Fibrillation
Diabetes Mellitus type 2
Hyponatremia
Rheumatic heart disease
Pulmonary hypertension
Hypertension
Hyperlipidemia
Chronic obstructive pulmonary disease
Transient ischemic attack
A-V malformation with recurrent GI bleeds
Depression
Hypothyroidism
Peripheral neuropathy
Hyponatremia
Glaucoma
Carotid disease
Osteoarthritis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with 1 assist
Incisional pain managed with tylenol as needed
Incisions:
Sternal - healing well, no erythema or drainage
Edema +1 lower extremity
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**8-23**] at 1:30pm
Cardiologist: Dr. [**Last Name (STitle) 4783**] [**Telephone/Fax (1) 5424**] on [**9-5**] at 10:45am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 83705**] in [**5-15**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: Atrial Fibrillation
Goal INR 2.0-2.5
First draw [**2114-8-8**]
Please check PT/INR Monday, Wednesday, and Friday for two weeks
then decrease as instructed by physician
Coumadin to be managed by rehab physician then please arrange
for follow up with PCP when discharged from rehab
Completed by:[**2114-8-7**]
|
[
"2761",
"496",
"4168",
"42731",
"25000",
"V5861",
"42789",
"4019",
"2449"
] |
Unit No: [**Numeric Identifier 70625**]
Admission Date: [**2154-12-20**]
Discharge Date: [**2154-12-23**]
Date of Birth: [**2154-12-20**]
Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Patient is a 3-day-old full-term
infant with tachypnea and cyanosis admitted to the neonatal
intensive care unit for further evaluation. Patient was born
at 41 weeks to a 41-year-old G1 woman. She was A+, antibody
negative, GBS negative, hepatitis B surface antigen negative
and was RPR nonreactive.
PAST MEDICAL HISTORY: Crohn disease treated with Azulfidine.
Unremarkable antepartum course. Admitted for induction.
Patient was a C-section for failure to progress. Apgars of 9
and 9.
SOCIAL HISTORY: Noncontributory.
FAMILY HISTORY: Noncontributory.
HOSPITAL COURSE: Patient was admitted to the newborn
nursery. Vital signs were remarkable for tachypnea, poor
feeding and repeated evaluation. Today patient had increasing
tachypnea with murmur noted. Patient was referred to NICU
for further evaluation.
PHYSICAL EXAMINATION: Term infant in mild respiratory
distress with temperature of 98.0, pulse of 138, respiratory
rate of 52, oxygen saturation of 87% in room air and failure
to increase with supplemented nasal cannula oxygen. Blood
pressure 62/45 with a mean of 51, weight 3970 grams. Color
pink. Soft anterior fontanel. Normal facies. Mild
retractions. Clear breath sounds. A II-III/VI harsh systolic
murmur at left lower sternal border. No gallop. Abdomen:
Soft, flat, nontender. Liver 2.5 cm below right costal
margin. Normal perfusion. Hips stable. Normal tone and
activity. Normal phallus, testes and scrotum.
Four extremity blood pressures showed no differential between
upper and lower pressures. Chest x-ray showed normal cardiac
silhouette with possible mild pulmonary edema. EKG showed
normal sinus rhythm at rate of 150 with intervals and axes
notable for right axis deviation and increased voltages in
the right-sided precordial leads. ABG notable for pressure of
oxygen of 42 with 200 ml of nasal cannula, otherwise pH of
7.43, paco2 of 36.
Preliminary echo results from [**Hospital3 1810**] pediatric
cardiology showed likely total or partial pulmonary venous
anomalus pulmonary venous return. Cardiology recommendations
followed. Total fluids assessed at 60 ml/kg per day. Lasix
administered 1/kg x1. Infant is on p.o. and IV fluids of
dextrose D10W. Blood culture was sent. Ampicillin and
gentamicin initiated upon obtaining a blood culture. Parents
were updated both by neonatology and cardiology. Awaiting bed
at 8 South. Dr. [**Last Name (STitle) **] updated.
DIAGNOSIS:
1) Congenital Heart Disease- Partial/Total Anomalous Pulmonary
Venous Return
2) Term infant
DISPOSITION:
Transfer to [**Hospital3 1810**] 8 South
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name8 (MD) 68276**]
MEDQUIST36
D: [**2154-12-23**] 18:03:38
T: [**2154-12-23**] 19:56:07
Job#: [**Job Number 70626**]
|
[
"V053"
] |
Admission Date: [**2130-6-9**] Discharge Date: [**2130-6-15**]
Date of Birth: [**2057-8-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath, chest pressure
Major Surgical or Invasive Procedure:
coronary artery bypass grafting x 2 (LIMA-LAD, SVG-OM) [**2130-6-11**]
History of Present Illness:
This is a 72 year old male with past medical history significant
for angioplasty and stenting of his circumflex artery, posterior
left ventricular artery and right coronary artery in [**2129-7-11**].
He returned to the cath lab later that month due to recurrent
angina and underwent stenting of his left
anterior descending artery. He was doing well until this past
[**Month (only) 958**] when he developed chest pressure with associated shortness
of breath while carrying trash up a flight of stairs. He has
also noted some mild chest pressure when he is on the treadmill
during cardiac rehab sessions, this also resolves when he either
slows his pace or stops walking. A stress test was performed on
[**2130-5-3**]
which showed inferolateral ischemia and was stopped due to
fatigue. He underwent a cardiac catheterization which revealed
single vessel coronary artery disease involving the left main
coronary artery and proximal left anterior descending artery
detected by IVUS. The former left anterior decending, circumflex
and right coronary artery stents were widely patent. Given the
anatomy of his disease, he has been referred to Dr. [**Last Name (STitle) **] for
surgical evaluation.
Past Medical History:
Coronary artery disease
s/p multiple drug eluting stents in [**7-19**]
Hypertension
Hypercholesterolemia
gastroesophageal reflux
History of Basal Cell Carcinoma
Social History:
Occupation: Pastor at a church in [**Location 15289**].
Tobacco: Quit [**2090**]
ETOH: one drink daily.
Family History:
[**Name (NI) **] brother with HTN. Most of his family died
early, but of cancer. No premature coronary disease.
Physical Exam:
admission:
temp 98, HR 82, BP 154/77, RR 16, 98%RA
Height: 66" Weight: 155
General: Elderly male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] - poor dentition
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Softly distended; asymetrical - larger on left than
right; non-tender [x] bowel sounds+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2 **bilateral femoral bruits**
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2130-6-14**] 10:53AM BLOOD UreaN-21* Creat-1.1 K-4.5
[**2130-6-13**] 03:21AM BLOOD WBC-12.0* RBC-3.62* Hgb-11.4* Hct-33.4*
MCV-92 MCH-31.4 MCHC-34.1 RDW-13.8 Plt Ct-221
[**2130-6-11**] 10:16AM BLOOD PT-13.8* PTT-32.8 INR(PT)-1.2*
[**2130-6-13**] 03:21AM BLOOD Glucose-122* UreaN-16 Creat-1.0 Na-138
K-4.2 Cl-103 HCO3-28 AnGap-11
[**2130-6-12**] 03:28AM BLOOD Glucose-103* UreaN-18 Creat-1.1 Na-140
K-4.5 Cl-107 HCO3-25 AnGap-13
[**2130-6-14**] 10:53AM BLOOD WBC-9.2 RBC-3.84* Hgb-12.1* Hct-35.7*
MCV-93 MCH-31.5 MCHC-33.9 RDW-14.0 Plt Ct-291
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
BP (mm Hg): 110/75 Wgt (lb): 155
HR (bpm): 81 BSA (m2): 1.80 m2
Indication: Coronary artery disease.
ICD-9 Codes: 786.05, 786.51
Test Information
Date/Time: [**2130-6-11**] at 09:24 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW001-0:00 Machine: ie33
Echocardiographic Measurements
Results Measurements Normal Range
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular
calcification.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
Pre-bypass:
The left atrium and right atrium are normal in cavity size. 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. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are 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 structurally normal. There is no pericardial
effusion.
Post-bypass:
The patient is receiving no inotropic support post-CPB.
Biventricular systolic function is preserved. There is 1+
tricuspid regurgitation. The aorta is intact post-decannulation.
All findings communicated to the surgeon intraoperatively.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2130-6-11**] where he
underwent coronary artery bypass grafting x 2 with Dr. [**First Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Vancomycin was
used for surgical antibiotic prophylaxis given the patient's
inpatient stay of 24hours preoperatively. 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. Fr. [**Known lastname 60285**] was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued in a timely fashion, without
complication. The patient was evaluated by the Physical Therapy
service for assistance with strength and mobility. By the time
of discharge on POD# the patient was ambulating freely, the
wounds were healing well and pain was controlled with oral
analgesics. Fr.[**Known lastname 60285**] was cleared by Dr.[**First Name (STitle) **] for discharge
to home on POD# 4 in good condition with appropriate follow up
instructions advised.
Medications on Admission:
Amlodipine 2.5mg qd
Plavix 75mg daily- LAST DOSE [**2130-6-4**]
Imdur 60mg Daily
Lopressor 50mg twice daily
Sublingual nitroglycerin as needed 0.3mg
Benicar 20/12.5mg daily
zantac 150mg [**Hospital1 **]
Crestor 20mg daily
Aspirin 325mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. 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*
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*50 Tablet(s)* Refills:*0*
7. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
coronary artery disease
s/p Coronary artery bypass grafting x 2 (LIMA-LAD, SVG-OM)
[**2130-6-11**]
s/p multiple drug eluting stents in [**7-19**]
Hypertension
Hypercholesterolemia
gastroesophageal reflux
History of Basal Cell Carcinoma
Left shoulder arthritis
Past Surgical History:
Resection of skin cancers
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2130-7-17**] 1:45
Please call to schedule appointments
PCP/Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 8725**] in [**2-11**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2130-6-15**]
|
[
"2859",
"53081",
"2720",
"41401",
"V4582",
"4019"
] |
Admission Date: [**2116-10-22**] Discharge Date: [**2116-11-12**]
Date of Birth: [**2096-8-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Tunnelled catheter placement
Hemodialysis
History of Present Illness:
20 F with Type I Diabetes, complicated by ESRD on HD for the
last year. Recently hospitalized here 2-3 weeks ago for
uncontrolled hypertension.
.
States that she has bifrontal headaches associated with her
hypertension. This was controlled for only a few days after her
discharge. Since then, she has had recurrent headaches at least
daily, sometimes lasting up to all day. They have been
relatively stable these past weeks. She denies associated CP,
SOB. No signs of infection including fevers, chills, new rash,
nausea, vomiting or diarrhea.
.
Was seen at endocrine clinic for her parathyroid adenoma, at
which time she was referred to the ED for her elevated blood
pressure to SBP > 200 and associated headache.
Past Medical History:
* Type I DM - since [**2098**]
* ESRD on HD (MWF in [**Hospital1 789**])
* Pulmonary embolism on coumadin (diagnosed 1 month prior per
patient)
* Hypertension
* Hyperlipidemia
* Retinal detachment L eye
* Bilateral cataracts
Social History:
The patient lives at home with her parents and younger sister.
She denies any alcohol or tobacco use.
Family History:
No history of headaches or migraines. Father and grandparents
with hypertension. Two grandparents are diabetic.
Physical Exam:
Physical Examination
VS - 98.1 bp 160/110 HR 91 RR 18 96%RA
GEN: NAD
HEENT - R pupil reactive; L globe scarred; OP clr, MMM
CV - RRR, no m/r/g
RESP - R anterior chest tunnelled HD line c/d/i; lungs CTAB
ABD - NABS, soft, NT/ND,
EXT - no edema
Pertinent Results:
[**2116-10-22**] 03:30PM GLUCOSE-188* UREA N-39* CREAT-6.3* SODIUM-140
POTASSIUM-6.3* CHLORIDE-96 TOTAL CO2-27 ANION GAP-23*
[**2116-10-22**] 09:03PM K+-5.7*
.
[**2116-10-22**] 03:30PM
WBC-6.4 RBC-3.86* HGB-11.8* HCT-38.0# MCV-98 MCH-30.6 MCHC-31.1
RDW-18.6*
NEUTS-54.5 LYMPHS-21.0 MONOS-3.3 EOS-17.6* BASOS-3.6*
.
[**2116-10-22**] 03:30PM PT-33.2* PTT-37.7* INR(PT)-3.6*
.
CXR [**10-22**]. IMPRESSION: Findings consistent with volume
overload. Repeat radiography following diuresis recommended.
Brief Hospital Course:
In summary, Ms. [**Known lastname **] is a 20 yo female with Type I DM, ESRD on
HD, h/o PE in [**8-11**] on coumadin, parathyroid adenoma, admitted
for hypertensive urgency.
.
HTN. Patient was initially treated in the MICU on a
nitroglycerin drip. Her BP improved. She was then transferred
to the floor after one day. She was resumed on her home BP
meds (labetolol and losartan and nifedipine). It remained
unclear if hypertension was due to medication noncompliance
(patient says she reliably takes all meds) versus chronic
underdializing and fluid overload. She was then transferred
back to the ICU for hypertensive urgency again. She required
labetolol gtt on and off to control her BP. She received daily
ultrafiltration and hemodialysis to regain fluid balance. She
was also started on additional oral BP meds including
hydralazine and minoxidil (avoided clonidine for concern over
reflex hypertention if there is medication non-compliance).
Once transferred back to the floor, minoxidil was uptitrated to
7.5mg daily. Hydralazine was dosed at 25mg po BID, was briefly
treated with QID dosing but both patient and her mother thought
this would be difficult to maintain while outpatient. Upon
discharge her BP ranged from SBP 120-130s directly after
dialysis to SBP 140-180 on non-dialysis days. When she did
exceed SBP > 200, or DBP > 120, she was given hydralazine 5mg IV
with appropriate effect. Discharged on labetolol, losartan,
nifedipine, minoxidil and hydralazine.
.
Line infection/bacteremia. At HD on [**10-26**] she was noted to have
rigors and subsequently developed a ACINETOBACTER BAUMANNII
bactermia and growth from her tunnelled cath tip (after it was
removed). She was treated with gentomycin until the
sensitivities returned and she was switched to ciprofloxacin. A
temporary line was briefly used and then a new tunneled catheter
was placed once surveillance cultures returned negative. She
completed a 14 day course of Cipro and then the medication was
discontinued.
.
HA. Patient reports unilateral throbbing headache associated
with photophobia and nausea. It was not clear if her headache
was due to hypertension or if she was having a migraine.
Throughout her course, her HA occurred nearly daily and had no
clear association with her blood pressure. She was treated also
with Dilaudid and morphine IV for pain which generally
controlled her pain. She was started on a trial of sumatriptan
for headaches which was moderately helpful, she was discharged
with a limited number of this medication. Fioricet was tested
and did provide moderate relief. She was discharged on a
limited number of this medication.
.
Parathryoid adenoma. Parathyroid scan on [**2116-10-2**] showed
anterior mediastinal parathyroid adenoma. Patient will need
surgical removal of adenoma in future given that hypercalcemia
likely contributes to both her headache and recurrent nausea.
Dr. [**Last Name (STitle) 26030**] was consulted while inpatient and planned on
removing her adenoma while inpatient. The day of the proposed
operation, however, her blood pressure was so poorly controlled
that anesthesiology thought it unsafe to proceed with surgery.
She was recommended to follow-up with Dr. [**Last Name (STitle) 26030**] as an
outpatient with an appropriate anesthesiology pre-operative
evaluation given the severity of her hypertension.
.
History of PE. Patient had PE at OSH in [**8-11**] and is on
Coumadin. She was continued on coumadin in the hospital with
her INR within goal range of [**2-8**]. Her coumadin was briefly held
while inpatient and she was transitioned to a heparin drip in
preparation for her parathyroid adenomectomy. Once it became
clear that her surgery could not be obtained while inpatient,
she was restarted on coumadin. The day of discharge she had a
therapeutic INR x 48 hours.
.
ESRD on HD: followed by renal consult. Continued on HD and
ultrafiltration. Also treated with Sevelamer and Cinacalcet per
Renal recommendations. Discharged with follow-up at prior
hemodialysis facility. Also instructed INR monitoring during
HD.
.
DM1. Long standing history on uncontrolled type 1 diabetes. She
was hyperglycemic initially with her infection, but then was
better controlled in the MICU. Continued on glargine [**Hospital1 **] and
humalog with meals. Maintained fair control while inpatient
from 100-200. Was continuously difficult to control given
erratic eating patterns, poor diet compliance and refusal by
patient & mother to adhere to prescribed insulin dosing at
various intervals. Discharged with glargine 15u at breakfast
and 12u at supper and a humalog insulin sliding scale. Also
set-up with VNA services given the complexity of her medical
issues.
.
Hyperkalemia. Intermittently hyperkalemic in the setting of
ESRD. Never symptomatic. No EKG changes. Treated
intermittently with kayexelate when K > 5.
.
Abdominal Pain - Intermittent abdominal pain described as vague
and diffuse. C/w with constipation in addition to possible
gastritis. Continued on PPI and an aggressive bowel regimen.
Resolved with these interventions. Was discharged without
abdominal pain x 48 hours.
.
H/O glaucoma. On multiple medications, eye drops consistent
with glaucoma. Additionally on prednisone gtts of unclear
reasoning. Patient insisted on continued drops during inpatient
stay. On discharge was recommended to follow-up with
ophthalmologist to better define course of prescribed
medications.
.
Discharged home with moderately controlled hemodynamic
stability, afebrile. VNA services set-up on discharge for
family support given complexity of her medical problems.
Medications on Admission:
1. B Complex-Vitamin C-Folic Acid 1 mg DAILY
2. Prednisolone Acetate 1 % Drops, One Drop Daily
3. Dorzolamide-Timolol 2-0.5 % Drops 1 Drop DAILY
4. Brimonidine 0.15 % Drops 1 Drop DAILY
5. Butalbital-Acetaminophen-Caff 50-325-40 mg One Tablet PO Q8h
PRN
6. Labetalol 800 mg PO TID
7. Prochlorperazine 10 mg PO Q8h prn nausea
8. Pantoprazole 40 mg PO Q24H
9. Sevelamer 1600 mg PO TID W/MEALS
10. Warfarin 5 mg PO at bedtime Mon, Wed, Fri, Sat; 2.5 mg Tues,
[**Last Name (LF) 5929**], [**First Name3 (LF) **]
11. Insulin Glargine 12 units with breakfast, 10 units at
bedtime
12. Humalog sliding scale
13. Cinacalcet 90 mg PO once a day
14. Losartan 100 mg PO once a day
15. Nifedipine 30 mg PO Q8h
Discharge Medications:
1. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): 1 DROP BOTH EYES DAILY .
2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic DAILY (Daily): 1 DROP BOTH EYES DAILY .
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily): 1 DROP BOTH EYES DAILY .
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Q MWFSAT ().
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Q TUETHURSUN ().
6. Imitrex 25 mg Tablet Sig: One (1) Tablet PO once a day as
needed for migraine: Please take within 2 hours of onset of
headache.
Disp:*30 Tablet(s)* Refills:*0*
7. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
11. Sevelamer 800 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
Disp:*150 Tablet(s)* Refills:*2*
12. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
16. Butalbital-Aspirin-Caffeine 50-325-40 mg Capsule Sig: One
(1) Cap PO every eight (8) hours as needed for headache.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
18. Minoxidil 2.5 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*1*
19. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Disp:*60 Tablet(s)* Refills:*1*
20. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO once a day.
Disp:*60 Tablet Sustained Release(s)* Refills:*1*
21. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for headache for 20 doses: Do not
exceed more than 3gm of Acetamenophen (Tylenol) in one day.
This medication contains 325mg per tablet.
Disp:*20 Tablet(s)* Refills:*0*
22. VNA port maintenance
Heparin Flush Port (10 units/mL) 5 ml IV each visit with
10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units
heparin) each lumen, each visit. Inspect site each visit.
23. Outpatient Lab Work
Please check INR at each Hemodialysis visit and forward
information to Dr. [**First Name (STitle) 29653**] Z [**First Name (STitle) **] at [**Telephone/Fax (1) 40070**] so that he
may adjust her coumadin dosing.
24. Lantus 100 unit/mL Solution Sig: 12-15 units Subcutaneous
twice a day: Take 15 units at breakfast and 12 units at bedtime
.
25. Humalog 100 unit/mL Solution Sig: As directed by insulin
sliding scale units Subcutaneous four times a day.
Discharge Disposition:
Home With Service
Facility:
VNA Care [**Location (un) 511**]
Discharge Diagnosis:
Primary: Hypertension, Diabetes Mellitis type I
Secondary: ESRD, parathyroid adenoma, hypercalcemia,
hyperlipidemia, prior pulmonary embolism on Coumadin
Discharge Condition:
Good, moderate hemodynamic control and afebrile
Discharge Instructions:
You were admitted for hypertension and associated headache.
Your blood pressure was controlled by increasing your
medications and your headache was controlled with agressive pain
relief. You additionally had an infection in your blood while
you were in the hospital. You have been treated for this
infection. On discharge you will have the continued VNA
services. You should also have hemodialysis every Monday,
Wednesday and Friday with monitoring of your INR while there.
You also need to schedule a follow-up appointment with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], M.D. at ([**Telephone/Fax (1) 9011**] for removal of your
parathyroid adenoma.
.
Please take all your medications as prescribed in the following
medication sheet. There have been several modifications
concerning your blood pressure medications but it is important
that you take all these medications as prescribed.
.
If you have worsening headache, blurry vision, nausea/vomiting,
shortness of breath, chest pain, or any other concerning
symptoms, please call your physician or come to the emergency
department.
.
Please keep all your outpatient appointments.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 40069**],
in 1 to 2 weeks. Please schedule an appointment by callling
[**Telephone/Fax (1) 40070**].
.
Or, if you prefer to have your primary care physician
transferred to [**Hospital3 **], you may call [**Hospital6 733**]
at [**Telephone/Fax (1) 250**] to make an appointment to establish care.
.
Please contact [**Name (NI) **] [**Name (NI) **], M.D. at ([**Telephone/Fax (1) 9011**] to
schedule a follow-up appointment for surgical removal of your
parathyroid adenoma. You will also need a preoperative
anesthesiology visit prior to this operation. You should
discuss this with Dr. [**Last Name (STitle) **].
.
Continue to follow-up closely with your gynecologist at Women &
Infant's Hospital.
.
Follow-up with your [**Hospital 197**] Clinic 3-5 days post-discharge for
a INR check and dose adjustment.
|
[
"0389"
] |
Admission Date: [**2166-7-13**] Discharge Date: [**2166-8-14**]
Date of Birth: [**2135-2-7**] Sex: F
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
seizure, hypoglycemia
Major Surgical or Invasive Procedure:
trans-esophageal echocardiogram
bronchoscopy
History of Present Illness:
31yoF w/ h/o DM1, HTN, s/p left sided hemorrhagic CVA (3 yrs
ago) s/p trach/PEG/chronically indwelling catheter presents to
ED from [**Hospital **] rehab today after having had witnessed "tonic
clonic" activity at which time her BS was found to be 30. NH
staff had also noted decreased alertness today prior to her
seizure activity and hypoglycemia. She has reportedly been
spiking temps since [**7-8**] at rehab. In review of her med list,
she was started on ceftriaxone, vancomycin and inhaled
tobramycin on [**7-10**] (planned for 2 wk course); abx were changed
from levaquin/vanco when sputum grew cipro resistant klebsiella
(sensitive to ceftriaxone).
.
Of note, pt. was recently hospitalized [**Date range (1) 6957**] for sepsis
(presumed pulmonary source). Course was c/b probable VAP and
she is s/p tracheostomy recannulation during last
hospitalization as well as s/p PEG placement as she had been
having increasing dysphagia at home. Also during this past
hospitalization, she was noted to be persistently febrile
without clear e/o of persistet infection and in the absence of
clear medication causes.
.
In the ED, initial VS revealed T 101.6 BP 110/71 HR 100 RR 20 O2
sat 100% on AC (Vt 450, rr 14, FiO2 0.60, PEEP 5). A CXR was
obtained and did not show e/o infiltrate. UA showed moderate
bacteria, but only 0-2 WBCs and she has a chronic indwelling
foley. She received ceftriaxone and vancomycin in addition to
approximately 2L IV NS.
.
ROS: Unable to obtain from patient
Past Medical History:
# Diabetes Mellitus type 1 (dx at age 3), hx of hypoglycemic
episodes
# CVA (hemorrhagic) at 27 with residual aphasia and Right
hemiparesis, tracheostomy post CVA now recannulated during
recent [**6-/2166**] admission
# Blindness in one eye
# History of aspiration pneumonia
# Although patient is on valproate, no reported history of
seizures
# Depression
# Hyperthyroidism
# Anemia (BL hct 22-25)
# HTN
# Gastroparesis
# LV dysfunction
.
Social History:
Remote smoking history in her teens, lived in CA previously and
has lived at the Greenery since coming to MA.
Family History:
healthy brother/sister. Maternal family history of DM.
Physical Exam:
T 94.2 BP 120/62 HR 83 RR 15 O2sat 100% (Vt 450, rr 14, FiO2
0.60, PEEP 5)
Gen: Pt. with trach on ventilator, in NAD
HEENT: Right pupil round and reactive to light, Left eye w/
what appears to be scar tissue overlying inferior [**Doctor First Name 2281**]
Neck: Supple
CV: RRR, no mrg
Resp: Coarse BS anteriorly, unable to appreciate post. BS
Abd: +BS, soft, ND, no rebound/gurding
Ext: Left arm able to move spontaneously, hand in [**University/College **], right
hand with contraction.
Neuro: Moves LUE, does not follow commands, but opens eyes to
voice/name.
Pertinent Results:
[**2166-7-12**] CXR: wet read without clear evidence of infiltrate.
.
[**2166-7-13**] sputum: sparse coag +staph = MRSA. S: gen, rifampin,
tetracycline, bactrim, vanco; R: clinda, erythromycin,
penicillin, and oxicillin
.
[**7-13**], [**7-14**], [**7-15**] stool neg. for c. diff
.
[**7-14**] UCx: yeasts > 100K
.
[**2166-7-15**] UA: +yeasts, mod leuk, no bact
.
[**2166-7-15**] EEG: This is a mildly abnormal portable EEG in the waking
and
drowsy states due to the disorganized and poorly sustained
background. There was no clear electrographic correlate for
clinically observed episodes of eye fluttering or leg tremor.
There were no clearly focal, lateralized, or epileptiform
features noted. There were no electrographic seizures.
.
[**2166-7-16**] CT head: no significant change since [**2166-6-27**]. no new IC
bleed or infarct
.
[**2166-7-16**] CT abd/ pelvis: pneumonic infiltrate of RLL, no
perinephric abscess, 4.5cm soft tissue mass in R breast (rec f/u
with US)
.
[**2166-7-18**] CT head: no significant interval change. no new IC bleed
.
[**2166-6-12**] Echo: LVEF 30-40% [**1-10**] to severe hypokinesis/akinesis of
the apical half of the left ventricle, mild pulmonary htn.
.
[**2166-7-19**] Echo: Mild mitral leaflet thickening but without
discrete vegetation or pathologic flow. Low normal left
ventricular systolic function. Compared with the prior study
(images reviewed) of [**2166-6-12**], left ventricular systolic
function is improved with lack of regional dysfunction. The
focal thickening of the anterior mitral leaflet was also present
on review of the prior study.
.
[**2166-7-20**] MRI/MRA: IMPRESSION:
1. Severe bilateral athermatous disease of the intracranial
internal carotid arteries.
2. Similar encephalomalacic changes in the left frontal lobe.
3. Extensive T2 signal abnormality in the cerebral white
matter, probably due to widespread chronic small vessel
infarction.
4. Marked brain atrophy.
5. No evidence of brain abscess or abnormal meningeal
enhancement.
.
[**2166-7-25**] RLE US: neg for DVT
.
[**2166-7-28**] CT head/ sinus: IMPRESSION: Similar appearance of
cystic encephalomalacia and other atrophic
changes in the brain. No acute intracranial hemorrhage or mass
effect. Clear sinuses.
.
[**2166-7-28**] CT chest/ abd/ pelvis: CONCLUSION:
1. Interval improvement in extent of right lower lobe
atelectasis, and development of small airspace opacity, that may
represent pneumonia vs. reexpansion changes.
2. Right lower lobe airspace consolidation, likely representing
atelectasis, underlying infection cannot be entirely excluded.
3. Arteriosclerosis.
4. No drainable fluid collection.
.
[**2166-7-30**] EEG: intermittent sharp wave, as well as spike and slow
wave discharges, seen in a multifocal fashion arising sometimes
in a generalized distribution but also were seen independently
in the bifrontal regions and the left temporal region. Also
noted were broad-based, high amplitude, blunted triphasic waves
in the region of the left anterior temporal and temporal
regions. Discharges were not repetitive and there were no
electrographic seizures noted. These multifocal regions of
discharges suggest areas of cortical irritability with potential
for epileptogenesis.
Also persistent slowing over the left temporal regions in the
setting of a persistent slow and disorganized background. The
slowing over the left hemisphere - subcortical dysfunction. The
otherwise slow and disorganized background rhythm suggests a
more global
and diffuse process consistent with an encephalopathy likely due
to
deeper midline or bilateral subcortical dysfunction.
Medications,
metabolic disturbances, infections, and anoxia are among the
most common causes of encephalopathy.
.
[**2166-7-30**] TEE: could not be done as probe could not be passed
.
[**2166-7-31**] TTE: could not be done as study is technically difficult
- no additional information would be provided from previous
.
[**2166-8-1**] EGD:
.
[**2166-8-1**] GJ tube exchange
.
[**2166-8-3**] CT chest/abd/pelvis: IMPRESSION:
1. Multifocal pneumonia with new left upper lobe and lingular
infiltrates and no significant change to left lower lobe air
bronchogram containing infiltrate. Near complete resolution of
previously identified patchy right lower lobe opacities. No
evidence of intra-abdominal abscess.
2. Unchanged atherosclerotic disease involving the aorta and
its branches as well as the coronary circulation much more
prominent than expected for patient's age.
.
[**2166-8-3**] Bronchoscopy:
LLL and RLL with some purulent secretions. no evidence of
bronchial obstruction. Sent LLL BAL.
.
[**8-7**] Bilat LE u/s:
IMPRESSION: No evidence of DVT in both lower extremities.
.
[**8-5**] Trans esophageal echo
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. A very small secundum
atrial septal defect is present. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque to 40 cm from the incisors.
The aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: No valvular vegetations identified. Mildly thickened
mitral and aortic valve leaflets. Trivial aortic and mitral
regurgitation. Mild tricuspid regurgitation. Small secundum
atrial septal defect.
.
[**8-11**] CXR:
Increased consolidation at left lung base which could represent
pneumonia. New development of left pleural effusion, small.
[**2166-7-12**] 09:10PM URINE RBC-[**2-10**]* WBC-0-2 BACTERIA-MOD YEAST-OCC
EPI-0
[**2166-7-12**] 09:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
[**2166-7-12**] 09:10PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2166-7-12**] 09:10PM PT-13.6* PTT-26.3 INR(PT)-1.2*
[**2166-7-12**] 09:10PM PLT COUNT-655*
[**2166-7-12**] 09:10PM NEUTS-77.1* LYMPHS-15.5* MONOS-6.7 EOS-0.1
BASOS-0.5
[**2166-7-12**] 09:10PM WBC-13.7*# RBC-3.06* HGB-9.6* HCT-28.0*
MCV-92 MCH-31.2 MCHC-34.1 RDW-15.5
[**2166-7-12**] 09:10PM VALPROATE-44*
[**2166-7-12**] 09:10PM estGFR-Using this
[**2166-7-12**] 09:10PM GLUCOSE-217* UREA N-45* CREAT-1.7* SODIUM-135
POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-24 ANION GAP-22*
[**2166-7-12**] 09:12PM %HbA1c-5.8
[**2166-7-12**] 09:20PM COMMENTS-GREEN TOP
[**2166-7-13**] 06:12AM PT-13.4* PTT-36.9* INR(PT)-1.2*
[**2166-7-13**] 06:12AM NEUTS-68.5 LYMPHS-22.0 MONOS-8.8 EOS-0.2
BASOS-0.4
[**2166-7-13**] 06:12AM VANCO-8.1*
[**2166-7-13**] 06:12AM OSMOLAL-293
[**2166-7-13**] 06:12AM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-2.5
[**2166-7-13**] 06:12AM GLUCOSE-38* UREA N-40* CREAT-1.2* SODIUM-138
POTASSIUM-2.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
[**2166-7-13**] 08:30AM URINE OSMOLAL-398
[**2166-7-13**] 08:30AM URINE HOURS-RANDOM UREA N-595 CREAT-72
SODIUM-29
[**2166-7-13**] 01:48PM GLUCOSE-78 UREA N-33* CREAT-1.1 SODIUM-139
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2166-8-14**] 04:39AM 8.7 3.02* 9.6* 27.9* 92 31.8 34.4 16.4*
462*
[**2166-8-13**] 04:14AM 7.7 3.17* 10.0* 28.9* 91 31.6 34.7 16.1*
422
[**2166-8-12**] 04:33AM 7.1 2.80* 9.1* 25.2* 90 32.7* 36.3* 16.3*
397
Source: Line-CVC
[**2166-8-11**] 05:18AM 5.7 2.80* 8.7* 25.7* 92 31.2 34.0 16.4*
378
Source: Line-L sc
[**2166-7-17**] 10:57PM 14.6* 3.97* 12.2 36.0 91 30.7 33.9 16.1*
342
Source: Line-Left subclavian
[**2166-7-17**] 04:00AM 10.4 3.50* 11.1* 31.7* 90 31.6 35.0 16.0*
244
[**2166-7-16**] 05:54AM 8.9 3.60*#1 11.4*#1 32.8*#1 91 31.5 34.6
17.0* 310
Source: Line-L subclavian
1 VERIFIED
[**2166-7-15**] 06:20AM 7.7 2.21* 7.1* 21.0* 95 32.0 33.6 15.8*
326
.
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2166-8-14**] 04:39AM 51.5 33.3 4.2 10.8* 0.2
[**2166-8-13**] 04:14AM 67.5 18.7 5.5 7.9* 0.4
[**2166-8-12**] 04:33AM 44.4* 38.9 4.4 11.9* 0.4
Source: Line-CVC
[**2166-8-11**] 05:18AM 40.5* 42.9* 3.9 12.5* 0.2
Source: Line-CVC
[**2166-8-10**] 04:41AM 34.5* 49.6* 4.7 10.8* 0.4
Source: Line-CVC
[**2166-8-9**] 04:30AM 56.4 32.1 3.5 7.8* 0.2
[**2166-8-2**] 04:21AM 74.9* 20.8 3.7 0.4 0.2
Source: Line-A line
[**2166-7-28**] 04:56AM 69.8 24.4 4.6 0.9 0.4
Source: Line-picc
[**2166-7-22**] 03:16AM 51.9 39.8 7.6 0.5 0.1
Source: Line-central
[**2166-7-19**] 03:10AM 55.4 35.5 7.3 1.5 0.3
Source: Line-lsc tlcl
[**2166-7-15**] 06:20AM 53.2 34.8 8.0 3.4 0.6
Source: Line-TLC
[**2166-7-13**] 06:12AM 68.5 22.0 8.8 0.2 0.4
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2166-8-14**] 04:39AM 161* 13 0.6 135 4.0 102 26 11
[**2166-8-13**] 04:14AM 56* 16 0.6 138 4.7 103 28 12
[**2166-8-12**] 04:33AM 153* 11 0.5 136 4.4 104 28 8
.
[**2166-8-5**] 04:30AM 84 10 0.7 138 3.7 110* 19* 13
Source: Line-left IJ
[**2166-8-4**] 04:10AM 71 9 0.8 139 3.9 112* 18* 13
[**2166-8-3**] 04:06AM 64* 11 0.9 141 3.4 112* 17* 15
.
[**2166-7-14**] 06:29AM 63* 20 1.0 143 4.0 111* 23 13
Source: Line-tlc; Vancomycin @ Trough
[**2166-7-13**] 01:48PM 78 33* 1.1 139 4.9 108 22 14
Source: Line-groin line
[**2166-7-13**] 06:12AM 38*1 40* 1.2* 138 2.6*1 101 23 17
.
LFTs ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2166-7-28**] 04:56AM 14 15 143 67 146* 0.1
.
Ft4 1.4 on [**8-11**] 2.0 on [**7-31**]
PTH 25 on [**7-21**]
.
ANCA neg [**Doctor First Name **] neg dsDNA neg
Brief Hospital Course:
# Fever: Febrile to 101.6 in ED where she received IV
ceftriaxone and vancomycin without clear infiltrate on CXR but
has extensive h/o aspiration pneumonia and was recently treated
for VAP for which she completed a course of meropenem and
vancomycin prior to d/c on [**7-4**]. On admission, with temp. and
tachycardia she met criteria for SIRS with no definitive source.
Blood and urine cultures were sent in the ED. Did have
elevated WBC count to 13.7, but no notable left shift and all
cell lines appeared to be up suggesting hemoconcentration. In
discussion w/ RN at [**Hospital1 **], she had been spiking temperatures
there since [**7-8**] at which time she was started on levofloxacin
and vancomycin. Her vancomycin level was noted to be elevated
so was held while levels resolve. Levaquin was reportedly
discontinued on [**7-10**] when her sputum was found to be growing
klebsiella resistant to ciprofloxacin, but sensitive to
ceftriaxone. Thus she was started on ceftriaxone and tobramycin
neb at that time.
She was started on vanco/zosyn for ?LLL pna here but then
these were stopped given negative infectious workup and no
significant LLL infiltrate on repeat CXR. However, fever spikes
continued (Tm 104.6 on [**7-19**], 104.2 on [**7-21**]) with negative
cultures. TTE and TEE showed no vegitations, CT abd showed no
abscess. LP negative for meningitis, cryptococcus negative,
viral culture still pending.
Sputum grew Klebsiella pneumonia on [**7-19**] which was sensitive
to Zosyn and she was treated with a full course of zosyn. She
continued to spike fevers after she was treated, ID was
consulted, review of culture data showed that she has a
sub-population of ESBL resistant klebsiella and so she was
subsequently treated with meropenem. She should continue
treatment until [**8-25**].
She was also found to have pseudomonas in her sputum which was
sensitive only to amikacin. She was started on amikacin and
should continue until [**8-28**]. Amikacin dosing switched to 750mg
q24 dosed at 4pm on day of discharge. She should have amikacin
levels draw just prior to administration of third dose (on [**8-16**]).
Goal trough is <4, if >4 can increase dosing interval to
q36hrs.
She had diarrhea of unclear etiology - it may have been due to
tube feedings and she was given banana flakes to good effect.
Because of fevers and prolonged antibiotics, C. diff was a
concern. C.diff toxin assay was negative, however given concern
a B-toxin was sent which is currently pending. She should
continue flagyl for another 7 days (until [**8-21**]) or until B-toxin
is negative.
Patient grew MRSA in sputum which was initially treated with
vancomycin then linezolid as there was concern for drug-fever
with vancomycin. Linezolid then stopped because of eosinophilia
(see below). Although CXR on [**8-11**] was read as having
consolidation in left lower lobe, she was clinically much
improved with fever curve trending down. Given much improved
respiratory status, MRSA was felt to be a chronic colonizer.
She had a UTI with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] which was treated with
voriconazole.
During her hospitalization, non-infectious sources of fever were
considered as well. Vancomycin was thought to be causing a drug
fever as above given that she was febrile to 106F. Vasculitis
panel was negative. Neurology consulted to consider autonomic
dysfunction/central causes of fevers but did not feel this would
explain fevers. She does have hyperthyroidism, but this also
was not though to explain fevers.
At discharge she had been afebrile x4 days. She should have a
repeat CXR in a few weeks to assess for resolution of pneumonia.
Overall antibiotic regimen included:
vancomycin [**Date range (1) 6958**]; [**7-28**] - [**8-6**]
zosyn [**Date range (1) 6959**]; [**Date range (1) 6960**]; [**8-2**] - [**8-4**]
meropenem 1g IV q8h [**8-4**] - [**8-18**] (planned)
amikacin [**8-8**] - [**8-21**] (planned)
Flagyl [**7-14**] - [**7-16**]; [**8-2**] - [**8-21**] (planned)
fluconazole [**7-16**] - [**7-19**]
Vori 200 PO BID [**8-4**] - [**8-8**]
cipro [**7-28**]- [**7-28**]
CTX [**7-13**] - [**7-13**]
Bactrim [**7-17**] - [**7-21**]
Linezolid [**8-8**] - [**8-11**]
.
# Seizure: Reportedly no h/o seizures previously despite having
been maintained on depakote (presumably started post CVA).
?seizure on day of admission seems more likely [**1-10**] to severe
hypoglycemia as opposed to structural abnormalities post CVA
acting as epileptiform nidus. A [**2166-6-11**] EEG did not reveal e/o
seizure/epileptiform activity. Pt now with increased resting
tremor of LUE. [**2166-7-15**] EEG results neg. for epileptiform
activity; no clear electrographic correlate for clinically
observed episodes of eye fluttering or leg tremor. CT head r/o
acute IC process/ new stroke since [**6-27**]. LFTs WNL. Neurology
believes tremor in hand is likely action tremor due to stroke
affecting basal ganglia. MRI/MRA neg. On [**7-21**] depakote changed
to keppra because it may be contributing to fevers. She was
continued on keppra with no further evidence of seizure activity
- she has a resting tremor of the left hand which was not felt
to represent epilectic activity.
.
# DM1/ Hypoglycemia: In review of her records, has h/o labile
BS and, as above, was found to be hypoglycemic to the 30s when
found to seize. Diabetes management service consulted.
Initially euglycemia maintained on insulin drip. Once patient
tolerating consistent tube feeds, she was transitioned to
glargine (currently 24 units) and QID insulin sliding scale.
Blood sugars still fairly variable, however given that she
presented for hypoglycemia, we erred on the side of higher blood
sugars.
Josline diabetes service had been considering switching to [**Hospital1 **]
lantus regimen at discharge but as blood sugars currently stable
she was not changed. This could be considered if blood glucose
is variable in the future.
.
# ARF: Baseline creatinine is 0.7-1.0 and was found to be
elevated to 1.7 on ED presentation (while it was normal on d/c
on [**7-4**]). Given it appears that she is hemoconcentrated by CBC,
most likely reflects prerenal azotemia. U lytes consistent with
prerenal ARF. She initially had a low bicarbonate (low of 17)
and urine electrolytes suggested renal tubular acidosis. This
had resolved on discharge.
.
# Respiratory failure: Has reportedly not attempted wean at
[**Hospital1 **] per limited progress notes sent w/ patient.
Respiratory distress has been complicated by tremors, apears to
be a central process with cyclical periods of tacchypnea that
had made weaning difficult. Once respiratory infection treated
she was transitioned to trach collar and has stayed on that with
40% FiO2 for 4 days prior to discharge.
.
# Coughing
Patient had intermittent paroxysms of coughing that persisted
even once respiratory infection was mostly treated.
Interventional pulmonology performed bronchoscopy which showed
that the trach was in good position but did show largyngeal
inflammation suggestive of GE reflux. She was started on [**Hospital1 **]
PPI and sucralfate (for possible element of gastritis),
sucalfate stopped prior to discharge.
.
#Aggitation
she has been receiving standing clonazepam for
aggitation/anxiety and occasional ativan IV with good effect.
.
# Hyperthyroidism: free t4 3.9 on admission, hyperthyroidism
treated with PTU, free t4 normalized to 1.4. She should
continue PTU until she follows up with her outpatient
endocrinologist in [**Location (un) 620**] in the next few months. Free t4
should be rechecked in [**3-14**] weeks.
.
# HTN: antihypertensives initially held for hypotension and
ARF. Metoprolol restarted at low doses and blood pressure began
to increase in the week before discharge. She was started on
captopril and metoprolol increased to 100mg [**Hospital1 **]. Outpatient
regimen was metoprolol 175mg PO bid, lisinopril 20mg daily, and
Lasix 40 mg daily. These medications should be restarted slowly
at rehab to control hypertension.
.
# Corneal opacity
Patient is blind in left eye from diabetic retinopathy. Eye
noted to have corneal opacity in inferior aspect of cornea for
at least a month. Ophthalmology consulted who felt this was
unlikely to be a corneal ulcer but that there may be some
abrasion for which they recommended erythromycin ophthalmic
ointment. This was stopped for concern of systemic absorption
causing eosinophilia. She should have her left eye kept closed
to prevent drying out of the cornea.
.
# Anemia: Baseline hct appears to be 22-25. Recent iron
studies during last hospitalization are c/w AOCD w/ low TIBC,
elevated ferritin. Patient transfused intermittently when HCT
fell below 21. No evidence of bleeding.
.
# Eosinophilia
Eosinophils rose to 7/8 on [**8-9**] and a maximum of 12.5 on [**8-11**].
Although she was afebrile at the time, this was thought to
perhaps be another representation of tendency towards drug
fever. linezolid and erythromycin ophthalmic ointment stopped
and eosinophilia began trending down. She should have a repeat
eosinophil count in a few days to confirm that it has gone down.
.
# Depressed LVEF: 40% on recent echo. On lasix, BB, ACEI as
outpatient (see HTN above)
.
# ?DVT: given cool extremities with decreased pulses noted [**7-25**]
but doppler U/S was negative on two occassions.
.
# FEN: Tube feed continued, electrolytes repleted as needed.
Reglan stopped for diarrhea.
.
# R breast mass: US evaluation as outpatient
.
Access: PICC placed [**8-13**]
Medications on Admission:
Meds (obtained from [**7-4**] d/c summary):
Ferrous sulfate 300mg liquid daily
Ceftriaxone 1g IV BID (started [**7-10**])
Cholestyramine/sucrose 4g daily
Reglan 10mg PO daily
ASA 81mg daily
MVI
Docusate
Senna
Folate 1mg daily
Diltiazem 120mg PO qid (on d/c summary from [**7-4**], but not on med
list from [**Hospital1 **])
SC heparin
Artificial tears
Albuterol prn SOB/wheezing
Ipratropium
Metoprolol Tartrate 175 mg PO bid
Miconazole Nitrate 2 % Powder qid prn rash
Ranitidine 150 mg q12h
Lantus 30U hs, 25 qam
Novolog SS
Propylthiouracil 100 mg PO Q8h
Lidocaine HCl 5 % Ointment [**Hospital1 **]: One (1) Appl Topical Q6h prn
Lisinopril 20mg daily
Lasix 20mg IV daily
Lasix 80mg PO bid
Valproate 1g q6h
Ativan 1mg q4h prn
Morphine 15mg PO q4h prn pain
Acetaminophen q4h prn
Beneprotein
Tobramycin neb q12h (started on [**7-10**])
.
All: NKDA
Discharge Medications:
1. Propylthiouracil 50 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Q8H
(every 8 hours).
2. Metronidazole 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3
times a day): last day [**8-21**].
3. Meropenem 1 g Recon Soln [**Month/Year (2) **]: One (1) Recon Soln Intravenous
Q8H (every 8 hours): last day [**8-25**].
4. Outpatient Lab Work
amikacin level before third dose of 750mg on [**8-16**] to be drawn
just prior to administration at 4pm.
goal is less than 4. if greater than 4 can increase interval to
q36
5. Levetiracetam 100 mg/mL Solution [**Month/Day (4) **]: Ten (10) mL PO BID (2
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1) inj
Injection TID (3 times a day).
7. Miconazole Nitrate 2 % Powder [**Month/Day (4) **]: One (1) Appl Topical QID
(4 times a day) as needed.
8. Acetaminophen 160 mg/5 mL Solution [**Month/Day (4) **]: 650-975 mg PO Q6H
(every 6 hours) as needed.
9. Clonazepam 0.5 mg Tablet [**Month/Day (4) **]: .5 Tablet PO BID (2 times a
day).
10. Lidocaine HCl 1 % Solution [**Month/Day (4) **]: Three (3) ML Injection Q4-6H
(every 4 to 6 hours) as needed.
11. Lidocaine HCl 2 % Gel [**Month/Day (4) **]: One (1) Appl Mucous membrane PRN
(as needed).
12. Codeine Sulfate 30 mg Tablet [**Month/Day (4) **]: 0.5 Tablet PO Q6H (every 6
hours) as needed.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
14. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID
(3 times a day).
15. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
16. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
17. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID (4 times a day).
18. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: 1-2 mg Injection Q2H (every 2
hours) as needed for agitation.
19. Amikacin 250 mg/mL Solution [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y (750)
mg Injection Q24H (every 24 hours): day 1=[**8-8**] last day =[**8-28**]
(current dosing started [**8-14**])
Should be given at 4pm
Please follow trough, should be less than 4.
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (4) **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
21. Lantus 100 unit/mL Cartridge [**Month/Day (4) **]: Twenty Four (24) units
Subcutaneous at bedtime.
22. Insulin Regular Human Injection
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary:
ventilator-associated pneumonia with pseudomonas, klebsiella,
and MRSA
Yeast UTI
hypoglycemic seizures
DM type I
Hyperthyroidism
.
secondary
Hypertension
Discharge Condition:
Fair - stable on trach collar with 40% FiO2. afebrile x4 days.
Discharge Instructions:
You were admitted for a low blood sugar, seizures, and fevers.
You low blood sugars were likely due fevers and to changes in
your tube feeding regimen and resolved with steady tube feed
intake and close monitoring of your blood sugars.
You had an extensive workup for your fevers. We believe the
fevers were due to infections in your lungs with two bacteria
and in your urine with yeast. These were treated with
antibiotics and antifungals. You should continue the
antibioitics as indicated below.
You are also being treated for an infectious diarrhea
associated with antibiotic use called Clostridium difficile.
Also, you were treated for hyperthyroidism, which is a high
level of thyroid hormone. You should follow up with your
outpatient endocrinologist regarding this.
Please return to the hospital if you have recurrent high
fevers, increased sputum production, seizures, or any other new
or concerning symptoms.
Followup Instructions:
Please follow-up with your outpatient endocrinologist and your
primary care doctor
|
[
"5849",
"4019",
"53081"
] |
Admission Date: [**2129-8-8**] Discharge Date: [**2129-8-15**]
Date of Birth: [**2072-11-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Lisinopril / Aloe / Shellfish
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
1. Off-pump coronary artery bypass graft x2: Left internal
mammary artery to left anterior descending artery and
saphenous vein graft to right coronary artery.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
Ms. [**Known lastname **] is a 56 year old female with dyslipidemia, HTN, and
known CAD, who was scheduled to see CT surgery as an outpatient
tomorrow for possible CABG, who presents now with chest pain and
SOB since yesterday. Patient underwent recent cardiac cath on
[**2129-7-26**] which was notable for proximal tubular 90% stenosis in
the LAD and proximal 50% stenosis in the RCA. She was scheduled
to see CT surgery tomorrow in consult for possible CABG, but
yesterday developed shortness of breath and left anterior chest
pain radiating to left arm after going up 2 flights of stairs.
Reports this pain was different from her typical anginal pain,
which is more substernal in nature and often radiates to the
back. The chest pain was not associated with any dizziness,
diaphoresis, or nausea. It would last for about 5-30 minutes at
a time and intermittently resolve, though overall she has not
been feeling well. Was not able to go into work today. Called
the Cardiology office, and was referred to ED for further
evaluation.
In the ED, initial vitals were 98.1 64 142/120 14 98% RA. She
was AAOx3, and in NAD. Received SL nitro x1 with relief of CP.
Per report, EKG showed mildly flattened T waves laterally. Trop
negative x2. Cardiology was consulted, and recommended heparin
gtt and admission to Cardiology. CT surgery also to be notified.
Vitals prior to transfer: 98.3 61 134/61 21 98% RA. On arrival
to floor, patient comfortable and chest pain free.
On review of systems, she reports recent headaches secondary to
her isosorbide mononitrate. Has occasional palpitations. Also
reports occasional orthopnea and PND, though attributes some of
this to her body habitus and sleep apnea. Typically has dyspnea
with 2 flights of stairs, therefore limits her activity. Reports
mild abdominal discomfort and loose stool yesterday, now
resolved. Denies fevers, chills, diaphoresis, nasal congestion,
sore throat, current N/V, abdominal pain, constipation, bloody
or dark tarry stools, dysuria, or hematuria. No lower extremity
edema. Has had myalgias in past when on a statin. All of the
other review of systems were negative.
Past Medical History:
Coronary Artery Disease
Hypertension
Irritable bowel syndrome
GERD
Esophageal spasms
Lyme disease
OSA - CPAP at home but does not use
Obesity
Hearing loss L>R
Memory problems
Sarcoidosis
Meningioma (calcified)
Past Surgical History:
Tonsillectomy
D&C x 2
Right breast lumpectomy x 2 (Lipomas)
Social History:
She lives with her husband and two teenaged sons. [**Name (NI) **] son is
about to start college and she's looking forward to moving him
into a dorm. She has never smoked. She drinks one or two
alcoholic beverages per week. She has no history of ilicit drug
use or intravenous drug use. She works as a fertility lab
manager at [**Company 2274**].
Family History:
Father: sudden death due to MI age 60
paternal uncle: sudden death due to MI age 61
brother: h/o cad s/p cabg in his 40s
mother died of pancreatic cancer
Physical Exam:
ADMISSION
VS: 98.6 140/84 62 18 98% RA
GENERAL: obese female, resting comfortably, oriented, NAD, mood
and affect appropriate
HEENT: NC/AT, PERRL, EOMI, sclera anicteric, conjunctiva pink,
MMM, OP clear
NECK: supple, no JVD or cervical LAD
CARDIAC: RRR, normal S1, S2, no r/m/g
LUNGS: CTAB, no crackles/wheezes/rhonchi, respirations
unlabored, no accessory muscle use
ABDOMEN: obese, soft, NTND, no organomegaly appreciated, no
guarding or rebound tenderness, normoactive bowel sounds
EXTREMITIES: warm, well-perfused, 2+ DP pulses, no edema
SKIN: No stasis dermatitis or ulcers
NEURO: CN II-XII grossly intact, strength 5/5 throughout
Pertinent Results:
[**2129-8-10**] TEE
Conclusions
PRE GRAFTING The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the study.
POST GRAFTING There is normal biventricular systolic function.
There is no change in valvular function. The thoracic aorta is
unchanged.
Chest X-Ray [**2129-8-13**]:
FINDINGS: In comparison with study of [**8-11**], there are continued
low lung
volumes. Opacification at the left base is consistent with
pleural effusion and volume loss in the left lower lobe. Some
increasing opacification at the right base most likely
represents atelectasis with crowding of vessels in the region of
the cardiophrenic angle. Mild blunting of the costophrenic
angle is seen. No evidence of vascular congestion.
[**2129-8-15**] 02:45AM BLOOD WBC-11.1* RBC-3.37* Hgb-10.0* Hct-29.5*
MCV-88 MCH-29.8 MCHC-34.0 RDW-12.6 Plt Ct-227#
[**2129-8-13**] 06:20AM BLOOD WBC-12.0* RBC-3.10* Hgb-9.5* Hct-27.2*
MCV-88 MCH-30.5 MCHC-34.8 RDW-12.8 Plt Ct-132*
[**2129-8-12**] 05:55AM BLOOD WBC-15.2* RBC-3.66* Hgb-10.9* Hct-32.4*
MCV-89 MCH-29.8 MCHC-33.7 RDW-13.0 Plt Ct-123*
[**2129-8-15**] 02:45AM BLOOD Glucose-139* UreaN-19 Creat-0.9 Na-135
K-4.3 Cl-101 HCO3-27 AnGap-11
[**2129-8-14**] 06:01AM BLOOD Glucose-118* UreaN-18 Creat-0.8 Na-139
K-4.2 Cl-103 HCO3-29 AnGap-11
[**2129-8-13**] 06:20AM BLOOD UreaN-17 Creat-0.9 Na-140 K-3.9 Cl-103
Brief Hospital Course:
The patient was brought to the Operating Room on [**2129-8-10**] where
the patient underwent Off-Pump CABG with Dr. [**First Name (STitle) **]. 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. She was
started on beta blockers and was gently diuresed toward the
preoperative weight. Both lopressor and lasix was decreased due
to mild hypotension. The patient 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 POD5 the patient was ambulating
freely, her wounds were healing well and her pain was
controlled with oral analgesics. The patient was discharged
home in good condition with appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Donnatol 1 tablet PO QID abdominal pain
4. Verapamil SR 240 mg PO Q24H
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/fever
2. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
3. Atorvastatin 10 mg PO DAILY
RX *atorvastatin 10 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
4. Clopidogrel 75 MG PO DAILY
off-pump
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*1
5. Docusate Sodium 100 mg PO BID
6. Metoprolol Tartrate 25 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
7. Miconazole Powder 2% 1 Appl TP QID:PRN rash
8. Omeprazole 20 mg PO DAILY Duration: 1 Months
RX *omeprazole [Prilosec] 20 mg 1 capsule(s) by mouth once a day
Disp #*60 Capsule Refills:*0
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth every six (6)
hours PRN Disp #*40 Tablet Refills:*0
10. Furosemide 20 mg PO DAILY Duration: 5 Days
RX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth once a day
Disp #*5 Tablet Refills:*0
11. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >
RX *potassium chloride [K-Tab] 10 mEq 20 mEq by mouth once a day
Disp #*5 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
Irritable bowel syndrom
GERD
Esophageal spasms
Lyme disease
OSA - CPAP at home but does not use
Obesity
Hearing loss L>R
Memory problems
Sarcoidosis
Meningioma (calcified)
Past Surgical History:
Tonsillectomy
D&C x 2
Right breast lumpectomy x 2 (Lipomas)
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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac [**Doctor First Name **] Office [**Telephone/Fax (1) 170**] [**2129-8-23**] at
10:00 am
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2129-9-13**] at 1:15p
Cardiologist: Dr. [**Last Name (STitle) 911**] [**2129-9-7**] at 10:20am [**First Name8 (NamePattern2) **] [**Location (un) 1439**],
MA
[**Telephone/Fax (1) 9347**]
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) **] in [**3-24**] weeks [**Telephone/Fax (1) 2010**]
**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:[**2129-8-15**]
|
[
"41401",
"4019",
"32723",
"2724",
"53081"
] |
Admission Date: [**2194-1-28**] Discharge Date: [**2194-2-5**]
Date of Birth: [**2107-6-29**] Sex: F
Service: MEDICINE
Allergies:
Scopolamine
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Malaise, weakness, reduced appetite
.
Reason for MICU transfer: cholangitis / pancreatitis / ARDS
Major Surgical or Invasive Procedure:
Intubation, mechanical ventilation
ERCP with two stent placed
Arterial lines X2
Right IJ line placement
History of Present Illness:
HPI gleaned from [**Hospital1 **] [**Location (un) 620**] notes and daugther since Pt is
intubated.
.
Pt is a 86 year old female w/ PMH of hypertension,
hyperlipidemia, and insulin-dependent diabetes mellitus who
complains of generalized malaise and weakness. According to
family she has had a six-month decline in her general function
including mobility, ability to communicate and mental status. At
baseline, she can transfer wheelchair to toilet with assistance
and some walking at home with physical therapy, but is "quite
confused".
According to the family, 2 days ago she had an episode of
hypoglycemia related to a insulin dose it was late in the
evening administered by her husband. Shortly afterwards, she
became combative and needed to be restrained by her son. They
called 911 and EMS found her blood sugars to be in the 40s. Her
mental status cleared after admin of D50 and glucagon.
Since that episode, she has had increased lethargy and weakness.
She has been refusing to get out of bed at all and she has been
moaning. No vomiting, no diarrhea, no fever. She did have
episode of incontinence however that was in the setting of not
getting out of bed. She always is a poor eater reported to
family however she's had much nothing to eat for the last 24
hours. Her husband states her blood sugars have been normal and
has been giving her her insulin as usual the last couple of
days.
Pt was brought to [**Hospital1 **] [**Location (un) 620**] ED for evaluation by family for
continued "moaning" and reduced responsiveness. At BIDN, initial
vitals were Temp: 100.6 HR: 98 BP: 120/46 Resp: 20 O(2)Sat: 94.
Pt complained of L chest pain and R wrist pain. Troponins were
negative, no concerning ECG changes. Plain CXR did not show any
fractures of the chest or R wrist. Pt's lipase was elevated to
[**2122**] and Pt developed a fever to 102F. She had a CT abdomen w/
contrast, which showed a common bile duct dilated to 2.8 cm w/
multiple stones and a question of obstructing ampullary stone.
Plan was made to transfer Pt to [**Hospital1 **] [**Location (un) 86**] for ERCP, and Pt
received a dose of Zosyn.
Before transport, the patient became unstable with SBP in 70's.
She was given 2L IVF and her BP remained low, and she was
started on peripheral levophed. [**Hospital1 **] [**Location (un) 620**] ED placed a R IJ
without complications, however she developed hypoxia just
afterwards and needed to be intubated for airway control. She
was intubated on second attempt with a 7.0 ETT. Her ETT and CVL
appear to be in correct position on CXR and [**Hospital1 **] [**Location (un) 620**] feels
she may have developed ARDS. Pt was then transferred to [**Hospital1 **]
[**Location (un) 86**] ED.
.
In the [**Hospital1 **] [**Name (NI) 86**] [**Name (NI) **], Pt was stable. CXR showed diffuse
bilateral infiltrates R > L and blunting of R costophrenic
angle, ?ARDS. Pt was on midaz/fent. On norepi 0.21. IJ + 2PIVs.
Received a dose of Vanc. Vent settings on transfer were FiO2 50%
TV 420 RR 20 PEEP 5. Vitals were 76, 107/49, 98%. Pt was
finishing 6th liter of IVF.
.
On arrival to the ICU, Pt's vital signs were 37.2C, HR 73, BP
109/46, RR 17, Sat 100% on FiO2 50%, intubated and sedated.
.
Review of systems: Unable to confirm due to intubation.
Per [**Hospital1 **] [**Location (un) 620**] records and daughter, Pt did not have fevers /
chills. No nausea or vomiting. No diarrhea. Reports malaise and
reduced appetite for several months, but especially so for the
last two days. No urinary symptoms.
Past Medical History:
insulin-dependent diabetes
hypertension
hyperlipidemia
benign stricture of the pylorus and duodenum s/p dilation [**2187**]
ampullary stenosis s/p sphincertotomy in [**2187**]
peptic ulcer disease
rheumatic heart dz
Mixed aortic valve disease (mild)
Mixed mitral valve disease (mild)
History of breast cancer; status post bilateral mastectomy
osteoporosis
chronic hip and leg pain
peripheral neuropathy
R hip "plate"
L carotid artery stenosis
? TIA
Social History:
Former smoker, quit decades ago. Denies EtOH. She lives with her
husband in their home. Has visiting PT 2x weekly.
Family History:
Alzheimer dementia in sisters
Physical Exam:
Vitals: 37.2C, HR 73, BP 109/46, RR 17, 100% on FiO2 50%.
General: intubated elderly woman
HEENT: pupils pinpoint, dry mucous membranes
Neck: R IJ
Lungs: Clear to auscultation bilaterally except for L base, no
wheezes or ronchi
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic and
diastolic murmurs, no rubs
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly
GU: foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**1-28**] 1.45a ABG: 7.26/42/87/20 on FiO2 50%.
[**1-27**] 11.50p Lactate 1.3
Lipase [**2122**]
[**1-27**] CBC: WBC 10.6, Hct 40.9, Plt 174.
[**1-27**] 4pm LFTs: AST 68, ALT 34, T bili 0.57, AP 82.
[**1-27**] Chem7: 138, 4.6, 102, 26.1, 19, 0.8, 112, Lactate 1.4.
[**1-27**] UA bland, troponin < 0.01
.
[**2194-1-27**]: CXR showed diffuse bilateral infiltrates R > L and
blunting of R costophrenic angle, ?ARDS
[**2194-1-27**]: CT abdomen w/ contrast: common bile duct dilated to 2.8
cm w/ multiple stones and a question of obstructing ampullary
stone. L1 impression fracture of uncertain age. Small right
upper lobe opacity consistent with resolving infection.
.
EKG: no prior available. NSR, normal axis, normal intervals, no
PQ or ST changes, T waves tall.
Brief Hospital Course:
86 yo F w/ PMH diabetes, hypertension, ampullary stenosis s/p
sphincterotomy who presented with increasing lethargy, fevers,
and hypotension, found to have septic [**Month/Day/Year **] from likely
cholangitis and gallstone pancreatitis.
She initially appeared to respond well to ERCP and antibiotics,
initially coming down on pressors and appeared close to
extubation. Then, however, her pressures began to drop and she
was put back on pressors. Her mental status was poor, even off
sedation, and she persistently failed her spontaneous breathing
trials. Leukocytosis and fevers increased, and it appeared her
sepsis and overall clinical status was worsening. At this
point, her family felt that she would not want to continue with
this level of treatment if it did not appear she would return to
her baseline. After a meeting with the entire family (including
daughter/HCP [**Doctor First Name 4134**], Dr. [**Last Name (STitle) **], and the rest of the ICU
team, her care was transitioned to comfort focused care. Her
pressors and antibiotics were stopped on [**2-4**], but she remained
intubated and ventillated, as the family did not want her to
feel air hunger. She passed away peacefully with family at her
side at 4:05pm on [**2194-2-5**]. Please see below for more detailed
summary of main hospital problems.
PRIMARY PROBLEMS:
# [**Name2 (NI) 21020**]: Thought to be septic in nature [**2-27**] cholangitis. Echo
showed significant multi-valve dysfunction, however there was no
evidence of cardiogenic component. Patient was intubated and
started on norepinephrine on arrival in the ICU. For source
control, she was sent to ERCP (see below) and started on empiric
vancomycin and zosyn. Blood pressure was originally reasonably
responsive to fluids, so patient was intermittently bolused and
weaned off pressors after 3 days. She then, however, began to
drop her pressures again requiring uptitration with pressors.
Leukocytosis increased and she developed new fevers, raising
concern for worsening of sepsis. No new source identified,
nothing grew on blood or urine cultures. UOP decreased despite
maintenance of MAPs. She began developing pleural effusions due
to administered fluid and leaky capillaries, worsening her
respiratory status. Given her overall worsening septic picture
despite aggressive interventions, her family decided to focus on
comfort and stop the antibiotics and pressors.
# Respiratory distress: Pt was intubated for hypoxia and dyspnea
at [**Hospital1 **] [**Location (un) 620**]. She initially met criteria for ARDS w/ acute
onset, bilateral infiltrates, PaO2:FiO2 of 174 on admission.
Likely cause was acute infectious process cholangitis vs
pancreatitis. Patient was difficult to extubate due to poor
gag, AMS and agitation as well as subsequent volume overload
with fluid administration which did not resolve with diuresis.
She continued to fail her SBTs daily and ultimately could not be
extubated.
# Cholangitis: OSH CT abdomen showed common bile duct dilated to
2.8cm w/ multiple stones. Given her presentation with fevers
and hypotension, it was thought that she developed septic [**Location (un) **]
from cholangitis or possibly gallstone pancreatitis (see below),
although LFTs were never singificantly elevated. Started on
vancomycin and zosyn. ERCP on [**2194-1-28**] showed 2 strictures, both
dilated, and an 8mm irregular stone which was not evacuated. 2
stents were placed. Initially she seemed to be improving after
this intervention and antibiotics, with WBC count and fever
coming down, weaned off pressors. After 5 days, however, her
leukocytosis and fevers began to climb again while on seemingly
adequate coverage with vanco/zosyn.
# Gallstone pancreatitis: Pt's lipase elevated to [**2122**] by report
at OSH, now down in the 100s. Given presence of multiple stones
in CBD, pancreatitis thought to be very likely due to
gallstones. ERCP done with stents placed in CBD, stone was not
removed. Serum TG 68. Given IVFs given aggressively and bowel
rest initially. Patient started on tube feeding several days
into ICU stay, however she did not tolerate these.
# Arrhythmias: On the morning of admission, she went into
numerous runs of ventricular tachycardia, which were sustained
for [**11-7**] secs but spontaneously resolved without intervention.
Later in her course, she developed atrial fibrillation with RVR
that was not responsive to control with diltiazem 5mg x 2,
metoprolol 5mg x2 plus 10mg x1. Started amiodarone drip w/
bolus. Hemodynamically unstable requiring increased pressor dose
at that time. After about one day, spontaneously converted back
to sinus after changing pressor to neosynephrine from levophed.
Amio drip was stopped. Remained in normal sinus after that
until she passed away.
# Myoclonus: On the morning of admission, started having
twitching of left shoulder and leg concerning for seizure
activity. Neuro consulted and felt abnormal movements were not
seizure activity, believes it is more consistent with myoclonus.
EEG according to neuro shows no signs of seizure (even during
marked periods of movements), just diffuse slowing consistent
with encephalopathy
Medications on Admission:
Atenolol 12.5 mg daily
Aggrenox 1 tablet twice a day
calcium 600 mg daily
vitamin D 1000 units a day.
Insulin - 70/30, 10 units before supper
B12 1000mcg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic [**Month/Year (2) **]
Cholangitis
Gallstone pancreatitis
Hypoxic respiratory failure
Atrial fibrillation with RVR
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"0389",
"78552",
"51881",
"42731",
"99592",
"4019",
"2724",
"V5867",
"4280",
"4240"
] |
Admission Date: [**2148-7-8**] Discharge Date: [**2148-7-15**]
Service: SURGERY
Allergies:
Penicillins / Optiray 350 / Lactose
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p fall with multiple right sided rib fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a [**Age over 90 **] yo male s/p fall. Patient attempted to sit into
chair and fell backwards onto coffee table. no LOC.
Past Medical History:
Parkinson's disease
DM2 c/b neuropathy on neurontin
diplopia x one year, horizontal, no clear etiology per patient,
followed by ophtho
HTN
Migraines
s/p MI [**57**] yrs ago
s/p cataract [**Doctor First Name **] bilat
s/p laminectomy in [**2089**]
Social History:
Recent move to [**Location (un) 86**] from NY 10 days ago. lives with wife in
senior citizen home, + tob 30yrs x 1ppd, quit 30 yrs ago, no
etoh, no drugs, has 2 sons
Family History:
Father with strokes, no seizures, no parkinsons, sons are
healthy
Brief Hospital Course:
[**Age over 90 **] y.o. male with multiple right sided rib fracture after fall
on [**7-8**]. He was admitted to the surgery service and taken to the
regular floor and because of his age, poor pain control and
multiple rib fractures he was transferred to Trauma SICU. Acute
Pain Service was consulted and an epidural catheter was placed
for better pain control; oral analgesics were eventually
introduced and his pain is currently under much better control.
He has required nasal oxygen since admission with saturations in
low 90's. He is on scheduled nebulizer treatments as well and
using the incentive spirometer much more effectively pulling
volumes of ~1200-[**Numeric Identifier 20476**] cc's.
He was seen by Neurology at the request of his family due to his
tremors. A head CT was recommended which showed no evidence of
acute intracranial abnormalities or interval change. He was
continued on his home meds which include carbidopa/levodopa,
Aricept/namenda; following his discharge from rehab he should
follow up with his PCP and primary movement disorder specialist
for any adjustments of his meds.
With regards to his PMH he has known chronic kidney disease and
appears to have a baseline creatinine around 2.5. His home
medications for his type II DM were continued.
He has a recent community acquired pneumonia (completed
Levaquin) and UTI treated with Bactrim which has been stopped.
He was evaluated by Physical therapy and is being recommended
for acute level rehab after his hospitalization.
Medications on Admission:
aricept, nameda, glipizide, neurontin, allopurinol, simvistatin,
lisinopril, amlodipine, atenolol, mirtazapine,
carbidopa-levadopa
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: Two (2) Tablet PO HS (at bedtime).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Amlodipine 5 mg Tablet Sig: 1 [**12-23**] Tablet PO DAILY (Daily).
13. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation DAILY (Daily).
15. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection [**Hospital1 **] (2 times a day).
17. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
18. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to chest wall over rib fracture sites .
20. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
22. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
24. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
25. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
s/p Fall
Right rib fractures [**6-30**]
Urinary tract infection
Secondary diagnosis:
Pneumonia (resolving was being treated for this prior to his
fall)
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 hospitalized following a fall where you broke many ribs
on your right side. These injuries did not require any
operations; an epidural catheter was placed to deliver pain
medication to help with managing the discomfort associated with
rib fractures. Once your pain was better controlledthe catheter
was removed and you were started on oral pain medications. It is
important that you continue to do your breathing exercises and
use the spirometer t least 10x every hour you're awake.
You were also seen by Neurology while here in the hospital per
request of your family due to your tremors, there were no major
recommendations other than some minor adjustments of your
Parkinson medication which they have deferred to your primary
movment disorder specialist.
Followup Instructions:
Follow up in [**1-24**] weeks in [**Hospital 2536**] clinic for your rib fractures;
call [**Telephone/Fax (1) 600**] for an appointment. You will need an end
expiratory chest xray for this appointment.
Follow up with your primary providers after discharge from
rehab.
Completed by:[**2148-7-15**]
|
[
"5849",
"5990",
"40390",
"412",
"5859",
"2767"
] |
Admission Date: [**2140-10-7**] Discharge Date: [**2140-10-10**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Fatigue, melena
Major Surgical or Invasive Procedure:
EGD
Angiography with chemoembolization to L gastric artery
History of Present Illness:
87 yo F with h/o CAD s/p MI [**2135**], CHF EF 30-40%, AR, MR, TR,
GERD, remote history of breast cancer who presented with 4
episodes of melena. The patient reported feeling fatigued for
several days, and then having first episode of melena on the
evening of [**10-6**] and then had additional 3 episodes. She denies
any prior episodes of melena or bright red blood per rectum. On
presentation, vital signs were stable and the patient's initial
hematocrit was 26.6. NG lavage did not clear with 1000 cc NS,
clots present. She denied nausea, vomiting and abdominal pain.
She also denied any NSAID use or additional aspirin use (takes 1
full dose aspirin/day).
Past Medical History:
1. CAD, QWMI [**2135**]. Subsequent P-MIBI with slightly rev [**First Name (Titles) **] [**Last Name (Titles) 99599**]t in distal anterior/inferior walls and apex. EF 30-40% at
that time.
2. MR, TR, AI
3. Breast cancer [**2125**] s/p excision/radiation/tamoxifen
4. Depression
5. Gout
Social History:
Widow. Lives in [**Hospital3 4634**].
Family History:
Non-contributory
Pertinent Results:
[**2140-10-7**] 01:30AM BLOOD WBC-15.7*# RBC-2.69* Hgb-8.5* Hct-26.7*
MCV-99* MCH-31.8 MCHC-32.1 RDW-17.1* Plt Ct-295
[**2140-10-7**] 01:30AM BLOOD Plt Ct-295
[**2140-10-7**] 01:30AM BLOOD Neuts-76.6* Bands-0 Lymphs-18.8 Monos-3.3
Eos-0.8 Baso-0.4
[**2140-10-7**] 01:30AM BLOOD PT-13.2 PTT-22.7 INR(PT)-1.1
[**2140-10-7**] 01:30AM BLOOD Glucose-155* UreaN-57* Creat-0.9 Na-142
K-4.5 Cl-106 HCO3-23 AnGap-18
[**2140-10-7**] 01:30AM BLOOD CK(CPK)-42
[**2140-10-7**] 01:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2140-10-7**] 06:00AM BLOOD Calcium-8.0* Phos-3.9 Mg-1.7
[**2140-10-7**] 01:30AM BLOOD VitB12-435 Folate-GREATER TH
EKG: Normal sinus rhythm. Q waves in leads V1-V3 suggest prior
anterior myocardial
infarction. Q waves in leads III and aVF consistent with prior
inferior
myocardial infarction. Non-specific ST-T wave flattening.
Compared to the
previous tracing of [**2140-4-7**] the ST segment elevations in leads
V2-V3 are no
longer present. Otherwise, no diagnostic interval change.
Brief Hospital Course:
87 yo female with history of CAD, HTN, CHF and breast cancer
admitted with melena.
1. UGIB- The patient presented with fatigue and melena. Her
initial hematocrit was 26. An NG lavage in the ED did not clear
with >1 liter saline. GI and surgery were consulted and
recommended urgent EGD. Her initial EGD showed diffuse red blood
in the fundus and body of the stomach with no identifiable
source. She was then taken emergently to IR for angiography.
Angiogram showed no obvious source of bleeding; however, the
left gastric artery was prophylactically emoblized with gel
foam. The patient subsequently had no further bleeding episodes
and her hematocrit stablilized. Her aspirin was discontinued.
She received a total of 4units of PRBCs and was started on
protonix. An H.pylori was sent and is pending at the time of
discharge. She had a re-look EGD on [**10-10**] which showed severe
diffuse gastritis with contact bleeding. She will need
outpatient GI follow-up.
2. CAD: The patient denied chest pain however given her history
of CAD she was ruled out for MI with serial cardiac enzymes. She
had no events on telemetry. Her aspirin and beta blocker were
held on admission; however, once her hematocrit stabilized her
beta blocker was restarted.
3. HTN: Restarted on beta blocker.
4. Depression: The patient was continued on celexa and remeron
with trazadone prn at night.
5. Access: 2 large bore IVs were maintained at all times.
6. Px- Pneumoboots, PPI
7. Code: Full, HCP: daughter-[**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 99600**].
8. Dispo: She is being discharged to home with PCP and GI
[**Name9 (PRE) 702**]. VNA services have been arranged for a hematocrit
check 2-3 days after discharge.
Medications on Admission:
lopressor 25 [**Hospital1 **]
lasix 20 every other day
ecasa 325 daily
mvi
celexa 20 daily
remeron 15 daily
trazadone 25 daily
Discharge Medications:
1. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
HS (at bedtime).
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO every twelve (12)
hours.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Primary diagnosis:
UGIB
Secondary diagnosis:
CAD
Depression
HTN
Discharge Condition:
No further episodes of melena. HD stable. Hct stable x 48 hours.
Discharge Instructions:
Please take your medications as prescribed and keep all
scheduled appointments.
Call your doctor or return to the ER if you experience worsening
fatigue, abdominal pain, chest pain, black stools or bloody
stools.
Do not take any aspirin or NSAIDs until further notice.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] Where: [**Name12 (NameIs) **] Date/Time:[**2140-10-20**] 1:30
Completed by:[**0-0-0**]
|
[
"2851",
"53081",
"41401",
"412",
"311"
] |
Admission Date: [**2162-2-15**] Discharge Date: [**2162-3-6**]
Date of Birth: [**2101-7-7**] Sex: M
Service: MEDICINE
Allergies:
Influenza Vaccine,Trival [**2159**]
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
s/p TACE
Major Surgical or Invasive Procedure:
Transarterial chemoembolization [**2162-2-15**]
mechanical intubation
History of Present Illness:
This 60-year-old gentleman with h/o chronic HCV and cirrhosis
who has been followed with regular u/s and MRIs and recently
found to have two less than 1 cm nodules that subsequently
progressed to numerous nodules. He was referred to [**Hospital1 18**] and
underwent targeted liver biopsy, which confirmed HCC in three of
the five nodules, making him no longer transplant eligible.
Today he underwent his first chemoembolization.
For his HCV, he had been treated with ribavirin and interferon,
without response. He is followed closely for this and was
diagnosed with varices in the past but recent endoscopy did not
show any varices. He has no histopry of encephalopathy, ascites
or GI bleed.
Pt underwent chemoembolization today and during procedure became
very uncomfortable with epigastric abd pain [**8-25**], requiring
dilaudid, toradol. His BP was increased to SBP 200s, and
required also hydralazine. At this time, the patient is feeling
better, his pain has decreased to [**2159-12-19**]. He denies any
associated n/v/fever, chills, rigors, lightheadedness,
palpitations.
ROS: pt denies HA, weight chamges, fatigue, cough, SOB, CP,
dysuria, constipation. Full ten point ROS was otehrwise
negative.
Past Medical History:
1. HCV cirrhosis complicated by portal hypertension, esophageal
varices, hepatoma.
2. Diabetes.
3. COPD.
4. Orbit repair
Social History:
Social History: Half-pack-per-day smoker. No ETOH, no IVDA,
occasional marijuana use. lives with his wife and dog. He has
three grown children. He works as a postal clerk.
Family History:
Family History: His mother was diagnosed with breast cancer at
the age of 84. He has never been in contact with his father.
Physical Exam:
Exam on admission:
VS T current 96.6 BP 120/84 HR 52 RR 16 O2sat
95%RA
Gen: In NAD.
HEENT: PERRL, EOMI. No scleral icterus. No conjunctival
injection. Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS, no HSM. well healed surgical scars
at the umbilicus and right upper quadrant
Extremities: warm and well perfused, no cyanosis, clubbing,
trace pedal edema B. R leg immobilizer in place, adequate B
pulses peripherally, no bruits in R femoral puncture site
Neurological: alert and oriented X 3, CN II-XII intact.
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
GU: deferred.
Discharge exam:
PHYSICAL EXAM:
VS: 97.3 112/55 63 18 94%RA
General: no acute distress, jaundiced, a+ox3
HEENT: +scleral icterus, MMM
Neck: supple, unable to assess JVP, no LAD
Lungs: CTA, no wheezes or rales appreciated
CV: Regular rate and rhythm, no murmurs appreciated
Abdomen: soft, mild distended, bowel sounds present, no rebound
tenderness or guarding, no ascites
Ext: warm, well perfused, 2+ pulses, 1+edema, scrotal edema
Pertinent Results:
MRI performed on [**2161-11-24**] showed at least four hepatic lesions
up to 1 cm in size, two of which have slightly increased and
demonstrate washout and two with borderline washout; all
concerning for HCC. Several additional nodules which are
subcentimeter in size, are also concerning for HCC but too small
for definitive imaging diagnosis.
.
ADMISSION LABS:
[**2162-2-15**] 08:14AM WBC-4.1 RBC-4.31* HGB-13.8* HCT-43.9
MCV-102*# MCH-32.0 MCHC-31.4# RDW-14.8
[**2162-2-15**] 08:14AM PLT COUNT-100*
[**2162-2-15**] 08:14AM PT-12.8* PTT-36.5 INR(PT)-1.2*
[**2162-2-15**] 08:14AM GRAN CT-2140*
[**2162-2-15**] 08:14AM ALBUMIN-3.0* CALCIUM-8.5
[**2162-2-15**] 08:14AM ALT(SGPT)-45* AST(SGOT)-70* ALK PHOS-129 TOT
BILI-1.8*
[**2162-2-15**] 08:14AM UREA N-7 CREAT-0.8 SODIUM-142 POTASSIUM-3.5
CHLORIDE-106
[**2162-2-15**] 08:14AM AFP-11.6*
[**2162-3-6**] 05:20AM BLOOD WBC-6.3 RBC-3.07* Hgb-11.0* Hct-35.6*
MCV-116* MCH-35.8* MCHC-30.9* RDW-19.1* Plt Ct-95*
[**2162-3-6**] 05:20AM BLOOD PT-21.2* PTT-53.3* INR(PT)-2.0*
[**2162-3-6**] 05:20AM BLOOD Glucose-84 UreaN-11 Creat-0.7 Na-135
K-4.0 Cl-102 HCO3-33* AnGap-4*
[**2162-3-6**] 05:20AM BLOOD ALT-85* AST-167* LD(LDH)-499*
AlkPhos-199* TotBili-8.6*
[**2162-3-6**] 05:20AM BLOOD Albumin-2.0* Calcium-7.8* Phos-2.6*
Mg-1.9
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Status post TACE treatment, complicating by
pneumonia and
hepatic coma. New oxygen requirement.
Comparison is made with prior study, [**2-24**].
Right lower lobe opacity has markedly increased, a combination
of pleural
effusion and adjacent consolidation. Left lower lobe opacities
have
increased, could be due to atelectasis or pneumonia. There is no
pneumothorax. Cardiac size is normal. Right PICC tip is in the
lower SVC.
LIMITED ABDOMINAL ULTRASOUND
DATE: [**2162-2-26**].
COMPARISON: Liver ultrasound [**2162-2-18**], CT abdomen and
pelvis [**2162-2-20**], chemoembolization [**2162-2-15**].
CLINICAL INDICATION: 60-year-old man with hepatitis C status
post TACE
procedure, elevated and rising bilirubin of unclear etiology.
Question
obstruction.
TECHNIQUE: Multiple son[**Name (NI) 493**] grayscale images of the abdomen
were obtained
with select images supplemented with color Doppler and spectral
waveform
analysis.
FINDINGS:
The liver demonstrates coarsened echotexture consistent with
known cirrhosis.
Echogenic foci within the right hepatic lobe are consistent with
sequelae of
recent TACE procedure. This examination was not tailored to
evaluate for
liver lesions. The gallbladder is nondistended and demonstrates
diffuse
gallbladder wall thickening measuring up to 3 mm, stable from
prior CT
examination. There is no intra- or extra-hepatic biliary
dilation with the
common hepatic duct measuring 4 mm.
The main portal vein is patent, but demonstrates persistent
hepatofugal flow.
Visualized portions of the pancreas are within normal limits
with the
pancreatic head, uncinate process and tail non-visualized
secondary to
shadowing from overlying bowel gas. There is a small amount of
ascites seen
in the right lower quadrant and perihepatic locations. The
spleen measures
approximately 13.2 cm. Representative images of the kidneys
demonstrate no
hydronephrosis.
IMPRESSION:
1. No evidence of biliary obstruction. Circumferential
gallbladder wall
thickening, stable from recent CT, which likely relates to
underlying liver
disease.
2. Sequelae of recent TACE. Coarsened, heterogeneous liver
consistent with
cirrhosis with stable reversal of flow in the patent main portal
vein.
3. Small amount of perihepatic and right lower quadrant ascites.
The study and the report were reviewed by the staff radiologist.
Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2162-2-24**]
8:44 PM
[**Last Name (LF) 2437**],[**First Name3 (LF) **] [**First Name3 (LF) **] [**Hospital Unit Name 153**] [**2162-2-24**] 8:44 PM
MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 91738**]
Reason: evaluate for cause of obtunded state
[**Hospital 93**] MEDICAL CONDITION:
60 year old man with HCC who is obtunded s/p TACE
REASON FOR THIS EXAMINATION:
evaluate for cause of obtunded state
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: Altered mental status, status post chemoembolization
procedure.
COMPARISON: CT head from [**2162-2-22**].
TECHNIQUE: MRI of the head was obtained before and after
administration of
contrast per department protocol.
FINDINGS: There is no evidence of hemorrhage, infarction, edema,
mass, or
mass effect. Ventricles and sulci are age appropriate. Few
scattered
T2/FLAIR hyperintensities are seen in the periventricular white
matter, which
are nonspecific and may represent small vessel ischemic disease.
Visualized
orbits, paranasal sinuses are unremarkable. There is minimal
fluid signal in
bilateral mastoid air cells. The post-contrast images are
degraded by motion.
IMPRESSION:
Post-contrast images are markedly degraded by motion artifact.
There are
several nonspecific FLAIR signal abnormalities may represent
small vessel
ischemic disease. This limited study is otherwise normal.
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
[**2162-2-20**] 4:11 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] 11R [**2162-2-20**] 4:11 PM
CT ABD & PELVIS WITH CONTRAST Clip # [**Clip Number (Radiology) 91739**]
Reason: ? infarct or infection
Contrast: OMNIPAQUE Amt: 130
[**Hospital 93**] MEDICAL CONDITION:
60 year old man with hepatic encephalopathy post TACE
REASON FOR THIS EXAMINATION:
? infarct or infection
CONTRAINDICATIONS FOR IV CONTRAST:
post TACE
Final Report
INDICATION: 60-year-old male with hepatic encephalopathy status
post TACE.
Question liver infarct or abscess.
COMPARISON: CT dated [**2162-2-16**] and MR dated [**2161-11-24**].
TECHNIQUE: MDCT images were acquired from the lung bases through
the pubic
symphysis following administration of intravenous contrast with
multiplanar
reformations.
CT ABDOMEN: An enteric tube is in place with tip extending to
the stomach.
There is a small right pleural effusion with compressive
atelectasis. Mild
dependent atelectasis is present on the left. The heart is
normal in size
without pericardial effusion. Multivessel coronary arterial
disease is
present. A 1-cm saccular enhancing structure at the
gastroesophageal junction
(300A, 27 and 2, 8) likely represents a paraesophageal varix.
A small perihepatic ascites is present. The liver is shrunken
and nodular,
consistent with cirrhosis. The portal veins are attenuated but
appear patent.
The patient is status post TACE with hyperdense Ethiodol
accumulating in known
lesions in segments V, VI and VII. The remainder of the liver
demonstrates no
evidence of infarct. Two subcentimeter hypodense lesions are
seen within
liver, segments [**Doctor First Name 690**] (2, 14) and IVb (2, 21), too small to fully
characterize.
Additional lesions demonstrated on preceding MRI are not evident
on current
single phase exam. The gallbladder demonstrates circumferential
mural edema,
likely reflecting underlying liver disease.
The spleen is enlarged to 17 cm and associated with prominent
splenorenal and
gastrosplenic varices. The pancreas and adrenal glands are
unremarkable.
Bilateral kidneys enhance symmetrically without hydronephrosis
or hydroureter.
A 2-cm lower pole exophytic left renal cyst is present.
Additional
subcentimeter renal hypodensities are too small to fully
characterize. The
small and large bowel loops are normal in caliber.
Scattered tiny retroperitoneal and mesenteric lymph nodes do not
meet size
criteria for adenopathy. Moderate atherosclerotic calcifications
are seen in
the infrarenal aorta extending into common iliac arteries.
CT PELVIS: The bladder is partially collapsed, containing a
Foley catheter
and probably post-instrumentation air. The prostate appears
unremarkable. A
rectal tube is in place. There is no inguinal or pelvic sidewall
adenopathy.
Trace free fluid is in the pelvis.
BONE WINDOW: No focal concerning lesion. Remote right posterior
rib
fractures are seen in ribs 9 and 10. A hemangioma is noted in L4
vertebral
body.
IMPRESSION:
1. No evidence of intra-abdominal or intrapelvic abscess.
2. Cirrhosis, splenomegaly, varices, and small ascites,
consistent with
portal hypertension.
3. TACE treated liver, without evidence of infarct.
4. Two subcentimeter hypoattenuating liver lesions within
segments [**Doctor First Name 690**] and
IVb, too small to fully characterize. Additional known liver
lesions are
better depicted on preceding MRI dated [**2161-11-24**].
5. Small right pleural effusion with compressive atelectasis.
6. Bilateral renal cysts, some of which are too small to fully
characterize.
7. Remote right ninth and tenth chronic appearing posterior rib
fractures.
Brief Hospital Course:
REASON FOR HOSPITAL ADMISSION
60 y/o M with recently diagnosed multifocal HCC, s/p selective
segment VI + right lobar TACE [**2162-2-15**].
.
HOSPITAL COURSE:
# hepatic encephalopathy: s/p selective segment VI and right
lobar TACE [**2-15**] for hepatic carcinoma. He became hypertensive at
the the end of the procedure, thought to be due to pain with BP
up to SBP 200, controlled with dilaudid, toradol for pain and
hydralazine. Slowly became obtunded and altered following the
procedure. His bilirubin and LFTs trended up. non-contrast CT of
liver done showed ethidiol in most of R hepatic lobe and
additional mass, no extravasation. Pt with persistent
nausea/vomiting/pain post procedure and marked increase in
transaminases and bilirubin and developed encephalopathy and
hypoxia, see below. Pt was transferred to the [**Hospital Unit Name 153**] for
unresponsiveness. C/f infection given pt was febrile to 101 on
[**2-21**]. Source of infection unclear. [**Name2 (NI) **] evidence of abscess or
liver infarct on [**2162-2-20**] CT ab/pelvis. RUQ u/s was negative. No
ascites to tap. BCx and Ucx are no growth to date. CXR x 2
concernign for RLL opacification. Head CT w & w/o was neg [**2-18**].
Pt started on vanc/ctx/flagyl initially, then broadened to
vanc/zosyn. Amonia level was 177. Pt was unresponsive to sternal
rub, off sedation. EEG did not show signs of epileptic activity.
Head CT stable without evidence of bleed. MRI head was performed
which showed only nonspecific signal abnormalities likely from
small vessel ischemic disease, nothing acute. RUQ u/s with
doppler obtained but did not suggest significant hepatic artery
or portal vein obstruction. Tube feeds were started via NG.
After 3 days in the [**Hospital Unit Name 153**] with aggressive lactulose therapy and
rifaxamin transaminases and bili were trending down, and pt
regained consciousness. Amonium level went down to 70. It was
felt this had been a toxic-metabolic encephalopathy likely [**12-17**]
elevated ammonium levels. He was extubated and slowly
re-oriented, making jokes with his family. Subsequently
bilirubin went up to 10.8 and pt developed severe jaundice. Pt
did not complain of RUQ pain at this time but given elevated
bili RUQ u/s obtained without evidence of obstruction. While on
the hepatology floor Tbili stabilized 7-8 range. He was started
on ursodiol 600 mg [**Hospital1 **].
# Hypoxia: Patient developed new O2 requirement on the floo
following the TACE procedure with O2 sat down to 86% on RA ->
92% on 3L shovel mask. Given hepatic encephalopathy/coma,
patient had increasing difficulty clearing his secretions and
developed diffuse rhonchi on exam. c/f aspiration pneumonia as
he also had a fever to 101.2. Vanc/zosyn initiated, pt
transferred to the [**Hospital Unit Name 153**] and was intubated. After 3 days in the
[**Name (NI) 153**] pt was extubated and regained significant neurologic
function. Hypoxia resolved. A 13 days course of vanc/zosyn for
HAP was finished on [**3-6**].
# Volume overload: Likely combiniation of hepatic failure and
IVF. Patient started on spironolactone and furosemide.
.
# Coagulopathy: Pt with INR 3.3, thrombocytopenia, fibrinogen
64, concern for DIC. Most likely secondary to hepatic
decompensation and poor synthetic function. No schistocytes on
smear. Pt was given IV vitamin K and this remained stable.
.
# Hypernatremia: Likely secondary to decreased free water intake
given mental status, as well as hypovolemia from diarrhea ([**12-17**]
lactulose for hepatic encephalopathy). While intubated pt
without access to free water. Pt was given slow rate D5W with
careful monitoring of electrolytes. No issues after resolution
and patient taking PO.
# Fever: Source unclear, although concern for respiratory
process given new hypoxia and O2 requirement in the context of
high risk for aspiration. Blood/urine cultures unrevealing.
Vanc/zosyn was continued for 13 day course for possible HAP.
# Hepatocellular carcinoma s/p TACE: s/p selective segment VI
and right lobar TACE. Patient had marked increase in
transaminases and bili with development of hepatic
encephalopathy as above. Per oncologist, prognosis for HCC alone
would be about 1year.
# Thrombocytopenia: baseline 100s due to portal hypertension.
PLTs in the 50s while in the [**Hospital Unit Name 153**]. Pt without signs of active
bleeding and it was felt appropriate to monitor; no transfusions
were given. Remained stable while on the floor.
# DM2: Initially getting D5W for hypernatremia. Post extubation
pt began taking PO. Insulin sliding scale was continued.
.
# Portal HTN: controlled on home nadolol
.
# Communication: wife [**Name (NI) 2048**]: cell [**Telephone/Fax (1) 91740**], H [**Telephone/Fax (1) 91741**]
.
Pt was maintained as FULL CODE throughout the course of this
hospitalization.
.
TRANSITIONAL ISSUES:
# Patient will need LFT monitoring including Tbili for the next
5 days to evaluate stability. If stable at this point no need
to continue to check unless otherwise indicated.
# Patient will need Chem7 monitoring for the next 5 days to
evaluate for hypokalemia or worsening renal function. If stable
at this point no need to continue to check.
Medications on Admission:
NADOLOL - (Prescribed by Other Provider) - 40 mg Tablet - 3
Tablet(s) by mouth once a day
Discharge Medications:
1. nadolol 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
3. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
4. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
5. insulin lispro 100 unit/mL Solution Sig: as directed units
Subcutaneous four times a day: per insulin sliding scale.
6. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical twice
a day as needed for [**Female First Name (un) **]: apply to groin area.
9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab, [**Location (un) 38**], MA
Discharge Diagnosis:
Hepatoma s/p chemoembolization
Hepatic Coma/Encephalopathy
Pneumonia
HCV cirrhosis
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted for transarterial chemoembolization of your
liver cancer. Unfortunately, the procedure was complicated by
injury to the normal liver cells as well as the cancer cells
which led you to have decompensation requiring intubation. You
were also found to have a pneumonia, for which you were treated
with IV antibiotics. You were extubated several days later and
have remain stable on room air. We have continued to treat you
with diuretics as well as lactulose and rifaximin. We also had
the nutritionist meet with you and your family to help you with
your caloric intake and dietary choices. We wish you a fast
recovery and hope you make it home soon.
The following changes have been made to your medications:
START Simethicone 80 mg up to 4 times a day as needed for gas
(take separate from other meds by at least 1 hr)
START Insulin glargine 12 units at bedtime
START Insulin lispro per sliding scale
START Spironolactone 150 mg daily
START Furosemide 40 mg daily
START Lactulose 30 mL TID (can increase or decrease but titrate
to [**1-17**] bowel movements daily)
START Miconazole powder to groin as needed for rash
START Rifaxamin 550 mg twice a day
START Ranitidine 150 mg twice a day
START Ursodiol 600 mg twice a day
Followup Instructions:
You have the following appointments:
Department: LIVER CENTER
When: THURSDAY [**2162-3-18**] at 1:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: FRIDAY [**2162-4-2**] at 1:40 PM
With: XMR [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2162-4-16**] at 2:30 PM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"5070",
"51881",
"2760",
"496",
"25000",
"3051"
] |
Admission Date: [**2124-10-20**] Discharge Date: [**2124-11-21**]
Date of Birth: [**2066-9-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient was a 58-year-old
man who was admitted to the Neurology Service on [**10-20**].
He initially presented to [**Hospital **] Hospital on [**10-18**] with
the acute onset of left-sided weakness. A right
.................... hemorrhage was diagnosed by noncontrast
head CT. While at [**Hospital **] Hospital, the patient fell, and
the thalamic hemorrhage expanded. It was not clear whether
the hemorrhage resulted in the fall or the fall resulted in
expansion of the hemorrhage. He was transferred to the [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2124-10-20**].
The initial exam documented that he was awake, obeying
commands, had a right gaze preference, and that he had left
arm ................... and face weakness. He was witnessed
to have three generalized tonic clonic seizures on admission.
Ativan and Dilantin were started at that time.
Although it was felt that his hemorrhage was a typical
occasion for hypotensive bleed ...................., rapid
increase in size despite control of blood pressure and
increased right temporal edema suggested the possibility of
an AVM or dual sinus thrombosis. Conventional angiogram as
normal. The patient blood pressure was controlled with IV
drips in the unit, and Labetalol was discontinued on [**10-24**]. He did require intermittent Hydralazine and Lopressor
for blood pressure control.
His exam was fluctuating, but he had no overt seizures since
presentation. For this reason, an EEG was obtained that
showed generalized background slowing. While in the
Intensive Care Unit, the patient had an induced sputum which
showed gram-positive cocci. He was treated initially with
Vancomycin and then with Oxacillin. Mannitol was started on
[**10-24**] for the fear of increased intracranial edema, and
noncontrast head CT showed increased edema. Mannitol was
discontinued the next day.
Since that time, the patient had reasonable control of his
blood pressure. He has been transferred to the Neurology
Floor for further management.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Alcohol abuse.
3. Atrial fibrillation times five years off Coumadin for two
years. 4. Depression. 5. Question of history of
myocardial infarction 6. Hiatal hernia.
MEDICATIONS ON ADMISSION: Digoxin, Paxil, Tagamet, Aspirin,
Albuterol inhaler.
MEDICATIONS ON TRANSFER TO NEUROLOGY: Tylenol p.r.n., Paxil
20 mg p.o. q.d., Digoxin 0.25 mg p.o. q.d., Albuterol
inhaler, Dilantin 200 mg IV q.8 hours, Colace, Insulin
sliding scale, Zantac 150 mg IV b.i.d., Oxacillin 2 g IV q.6
hours, Neutra-Phos, Hydralazine 20 mg IV q.6 hours, Lopressor
75 mg p.o. b.i.d.
ALLERGIES: SULFA.
SOCIAL HISTORY: Unable to be obtained.
FAMILY HISTORY: Unable to be obtained.
PHYSICAL EXAMINATION: Vital signs: The patient was
afebrile, blood pressure 132/68, heart rate 96, oxygen
saturation 100%. General: He appeared older than stated
age. Difficult to arouse. HEENT: Dry mucous membranes.
Neck: No thyromegaly or carotid bruits. Pulmonary: Coarse
breath sounds throughout. Cardiovascular: Atrial
fibrillation. No murmurs. Abdomen: Soft and nontender.
Positive bowel sounds times four. Extremities: There were
1+ peripheral pulses. No edema. [**Month (only) **]: He was
sleeping but aroused by name being called loudly. He kept
his eyes open for a minute before falling back asleep. He
did not attempt to communicate. He blinks to threat.
Right-sided gaze preference. Pupils equal and reactive. He
had ................... strength in right hand. He could
squeeze with good effort. He moved right leg back and forth.
Left side was flaccid. Toes upgoing in the left, and
downgoing in right. Reflexes 3 in the upper extremities, 1+
at the patella, no ankle jerks.
LABORATORY DATA: White count 13.5, hematocrit 35.5 platelet
count 220; sodium 140, potassium 3.7, chloride 110, bicarb
26, BUN 19, creatinine 0.5, glucose 141, calcium 8.0,
magnesium 1.8, phosphate 3.0.
Head CT showed a large right .................. hemorrhage.
HOSPITAL COURSE: As noted above, the patient was initially
admitted to the Neurology [**Month (only) **]. After being transferred to
the Neurology floor on [**10-28**], he was continued on
Mannitol with an osmolality of 308. The patient's mental
status did not improve on Mannitol. His edema did not
resolve on CT. He was therefore tried on an empiric course
of Decadron, a 10 mg bolus followed by 4 mg p.o. q.6 hours.
The patient's alertness improved on the Decadron, and
follow-up head CT demonstrated somewhat less edema with
decreased flattening of the ventricle. The patient became
more alert, and the Decadron was tapered over two weeks. The
patient's Oxacillin was discontinued after a ten-day course.
He has had no further issues with pneumonia.
The patient continue to make progress. He was more alert,
although still not moving the left side of his body which has
remained hemiplegic. He was not taking adequate oral intake,
so he was evaluated by Gastroenterology for placement of PEG
tube. The PEG tube could not be placed because of his
ascites which was noted on ultrasound, and gastroesophageal
varices which was seen on EGD.
His current examination shows that he is awake and alert. He
does not know the date but knows that he was in [**Hospital6 1760**]. His eye movements are full
to both sides. His pupil are equal. He has a left facial
droop, and his head was turned to the right. He is
hemiplegic on the left side. His toes are upgoing in the
left.
The patient will be discharged to rehabilitation on [**2124-11-21**].
DISCHARGE DIAGNOSIS:
1. Right .................. hemorrhage.
2. Hypertension.
3. Portal hypertension complicated by varices.
DISCHARGE MEDICATIONS: Lopressor 75 mg p.o. b.i.d., Colace
100 mg p.o. b.i.d., Paxil 20 mg p.o. q.d., Zantac 150 mg p.o.
b.i.d., Digoxin 0.25 mg p.o. q.d., Lactulose 30 cc p.o. q.6
hours, Nadolol 20 mg p.o. b.i.d.
FOLLOW-UP: The patient will follow-up with myself, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1206**].
CONDITION ON DISCHARGE: He is discharged in fair condition.
DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 13.140
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2124-11-20**] 18:04
T: [**2124-11-20**] 18:17
JOB#: [**Job Number 45082**]
|
[
"51881",
"42731"
] |
Admission Date: [**2159-2-14**] Discharge Date: [**2159-2-21**]
Date of Birth: [**2100-12-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
cardiac catheterisation
History of Present Illness:
58M hx CAD s/p 2 stents 9 years prior to unknown artery, hep C,
HTN, HLP who presented to OSH today for elective L hip ORIF. He
was off his plavix and aspirin since [**2-5**] in preparation for
the procedure. Arrived to PACU @ 12:56pm today c/o chest
pressure with lateral ST elevations & HR in the 120s 127/80. He
received Plavix 600mg, [**Year (2 digits) **] 325 mg, IV ntg @ 20 mcg, heparin @
1300 units/hr no [**Year (2 digits) 1868**], lipitor 80mg, IV lopressor 5mg x2. HR
down to 72, BP 107/78 with 6/10 chest pressure. He was
transferred to [**Hospital1 18**] for urgent cath.
.
In cath lab, he underwent thrombectomy and DES to the LAD. He
underwent the procedure without complication, suffering only
some nausea. On transfer to the floor, he was hemodynamically
stable, awake and alert without complaints.
.
During the first few hours of his CCU course, he experienced an
episode of nausea with loss of conciousness and was found to be
pulseless. CPR was begun and stopped quickly after patient
regained conciousness. IO and central line access were obtained
as was epinephrine given during the code, with dopa and neo
afterward. Labs showed HCT of 24 from 32 at OSH prior to ORIF.
2L IVF were given and he was stabilized.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: ?MI in past, s/p multiple stents 9 years
prior
3. OTHER PAST MEDICAL HISTORY:
Hep C
HTN
HLP
Social History:
- Tobacco history: Quit 15yrs prior
- ETOH: 1-2 drinks per day
- Illicit drugs: none
Family History:
- Brother with cardiac disease, sister "on LVAD"
Physical Exam:
On admission: VS: Pulse 97 BP 108/56 100%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVD unable to be appreciated due to habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, heart sounds distant.
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. IO line in place on
the right tibial tuberosity.
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+
At discharge: 98.9, 125/78, 90, 20 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Central
line in place.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVD unable to be appreciated due to habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, heart sounds distant.
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. Left hip bandaged,
taut, tender to palpation.
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:
[**2159-2-14**] 05:32PM BLOOD WBC-10.7 RBC-2.76* Hgb-7.8* Hct-23.9*
MCV-87 MCH-28.4 MCHC-32.8 RDW-13.1 Plt Ct-188
[**2159-2-14**] 09:53PM BLOOD Hct-30.8*# Plt Ct-152
[**2159-2-15**] 01:37AM BLOOD Hct-30.2*
[**2159-2-15**] 06:13AM BLOOD WBC-9.2 RBC-3.38* Hgb-9.8*# Hct-28.8*
MCV-85 MCH-29.0 MCHC-34.0 RDW-13.9 Plt Ct-172
[**2159-2-15**] 11:03AM BLOOD Hct-26.4*
[**2159-2-15**] 04:01PM BLOOD Hct-23.1*
[**2159-2-15**] 11:28PM BLOOD Hct-25.7*
[**2159-2-16**] 03:15AM BLOOD WBC-8.4 RBC-2.94* Hgb-8.6* Hct-24.7*
MCV-84 MCH-29.3 MCHC-34.9 RDW-13.5 Plt Ct-138*
[**2159-2-16**] 08:43AM BLOOD Hct-23.8* Plt Ct-142*
[**2159-2-16**] 03:20PM BLOOD Hct-25.9*
[**2159-2-16**] 09:08PM BLOOD Hct-22.6*
[**2159-2-17**] 06:21AM BLOOD WBC-9.7 RBC-2.98* Hgb-8.8* Hct-24.8*
MCV-83 MCH-29.7 MCHC-35.6* RDW-13.7 Plt Ct-138*
[**2159-2-17**] 05:30PM BLOOD Hct-26.4*
[**2159-2-17**] 11:28PM BLOOD Hct-25.0*
[**2159-2-18**] 05:34AM BLOOD WBC-10.5 RBC-2.94* Hgb-8.6* Hct-24.6*
MCV-84 MCH-29.2 MCHC-34.9 RDW-13.1 Plt Ct-179
[**2159-2-18**] 03:00PM BLOOD Hct-24.1*
[**2159-2-19**] 03:59AM BLOOD WBC-11.4* RBC-2.86* Hgb-8.2* Hct-24.0*
MCV-84 MCH-28.9 MCHC-34.4 RDW-13.3 Plt Ct-230
[**2159-2-20**] 05:10AM BLOOD WBC-12.2* RBC-2.98* Hgb-8.6* Hct-25.4*
MCV-85 MCH-28.7 MCHC-33.6 RDW-12.9 Plt Ct-313
[**2159-2-20**] 05:10AM BLOOD Neuts-68.7 Lymphs-15.1* Monos-10.5
Eos-5.3* Baso-0.4
[**2159-2-14**] 05:32PM BLOOD Plt Ct-188
[**2159-2-14**] 05:32PM BLOOD PT-16.7* PTT-46.9* INR(PT)-1.6*
[**2159-2-14**] 09:53PM BLOOD Plt Ct-152
[**2159-2-15**] 06:13AM BLOOD Plt Ct-172
[**2159-2-16**] 03:15AM BLOOD PT-14.4* PTT-28.3 INR(PT)-1.3*
[**2159-2-16**] 03:15AM BLOOD Plt Ct-138*
[**2159-2-16**] 08:43AM BLOOD Plt Ct-142*
[**2159-2-17**] 06:21AM BLOOD PT-14.1* PTT-29.0 INR(PT)-1.3*
[**2159-2-14**] 05:32PM BLOOD Glucose-208* UreaN-19 Creat-0.9 Na-140
K-3.6 Cl-111* HCO3-18* AnGap-15
[**2159-2-14**] 09:53PM BLOOD Na-137 K-4.4 Cl-108
[**2159-2-15**] 06:13AM BLOOD Glucose-162* UreaN-25* Creat-1.2 Na-138
K-4.8 Cl-108 HCO3-24 AnGap-11
[**2159-2-16**] 03:15AM BLOOD Glucose-126* UreaN-17 Creat-0.7 Na-135
K-3.8 Cl-106 HCO3-23 AnGap-10
[**2159-2-16**] 03:20PM BLOOD Glucose-139* Na-135 K-4.3 Cl-103 HCO3-23
AnGap-13
[**2159-2-17**] 06:21AM BLOOD Glucose-121* UreaN-10 Creat-0.8 Na-137
K-3.7 Cl-104 HCO3-27 AnGap-10
[**2159-2-17**] 05:30PM BLOOD Na-136 K-3.9 Cl-102
[**2159-2-18**] 05:34AM BLOOD Glucose-116* UreaN-11 Creat-0.7 Na-137
K-3.8 Cl-103 HCO3-26 AnGap-12
[**2159-2-18**] 03:00PM BLOOD Na-135 K-4.3 Cl-101
[**2159-2-19**] 03:59AM BLOOD Glucose-127* UreaN-16 Creat-0.8 Na-137
K-4.1 Cl-103 HCO3-26 AnGap-12
[**2159-2-20**] 05:10AM BLOOD Glucose-112* UreaN-15 Creat-0.9 Na-138
K-4.4 Cl-103 HCO3-23 AnGap-16
[**2159-2-14**] 05:32PM BLOOD CK(CPK)-1709*
[**2159-2-15**] 01:37AM BLOOD CK(CPK)-1718*
[**2159-2-15**] 06:13AM BLOOD CK(CPK)-1279*
[**2159-2-15**] 11:03AM BLOOD CK(CPK)-924*
[**2159-2-14**] 05:32PM BLOOD CK-MB-174* MB Indx-10.2* cTropnT-3.94*
[**2159-2-14**] 09:53PM BLOOD CK-MB-241*
[**2159-2-15**] 01:37AM BLOOD CK-MB-191* MB Indx-11.1* cTropnT-6.80*
[**2159-2-15**] 06:13AM BLOOD CK-MB-129* MB Indx-10.1* cTropnT-6.77*
[**2159-2-15**] 11:03AM BLOOD CK-MB-85* MB Indx-9.2* cTropnT-5.64*
[**2159-2-14**] 05:32PM BLOOD Calcium-6.8* Phos-3.4 Mg-1.4*
[**2159-2-15**] 06:13AM BLOOD Calcium-7.8* Phos-3.9 Mg-2.3
[**2159-2-16**] 03:15AM BLOOD Calcium-7.7* Phos-1.5*# Mg-2.0
[**2159-2-16**] 03:20PM BLOOD Calcium-8.0* Phos-3.1# Mg-2.0
[**2159-2-17**] 05:30PM BLOOD Calcium-8.1* Mg-1.8
[**2159-2-18**] 05:34AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9
[**2159-2-18**] 03:00PM BLOOD Mg-2.2
[**2159-2-19**] 03:59AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
[**2159-2-20**] 05:10AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.2
.
Discharge labs:
[**2159-2-21**] 19 122 AGap=14
4.8 25 0.8
Ca: 8.5 Mg: 2.0 P: 3.8
13.6>8.2/24.5<353
PT: 13.9 PTT: 29.9 INR: 1.3
.
[**2159-2-14**] CARDIAC CATHETERISATION
1. Selective coronary angiography of this right-dominant system
demonstrated severe 2 vessel CAD. The LMCA had no significant
stenosis.
The mid LAD had a large occlusive thrombus in the prior stent.
The LCX
had 60% stenosis at the origin. A large OM1 branch had 60%
stenosis. The
dominant RCA had 80% stenosis in the mid RPDA branch.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressures with a measure central aortic pressure of 114/80/83.
3. Left ventriculography was deferred.
4. Very late stent thrombosis in the LAD (previous stent
deployed in
[**2149**]) with acute antero-lateral MI.
5. LAD stenosis successfully treated by aspiration thrombectomy
and
deployment of a 3.0 x 12 mm Promus drug-eluting stent.
.
FINAL DIAGNOSIS:
1. Acute anterior [**Year (4 digits) **].
2. 3 vessel CAD.
3. Very late stent thrombosis in the LAD treated successfully
with
aspiration thrombectomy and deployment of a 3.0 x 12 mm Promus
drug-eluting stent.
4. [**Year (4 digits) **] 325mg/day; plavix 75mg/day for minimum 1 year.
.
[**2159-2-14**] HIP XRAY WITH PELVIS
Left total hip arthroplasty in satisfactory alignment with no
evidence of immediate post-surgical complications.
.
[**2159-2-15**] ECHOCARDIOGRAPHY
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with moderate anterior septal hypokinesis and mild
inferior septal hypokinesis. 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.
.
IMPRESSION: Moderate hypokinesis of the anterior septum, mild
hypokinesis of the inferior septum. No significant valvular
abnormality seen.
.
[**2159-2-16**] CT Abdomen/Pelvis without contrast
1. No retroperitoneal hematoma.
2. Expected soft tissue edema and subcutaneous air, consistent
with
post-surgical changes from left total hip arthroplasty.
3. Bilateral fat-containing inguinal hernias.
.
[**2158-2-19**] CXR
No evidence of pneumonia.
Brief Hospital Course:
58M hx CAD with LAD and ?other stents 9 years prior, hep C, HTN,
HLP who presented to OSH for elective L hip ORIF. In PACU,
developed substernal chest pressure, was found to have ST
elevations in V2-V4 and transferred for cath.
.
# CAD: Unclear history of cardiac disease, has had at least one
stent to the LAD ~9 years prior. Post-operatively had ST
elevations in the precordial leads. Was plavix loaded, put on
hep gtt without [**Last Name (LF) 1868**], [**First Name3 (LF) **] 325, atorva 80, was on a nitro gtt
for hypertension and received lopressor 5 IV x2. Cath showed
large LAD thrombus in the old stent, s/p thrombectomy with [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 5175**]. EKG after stent showed resolution of ST elevations.
He will continue on aspirin, plavix, atorvastatin, metoprolol
and lisinopril following discharge.
.
# PEA: On [**2158-2-14**], patient experienced a PEA arrest. Likely
vagal episode (nausea prior to event) versus hypovolemia (blood
loss into RP versus into hip). Stabilized after short course of
CPR and epinephrine, transiently on dopamine/neo. s/p 2L IVF.
HCT 24 from 32 at OSH. Currently stable. No further PEA
episodes.
.
# L hip ORIF: s/p elective surgery. Possible site of bleeding
for PEA etiology. Unfortunately due to [**Date Range **] and DES, will
require [**Date Range **]/plavix. ongoing bleeding, likely into left hip.
Ortho was not concerned for compartment syndrome currently.
Hematocrit was currently stable. CT [**Last Name (un) 103**]/pelvis was not
concerning for RP bleed. He received a total of 6 units PRBCS
and 1 unit FFP. His hemotcrit subsequently stabilised and was
trending up at the time of discharge. He will continue lovenox
for DVT prophylaxis for a total of 4 weeks.
.
# Leukocytosis: WBCs up to 12.2 currently from 8.4 on [**2158-2-16**].
Etiology unclear. [**Name2 (NI) **] localizing symptoms. LIkely [**3-15**]
inflammation from recent hip surgery and cardiac manipulation.
cx ngtd. UA and CXR were negative for infection.
.
# CHF: No history of CHF. Appears hemodynamically stable
without evidence of pulmonary congestion. In setting of volume
resuscitation/blood and anterior [**Last Name (LF) **], [**First Name3 (LF) **] monitor fluid
status and oxygenation. We restarted ACE inhibitor and he will
followup with cardiology as an outpatient.
.
# HTN: Restarted home lisniopril one Hct was stable.
.
# HLD: increased atorvastatin to 80 daily.
Medications on Admission:
Toprol XL 50
Atorvastatin 40
Plavix 75 (held on [**2-5**] for procedure)
Lisinopril 10
Aspirin 81 (held on [**2-5**] for procedure)
MVI
Discharge Medications:
1. aspirin 325 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 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 24 days.
Disp:*48 * Refills:*0*
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. metoprolol succinate 200 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:*0*
7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours:
please hold for sedation, do not take if you are drowsy or are
having difficulty breathing. Please do not drive while you are
taking this medication.
.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Primary: ST Elevation Myocardial Infarction, PEA Arrest
Secondary: s/p Open Reduction Internal Fixation, Acute Blood
Loss
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 the [**Hospital1 771**]. You were admitted with a heart attack
following your hip surgery. We performed a cardiac
catheterisation and found some blockage to the blood flow to
your heart, which we repaired by placing a stent.
During your stay in our intensive care unti, you transiently
lost your pulse. We performed CPR and were able to rapidly
restore your pulse. This episode was probably due to some blood
loss during your surgery, and you had no further episodes during
your hospitalization. We monitored your hematocrit (a measure
of your blood levels) and found that it was dropping, probably
due to slow ongoing bleeding into your left hip. We gave you
blood transfusions and your hematocrit level was stable by the
time of discharge.
We made the following changes to your medications.
-INCREASED Metoprolol XL to 200 mg daily
-INCREASED Atorvastatin to 80 mg daily
-INCREASED Lisinopril to 20 mg daily
-INCREASED Aspirin to 325 mg daily
-STARTED Enoxaparin
-STARTED Percocet
Please continue taking your other medications as usual.
Please followup with your doctors, see below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 251**] T.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appointment: TUESDAY [**2-27**] AT 2:45PM
Department: CARDIAC SERVICES
When: MONDAY [**2159-3-26**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You will also need to followup with your orthopedic surgeon at
[**Hospital3 **]. Please call his office to make a followup
appointment regarding your hip.
Completed by:[**2159-2-21**]
|
[
"2851",
"V4582",
"2724",
"4019",
"41401",
"412",
"V1582"
] |
Admission Date: [**2131-11-6**] Discharge Date: [**2131-11-20**]
Date of Birth: [**2051-11-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
1. Colon Cancer
2. Recurrent Ventral Hernia
Major Surgical or Invasive Procedure:
[**2131-11-6**]: 1. Exploratory laparotomy. 2. Removal of mesh. 3. Left
colectomy. 4. Ventral hernia repair with component separation.
History of Present Illness:
79M w multiple medical problems who on screening colonoscopy
[**8-7**] was found to have a descending colon adenocarcinoma.
Preoperatively, patient denies any symptoms that could be
related to his diagnosed cancer, including bleeding, abdominal
pain, nausea, vomiting, change in bowel movements, change in
size
of bowel movements, constipation or any other problems. [**Name (NI) **] does
have a large lump on his belly, which looks like an incarcerated
hernia and occasionally causes him some discomfort; however, he
never had any obstruction symptoms from this. At this point, he
is feeling well and does not have any concerns.
Past Medical History:
# Colon adenocarcinoma
# Diabetes type 2
# CAD status post stent
# Hypertension
# SVT (AVNRT) status post ablation
# Hypercholesterolemia
# Rib fracture
# Dislocated right shoulder
# Reactive airway disease during the winter months,
# Epigastric hernia that was repaired in [**2116**] under general
anesthesia
# Cataract surgery of his left eye.
Social History:
- Spanish speaking
- Lives alone in a senior housing apartment
- Has 3 sons in the area
- Tobacco: 20 pack year smoking history. Quit 15 years ago.
- Alcohol: None. Quit many years ago
- Illicits: None
Family History:
Mother died of unknown causes.
Father died of heart disease at the age of 86, had heart disease
starting in his 50s.
Sister has diabetes.
Physical Exam:
Physical Exam on Discharge
Tmax: 99.3 ??????F, Tcurrent: 97.5??????F, HR: 75-108bpm, BP
(126-150)/(57-84)mmHg, RR 22 insp/min, SpO2 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Reduced BS on left, + wheeze
CV: Tachy, PMI not displaced, no murmors appreciated
Abdomen: soft, non-distended, non-tender;
GU: + foley
Ext: palpable pulses, 1+ lower extremity edema, +[**Male First Name (un) **] stockings
Pertinent Results:
=================
LABS
=================
[**2131-11-6**]
- CBC with differentials: WBC-7.2 RBC-3.62* Hgb-10.0* Hct-30.7*
MCV-89 MCH-27.7 MCHC-31.1 RDW-16.3* Plt Ct-276 Neuts-79* Bands-0
Lymphs-14* Monos-4 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0
- CHEM 6: UreaN-27* Creat-1.4* Na-143 K-4.5 Cl-110* HCO3-21*
- Cardiac enzymes @ 1:52PM: CK(CPK)-453* CK-MB-4 cTropnT-0.04*
- Cardiac enzymes @ 10:22PM: CK(CPK)-699* CK-MB-4 cTropnT-0.05*
[**2131-11-7**]
- CHEM 7: Glucose-139* UreaN-38* Creat-2.2* Na-142 K-5.0 Cl-109*
HCO3-20*
- Cardiac enzymes @ 06:36AM: CK(CPK)-1124* CK-MB-4 cTropnT-0.04*
- CK (CPK) @ 02:22PM: 1268*
- Lactate: 2.7*
- UA: Coloer-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016 Blood-SM
Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG
Urobiln-NEG pH-5.0 Leuks-SM RBC-16* WBC-7* Bacteri-FEW
Yeast-NONE Epi-<1 CastHy-5* AmorphX-RARE Mucous-RARE
Eos-NEGATIVE
- Urine lytes: UreaN-470 Creat-162 Na-15 K-90 Cl-44 Calcium-0.6
Uric Ac-18.3 Osmolal-440
[**2131-11-8**]
- LFTs: ALT-16 AST-31 AlkPhos-79 TotBili-0.3
- CK (CPK) @ 5:35AM: 1171*
[**2131-11-9**]
- CBC: WBC-9.1 RBC-2.25* Hgb-6.5* Hct-19.8* MCV-88 MCH-28.7
MCHC-32.6 RDW-17.0* Plt Ct-247
- Cardiac enzymes @ 08:30PM: CK (CPK) 688* CK-MB-3 cTropnT-0.03*
[**2131-11-10**]
- Lactate: 1.3
[**2131-11-11**]
- CBC: WBC-6.1 RBC-3.08* Hgb-9.0* Hct-27.2* MCV-88 MCH-29.1
MCHC-33.0 RDW-16.6* Plt Ct-272
- CHEM 7: Glucose-181* UreaN-47* Creat-1.7* Na-142 K-3.6 Cl-102
HCO3-28
===================
MICROBIOLOGY
===================
[**2131-11-6**]
- abdominal wound swab: 1+ Polymorphonuclear leukocytes, wound
culture negative, NGTD anaerobics
[**2131-11-7**]
- Urine cx- negative
[**2131-11-8**]
- Blood cx 1x- NGTD
[**2131-11-12**]: C. diff: POSITIVE
==================
IMAGING
==================
[**2131-11-6**]
- CXR: Left lower lobar collapse with small pleural effusion.
Diaphragmatic injury from procedure is possible, but unlikely.
[**2131-11-9**]
- CXR: Increased moderate biventricular congestive heart
failure.
- Echo: The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is mild anterior leaflet
mitral valve prolapse. An eccentric, inferolaterally directed
jet of mild-moderate ([**12-30**]+) mitral regurgitation is seen. Due to
the eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect). There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mitral valve prolapse with at least mild-moderate
mitral regurgitation. Mild pulmonary artery systolic
hypertension. Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Compared
with the prior study (images reviewed) of [**2131-7-6**], the
estimated pulmonary artery systolic pressure is now higher. The
other findings are similar.
PATH [**2131-11-6**]:
1.7cm colonic adenocarcinoma
T1N1aMx; [**1-9**] lymph nodes positive
Brief Hospital Course:
79 yo Spanish speaking M w/ colon adenocarcinoma (dx in [**8-7**]),
DM, CAD s/p stent LAD/first diag ([**2123**]), SVT s/p ablation, HTN,
DLP, CRI (Cr 1.4) s/p left colectomy with component
separation/ventral hernia repair, drainage of abcess related to
old abdominal mesh. Immediate postoperative course c/b
hypertension, tachycardia, and hypoxia transferred to [**Hospital Unit Name 153**] for
further care. Consults were obtained from the [**Hospital Ward Name 332**] ICU,
cardiology and geriatrics for assistance with this patient's
care.
Neuro: Pre-operatively, an epidural was placed for pain control.
Post-operatively, the patient continued with epidural
anesthesia with good effect and adequate pain control. Epidural
was removed on POD4 and pain control managed with intermittent
morphine IV. When tolerating oral intake, the patient was
transitioned to oral pain medications. Per recommendations from
geriatrics, narcotic pain medications were discontinued on POD9
secondary to increased risk delirium in geriatric population.
Pain control then managed with non-narcotic po medication.
CV: The patient was initially hypertensive postoperatively but
then became hypotensive likely secondary to CHF. Cardiac
enzymes were drawn times three to rule out myocardial infarction
and they were negative. A cardiology consult was sought on
POD3, there assessment was that underlying mitral regurgitation,
continued hypertension, and overall positive fluid balance since
surgery were contributing to his CHF picture. A TTE was
obtained on POD3 and results are above. Patient was found to be
intermittently in atrial fibrillation and recommendations per
cardiology were followed-beta blocker, amlodipine were titrated
to appropriate heart rate and blood pressure. Patient's fluid
balance was carefully monitored and he intermittently received
lasix vs fluid to achieve euvolemia such that he was adequately
supported from a cardiovascular standpoint without fluid
overload compromising his pulmonary status. Patient also was
transfused packed RBCs when appropriate to maintain adequate
volume status without fluid overload. Patient's vital signs
were routinely monitored.
Pulmonary: Postoperatively, patient required non-rebreather in
ICU setting to maintain oxygenation. As patient was diuresed
oxygen requirement diminished and patient was transferred to
floor on POD6 on supplemental oxygen via nasal canula and
intermittent nebulizer treatments for shortness of
breath/wheezing. The patient's fluid balance was balanced as
per above. Patient with baseline COPD and patient received
intermittent CXR's in addition to monitoring of vital signs to
achieve adequate oxygen saturation.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. He was found to have elevated creatinine
postoperatively consistent with ATN per his FeNa. He was
hydrated judiciously and his renal function eventually returned
to baseline. Patient's ACE inhibitor was held during admission
secondary to increased creatinine. It may be restarted per his
PMD after assessment of renal function one week postoperatively.
His diet was advanced when appropriate, which was tolerated
well. Foley was maintained throughout admission and will be
continued following discharge given sensitive fluid balance
issues and need for urine output monitoring. Intake and output
were closely monitored.
ID: The patient was given appropriate preoperative antibiotics.
These were continued postoperatively (cipro/flagyl) as empiric
coverage for possible infection. On POD4, patient was found to
be positive for C diff and started on po vancomycin and IV
flagyl. Patient's number of bowel movements decreased on
antibiotic therapy and he will be discharged to complete a 10
day course. The patient's temperature was closely watched for
signs of infection.
Endocrine: Patient was maintained on an insulin sliding scale
and diabetic appropriate diet secondary to his DM2. Geriatrics
assisted in management of his blood sugars which
Hem/Onc: Patient transfused as per above to maintain adequate
cardiopulmonary function. Pathology showed T1N1aMx colonic
adenocarcinoma. He will be followed by medical oncology and
surgery for management of this issue.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#14, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating with assistance, with a foley in place, and pain was
well controlled.
Medications on Admission:
Home Medications:
AMLODIPINE 5 mg daily
ATORVASTATIN 40 mg daily
LISINOPRIL-HYDROCHLOROTHIAZIDE 20 mg-25 mg daily
METOPROLOL TARTRATE 50 mg daily
NITROGLYCERIN 0.4 mg Tablet, Sublingual prn
RANITIDINE HCL 150 mg Tablet [**Hospital1 **]
SITAGLIPTIN [JANUVIA] 50 mg daily
ASPIRIN 325 mg Tablet daily
Medications upon transfer to [**Hospital Unit Name 153**]:
Heparin 5000 UNIT SC BID
1000 ml LR Continuous at 85 ml/hr
Hydromorphone 10 mcg/ml + Bupivacaine 0.1% 1 mg/ml ED
Insulin SC (per Insulin Flowsheet)
Acetaminophen 1000 mg PO TID
Ipratropium Bromide Neb 1 NEB IH Q6H
Ciprofloxacin 200 mg IV Q12H
Metoclopramide 10 mg IV Q6H
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: [**11-6**] @ 1243
DiphenhydrAMINE 12.5-25 mg PO/IV Q6H:PRN Itching
Metoprolol Tartrate 10 mg IV Q6H
Droperidol 0.625 mg IV Q6H:PRN Nausea
Nitroglycerin SL 0.4 mg SL PRN chest pain
Enalaprilat 0.625 mg IV Q6H
Ondansetron 4 mg IV Q6H:PRN nausea
Famotidine 20 mg IV Q24H
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: 20.3 ml PO Q6H
(every 6 hours) as needed for pain.
2. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for C diff for 4 days.
Disp:*40 Capsule(s)* Refills:*0*
3. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for pruritis.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q4H (every 4
hours) as needed for shortness of breath or wheezing.
8. ipratropium bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 4 days.
Disp:*30 Tablet(s)* Refills:*0*
10. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day) for 10 days: Please give no sooner than
three hours prior to vancomycin dosing. Thank you. .
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
12. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
13. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Colon Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the Colorectal Surgery service for Open
Left Colectomy and Ventral Hernia Repair.
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
wheeze.
*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 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 concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash 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.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in three weeks. Call
([**Telephone/Fax (1) 3378**] for an appointment. Thank you.
Completed by:[**2131-11-20**]
|
[
"5845",
"5180",
"9971",
"2762",
"4240",
"42731",
"25000",
"40390",
"2859",
"5859",
"2720",
"4280",
"53081",
"V4582",
"V1582"
] |
Admission Date: [**2193-6-18**] Discharge Date: [**2193-6-28**]
Date of Birth: [**2123-2-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Respiratory failure
.
Major Surgical or Invasive Procedure:
PICC line placement
Endotracheal intubation
.
History of Present Illness:
70 yo woman with h/o CAD, CABG, last DES [**1-17**], IDDM, CKD, CHF
on lasix here from [**Hospital3 4107**] with R sided PNA, NSTEMI. She
reports chest pain, typical for her angina but resistent to SLNG
(5-6 tabs) over the last 5 days (longer duration than normal).
She also c/o dizziness/lightheadedness, nausea/vomitting
(bilious, NB) for the past 2 days, with diarrhea yesterday
(watery, non-bloody, no mucous, but black at baseline given
iron), with no abdominal pain. She notes fever to 102 at home
yesterday. She denies ill contacts, travel, exotic foods. She
does not normally have diarrhea but sometimes can get n/v with
her chest pain. She describes the chest pain as sharp, rated
[**8-22**] yesterday, currently very dull. She notes being seen at [**Hospital1 2177**]
and [**Hospital **] hosp over the past 5 days and told she had
musculoskeletal chest pain. She denied cough to me but did
endorse a feeling of wheezing. She has home oxygen only for
anginal relief and O2 sat monitoring (baseline 95-96% on RA) but
noted decreased O2 sat yesterday to 70's on RA. She was seen at
[**Hospital1 **] [**6-17**], T 101.2 HR 96 RR 18 BP 124/96 Sat 95% NRB, CK 171,
Trop 1.67, WBC 16.3, (N 88, L 5). She was found on CXR with
'right lung white out' and NSTEMI. She was given levofloxacin
500mg iv, compazine iv, 0.5mg ativan, zofran, 1 gm tylenol,
aspirin 325mg, 1" nitro paste.
.
She was then transferred here. VS on arrival T 101, HR 92 BP
158/85, RR 18 Sat 85% on RA. She was given 2.5mg iv metoprolol,
1L NS, 4 gm mag. Her ECG was similar to [**Hospital1 **], but trop
continued to rise. She was started on heparin gtt. Stool guaiac
negative here.
.
ROS: wt stable, no increased swelling, no HA, chronic
(unchanged) photphobia, no neck stiffness, no congestion, denies
cough to me, no orhtopnea, denies palpitation, sore throat,
dysuria, hematuria, rash, + myalgias and chronic joint pain.
Past Medical History:
-CAD: s/p CABG, last DES 12/05 per her, with unstable angina
(comes and goes at rest), Dr. [**Last Name (STitle) 58088**] called, cardiologist at
[**Hospital1 2177**], s/p CABG with LIMa, SVG x2, cath x2, one complicated by LAD
disection, no further anatomical intervtion for improvement, she
does go for outpatient counterpulasion treatments for treatment
of her CAD/CHF
-IDDM: insulin x22 years, A1C 9 last, s/p B toe nail removal [**3-16**]
DM
-CKD (baseline crt 1.9)
-CHF
-low back surgery
-arthiritis: osteo ? hands, knees
-Le edema
-vertigo
-PVD
Social History:
Widowed, many children live near by, lives with one son (he's
moving), no tobacco, etoh, illicit drug use now or in past.
Family History:
Mother rheumatic heart dx, father cva.
Physical Exam:
VS: T 97.9 HR 85 BP 163/80 RR 26 Sat 99% on NRB
GEN: NAD, comfortable, able to speak in full sentences
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM
Neck: supple, no LAD, JVP to 8 cm
CV: RRR, nl s1, s2, III/VI HSM at RUSB with radiation to B
carotids, no rubs/gallops
PULM: Diffuse expiratory wheezes, scattered rales, no accessory
muscle use but abdominal paradox in breathing
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL radial and DP; soft tissue
swelling of MCP's B without erythema, warmth, tenderness, B
tenderness to MCP squeeze, bony deformity of DIP's/PIP's.
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated.
Skin: no rash
Pertinent Results:
PERTINENT LABS:
STUDIES:
CXR [**6-18**]: 1. Focal opacity at right lung base concerning for
pneumonia. 2. Likely mild pulmonary edema. 3. Probable small
bilateral pleural effusions.
.
TTE [**6-18**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is moderate regional left ventricular systolic dysfunction
with hypokinesis of the mid- and distal segments of the anterior
wall, and severe hypokinesis/akinesis of the distal [**2-14**] of the
left ventricle, c/w LAD disease. The remaining segments contract
normally (LVEF = 30-35%). No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. There are three moderately thickened aortic
valve leaflets. There is mild aortic valve stenosis (area
1.2-1.9cm2). The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is moderate pulmonary artery systolic hypertension. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Mild calcific aortic stenosis. Moderate
pulmonary hypertension.
.
BILATERAL LENIS [**6-18**]: No deep vein thrombosis identified in
either leg.
.
CXR [**6-20**]: Significant interval improvement in bilateral perihilar
opacities is consistent with resolution of pulmonary edema.
Still present bibasilar consolidations might represent
atelectasis and/or infectious process as well as there is no
significant change in bilateral pleural effusions.
.
CT TORSO [**6-20**]: 1. Cardiomegaly with small bilateral pleural
effusions and mild pulmonary edema. Mild bibasilar atelectasis
vs aspiration.
2. Extensive coronary artery calcification.
3. Normal positioning of lines and tubes.
4. Nonobstructing renal calculus measuring 3 mm in the lower
pole of the right kidney.
5. Extensive mesenteric vascular calcifications and renal
arterial
calcifications.
6. Scoliosis with degenerative changes.
7. Two small pulmonary nodules measuring less than 4mm. One year
follow-up chest CT or comparison with prior outside studies is
recommended.
.
TTE with bubble study [**6-21**]: No obvious intracardiac shunt
detected.
.
CXR [**6-22**]: Combination of bibasilar atelectasis and small right
pleural effusion are unchanged over the past two days. Moderate
cardiomegaly is stable though larger today than yesterday
accompanied by increase in caliber of the central pulmonary
arteries and azygos vein, all of which may be due to interval
extubation rather than cardiac decompensation. Left PIC line
ends in the mid-SVC. No pneumothorax.
.
[**2193-6-17**] WBC-16.8 Hgb-13.6 Hct-39.5 MCV-95 Plt Ct-259
[**2193-6-17**] Neuts-91.6 Lymphs-5.3 Monos-2.8 Eos-0.2 Baso-0.1
[**2193-6-18**] WBC-17.7 Hgb-13.3 Hct-38.4 MCV-95 Plt Ct-282
[**2193-6-25**] WBC-11.1 Hgb-11.5 Hct-33.3 MCV-93 Plt Ct-349
[**2193-6-17**] Glucose-281 UreaN-28 Creat-1.8 Na-138 K-3.6 Cl-101
HCO3-19
[**2193-6-25**] Glucose-202 UreaN-78 Creat-2.7 Na-137 K-3.6 Cl-93
HCO3-33
[**2193-6-17**] CK(CPK)-201 CK-MB-17 MB Indx-8.5
[**2193-6-20**] cTropnT-0.85
[**2193-6-18**] proBNP- >70,000
[**2193-6-18**] ALT-17 AST-44 CK-234 AlkPhos-103 Amylase-17 TBili-0.4
Lipase-11
[**2193-6-25**] ALT-29 AST-35 LDH-248 AlkPhos-100 Amylase-24
TotBili-0.4 Lipase-23
[**2193-6-18**] %HbA1c-8.4
[**2193-6-18**] TSH-2.1
.
[**2193-6-18**] URINALYSIS Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG RBC-8* WBC-8*
Bacteri-NONE Yeast-NONE Epi-<1 CastHy-6*
[**2193-6-19**] URINE Osmolal-309 UreaN-153 Creat-23 Na-97
.
MICRO:
5/5 BLOOD CX- no growth
[**6-20**] BLOOD CX- pending at time of discharge
[**6-18**] URINE CX- no growth
[**6-19**] URINE CX- no growth
[**6-19**] BAL-
GRAM STAIN (Final [**2193-6-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2193-6-21**]): ~1000/ML
OROPHARYNGEAL FLORA.
[**6-19**] SPUTUM CX-
GRAM STAIN (Final [**2193-6-19**]):
[**12-7**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2193-6-21**]): NO GROWTH.
[**6-20**] STOOL C DIFF- negative, FECAL CX- negative
Brief Hospital Course:
Ms. [**Known lastname **] is a 70 year-old female with history of CAD, CHF with
EF 30%, HTN, DM2 who presented from an OSH with hypoxic
respiratory failure and NSTEMI. She was initially admitted to
the MICU. She was treated with levofloxacin and vancomycin to
cover for HAP. Cardiology consult was obtained and recommended
medical management as she is not a candidate for
revascularization. BNP was noted to be >70,000. She was diuresed
with IV lasix and is [**Location 10226**]4L. Overnight on [**6-18**] she developed
Afib with RVR to 120-130s and transient desat to 70s on CPAP,
felt to be [**3-16**] hypoxia and pneumonia. Rate controlled with
metoprolol and diltiazem. On [**6-19**] she was electively intubated
for failing CPAP. Trop peaked at 0.82 and heparin gtt was
discontinued on [**6-20**]. Converted back to NSR on [**6-20**]. Started lasix
gtt on [**6-20**] for diuresis. She was successfully extubated on [**6-21**].
On [**6-23**], she was transferred to the medical floor.
.
# Respiratory failure: This was felt to be due to a mixed
picture of CHF +/- PNA on CXR; both improved clinically and on
imaging with antibiotics and diuresis with lasix. She was
elective intubated the day after admission (after a 24h trial of
CPAP failed to improve her respiratory status) and successfully
extubated on hospital day 3. PaO2/FiO2 initially 200-300 - [**Doctor Last Name **].
Low probability PE with Well's criteria. US to assess pleural
effusions [**6-20**] - no appreciable effusions. CT chest without
contrast [**6-20**] - small bilateral pleural effusions and mild
pulmonary edema, mild bibasilar atelectasis vs aspiration.
Sputum culture, mini-BAL - no organisms on gram stain, cultures
pending - potential viral/atypical infection. Vanco was
discontinued given negative cultures. She was quickly weaned off
of oxygen once she reached the medical floor. She completed an
eight-day course of levofloxacin to empirically treat for
health-care associated pneumonia. CXR 2 days prior to discharge
showed resolution of pulmonary edema and infiltrates.
.
# Acute on chronic systolic congestive heart failure: She has an
EF 30-35%, and as above, was felt to be in florid heart failure
on initial presentation. BNP was >70,000 with pulmonary edema on
CXR and hypoxic respiratory failure requiring intubation. Fluid
overload improved with diuresis. Diuresis was complicated by
acute renal failure (cr 1.8-->2.7) so lasix were held on the
medical floor. She remained euvolemic and creatinine returned to
her baseline. She was continued on optimal medical management
with metoprolol, imdur, and hydralazine. She has a reported
allergy to ACEI and [**Last Name (un) **]. Could consider EP evaluation as
outpatient for AICD placement for primary prevention.
.
# NSTEMI/CAD: Suspected to be due to demand in the setting of
hypoxic respiratory failure. Also likely related to her
inability to take her cardiac meds the 2 days prior to her
initial admission to OSH [**3-16**] n/v/d. Patient has been deemed not
a candidate for further revascularization based on cardiac
catheterization reports from [**Hospital1 2177**]. Heparin gtt was discontinued
on [**6-20**] (48 hours since event). She was continued on ASA, plavix,
BB, statin, imdur, ranexa. Medications were titrated to optimal
medical management, with cardiology consult assistance.
.
# Fever/leukocytosis: Either due to PNA or a presumed viral
gastrointestinal process. Bacterial cultures were negative. UA
negative; urine culture negative; blood cultures no growth. LFTs
unremarkable. No diarrhea since admission. She completed an 8
day course Levofloxacin for empiric treatment of PNA or GI
source of infection.
.
# AFib with RVR: Occurred in the setting of PNA/hypoxic
respiratory failure and fluid overload. TSH WNL. CHADS2 score 3.
She was effectively treated with antibiotics and diuresis and
converted to sinus rhythm. Metoprolol was continued for rate
control. No further episodes.
.
# ARF on CRF: Her baseline creatinine is 1.9. On admission her
creatinine was 1.8. As she was diuresed her creatinine rose to
2.7 by the day of transfer to the floor, likely pre-renal ARF.
Lasix was held initially after transfer. Her medications were
renally dosed.
.
# Hypertension: She is on an extensive blood pressure regimen at
home, including imdur, toprol, clonidine, and norvasc. Her
regimen was slowly up-titrated toward her home regimen.
Hydralazine was also added. Clonidine was held.
.
# DM2: Her Diabetes is poorly controlled as an outpatient,
evidenced by her HbA1C of 8.4. She was continued on lantus and a
humalog insulin sliding scale. Her lantus dose was increased to
achieve better control.
.
# Nausea/vomitting/diarrhea: She had 2 days of nausea, vomiting,
and diarrhea associated with fever prior to admission to the
OSH. This was felt likely to represent an infectious (viral)
gastroenteritis. Less likely diabetic gastroparesis. LFTs,
amylase/lipase unremarkable. C diff and stool cultures were
negative. Stool cx negative. These symptoms quickly resolved
after admission, until she had a recurrent episode 1 week into
her admission (see below).
.
# Nausea/vomiting/lightheadedness (second episode)-- Coffee
grounds emesis: On the day following being called out out of the
MICU, the patient complained of lightheadedness and nausea,
exacerbated by movement. The following day she was unable to
tolerate PO liquids or solids. No diarrhea. Later that day she
developed one episode of small coffee grounds emesis. This
cleared quickly with NG lavage with no evidence of bright red
blood. Felt most likely related to mucosal irritation or small
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] tear from excessive vomiting. EKG was obtained
without ischemic changes. She was orthostatic with SBP
140s-->120s from lying to sitting. PO lasix was held out of
concern that her symptoms were due to being over-diuresed. LFTs,
amylase, and lipase were within normal limits. She was afebrile.
KUB was unremarkable. The patient had been constipated for >1
week. After an aggressive bowel regimen was instituted she
eventually had a large bowel regimen. Her symptoms of nausea and
vomiting quickly resolved and she was able to tolerate POs
again.
.
# PVD: No active issues. Continued her outpatient cilostazol.
.
# Depression: No active issues. She was continued on her
outpatient celexa.
.
# Hypothyroid: No active issues. TSH 2.1. She was continued on
her outpatient levothyroxine dose.
.
# Vertigo/history of Meniere's disease: Takes meclizine at home.
Occasionally this acts up when she is hospitalized. Meclizine
had been held for most of her hospitalization but was re-started
in the setting of her nausea and dizziness, thinking that her
Meniere's disease could be contributing.
.
# Pulmonary nodules: Two small pulmonary nodules measuring less
than 4mm were seen on CT scan. One year follow-up chest CT or
comparison with prior outside studies is recommended.
.
Medications on Admission:
imdur 240mg daily
toprol xl 200 [**Hospital1 **]
plavix 75mg daily
aspirin 325mg daily
SLNG prn
ranexa 500mg [**Hospital1 **]
norvasc 10 po daily
clonidine 0.3mg po bid
levoxyl 75mcg daily
protonix 40 daily
lasix 120mg qam 80mg qpm
mvi
lipitor 80 daily
zetia 10 daily
cilostazol 100mg qam 50 qpm
lantus: 22u qhs
iron 325mg daily
celexa 20 daily
ativan 0.5mg q4 prn
meclizine 25mg daily
colace 100mg [**Hospital1 **]
ambien 5mg qhs
nystatin to skin
novolog 4u ac meals
.
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. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
8. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
9. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO BID (2 times a day).
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Four (4) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO twice a day.
13. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
14. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
18. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed.
19. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
20. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale Subcutaneous four times a day.
21. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous at bedtime.
22. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
23. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
24. Novolog 100 unit/mL Solution Sig: Four (4) units
Subcutaneous three times a day: with meals.
25. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed.
26. Lasix 40 mg Tablet Sig: Three (3) Tablet PO qAM.
27. Lasix 40 mg Tablet Sig: Two (2) Tablet PO qPM.
28. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
29. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary: NSTEMI, CHF exacerbation, pneumonia
Secondary:
-CAD
-IDDM
-CKD (baseline crt 1.9)
-CHF
-low back surgery
-arthiritis
-Le edema
-vertigo
-PVD
.
Discharge Condition:
Vitals stable. Satting well on RA. Tolerating a regular diet.
.
Discharge Instructions:
You were admitted to the hospital with a heart attack and
worsening of your heart failure, as well as possible pneumonia.
These were treated with antibiotics, heart medications, and
lasix. You also had nausea and vomiting, likely from
constipation.
.
Take all medications as prescribed.
.
If you develop shortness of breath, chest pain, fevers>101,
persistent nausea and vomiting, or other concerning symptoms,
you should return to the nearest ED.
.
Followup Instructions:
You should follow up with your PCP within the next 2 weeks.
[**Last Name (LF) **],[**First Name3 (LF) **] A [**Telephone/Fax (1) 8960**].
.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"486",
"41071",
"5849",
"51881",
"4280",
"5859",
"40390",
"2449",
"42731",
"V4581",
"25000",
"V5867"
] |
Admission Date: [**2200-1-3**] Transfer Date to NBN: [**2200-1-7**]
Date of Birth: [**2200-1-3**] Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname 59899**] is a 38 2/7 weeks gestational age
male born to a 35 year old gravida III, para II mother with
the following prenatal laboratories: Blood type O positive,
antibody negative, hepatitis surface antigen negative, RPR
nonreactive, Rubella immune, GBS unknown. Maternal history
is significant for mother being a known carrier for
hemophilia B (factor 9 deficiency), diagnosed after a
relative presented with bleeding in neonatal period. Parents
first son is noted to have hemophilia B with factor 9 levels
of approximately 13 percent. Of note, this son is largely
asymptomatic.
Pregnancy was uncomplicated. Delivery was scheduled, repeat
cesarean section secondary to risk of hemophilia in infant.
Infant emerged with vacuum assist, Apgars 9 and 9 at one and
five minutes. Cord blood was promptly sent for factor 9
level. Infant was delivered with vigorous tone, regular
respirations but persistent grunting was noted in the first
hour of life and the infant was brought to the Neonatal
Intensive Care Unit for further stabilization.
PHYSICAL EXAMINATION ON PRESENTATION: Birth weight 3700
grams, head circumference 36.5 cm, length 51 cm. Vital
signs: 98.1 temperature, respirations 40 to 50, heart rate
120, blood pressure 67/35 with a mean of 50, O2 saturation of
95 percent on room air. General: Term male infant in no apparent
distress. Head, eyes, ears, nose and throat: No dysmorphic
features, anterior fontanelle open and flat, palate intact.
Oropharynx clear. Neck supple, no crepitus.
Respiratory: Clear to auscultation bilaterally, good air
entry, mild intermittent retractions.
Cardiac: Regular rate and rhythm, S1, S2 normal, no murmur.
Abdomen: Soft, nondistended, hypoactive bowel sounds, no
hepatosplenomegaly. Extremities: Well perfused, no cyanosis or
edema. Femoral pulses 2 plus bilaterally.
Spine intact, no dimpling, anus patent. No Ortolani or
Barlow sign present. Neurologic: Appropriate tone on
examination. Spontaneous MAE.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The patient initially was observed to be in
mild respiratory distress with intermittent retractions
and grunting. In the first several hours of life this
respiratory distress resolved and patient remained stable
on room air throughout the remainder of his hospital
course.
2. CARDIOVASCULAR: The patient remained cardiovascularly
stable throughout his hospital course.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Patient was allowed
to P.O. ad lib feeds on day of life number one with
excellent results.
4. HEMATOLOGY: Cord blood was sent for factor 9 level which
came back at minimal levels, less than 1.7%. This result was
consistent with hemophilia B. Other additional
laboratories include abnormal coagulation studies of PT of
15.8, a PTT 85.9 and INR of 1.6. The hematology/oncology
service from [**Hospital3 1810**] consulted on this child
and agree that the laboratories were consistent with a
diagnosis of hemophilia B. The patient was scheduled to
receive hematology follow up at one month of age. On day
of life 2 the patient did experience overall low volume
bouts of emesis that were tinged brown. The emesis was
heme positive. At this time the patient was made NPO and
a KUB was obtained which was within normal limits. On day
of life number 3 this coffee ground emesis resolved. This
emesis was likely due to swallowed maternal blood as
opposed to active bleeding from the patient.
5. INFECTIOUS DISEASE: Due to lack of maternal risk factors
for sepsis the patient did not receive enteric
antibiotics.
6. GASTROINTESTINAL: Patient was started on P.O. ad lib
feeds with Special Care/breast milk 20 kilocalories per
ounce. The patient took in sufficient amounts of formula
to maintain caloric intake.
No hearing screen was performed prior to transfer to NBN. State
Newborn Screen was sent at 48 hours of life. No car seat
position test was performed. No immunizations administered.
On day of life three, on [**2200-1-6**] the patient was
transferred to the normal Newborn Nursery for further
management.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To normal Newborn Nursery.
FEEDS AT DISCHARGE: Breast milk/Special Care 20 kilocalories
per ounces, P.O. ad lib. No medications.
DISCHARGE DIAGNOSES:
1. Respiratory distress resolved.
2. Probable Hemophilia B, factor 9 level, less than 1.7 percent.
3. Coffee ground emesis, resolved.
Patient has follow up scheduled with pediatric hematology at
the [**Hospital3 1810**] at one month of age.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) 56760**]
MEDQUIST36
D: [**2200-1-8**] 13:54:18
T: [**2200-1-8**] 15:33:03
Job#: [**Job Number 59900**]
|
[
"V290"
] |
Admission Date: [**2158-10-24**] Discharge Date: [**2158-11-10**]
Date of Birth: [**2092-6-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Placement of PICC
Aspiration of fluid from right Shoulder
History of Present Illness:
Mr. [**Known lastname 86903**] is a 66 yo man with AML M1-2 s/p induction currently
C1D16 on HIDAC consolidation who presents with R shoulder pain
and fatigue. Seen at 7Feldberg outpatient clinic for count check
yesterday; he complained of feeling very poorly and requested to
come in early, gait was unstable & he used a wheelchair. He
states that since sleeping on his R shoulder on Sunday night, he
has had [**8-4**] pain in the shoulder and difficulty moving it
secondary to pain. States that he was unable to sleep at all the
past two nights secondary to the pain. His vital signs at clinic
the day prior to admission were BP 129/86, HR 116 T 98.2 RR 18
O2 Sat%: 98%. His labs were wbc 0.1 hgb.7.8/hct.21.8 and
platelets 5; he was transfused with 2u prbc and 1 bag of
platelets.
.
Today the patient reports that he was feeling extremely fatigued
and so called an ambulance. He was taken to an outside hospital
where he received vancomycin and zosyn. He was then transferred
to [**Hospital1 18**] for further management and found to have T 103.3,
tachycardia to 120s, and SBP 94. Blood cultures were sent and he
was started on vanc/cefepime.
Past Medical History:
Oncologic History:
His induction chemotherapy was complicated by acute kidney
injury and neutropenic fever. Induction with 3+7 was
unsuccessful, so he was re-induced with MEC, which resulted in
prolonged cytopenias and a brief ICU stay for respiratory
difficulty. His only sibling is not a match and a search for a
matched unrelated donor has not been fruitful. He has therefore
enrolled in a dendritic fusion vaccine trial (protocol 09-014)
with PT1 and is now starting consolidation.
.
ROS: He reports extreme fatigue, R shoulder pain, blood tinged
mucus from right nostril. Denies wght loss, headache, dizziness,
visual changes, chest pain, dyspnea, cough, abd pain, back pain,
constipation, diarrhea, hematochezia, hematuria, other urinary
symptoms, or rash.
.
Past Medical History:
- AML M1-2, normal cytogenetics, NPM-1 negative, FLT3 negative,
s/p 3+7 induction, MEC re-induction, complicated by acute kidney
injury and neutropenic fever.
- Osteoarthritis, s/p L TKA, R THA.
- h/o negative colonoscopy-last [**2154**].
- Hypertension.
- Seasonal Allergies.
- GERD.
Social History:
Never married, no children. Lives alone. Retired fireman.
U.S.M.C. veteran during [**Country 3992**], stationed in Okinawa. He is a
never smoker, denies alcohol and illicit drug use. He
frequently travels to the southwest (e.g. [**State 15946**]).
Family History:
Thinks he had an uncle w/ liver cancer. Father died of AAA,
mother of ?CHF. Multiple family members w/ CVA as cause of
death. No known h/o hematologic malignancies.
Physical Exam:
VS: 100.8 105 102/65 76 96%3L nc.
Gen: NAD
HEENT: MM dry, OP clear without lesions, exudate, or erythema.
CV: Tachy S1+S2.
Pulm: Bibasilar crackles (R>L)
Abd: S/NT/ND _bs
Ext: Trace edema bilaterally.
MSK: Right shoulder pain to active and passive motion.
Neuro: AOx3, CN II-XII intact.
Pertinent Results:
Admission Labs:
[**2158-10-23**] 11:10AM BLOOD WBC-0.1*# RBC-2.45* Hgb-7.8* Hct-21.8*
MCV-89 MCH-31.8 MCHC-35.6* RDW-15.7* Plt Ct-5*#
[**2158-10-24**] 12:45PM BLOOD Neuts-0* Bands-0 Lymphs-87* Monos-13*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2158-10-23**] 11:10AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2158-10-23**] 11:10AM BLOOD Plt Smr-RARE Plt Ct-5*#
[**2158-10-24**] 12:45PM BLOOD PT-13.4 PTT-25.3 INR(PT)-1.1
[**2158-10-24**] 12:45PM BLOOD Fibrino-787*#
[**2158-10-24**] 05:55PM BLOOD Gran Ct-0*
[**2158-10-23**] 11:10AM BLOOD UreaN-24* Creat-1.1 Na-137 K-4.0 Cl-102
HCO3-26 AnGap-13
[**2158-10-23**] 11:10AM BLOOD ALT-65* AST-31 LD(LDH)-157 AlkPhos-186*
TotBili-1.1
[**2158-10-25**] 12:00AM BLOOD proBNP-4078*
[**2158-10-24**] 12:45PM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.9 Mg-1.6
Micro:
Blood cultures- [**10-24**], [**Date range (1) 86904**], [**10-30**], [**10-31**]- No growth.
C. diff- [**10-27**], [**10-28**]- Negative
.
[**2158-10-26**] 10:00 am JOINT FLUID Source: Right Shoulder.
GRAM STAIN (Final [**2158-10-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2158-10-29**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2158-10-27**]): NO ACID FAST BACILLI SEEN
ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Jt fluid- 2500 WBC; 0% polys
.
[**2158-10-31**] 1:25 pm JOINT FLUID Source: R shoulder.
GRAM STAIN (Final [**2158-10-31**]): 2+ (1-5 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2158-11-3**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2158-11-1**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Jt Fluid- 4500 WBC; 83% polys
.
[**2158-11-3**] 4:00 pm FLUID,OTHER RIGHT SHOULDER.
**FINAL REPORT [**2158-11-9**]**
GRAM STAIN (Final [**2158-11-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2158-11-6**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2158-11-9**]): NO GROWTH.
Studies:
[**10-25**] TTEcho: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thicknesses and cavity size
are normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The ascending aorta and aortic
arch are mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2158-8-1**], the
left ventricular systolc function is now less vigorous (low
normal) but without regional dysfunction. Valvular morphology is
similar.
[**10-25**] EKG: Sinus tachycardia. Otherwise, normal tracing. Compared
to
the previous tracing ST-T wave changes are less prominent and
the Q-T interval is shorter.
[**10-26**] RUQ U/S: The liver demonstrates no definite focal or
textural abnormality. There is no biliary dilatation. The CBD is
normal in caliber, measuring 4 mm. The portal vein demonstrates
normal hepatopetal flow. The gallbladder appears mildly
distended without evidence of internal stone or sludge.
Previously seen tiny anterior wall gallbladder polyp is not
demonstrated on current exam. There is no gallbladder wall
thickening or pericholecystic fluid. A 3.6 cm simple upper pole
right renal cyst is unchanged. There is no perihepatic fluid.
Partially visualized pancreas appears within normal limits. No
elicited [**Doctor Last Name **] sign.
IMPRESSION:
1. No focal liver abnormality.
2. Mildly distended gallbladder without wall thickening or
pericholecystic
fluid.
3. Stable simple right renal cyst.
[**10-27**] CT Chest/Abdomen/Pelvis-
1. Multifocal bilateral ground-glass opacities represent either
infectious or inflammatory foci.
2. Small amount of new, intermediate density peritoneal and
pelvic fluid, but no evidence of organized chest, abdominal or
pelvic fluid collections to suggest abscess.
3. Unchanged, enlarged pulmonary artery measuring 4 cm
consistent with
pulmonary hypertension.
[**10-27**] CT Head- There is no evidence for acute intracranial
hemorrhage, large mass, mass effect, edema, or hydrocephalus.
There is bifrontal cortical atrophy. Sinus mucosal disease is
again seen with increased opacification of the anterior ethmoid
air cells, increased mucosal thickening and a mucus retention
cyst in the left sphenoid sinus, and mild mucosal thickening in
the maxillary sinuses. Visualized bony structures are grossly
unremarkable.
[**10-30**] MRI R Shoulder- 1. Small glenohumeral joint effusion.
Extensive subacromial/subdeltoid bursitis. In the setting of
neutropenia and fever, infection is a primary consideration. In
presence of full-thickness rotator cuff tear, bursal fluid is in
direct communication with joint space. The bursal fluid is
amenable to ultrasound guided aspiration.
2. Extensive myositis; the differential diagnosis is broad and
includes
infection among other causes for myositis.
3. Full-thickness tear of supraspinatus tendon with retraction.
4. Tendinopathy of the infraspinatus tendon.
5. Long head of the biceps tendon tear.
6. Abnormal signal in superior and inferior labrum.
7. Moderate AC joint arthropathy.
8. Abnormal signal in the posterior right lung, suboptimally
evaluated on
this nondedicated study. Should further investigation be
required, this would be better evaluated with CT.
[**10-30**] R Shoulder U/S: Two focal fluid collections about the right
shoulder, the larger measuring 3.0 x 1.9 x 0.5 cm and located
along the anterolateral aspect of the joint.
[**11-4**]: RUE Venous U/S: No evidence of right upper extremity DVT.
[**11-8**] Chest CT: Many new predominantly peripheral nodules, a
couple with
cavitation, as well as increasing mixed consolidative and
ground-glass opacity in the lingula. Although differential
considerations include the possibility of septic emboli, the
appearance is not entirely typical, and atypical etiologies of
infection including the possibility of aspergillosis should be
considered in the appropriate clinical setting.
[**11-10**] TTEcho:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion 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 and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are mildly thickened (?#). No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
No mass or vegetation is seen on the mitral valve. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Preserved regional and global biventricular ventricular systolic
function.
Compared with the prior study (images reviewed) of [**2158-10-25**],
heart rate is slower. Estimated pulmonary artery pressures are
lower. Left ventricular function is slightly more vigorous.
.
Discharge Labs:
Na 139 Cl 103 BUN 14 gluc 87 AGap=14
K 3.9 HCO3 26 Cr 0.9
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
Ca: 9.3 Mg: 2.0 P: 5.0
ALT: 17 AP: 257 Tbili: 0.8 Alb: 3.3
AST: 16 LDH: 178 Dbili: TProt:
[**Doctor First Name **]: Lip:
Source: Line-PICC
WBC 2.6 HGB 8.9 24.8 plts 76
N:52 Band:0 L:20 M:26 E:0 Bas:0 Atyps: 1 Myelos: 1
Hypochr: NORMAL Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ Microcy: 1+
Polychr: 1+ Spheroc: 1+ Ovalocy: 1+ Schisto: OCCASIONAL
Comments: MANUALLY COUNTED
Plt-Est: Very Low
Other Hematology
Gran-Ct: 1378
Source: [**Name (NI) 71017**]
PT: 13.7 PTT: 26.9 INR: 1.2
Brief Hospital Course:
66 year old male with history of AML s/p 7+3 therapy and D17 s/p
cycle 1 HIDAC on presentation, admitted with right shoulder pain
and fatigue.
# MSSA sepsis: Patient was initially admitted to BMT floor
service and treated with vanco and cefepime with intermittent
hypotensive which improved after 4L IVF and 1 unit PRBC. Morning
after admission, patient developed a new O2 requirement and was
felt to be volume overloaded, and so received 30 mg IV lasix.
OSH blood cultures were then found to be positive for S.aureus
(within 12 hours) ([**2-26**]) and he received a dose of linezolid in
addition to vancomycin. He then was febrile to 102 and was found
to be hypotensive to SBP 70s that was unresponsive to 1L IVF. He
was started on peripheral levophed and transferred to the [**Hospital Unit Name 153**]
for further management.
He was started on Vancomycin, cefepime, and linezolid for
empiric therapy for febirle neutropenia. He required a brief
period of pressor support with norepinepherine as his MAP was
<60 on ICU admission. During this time, he was also
experiencing right shoulder pain. Joint space aspiration
revealed 2500 leukocytes concerning for a septic joint. His
blood cultures from OSH grew out [**2-26**] MSSA. TTE was negative for
valvular vegetations. His abx therapy was down graded to
nafcillin and ciprofloxacin by ICU day #3. However, due to
recurrent low grade fevers, he was placed on fluconazole. A
thoracic CT scan as well as head CT were performed to look for
an indolent infection/abscess/phlegmon. CT's failed to reveal a
distinct collection, though did show multifocal bilateral
ground-glass opacities. He continued to have low grade fevers
which were attributed to a possibly septic joint/shoulder
infection.
He was transferred back to the floor after a 4 day ICU stay and
his antibiotics were reduced to primarily nafcillin, with
fluconazole and acyclovir for PPX. He remained febrile until
after undergoing two further drainages of the fluid from his
shoulder (see below). After the second drainage, patient was
afebrile for the rest of his hospitalization and continued on
nafcillin without event.
He underwent repeat chest CT when an CXR showed possible
progression of the earlier opacities/nodules and this showed new
predominantly peripheral nodules, a couple with cavitation, as
well as increasing mixed consolidative and ground-glass opacity
in the lingula concerning for septic emboli. Pulmonology was
consulted and recommended TTE (Please see note for further
details). Patient underwent a repeat TTE to assess for valvular
disease which was negative. TEE was deferred secondary to the
patient's low platelets.
To Follow Up-
- Patient will need repeat chest CT in [**12-28**] months to assess
progression of nodules and ground glass opacities
- urine histoplasma and galactomannan pending on discharge
.
# Febrile neutropenia: Presented s/p 7+3 therapy and C1D17 from
HIDAC. Fevers were thought to be due to MSSA septicemia in
conjunction with septic joint. Neutropenic [**12-27**] chemotherapy.
Started on filgastrim and continued until counts recovered.
.
# R septic shoulder: On presentation patient had extreme right
shoulder pain. Orthopedics was consulted and felt that his
symptoms were secondary to a rotator cuff tear though septic
joint was in the differential. They tapped the shoulder- joint
fluid showed 2500 leukocytes- elevated in the setting of
leucopenia concerning for septic arthritis. As the patient's
neutropenia resolved his shoulder swelled up signficantly and
pain worsened. He underwent MRI of the shoulder which showed
joint effusion, extensive subacromial/subdeltoid bursitis,
extensive myositis of the shoulder girdle and a full thickness
rotator cuff tear. The patient underwent two subsequent taps,
one by ortho (appx 2 ccs) [4500 WBC, 83% polys, no orgs on GS or
culture] and the final by IR (appx 10cc), which showed 2+ polys
and no organisms on gram stain or culture. The patient became
and remained afebrile after the third tap. He was continued on
nafcillin with a planned antibiotic course of 6 weeks.
.
#. Narrow-complex Tachycardia: Patient had sporadic bouts of SVT
while in the ICU, reaching rates of about 200 bpms. Usually
broke SVT on own, but on ICU day #3 had an early morning bout of
SVT to 180's. Given 5 mg IV metoprolol and carotid massage,
bringing HR down to 100. Thought to be due to fevers. BMT
concerned of possible intracrdiac/valvular infection which may
be affecting conduction system. No signs of infectious
collection seen on imaging. Started on low dose beta blocker
12.5 mg metoprolol [**Hospital1 **] for baseline rate control on ICU day #4.
The patient's heart rate was better controlled for the remainder
of his hospitalization and he was discharged on this medication.
.
#. Right calf nodule- Patient with small erythematous macule on
lateral right calf which progressed to a non tender erythematous
nodule. Derm was consulted and did not feel that this was a
manifestation of septic emboli; they felt it was more likely a
resolving inflammatory process. Given location of nodule and
patient already on optimal therapy, biopsy was not performed.
.
#. Hypertension: Patient with history of hypertension on
amlodipine at home. This medication was discontinued on
admission secondary to his low blood pressures in the setting of
sepsis. Following his ICU stay, he was normotensive off of
amlodipine and on metoprolol. He was discharged on metoprolol
and amlodipine was discontinued.
.
# Hyperbilirbuinemia: Bilirubin slowly trending up from <1.0 to
2.7 on ICU day #4. [**Month (only) 116**] be due to recent transfusions he
previously received on ICU admission. RUQ US did not show any
cholangitic or hepatic process/obstruction. This trended down
during the rest of his hospitalization.
Medications on Admission:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**11-26**] Tablet,
Rapid Dissolves PO three times a day as needed for nausea.
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H (every 4 hours).
4. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Acute myelogenous leukemia
Methicillin sensitive staphylococcus aureus bacteremia
Right shoulder infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with fatigue and right
shoulder pain. You were found to have bacteria growing in your
blood and required a stay in the intensive care unit. Your
infection was treated with antibiotics and your condition
improved. The source of your infection was believed to be your
shoulder- an MRI showed inflammation and tear of the muscles as
well as fluid in the joints. Some of this fluid was drained and
your fevers resolved. Please continue to take the antibiotics
for six weeks.
We made the following changes to your medications:
- START taking nafcillin for your infection
- START taking metoprolol for your heart rate and blood pressure
- START taking fluconazole to prevent fungal infection
- CHANGE your dose of acyclovir to 400 mg every eight hours
- STOP taking amlodipine for your blood pressure
Followup Instructions:
Please follow up at the appointments below:
Department: INFECTIOUS DISEASE
When: MONDAY [**2158-11-27**] at 9:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2158-11-27**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2158-11-27**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], 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) **] MD [**MD Number(2) 3922**]
Completed by:[**2158-11-10**]
|
[
"78552",
"4019",
"42789",
"99592"
] |
Admission Date: [**2165-6-23**] Discharge Date: [**2165-6-28**]
Date of Birth: [**2085-6-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
fear of eating / syncopal episodes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 yo male with known Type B dissection ([**1-13**]) has had a fear
of food for about one month. Now presents with 2 syncopal
episodes and admitted to [**Hospital 1474**] Hospital. CT revealed ? 7 cm
thoracic aneurysm. Transferred to [**Hospital1 18**] for evaluation by Dr.
[**Last Name (STitle) **]. Had a 30# weight loss, but no abdominal pain or chest
pain. He has had dysphagia with both liquids and solids.
Past Medical History:
Type B aortic dissection
MI/CAD/2 LAD stents
Afib
SVT / s/p AV ablation
HTN
prostate Ca/XRT/ bone mets
GERD
elev. lipids
s/p appendectomy
Social History:
no tobacco or ETOH
Family History:
lives with wife
Physical Exam:
97.5 right 112/50 left 118/56 ( on esmolol)
HR 82 RR 13 100% sat on 4L NC
65 kg
alert and oriented x 3
NAD, PERRL
no JVD, no carotid bruits
CTAB
RRR
abd soft, NT, ND, no pulsatile mass
bilat. carotids/brachials/radials/fems/pops/ 2+
bilat. DP/PT 1+
Pertinent Results:
[**2165-6-28**] 08:30AM BLOOD WBC-6.1 RBC-3.31* Hgb-9.8* Hct-29.7*
MCV-90 MCH-29.5 MCHC-32.9 RDW-23.8* Plt Ct-135*
[**2165-6-28**] 08:30AM BLOOD Plt Ct-135*
[**2165-6-27**] 12:27AM BLOOD PT-15.2* PTT-24.1 INR(PT)-1.4*
[**2165-6-27**] 12:27AM BLOOD Glucose-138* UreaN-31* Creat-1.0 Na-141
K-4.1 Cl-113* HCO3-18* AnGap-14
[**2165-6-27**] 12:27AM BLOOD Calcium-7.0* Mg-2.4
[**2165-6-23**] 06:06PM BLOOD calTIBC-199* TRF-153*
[**Known lastname **],[**Known firstname **]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 43669**]
FINAL REPORT
INDICATIONS: 80-year-old man with known type B aortic
dissection, who
presented to an outside hospital with dysphasia. Concern is that
the aorta
has enlarged.
COMPARISONS: [**2164-1-21**]. That was an MR of the torso.
More recent
studies are not available.
TECHNIQUE: Axial CT images of the chest, abdomen, and pelvis
were obtained in
the arterial phase of intravenous contrast administration.
CT OF THE CHEST WITH IV CONTRAST: There is no axillary, hilar,
or mediastinal
lymphadenopathy. Coronary artery calcifications are noted. There
is a type B
dissection, as noted previously with the false lumen beginning
shortly after
the takeoff of the left subclavian artery, about 2 cm more
distally. The
aorta is ectatic. At the level of the passage into the abdomen
at the
diaphragmatic hiatus the aorta is overall slightly larger,
measuring 6.4 x 4.4
cm in axial dimensions, compared to 3.6 x 4.9 cm previously.
There is some
narrowing of the true lumen at the diaphragmatic inlet, as low
as 2.3 x 0.6 cm
in axial dimensions. At all levels, there are few calcifications
along the
outer wall of the aorta. The celiac, and superior and inferior
mesenteric
arteries are supplied by the true lumen which is well opacified.
The left
common iliac is supplied by the true lumen entirely. As noted on
the prior
MR, the dissection extends into the proximal right external
iliac artery,
where it appears that the distal arterial distribution for the
right leg is
supplied by the true lumen. The false lumen ends in the proximal
right common
iliac artery. The internal iliac artery on the right is also
supplied by the
true lumen. At the site of the gastroesophageal junction, the
axial
dimensions of the aorta are somewhat larger than before, mostly
because of
expansion of the false lumen since the prior study. At this
level, it
measures 4.3 x 5.4 cm in axial dimensions (series 8, image 86)
compared to 3.7
x 3.2 cm previously.
There is bibasilar atelectasis and tiny right effusion, but
otherwise the
lungs are clear.
CT OF THE ABDOMEN WITH IV CONTRAST: There is contrast in the
gallbladder,
probably from a recent CT. The liver appears normal. Although
there is
motion artifact limiting evaluation of the upper abdomen, the
pancreas,
spleen, and adrenal glands appear normal. There are several
hypoattenuating
foci bilaterally in the kidneys, the larger ones over a cm,
which can be
characterized as cysts and are unchanged since the prior MR
study. A few
subcentimeter bilateral hypoattenuating foci, however, are too
small to
characterize. There is no mesenteric or retroperitoneal
lymphadenopathy or
free air or fluid. Stomach, small and large bowel are within
normal limits.
CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter in
the bladder,
and a large right diverticulum, which could be due to prior
obstruction. The
prostate and seminal vesicles are unremarkable. The sigmoid and
rectum are
within normal limits. There is a trace free fluid only, but no
pelvic or
mesenteric lymphadenopathy.
BONE WINDOWS: There is very extensive involvement of sclerotic
metastatic
disease, attributed to the history of prostate cancer throughout
the
visualized skeleton.
IMPRESSION:
1. Type B aortic dissection extending from the ascending aorta
and
terminating in the right external iliac artery. Its overall
structure is
similar to [**2164-1-21**], but particularly near the
diaphragmatic hiatus,
the overall size of the aorta is somewhat larger, particularly
because of
increased size of the false lumen.
2. Some compression of the true lumen at the same level.
3. Large bladder diverticulum.
4. Very extensive sclerotic metastases.
The findings were discussed with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] shortly after
the study.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: MON [**2165-6-24**] 8:33 PM
Procedure Date:[**2165-6-24**]
INDICATION: 80-year-old man with dysphasia and thoracic aortic
aneurysm.
No comparison studies.
BARIUM ESOPHAGRAM:
Exam was limited to prone and supine evaluation of the distal
esophagus given
limited patient mobility and blood pressure lability. Within the
upper
esophagus, there is limited filling seen at the level of the
aortic arch and
lower trachea, corresponding with site of adjacent thoracic
aortic aneurysm
with dissection. Distal to this region, there is no evidence of
stricture or
abnormal dilatation. Mucosal abnormalities were difficult to
assess given
limitations of the study and lack of double contrast. Barium
does pass freely
through the esophagus; however, multiple tertiary esophageal
contractions are
noted. No evidence of hiatal hernia. Barium passes through the
stomach
promptly.
IMPRESSION: limited filling of the upper esophagus at level of
the aortic
arch, likely secondary to mass effect caused by thoracic aortic
aneurysm.
These findings could explain patient's dysphagia. Tertiary
contractions
consistent with presbyesophagus. No evidence of hiatal hernia.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: WED [**2165-6-26**] 10:21 PM
Procedure Date:[**2165-6-26**]
Brief Hospital Course:
Admitted on [**6-23**] and esmolol drip used for tight BP control.
Evaluated for possible surgery or stent grafting. CT scanning
repeated as well as esophageal evaluation done. Determined not
to be a surgical candidate by Dr. [**Last Name (STitle) **]. UTI and oral [**Female First Name (un) **]
diagnosed and treated with abx. Also diagnosed with mass effect
of aneurysm on esophagus as well as aging motility. IV BP meds
titrated to oral meds with goal SBP 120's.To follow up with Dr.
[**Last Name (STitle) **] (GI)to monitor dysphagia. Cleared for discharge to rehab
on [**6-28**].
Medications on Admission:
casodex 50 mg daily
? zocor 20 mg daily
flomax 0.4 mg daily
toprol XL 50 mg daily
prednisone 10 mg [**Hospital1 **]
prozac 10 mg daily
megace
fentanyl patch 50 q week
morphine q 3-4 hours
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
Type B aortic dissection
MI
CAD/ 2 LAD stents
Afib/ SVT
prostate CA /XRT/ with bone metastases
HTN
GERD
elev. lipids
UTI
oral [**Female First Name (un) **]
presbyesophagus
s/p AV ablation
s/p appendectomy
Discharge Condition:
stable
Discharge Instructions:
tight BP control (SBP 120's)
Completed by:[**2165-6-28**]
|
[
"42731",
"5990",
"412",
"41401",
"V4582",
"42789",
"4019",
"53081",
"2720"
] |
Admission Date: [**2139-5-13**] Discharge Date: [**2139-5-19**]
Date of Birth: [**2099-9-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Amlodipine overdose
Major Surgical or Invasive Procedure:
Central line placement in Right Internal jugular vein
History of Present Illness:
This is a 39 year old with history of depression, COPD,
non-Hodgkin's lymphoma (in remission) transferred from [**Hospital **]
Hospital for evaluation of amlodipine ingestion in suicide
attempt. This AM, Mr. [**Known lastname **] [**Last Name (Titles) 7345**] ~700 mg amlodipine (70 tabs
of 10 mg Norvasc) at approximately 11 AM. He has had increasing
hopelessness over the last month and recently ordered amlodipine
over the internet. This AM, he [**Last Name (Titles) 7345**] the above pills and
felt lightheaded, fatigued and nauseated. He told his mother
about [**Name2 (NI) **] ingestion and she brought him to [**Hospital6 16464**]. At [**Hospital3 1280**], he reportedly had 2 episodes of syncope
and was initially noted to BP 90/47 with HR 120s with FSG 128.
His BP subsequently dropped to 70s and was given 2 L NS. He
also received 60 u insulin, 5 amps calcium, activated charcoal,
and started on levophed. Femoral line was attempted and
unfortunately was noted to be arterial and thus removed.
.
At [**Hospital1 18**] ER, BP 89-95/40-45 HR 90s-100s RR 18. He was seen by
toxicology with plans for Q30 min FSG and Q2H calcium checks.
He was continued on levophed peripherally and was transferred to
the MICU.
.
On arrival to the MICU, he reports feeling tired and wanting to
sleep. He notes that he no longer wants to harm himself and
noted that he is "too tired to even think about that."
Past Medical History:
COPD
Depression
Non-Hodgkin's Lymphoma
s/p facial skin graft for burns
Social History:
Denies smoking, ETOH
Family History:
Non-contributory
Physical Exam:
BP 93/64 HR 120s 97% RA T 97
Gen: Well-appearing male in NAD
HEENT: PERRLA, EOMI
CV: RRR S1 s2, no m/r/g
Resp: CTA anteriorloy
Abd: Soft, NT/ND +BS
Neuro: CN II-XII grossly in tact
Pertinent Results:
[**2139-5-14**] 04:24AM BLOOD WBC-8.7 RBC-4.78 Hgb-15.2 Hct-42.9 MCV-89
MCH-33.6* MCHC-37.9* RDW-13.8 Plt Ct-283
[**2139-5-13**] 04:20PM BLOOD WBC-11.5* RBC-4.56* Hgb-14.8 Hct-41.8
MCV-92 MCH-32.5* MCHC-35.5* RDW-13.8 Plt Ct-249
[**2139-5-13**] 04:20PM BLOOD Neuts-85.3* Lymphs-8.7* Monos-5.3 Eos-0.4
Baso-0.4
[**2139-5-13**] 04:20PM BLOOD Glucose-64* UreaN-12 Creat-1.1 Na-143
K-3.2* Cl-111* HCO3-21* AnGap-14
[**2139-5-13**] 09:05PM BLOOD Glucose-191* UreaN-13 Creat-1.1 Na-138
K-3.9 Cl-108 HCO3-20* AnGap-14
[**2139-5-14**] 04:24AM BLOOD Glucose-129* UreaN-10 Creat-1.0 Na-139
K-3.8 Cl-107 HCO3-22 AnGap-14
[**2139-5-14**] 12:24PM BLOOD TSH-0.79
[**2139-5-13**] 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2139-5-16**]
2:01 PM
IMPRESSION:
1. No central or segmental pulmonary embolism.
2. Moderate bibasal effusions and atelectasis at the lung bases.
3. Indeterminate 11-mm left lobe of thyroid nodule which can be
further
evaluated with a nonemergent ultrasound of the thyroid.
Brief Hospital Course:
This is a 39 yo with depression, COPD, Non-Hodgkin's lymphoma
admitted with CCB ingestion in suicide attempt and resultant
hypotension requiring pressors.
.
# CCB Ingestion: Patient [**Date Range 7345**] 700 mg of amlodipine, a
dihydropyridine, which predominantly causes vasodilitation and
can also cause resultant tachycardia. Elevated FSG is
frequently a sign of severe toxicity. Toxicology was called on
pt's arrival and serum calcium and fingersticks were closely
monitored in the ICU overnight. Pt was given a total of 2gm
calcium gluconate here. Fingersticks remained in the normal
range. A CVL was placed and levophed continued overnight and
weaned on the morning of [**2139-5-14**]. The pt remained stable on the
floor on [**2139-5-14**], and was medically cleared for discharge to
psychiatric facility on [**2139-5-14**]. Psychiatry and social work were
consulted and the pt was placed on a 1:1 sitter.
.
# Hypotension: Secondary to amlodipine ingestion and resultant
vasodilation and reflex tachycardia. Per pt, did not ingest any
other agents. Tox screen negative. No reason to suspect
infection, as remains afebrile. Urine cultures and blood
cultures were sent to rule out any infectious causes of
hypotension. Urine cultures were negative. Blood cultures from
[**2139-5-14**] show no growth to date on discharge, but are not yet
finalized.
.
# Tachycardia - patient was found to consistently tachycardic to
100-110s, likely compensation for vascualr vasodilation from
overdose of amlodipine. Patient was hydrated with IVF with some
improvement, now in the 90s. Amlodipine has a half life of
30-50hrs, will require more time before medication fully clears
his system. CTA of the chest did not show pulmonary embolism.
.
# COPD: Lungs clear. The pt's outpatient regimen of spiriva was
continued.
.
# Depression: Pt's outpatient psychiatric regimen was held as
patient's regimen was to be readdressed once in an inpatient
psychiatric facility.
.
# F/E/N:
Regular diet, replete electrolytes as above
.
# PPX:
heparin sq
.
# Full code
FOLLOW UP:
# Thyroid nodule: Please follow up " Indeterminate 11-mm left
lobe of thyroid nodule" seen on CTA of chest.
Medications on Admission:
Spirva
Prozac
Resperidone
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
consipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Location (un) 10059**]
Discharge Diagnosis:
Suicide Attempt
Amlodipine overdose
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after attempting suicide by taking an overdose
of amlodipine pills. You were treated in the ICU and then you
were medically cleared for discharge to a psychiatric facility.
Psychiatry saw you while you were inpatient.
You had a CT scan of the chest during this admission to rule out
a pulmonary embolism. The CT was negative. It did show a
Indeterminate 11-mm left lobe of thyroid nodule that should be
followed up with your primary care doctor.
Your home medications have been stopped, except for the Spiriva.
You will start a new psychiatric medication regimen at the
psychiatric facility you are going to.
Followup Instructions:
With: NP[**Last Name (un) **] [**Doctor Last Name 86517**]
Location: [**Street Address(2) 86518**], [**Location (un) 70989**] [**Numeric Identifier 86519**]
Phone: [**Telephone/Fax (1) 86520**]
Appointment: [**2139-6-9**] 9:00am
|
[
"311",
"496"
] |
Admission Date: [**2200-1-20**] Discharge Date: [**2200-1-28**]
Date of Birth: [**2148-7-12**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
CC: headache, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51 yo F w/ h/o DM1, CRI, CAD s/p CABG, renal transplant in [**2185**]
donor sister, on cyclosporine and Imuran who presents with
complaint of HA, sudden onset since 5 PM yesterday, [**8-8**],
+nausea, increasing dyspnea on exertion x 1 month worsening over
two weeks. Pt reports taking meds after dinner within minutes
nausea, lightheadedness, blurry vision, headache. Blood pressure
140/80. +dizziness, +CP w/ SOB. Nausea, sob EKG NS 60, Right
axis. ST depressions in I,II, AVF, V4-6, ST elevations V1, R.
Unchanged. Stress MIBI in [**Month (only) 205**] normal. To ED when no resolution
in headache and nausea. Headache only when laying flat.
.
In ED cardiac enzymes drawn with troponin to 1.88. Cr to 3.
Started on heparin in the ED. Fluids started. FS elevated to
critical levels but to 388 with 10 units of insulin sub q. Pt
reports glucose elevated to 600, 2 days prior. In ED
Past Medical History:
1. Diabetes mellitus type 1 since age 11, c/b neuropthy,
retinopathy, and nephropathy.
2. Diabetic ketoacidosis.
3. Hypo/hyperglycemia followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Last Name (un) **].
4. Renal failure, status post renal transplant in [**2185**], baseline
creatinine around 2.5.
5. Coronary artery disease, status post myocardial infarction in
[**2188**], status post coronary artery bypass graft in [**2193**], SVG
graft failure x2, LIMA to LAD patent.
6. Hypertension.
7. Hypercholesterolemia.
8. Peptic ulcer disease.
9. Deep vein thrombosis.
10. Status post amputation of the left toe.
11. Peripheral vascular disease.
12. Diverticulitis.
13. Gout.
14. Pancreatitis.
15, recurrent cellulitis
.
PSHx:
s/p orthoscopic L knee surgery [**2173**]
s/p tuboligation [**2184**]
s/p Left LE DVT complicated by left big toe gangrene
w/amputation 1005
s/p RUE clot [**2188**]
s/p ORIF Right femur [**2188**]
s/p cataract implant [**2189**]
s/p release of hand contractions
s/p CABG [**2193**]
s/p cholecystectomy [**2197**]
Social History:
The patient currently lives in [**Location 15749**] with her husband, they
have no children (patient has lost 5 pregnancies previously).
She is employed at [**Company 2676**] as an administrative assistant. She
denies any tobacco, ETOH, or illict drug use. She uses a scooter
to get around at work for longer distances.
Family History:
Significant for father with CABG and valvular surgery. Mother
healthy. Siblings sig for sister with [**Name (NI) 21418**] and gout. No other
family members with [**Name (NI) **].
Physical Exam:
PE:
Vitals- 97.3, 98/54, 62,18, 93% on 2L
Gen- well appearing female in no acute distress sitting up in
bed.
HEENT- EOMI, bilateral surgical pupils, non elevated JVP.
Cor- RRR no m/r/g
Pulm- CTAB, no W/R/R
Abd- soft non tender non distended. + BS. surgical incision
scars.
Extr- 2+ edema L>R,non tender. toe amputation.
Pertinent Results:
[**2200-1-20**] 04:30AM PLT COUNT-324
[**2200-1-20**] 04:30AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MICROCYT-2+
[**2200-1-20**] 04:30AM NEUTS-86.1* LYMPHS-8.7* MONOS-3.8 EOS-1.1
BASOS-0.3
[**2200-1-20**] 04:30AM WBC-11.5* RBC-4.28 HGB-11.5* HCT-34.7*
MCV-81* MCH-26.8* MCHC-33.1 RDW-18.5*
[**2200-1-20**] 04:30AM CALCIUM-9.6 PHOSPHATE-4.7* MAGNESIUM-2.2
[**2200-1-20**] 04:30AM CK-MB-13* MB INDX-8.0*
[**2200-1-20**] 04:30AM cTropnT-1.88*
.
[**1-20**]- EKG unchanged from prior (same STE in v1 and AVR and
diffuse ST depression elsewhile.
.
CHEST (PA & LAT) [**2200-1-20**] 12:13 PM
Stable radiograph with no convincing radiographic evidence of
acute superimposed disease.
.
REST MIBI [**2200-1-20**]
INTERPRETATION:
Following injection of MIBI while patient was at rest and
experiencing chest pain, static and gated SPECT images were
obtained and analyzed. A bull's-eye display of tracer
distribution throughout the myocardium was also obtained.
Imaging Protocol:
This study was interpreted using the 17-segment myocardial
perfusion model. The image quality is severely limited by soft
tissue attenuation.
Rest images show some irregular tracer uptake in the ventricular
walls.
However, due to severe attenuation artifacts, images are
diagnostically
uninterpretable.
IMPRESSION:
Diagnostically uninterpretable study due to artifacts from
significant softtissue attenuation.
.
CT HEAD W/O CONTRAST [**2200-1-20**] 5:24 AM
No intracranial hemorrhage or mass effect.
.
[**1-20**] Negative left lower extremity DVT study.
.
CHEST (PORTABLE AP) [**2200-1-22**] 5:10 PM
FINDINGS: Patient demonstrates low lung volumes when compared to
previous radiograph. Increased prominence of vascular markings
noted with cephalization. Cardiomediastinal silhouette is
unchanged in appearance. Median sternotomy wires and mediastinal
clips signify previous coronary artery bypass grafting. No
pleural effusions or pneumothoraces identified. No definite
consolidation identified.
IMPRESSION: Although low lung volumes when compared to previous
radiograph which can produce vascular crowding, increased
vascular markings with cephalization identified consistent with
mild CHF.
.
Brief Hospital Course:
51 yo F w/ h/o DM1, CRI, CAD s/p CABG, renal transplant in [**2185**]
donor sister, on cyclosporine and Imuran who presented to the ED
[**1-20**] with 8/10HA associated with nausea.
.
NSTEMI/troponin leak- Her ECG was unchanged from prior. Her trop
was 1.88 (Bl <.01) and Cr 3, consistent with NSTEMI. Head CT and
LENIs negative. She was given IVF and heparin and admitted to
the floor. Associated headache and nausea resolved. On the
floor, troponin peaked on [**1-21**] at 2.65 and then trended down,
now to 1.53. EKG's remained unchanged and no events on tele. She
was medically managed with heparin gtt, ASA and BB. No cath
given transplant patient with elevated creatinine. Did not want
to cause harm with impending dialysis with dye load. Pt also did
not want catheterization. AS per Dr. [**Last Name (STitle) **], diuresis, and
optimal medical management initiated.
.
DM I- Glucose elevated since ED to critically high levels.
Controlled with 10 units of humulog and sent to floor. [**Last Name (un) **]
consulted day of admission. Saw patient day two and recommended
reinitiating home regimen. As per patient glucose to 600's 2
days prior to admission on regimen of Apidra and Levimir. Lantus
and humulog sliding scale initiated [**1-21**]. [**1-22**] Glucose to 500 +
despite several units of Apidra, and home regimen of Levemir.
Increasing white count. No gap at that time. Glucose unable to
be controlled and patient sent to the MICU for insulin gtt with
concern for impending DKA. Elevated white count above admission,
concerning for infection, especially given on immunosuppressive
therapy. UA and cultures sent.
.
CRI- patient s/p renal transplant on Imuran and cyclosporine.
Maintained on doses. Continued lasix given patient prone to
flash pulmonary edema. Creatinine rose to 3.3 from baseline 2.4
day two of admission to 2.7 [**1-22**]. DC'd HCTZ, and decreased BB to
50 [**Hospital1 **] given episodes of hypotension day 1 of admission. Renal
and transplant involved.
.
Patient was scheduled for discharge when her glucose levels were
noted to be uncontrollable with SQ insulin and [**Last Name (un) **]
recommended an insuling gtt. She was then transferred to the
MICU for management. In the MICU, management was obtained with
help of [**Last Name (un) **], increasing her glargine dose, using her own
insulin from home and covering meals with insulin. Her specific
dosing was glargine 25 units [**Hospital1 **], Apidra, and new carb ratio for
her insulin. Additionally she was started on plavix while in
the ICU and her metoprolol was titrated up. She was discharged
from the ICU due to her desire to leave the hospital. She
understood the risk of leaving, and was well informed about her
disease and follow up.
Medications on Admission:
1. Pravastatin 40mg PO HS
2. Aspirin 325mg PO qD
3. Apidra Subcutaneous
4. Levemir Flexpen Subcutaneous
5. Omeprazole 20mg PO BID
6. Amitriptyline 100mg PO HS
7. Azathioprine 50mg PO qD
8. Cyclosporine 100mg PO qD
9. Isosorbide Dinitrate 40mg PO BID
10. Furosemide 40mg PO qD
11. Hydrochlorothiazide 12.5mg PO qD
12. Valsartan 80mg PO qD
13. Metoprolol 100mg PO BID
14. Clonidine 0.3 mg/24 hr Patch 2xwk
15. Acetaminophen 325mg PO Q4-6H prn
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
8. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
10. oxygen
Patient needs home oxygen, 2L continuously for saturations of
79% on RA. status post MI and multiple other comorbidities.
11. Cyclosporine 25 mg Capsule Sig: Three (3) Capsule PO once a
day.
Disp:*90 Capsule(s)* Refills:*0*
12. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical
Discharge Diagnosis:
1. NSTEMI/troponin leak
2. hyperglycemia
3. Renal failure
4. Hypertension
Discharge Condition:
chest pain free, tolerating PO, ambulating, decreasing
creatinine, decreasing cardiac enzymes, improving glucose
control
Discharge Instructions:
You were admitted with severe headache and nausea, found to have
an elevated troponin with question of NSTEMI/troponin leak. A
cath was not performed given your elevated creatinine. Risks and
benefits discussed with you and in accordance with Dr. [**Last Name (STitle) **]
medical management undertaken.
It was also quite difficult to manage your blood glucose levels
while in the hospital. You were given an insulin drip to help
control them. You should follow up with the [**Hospital **] clinic to
ensure that your sugars continue to be controlled.
Please take all medications as prescribed to you.
Please discontinue HCTZ, and clonidine patch.
Please take decreased dose of metoprolol not 50 mg twice a day
Please keep all appointment.
Please maintain low salt diet and work on diet regimen as
discussed in depth with Dr. [**Last Name (STitle) **]
[**Name (STitle) 21421**] return to the hospital if you are expierencing chest
pain, shortness of breath, fever, severe nausea, increased
glucose, or headache or any other symptoms concerning to you.
Followup Instructions:
Please follow up with [**Last Name (un) **] Center to discuss insulin regimen.
Provider: [**Name10 (NameIs) 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2200-1-29**] 3:00
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2200-3-18**] 11:10
|
[
"41071",
"40391",
"V4581",
"2720"
] |
Admission Date: [**2170-3-18**] Discharge Date: [**2170-3-22**]
Date of Birth: [**2129-6-22**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Hydralazine / Pyridium / Bactrim / Nitrofurantoin /
Dapsone / Quinine / Quinidine / Methylene Blue
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Hypoglycemia.
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
40 yo man with h/o VonGierke's dx with h/o hypoglycemia who
presented to the ED [**3-18**] with 4-5 days of labile blood sugar and
fatigue. He called EMS as he felt week. BG in field was 140
(after ensure) but on arrival in ED was 29. On arrival in the
icu he is reticent to answer questions and refers me to his
father. [**Name (NI) **] does acknowledge feeling thirsty, having poor po, and
feeling constipated. He denies fevers, chills, dizziness, chest
pain, sob, palpitations, n/v/abdominal pain. Further discussion
with his parents reveals subacute decline since receiving alpha
interferon therapy in [**2169-10-28**]. He has had weight loss of
approx 25 lbs since then (? poor appetite vs. poor mastication
as seems unable to chew/swallow). Additionally he has had
diarrhea, which recently may have been slightly better, thought
to represent poor absorption of corn starch, along with labile
BG. He has been fatigued with generalized weakness to the point
he has difficulty getting out of chair and has been using a
walker for ambulation. The past 2 days he has been so weak he
has been unable to ambulate and requested to come to the
hospital (despite disliking hospital). He
In the ED, VS: T 98.4 HR 119 BP 92/74 RR 22 Sat 95%. BG 29,
given 1 amp D50 then started on D10 1/2 NS gtt.
ROS: Per pt above, per parents: + for wt loss, fatigue,
weakness, poor appetite, difficulty with mastication (all as
above), poor sleep (chronic), decreased UOP, occaisional feet
falling asleep, and diarrhea, that may be slightly better,
though he currently feels constipated, rash bilateral feet since
previous hospitalization. Negative for HA, f/c/ns, congestion,
cough, sob, cp, palpitations, abdominal pain, nausea, vomitting,
melena, BRBPR, dysuria, focal weakness. Per his parents he has
been tachycardic on all previous admits but baseline HR unknown.
Past Medical History:
1) [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] disease: followed by Dr. [**Last Name (STitle) **]; with hepatic
angiomas, hemangiomas, LD (no surgical intervention per previous
not for liver lesions), hyperuricemia [**12-30**] gsd, on allopurinol
2) s/p porto-caval shunt
3) Anemia
4) NSAID related duodenal ulcer/GIB ([**2-3**])
Social History:
Lived independently in [**Location (un) 745**] until recently, now lives with
parents. No current tobacco, alcohol, or IVDA.
Family History:
Brother passed away from complications of [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 93502**] diease
(developed malignancy related to blood transfusion).
Physical Exam:
VS: T: 99.1 HR: 117 BP: 97/65 RR: 24 Sat: 99% RA
Gen: NAD, A&Ox3
HEENT: NC/AT, + scleral icterus, temporal waisting, MM very dry
with crusting dried blood, ? whitish plaques
Neck: Supple, JVP flat; 2cm x 2cm very firm area at the left
base of posterior cervical chain (?LAD) no other lad
Resp: CTAB, no w/r/r
CV: Tachycardic but no m/r/g, regular rhythm
Abdomen: Protuberant, distended (per pt at baseline) with caput
medusa, well-healed RUQ, LM scars, NT, +BS, massive
hepatomegally
Ext: 1+ PE B LE to thigh, no c/c
Neuro: A&O x3, CN II-XII intact, strength 4/5 UE/LE B, 2+ DTR's,
no asterixis
Skin: + jaundice, no rash or ulcerations.
Pertinent Results:
Admission labs:
[**Age over 90 **]|95|17
--------<20 lactate 10.3 AG 16
5.6|21|0.5
Comments: Na: Anion Gap Verified
K: Hemolysis Falsely Elevates K
.
ALT: 21 AP: 3886 Tbili: 7.2 Dir 5.1 I 2.1
AST: 101 Dbili: 7.2 LDH: 341 Tprot 5.9 Glob 3.6
Lip: 11 Hapto: Pnd
ammonia 65
7.0
16.0>--<575
24.1
N:81 Band:9 L:8 M:2 E:0 Bas:0
Hypochr: 2+ Anisocy: 2+ Poiklo: 1+ Macrocy: 1+ Microcy: 1+
Target: 1+
ROULEAUX FORMATION AND RBC AGGLUTINATION PRESENT
PT: 18.0 PTT: 39.5 INR: 1.6
UA [**3-18**]: Color Amber Appear Clear SpecGr 1.021 pH 6.5 Urobil 4
Bili Lg Leuk Neg Bld Tr Nitr Neg Prot Tr Glu Neg Ket Tr
Micro:
Urine Cx [**3-18**] pending
Blood Cx [**3-18**] pending x2
CXR [**3-18**]: (my read, not radiology) AP portable, pt rotated,
cardiomegally, low-lung volumes, no effusion or infiltrate.
Brief Hospital Course:
Patient was admitted with hypoglycemia secondary to [**First Name5 (NamePattern1) **]
[**Last Name (Prefixes) 93504**] glycogen storage disease, not amenable to treatment at
home with corn starch. He was treated with increasing levels of
10% dextrose solution. Given that his requirement of dextrose
was so elevated, after discussion with Glycogen storage disease
specialist Dr. [**Last Name (STitle) **], and the liver consult service, it was
determined that patient's overall long-term prognosis due to
progressive liver dysfunction, would remain poor without
transplant. Transplant was not a consideration for the patient
or the family, who did not want to pursue such aggressive
measures. It was then determined to focus on patient's comfort,
and his pain was treated with intravenous morphine and
lorazepam. He expired on [**2170-3-22**] at 11:55 PM from a
bradycardic arrest.
Medications on Admission:
Allopurinol 300 mg by mouth DAILY
Corn Starch Powder 55gm by mouth every four hours (Per protocol)
iron 160mg daily (since [**3-9**])
nizatidine 150mg [**Hospital1 **] (since [**3-12**]
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver Failure
Bradycardic Arrest
Discharge Condition:
Expired
Followup Instructions:
N/A
Completed by:[**2170-3-23**]
|
[
"5849",
"2859"
] |
Unit No: [**Numeric Identifier 70182**]
Admission Date: [**2122-12-16**]
Discharge Date: [**2122-12-26**]
Date of Birth: [**2122-12-16**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 70183**]-[**Known lastname 70184**]
delivered at 35 and 2/7 weeks gestation with a birth weight
of 2235 grams and was admitted to the newborn intensive care
nursery from labor and delivery for management of prematurity
and respiratory distress.
Mother is a 33 year-old, Gravida VI, Para 2 now 4 mother with
estimated date of delivery of [**2123-1-18**]. Prenatal screens
include blood type B negative, antibody screen negative,
hepatitis B surface antigen negative, Rubella immune, RPR
nonreactive and group B strep positive. The mother received
RhoGAM during the pregnancy due to her Rh negative status.
Labor was induced due to concerns for growth restriction on
both the twins. This twin, twin #1 delivered by spontaneous
vaginal delivery. He had spontaneous respiratory rate and cry
in the delivery room and required bulb suctioning and free
flow oxygen. Apgar scores were 7 and 8 at 1 and 5 minutes
respectively.
Physical examination on admission revealed a weight of 2235
grams; head circumference 32 cm; length 46 cm. Anterior
fontanel soft, flat, red reflex bilaterally. No dysmorphic
features, no neck masses. Breath sounds: Mild to moderate,
retracting equal breath sounds. No murmur. Heart: Regular
rate and rhythm. No murmur, +2 equal pulses. Abdomen:
Soft, no hepatosplenomegaly, no masses. Normal preterm male,
testes descended bilaterally. Back normal. Extremities
normal. No lesions, no rashes. Active with normal cry and
reflexes, normal tone and strength.
HOSPITAL COURSE: Due to respiratory distress, he was
initially placed on C-Pap of 6 room air, due to increased
respiratory distress, was intubated and given one dose of
Survanta. He was extubated to room air around 8 hours of
life. He has remained in room air since with comfortable work
of breathing. Respiratory rate in the 30s to 50's. No apnea
of prematurity.
Cardiovascular: No murmur. Heart rate ranges in the 120s to
160s. Recent blood pressure 75 over 40 with a mean of 53.
Fluids, electrolytes and nutrition: Was initially n.p.o.
with an IV of 10% dextrose. On day of life 1, started feeds
and was weaned off the IV fluids. Is currently breast
feeding/ bottle feeding of 24 calories/oz made with Neosure.
Weight at discharge is 2130 grams.
Gastrointestinal: Bilirubin was followed. It peaked on day
of life 4 with a total of 10, direct of .3, was started on
single phototherapy, rebound bili on [**12-22**] was 7.2/0.3.
Hematology: Hematocrit on admission was 40.1%. Patient's
blood type is AB negative, direct Coombs negative.
Infectious disease: Received 48 hours of Ampicillin and
Gentamycin for rule out sepsis. CBC was normal. Blood culture
was negative.
Neurology: Exam is age appropriate.
Sensory: Hearing screening passed on [**12-24**].
Immunizations: Hep B given [**12-21**].
NAME OF PRIMARY PEDIATRICIAN: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) 60344**], MD
To have f/u appt within 3-5 days of discharge.
VNA to come to house within 2 days post discharge.
MEDICATIONS: Vitamins 1 cc PO daily.
Ferrous sulfate 0.2 cc's PO day.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age preterm male, twin #1.
2. Respiratory distress syndrome, resolved.
3. Hyperbilirubinemia.
4. Rule out sepsis.
5. Immature temp control
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2122-12-21**] 18:26:57
T: [**2122-12-21**] 19:29:11
Job#: [**Job Number 70185**]
|
[
"7742",
"V053",
"V290"
] |
Admission Date: [**2163-10-4**] Discharge Date: [**2163-10-12**]
Date of Birth: [**2087-11-14**] Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide / Prochlorperazine / amiodarone
Attending:[**Last Name (un) 11974**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
ventricular tachycardia ablation
History of Present Illness:
Ms. [**Known lastname 90719**] is a 75yo female who initially presented to an OSH
with palpitations. Her AICD fired and she was noted to be in
recurrent v-tach at the OSH ED. She denies CP and SOB.
OSH Course:
She was transferred to the CCU at the OSH and had recurrent
episodes of v-tach with AICD pacing her. Subsequently, her
v-tach resolved spontaneously. In the CCU at the OSH, her vitals
at presentation were 130/90 HR 70-130 (tachycardia was
ventricular tachycardia) T98 RR 20 and satting 96% on RA.
Reportedly, device interrogation demonstrated recurrent runs of
ventricular tachycardia, some of which were pace-terminated but
one of them required of electrical cardioversion on [**2163-10-1**]. CXR
showed cardiomegaly but no lung pathology and EKG with
ventricular tachycardiat at 129 beats per minute, left bundle
branch with superior axis with atypical right bundle branch in
leads V1 and V2. The patient had WBC of 7 and hct of 34 with a
negative troponin and CPK times two, and K 3.4 and Mg 2.0. The
ICD was adjusted, enabling adaptive and pacing thresholds as
well as lowering the detection rate of slow ventricular
tachycardia zone from 140-120 beats per minute. The patient was
started on quinidine 324mg [**Hospital1 **] and her home dose of metoprolol
from 150mg [**Hospital1 **] to 100mg [**Hospital1 **].
.
Vitals on transfer were T 97 HR 70 BP 123/72 RR 18 O2 Sat: 97%
RA
.
On arrival to the floor, patient reported that she is tired, but
is asymptomatic. She denies CP, SOB. She reports ongoing
intermittent palpitations but has never had LOC. She says that
she feels well and is looking forward to her ablation so she can
"stop feeling this way." She does endorse dyspnea on exertion,
which she says is unchanged from her.
Past Medical History:
1. CARDIAC RISK FACTORS: NO Diabetes, NO Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CHF EF 35-45% with posterobasal aneurysm, atrial fibrillation,
bradycardia, 70% obtuse marginal branch stenosis and an occluded
RCA which are medically managed and LAD stent.
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: LAD stent. Multiple
percutaneous interventions and ventricular tachycardia ablation
at [**Hospital6 **].
-PACING/ICD: AICD
3. OTHER PAST MEDICAL HISTORY:
1. c. diff colitis- [**2163-6-29**]
2. PVD s/p PTCA of bilateral lower extremities [**2160**]
3. Renal artery stenosis
4. carotid artery stenosis
5. vertebral artery stenosis
6. s/p thyroidectomy; hypothyroidism.
7. s/p appendectomy
8. COPD
Social History:
-Tobacco history: 1 ppd x 60 years ex-smoker, quit 4 years ago.
-ETOH: has not had alcohol for years. She used to drink
occassionally.
-Illicit drugs: denies
Family History:
No family history of CAD. Negative for early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T97 BP 123/72 HR 70 RR 18 O2 sat 97% RA
GENERAL: 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.
CN II-XII intact.
NECK: Supple with JVP at clavicles. No carotid bruits.
CARDIAC: RR, normal S1, S2. III/VI systolic murmer. No thrills,
lifts. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi. Diminished breath
sounds at bases bilaterally. Resp were unlabored, no accessory
muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: no pronator drift.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
.
DISCHARGE PHYSICAL EXAM:
BP 86-123/58-79 HR 64-75 >94% RA
no LE edema, JVP at clavicles when patient is at 25 degree
elevation of head of the bed. She is alert and oriented but does
feel "weakness" in LE when ambulating.
Pertinent Results:
ADMISSION LABS
[**2163-10-4**] 01:15PM BLOOD WBC-11.1* RBC-4.05* Hgb-12.6 Hct-36.0
MCV-89 MCH-31.1 MCHC-35.1* RDW-16.4* Plt Ct-210
[**2163-10-6**] 03:28AM BLOOD Neuts-83.2* Lymphs-9.8* Monos-5.2 Eos-0.9
Baso-0.8
[**2163-10-4**] 01:15PM BLOOD Plt Ct-210
[**2163-10-4**] 01:15PM BLOOD Glucose-76 UreaN-21* Creat-1.2* Na-129*
K-4.6 Cl-91* HCO3-27 AnGap-16
[**2163-10-4**] 01:15PM BLOOD Calcium-8.7 Phos-4.2 Mg-2.2 Cholest-141
PERTINENT LABS AND STUDIES
[**2163-10-4**] 01:15PM BLOOD Triglyc-60 HDL-45 CHOL/HD-3.1 LDLcalc-84
[**2163-10-4**] 01:15PM BLOOD TSH-6.4*
DISCHARGE LABS AND STUDIES
[**2163-10-12**] 05:35AM BLOOD WBC-7.2 RBC-3.26* Hgb-10.0* Hct-29.2*
MCV-89 MCH-30.7 MCHC-34.3 RDW-16.2* Plt Ct-228
[**2163-10-12**] 05:35AM BLOOD Plt Ct-228
[**2163-10-6**] 03:28AM BLOOD PT-12.4 PTT-27.7 INR(PT)-1.0
[**2163-10-12**] 05:35AM BLOOD Glucose-86 UreaN-18 Creat-1.4* Na-129*
K-4.3 Cl-95* HCO3-26 AnGap-12
[**2163-10-12**] 05:35AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.1
Brief Hospital Course:
71yo female with significant past cardiac history presenting s/p
ablation for ventricular tachycardia, now with ongoing
hypotension and malaise.
.
ACUTE CARE
# RHYTHM: Initially presented with paroxysmal ventricular
tachycardia, for which she would receive ICD firings. She is s/p
ablation but did have VT on the table so it may not have been
successful. Patient is refusing amiodarone due to history of QT
prolongation. She has had [**4-2**] nonsustained beats of vtach, which
the patient reports some fluttering at the time of these
findings. Mexiletine was started [**10-11**], with improvement in blood
pressures (previously had been symptomatically hypotensive to
the systolic 80s with feelings of "dizziness and weakness" and
some orthostatic hypotension).
.
# CORONARIES: known CAD. Medically managed and s/p PCI.
Continued [**Last Name (LF) **], [**First Name3 (LF) **], BB, statin. Stopped Imdur as the patient
is not having anginal chest pain. She presented on Metoprolol
tartrate 150mg [**Hospital1 **] but was not tolerating this dose after her
ablation and is on a lower dose of metoprolol tartrate now, 25mg
[**Hospital1 **]. She had not previously been on an [**Last Name (LF) **], [**First Name3 (LF) **] Lisinopril 5mg
was started. Lipids not at goal with LDL of 141 in setting of hx
of CAD, continue statin therapy, consider uptitration of statin.
.
# UTI: Bactrim started [**10-8**], completed a 5 day course. Culture
did show e. coli which was sensitive to bactrim. Patient was asx
and it was an incidental finding.
.
# PUMP: CHF with EF of 35%. Currently optimized and not
fluid-overloaded, not symptomatic. Continued Aldactone. The
patient did have hypokalemia prior to starting her Aldactone but
this was resolved after introduction of the aldactone. She could
not tolerate Lasix, as her hypotension was limiting. She is
being discharged without this medication, but it could be
restarted in the outpatient setting.
.
# HYPOTHYROIDISM: currently asx, on home regimen of
levothyroxine, the patient is s/p thyroidectomy. TSH elevated at
6.6, will allow for outpatient f/u because we will do not
increase synthroid in the inpatient setting.
.
CHRONIC CARE
# GERD: continued Ranitidine. Not symptomatic during
hospitalization.
.
#COPD: continued Spiriva
.
# PSYCH: insomnia and anxiety-continued home ambien 5mg qhs. She
did have significant anxiety in the setting of her ICD firing
and the procedure and benefited from her home dose of Lorazepam
0.5mg prn 6h anxiety in setting of procedure.
.
ISSUES OF TRANSITIONS IN CARE:
CODE STATUS: DNR DNI
CONTACT: [**Name (NI) 13291**] [**Name (NI) 90719**] (son) [**Telephone/Fax (1) 90720**]
[**First Name8 (NamePattern2) **] [**Known lastname 90719**] Harding (daughter) [**Telephone/Fax (1) 90721**]
PENDING STUDIES: NONE
FOLLOW UP ISSUES OF CARE:
-Finding of elevated TSH (6.6) during hospitalization.
-Finding of elevated LDL (141).
-Note: discontinued Lasix (due to hypotension during the
hospitalization) and started Lisinopril, (because she has known
coronary artery disease and CHF).
Medications on Admission:
1. [**Telephone/Fax (1) **] 325mg daily
2. Lasix 40mg [**Hospital1 **]
3. Spiriva 18mcg daily
4. Levothyroxine 25mcg daily
5. Ambien 5mg qhs
6. Zocor 40mg
7. [**Hospital1 **] 75mg qday
9. Nitroglycerin .4mg prn chest pain
10. Calcium carbonate 1000mg [**Hospital1 **]
11. Ativan .5mg [**Hospital1 **] prn anxiety
12. Imdur 30mg daily
13. Metoprolol tartrate 150mg [**Hospital1 **]
14. Zantac 150mg [**Hospital1 **]
15. Aldactone 25mg daily
17. Lactobacillus gg 1 cap daily
OSH Medications: as above as well as:
- Lasix 40mg [**Hospital1 **]
- Quinidine 324mg [**Hospital1 **]
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*0*
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day) as needed
for dyspepsia.
14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual up to 3 times prn as needed for chest pain.
15. Outpatient Lab Work
please obtain CBC and chemistry on Friday [**10-14**]. Please send
results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], phone is ([**Telephone/Fax (1) 90722**]
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Hospital **] Nursing Home - [**Location (un) 5087**]
Discharge Diagnosis:
primary diagnosis: ventricular tachcardia
secondary diagnoses: peripheral vascular disease, peripheral
arterial disease, hypothyroidism, Chronic Obstructive Pulmonary
Disease, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 90719**],
It was a pleasure taking care of you. You were admitted to the
hospital for ventricular tachycardia and you were transferred to
[**Hospital1 69**] for ablation for this
condition. You underwent the ablation with the following result:
improvement in your symptoms.
.
Please note the following changes to your medications:
- STOP Imdur
- STOP Lactobacillus
- STOP Lasix
- DECREASE Metoprolol
- START Lisinopril
- START Mexilitine.
Please keep your follow up appointments with your physicians.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please make an appointment to see your cardiologist within [**4-1**]
weeks.
.
Please make an appointment to see your PCP [**Name Initial (PRE) 176**] 2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
|
[
"5990",
"42731",
"496",
"4280",
"41401",
"V4582",
"V1582",
"412",
"2859"
] |
Admission Date: [**2151-12-30**] Discharge Date: [**2152-1-13**]
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female with a significant past medical history of
hypertension, recent urinary tract infection, hypothyroidism,
who called EMS on [**2151-12-30**] after feeling unwell and
experiencing chest pain. The patient was found to be
unresponsive and a junctional rhythm in the 40s with no
palpable pulse in respiratory distress. She was intubated in
the field and received 1 mg atropine with a responsive heart
rate 80s, blood pressure 80/palp. She was taken to the
[**Hospital 4068**] Hospital and subsequently transferred to [**Hospital6 1760**] for cardiac catheterization
as the patient was felt to be in cardiogenic shock.
Catheterization revealed three vessel disease (90% left
anterior descending, 90% left circumflex artery, presumed
occluded right coronary artery) and septic physiology (SVR
577, cardiac index 4.5, SCV02 82%). The procedure was
complicated by a right iliac dissection necessitating a
brachial artery approach. The patient was transferred to the
Medical Intensive Care Unit for sepsis of unclear etiology.
She had a dirty urinalysis at outside hospital with negative
urine and negative blood cultures. There was some concern
for aspiration in the setting of her intubation and she was
therefore treated empirically with levofloxacin and Flagyl.
She was extubated on [**12-31**] but had a new 02 requirement
felt likely to be secondary to pulmonary edema. She received
six liters as part of her fluid resuscitation. Diuresis was
complicated by a rising creatinine.
At time of transfer to the floor, the patient felt well and
denied fever, chills, headache, chest pain and shortness of
breath, diarrhea, constipation, abdominal pain, nausea or
vomiting.
PAST MEDICAL HISTORY:
1. Status post E. Coli urinary tract infection in [**2151-10-25**].
2. Hypertension.
3. Osteoarthritis.
4. Hypothyroidism, status post thyroidectomy.
5. Appendectomy.
6. Humerus fracture.
HOME MEDICATIONS:
1. Levoxyl 0.05 mg po q.d.
2. Lisinopril 10 mg po q.d.
3. Aspirin.
4. Celebrex 200 mg b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No illicit drugs times three. Lives at home
with sister who is [**Age over 90 **] years old.
FAMILY HISTORY: Noncontributory
PHYSICAL EXAMINATION AT TIME OF TRANSFER TO THE FLOOR:
Temperature 97.9. Temperature maximum 99.4. Blood pressure
110/80. Heart rate 92. Respiratory rate 20, saturating
93-95% on shovel mask. General: Pleasant female with mild
tachypnea. Head, eyes, ears, nose and throat: She is
anicteric. Oropharynx clear. Neck: Jugular venous
distention difficult to appreciate but EJ distended at 45
degrees. Cardiovascular: Regular rate and rhythm without
murmurs. S3, S4 not appreciated. Lungs: Mild crackles at
bases bilaterally. Positive expiratory wheezes. Abdomen:
Decreased bowel sounds, soft, nontender. Extremities: No
edema. 1+ pulses posterior tibial and dorsalis pedis
bilaterally, warm, right groin without bruit or hematoma.
Neurological: Alert and oriented times three. Cranial
nerves II through XII are intact. No gross, motor or sensory
deficits.
DATA: Cardiac catheterization on [**12-30**] revealed three
vessel coronary artery disease with normal left main, 90%
left anterior descending, 90% left circumflex artery,
presumed occluded right coronary artery. Supranormal cardiac
output with low SVR. SVR 577, cardiac output 6.8, cardiac
index 4.5. Pulmonary capillary wedge pressure 13.
Dissection of right iliac artery.
Transthoracic echocardiogram on [**12-31**] revealed mild left
atrium dilation, moderately depressed left ventricular
ejection fraction at 35% with anterior septal and apical
hypokinesis to akinesis. 1+ aortic regurgitation, 2+ mitral
regurgitation, 2+ tricuspid regurgitation.
CT of the head on [**1-10**] showed no acute intracranial
hemorrhage or hydrocephalus, changes consistent with age
related atrophy present.
CT of the chest on [**1-7**] indicated bilateral pleural
effusions and findings suggestive of pulmonary edema. No
evidence of infection.
Micro: Patient's Clostridium difficile negative times two.
>.....<culture positive for Methicillin resistant
Staphylococcus aureus on [**1-7**]. Repeat urine [**1-10**] is contaminated by no evidence of Staph aureus. Blood
cultures negative throughout her stay. Sputum culture on
[**12-31**] negative.
LABORATORIES AT THE TIME OF DISCHARGE: White blood cell
count 17.2, hematocrit 30.2, MCV 95, platelet count 176,000.
Chem-7: Sodium 138, potassium 4.1, chloride 101, bicarbonate
29, BUN 53, creatinine 1.1, glucose 109.
HOSPITAL COURSE SUMMARY: Patient is a [**Age over 90 **]-year-old
functionally independent female with a history of
hypertension, hypothyroidism, recent urinary tract infection
found to be unresponsive by EMS who was transferred to [**Hospital6 1760**] from [**Hospital3 4527**] for
emergent cardiac catheterization secondary to concerns for
cardiogenic shock, but was transferred to the Medical
Intensive Care Unit after catheterization revealed septic
physiology of unclear etiology.
1. Respiratory distress: The patient was extubated on
[**12-31**]. She had a short Medical Intensive Care Unit
course as described in the history of present illness.
Patient was transferred to the floor with a significant 02
requirement and mild level of respiratory distress felt to be
secondary to pulmonary edema in the setting of her
intravenous fluid resuscitation upon admission. She was
transferred to the floor for ongoing diuresis, and her 02
requirement was weaned to 1-2 liters nasal cannula at the
time of this dictation. She has had coarse upper airway
sounds and secretions which she has been unable to clear, but
she has had multiple chest x-ray's and a chest CT, which were
all negative for any evidence of infection. AT various
points throughout her stay, she had mild desaturations into
the mid 80s, which responded to increased pulmonary toilet
and chest physical therapy as they were felt secondary to
aforementioned secretions.
2. Cardiovascular: The patient found to have three vessel
coronary artery disease and a depressed ejection fraction.
Also with non ST elevations myocardial infarction. Patient
was started on a cardiac regimen of aspirin, Plavix, statin
and low dose beta-blocker and ACE inhibitor as tolerated by
her blood pressure. Family is aware of the patient's
diagnosis of three vessel coronary artery disease and
depressed ejection fraction, and are also aware that in
certain settings, these would be indications for coronary
artery bypass graft, and or ICD placement. However, given
the advanced age of the patient, they were in agreement that
medical management be pursued at this time.
3. Infectious Disease: Patient admitted to the Medical
Intensive Care Unit with septic physiology but no clear
source. She completed an initial seven day course of
levofloxacin and Flagyl, as well as a seven day course of
stress dose steroids. She had a leukocytosis on the floor,
but remained afebrile throughout her entire stay. Repeat
chest x-ray's and CT were negative for evidence of a
pulmonary etiology. She had a urine culture on [**1-7**]
that grew Methicillin resistant Staphylococcus aureus at
which time she was started on vancomycin to complete a 14 day
course. A repeat urine culture on [**1-10**] was
contaminated but had no evidence of Staph aureus.
4. Mental status: On approximately [**1-8**] and [**1-9**], the patient was noted to have a decreased level of
alertness, although, she remained oriented times three. This
prompted a head CT which revealed no acute process. She also
had repeat arterial blood gases, which revealed very mild CO2
retention and no evidence of acidemia. Her urinary tract
infection is resolving. It was felt at the time that the
patient looked intervascularly dry and was given a trial of
intravenous fluids to which she responded well, and appeared
to be more alert on the following day. She remained without
any focal neurological findings.
5. Acute renal failure: The patient had an episode of an
increased creatinine both in the Intensive Care Unit and on
the floor secondary to overdiuresis, but these episodes
responded well to gentle intravenous fluids and
discontinuation of her diuretics. At the time of discharge
she remained on no active diuretic regimen.
6. Right iliac artery dissection: Was a complication of her
cardiac catheterization. Per discussion with Cardiology, no
further intervention is needed, and patient is okay to be on
subcutaneous heparin and Plavix. She remained with equal
dorsalis pedis and posterior tibial pulses in both feet.
7. Macrocytic anemia: Patient had stable hematocrit
throughout her stay. Studies were consistent with Vitamin
B12 deficiency, at which point, patient was given a week
course of Vitamin B12 1 mg intramuscularly q.d. and at the
time of discharge she is to begin 1 mg
intramuscularly/subcutaneous q. week for one month, then
receive 1 mg injection q. month.
8. Aspiration: At the time of discharge patient was felt to
be aspirating and was undergoing a video speech and swallow
study; the results of which are pending at this time.
9. Urinary retention: Patient's Foley catheter was
discontinued in the setting of a urinary tract infection
after which she was noted not to have any voids and a Foley
catheter was reinserted with return of 600-700 cc of urine.
A second trial at discontinuing her Foley catheter was also
met with urinary retention and failure to void, and
therefore, the Foley catheter was inserted yet again and
recommended that it remain there for at least one week.
There is no evidence to suspect neurologic etiology or
medications, therefore, it was felt that her retention was
multifactorial related to her urinary tract infection and
prolonged hospital course.
10. Code status: Patient's code status was addressed with
the family and they wished to defer the discussion, at which
time the patient could not be involved in making the
decision, therefore, she remains full code at this time.
CONDITION OF DISCHARGE: Patient in stable condition,
saturating greater than 92% on one to two liters nasal
cannula.
DISCHARGE STATUS: Patient is to be discharged to an acute
rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Cardiac arrest.
2. Coronary artery disease, status post non ST elevation
myocardial infarction.
3. Congestive heart failure.
4. Urinary tract infection.
5. Acute renal failure.
6. Hypothyroidism.
7. Macrocytic anemia.
8. Vitamin B12 deficiency.
9. Urinary retention.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po q.d.
2. Tylenol prn.
3. Colace.
4. Lipitor 20 mg po q.d.
5. Senna 1 tablet po b.i.d.
6. Insulin sliding scale.
7. Levothyroxine 50 mcg po q.d.
8. Albuterol inhaler prn.
9. Atrovent inhaler prn.
10. Metoprolol 12.5 mg po b.i.d.
11. Captopril 12.5 mg po t.i.d.
12. Plavix 75 mg po q.d.
13. Cyanocobalamin 1000 mcg intramuscular injection q. week
for four doses.
14. Vancomycin 500 mg intravenous q.d. for seven days to be
completed [**2152-1-20**].
FOLLOW-UP PLANS: The patient is to call her primary care
physician to schedule appropriate follow-up. His name is
[**Name (NI) 333**] [**Name (NI) 1968**]. Phone number [**Telephone/Fax (1) 8477**].
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 8478**]
MEDQUIST36
D: [**2152-1-21**] 02:27
T: [**2152-1-13**] 14:57
JOB#: [**Job Number 8479**]
|
[
"41071",
"41401",
"0389",
"99592",
"5070",
"4280"
] |
Admission Date: [**2118-11-29**] Discharge Date: [**2118-12-10**]
Date of Birth: [**2069-10-26**] Sex: F
Service: SURGERY
Allergies:
Zantac 75 / Lipitor
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Fatigue, nausea/vomiting, left neck swelling and pain
Major Surgical or Invasive Procedure:
CT guided drainage of abdominal abscess
History of Present Illness:
The patient is a 49 y/o female with h/o diverticulitis and
multiple abdominal surgeries presents with increasing lethargy
for 3-4 days. She began to notice swelling of her left neck 4
days ago accompanied by ear pain and pain on swallowing. Her
husband has noticed increased drainage from her abdominal wound.
The patient has also had frequent episodes of nausea and
vomiting. She denies fever, chills, shortness of breath, chest
pain, or abdominal pain. Her ostomy output has remained
constant.
Past Medical History:
PMH:
1.)Colocutaneous Fistula
2.)Aspiration pneumonia with MRSA
3.)Diverticulitis
4.)Anxiety
5.)Depression
6.)afib
PSH:
1.)[**2118-7-21**]- Exploratory laparotomy with total colectomy
2.)[**2118-7-23**]- Takedown of ileorectal anastomosis, [**Doctor Last Name **] pouch,
ileostomy
3.)[**2115**]- Sigmoid Colectomy
4.)[**2109**]- Cholecystectomy
Social History:
Mrs. [**Known lastname 69147**] lives in [**Location **] with her husband and four kids
(7,9, 17, and 19 years of age). This is her second marriage and
she stays at home and cares for the children. Before her first
marriage, she worked at a nursing home. She has a 16 pack-year
smoking history, quitting in [**Month (only) 216**] due to her hospitalization.
She drinks alcohol occassionally and has no history of illicit
drug use. She buckles up when she drives and does not own a
gun. She does not bike and has no history of felonies or
misdemeanors. She is on a limited hospital diet and does not
actively exercise. She has not been sexually active due to her
hospitalizations but otherwise, only has sex with her current
husband.
Family History:
Mother passed away of lung cancer and was a heavy smoker. Her
father is alive and well. There is no history of
diverticulitis, diabetes, cancer or cardiac problems.
Physical Exam:
T 95 P 70 BP 100/60 R 20 SaO2 100%
Gen - no acute distress
Heent - no scleral icterus, tympanic membranes clear; fullness,
warmth, and erythema along left sternocleidomastoid muscle
Lungs - clear
Heart - regular rate and rhythm
Abd - soft, nontender, nondistended, bowel sounds audible;
ostomy patent; purulent material draining from abdominal wound
Extrem - no lower extremity edema
Pertinent Results:
[**2118-11-29**] 12:19AM BLOOD WBC-13.0* RBC-3.10* Hgb-8.7* Hct-25.7*
MCV-83 MCH-28.2 MCHC-34.0 RDW-14.1 Plt Ct-363
[**2118-11-29**] 12:19AM BLOOD PT-32.6* PTT-54.6* INR(PT)-3.5*
[**2118-11-29**] 12:19AM BLOOD Glucose-97 UreaN-22* Creat-1.1 Na-133
K-3.1* Cl-100 HCO3-23 AnGap-13
[**2118-11-29**] 12:19AM BLOOD ALT-9 AST-14 AlkPhos-302* Amylase-108*
TotBili-0.2
[**2118-11-29**] 12:19AM BLOOD Lipase-16
[**2118-11-29**] 11:00 am ABSCESS RIGHT RETRO PERITONEAL .
**FINAL REPORT [**2118-12-4**]**
GRAM STAIN (Final [**2118-11-29**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2118-12-4**]):
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).
WORK UP OF GRAMNEGATIVE RODS REQUESTED BY DR [**First Name (STitle) **] [**2118-12-2**].
ESCHERICHIA COLI. HEAVY GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
ESCHERICHIA COLI. HEAVY GROWTH. SECOND STRAIN.
Trimethoprim/Sulfa sensitivity testing available on
request.
ESCHERICHIA COLI. HEAVY GROWTH. THIRD STRAIN.
Trimethoprim/Sulfa sensitivity testing available on
request.
ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE.
STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE.
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-/2418**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| | ESCHERICHIA
COLI
| | |
ENTEROCOCCUS SP.
| | | |
STAPH
| | | |
| K
| | | |
| |
AMPICILLIN------------ =>32 R =>32 R =>32 R <=2 S
AMPICILLIN/SULBACTAM-- =>32 R =>32 R 16 I
4 S
CEFAZOLIN------------- <=4 S <=4 S <=4 S
<=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S
<=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S
<=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
<=1 S
CEFUROXIME------------ 8 S 16 I 4 S
<=1 S
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
1 S
ERYTHROMYCIN----------
=>8 R
GENTAMICIN------------ <=1 S <=1 S <=1 S
<=0.5 S <=1 S
IMIPENEM-------------- <=1 S <=1 S <=1 S
<=1 S
LEVOFLOXACIN---------- =>8 R =>8 R =>8 R
=>8 R 1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
<=0.25 S
OXACILLIN-------------
=>4 R
PENICILLIN------------ 8 S
=>0.5 R
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S
<=4 S
RIFAMPIN--------------
<=0.5 S
TETRACYCLINE----------
<=1 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
<=1 S
VANCOMYCIN------------ <=1 S
<=1 S
ANAEROBIC CULTURE (Final [**2118-12-3**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient presented to the ED and had an abdominal CT scan
which showed a large right sided peritoneal fluid collection
despite an appropriately placed drainage catheter. She
presented with a clinical picture of sepsis as she was
hypotensive with SBP in the 80s. She was transferred to the
SICU for intensive monitoring and was started on broad spectrum
antibiotics of Vancomycin and Zosyn. A levophed drip had to be
started for the patient's hypotension. The patient had been on
coumadin for a history of atrial fibrillation and came in with
an INR of 3.5. The patient was given FFP to bring the INR down
so that she could have CT guided drainaged of her abscess.
450cc was able to aspirated during the procedure and the
loculations were broken up. The aspirated fluid was sent for
cultures, which grew back E. coli and MRSA.
ENT was consulted for the patient's neck pain which was
diagnosed to be parotitis, This was treated with sialogues, hot
compresses, aggressive parotid massage, and IV antibiotics.
These measures were successful in treating her parotitis.
The patient was transfused one unit of packed RBCs for a Hct of
22.6. The patient was able to be weaned off the Levophed drip
and was stable enough to be transferred to the floor on hospital
day 2. The patient's diet was able to be advanced and she was
able to tolerate a regular diet. However, the patient continued
to feel lethargic and nauseous and have a low level of activity.
On hospital day 6, she vomited and she was made NPO. She
continued to have good ostomy output and drainage from her
abdominal drain at this point. Another CT scan was obtained to
assess the abscess drainage which revealed near-complete
resolution of right lower quadrant fluid collection with pigtail
catheter in place. There was also decrease in size of posterior
fistulous tract through the right flank muscles. Given these
findings, the patient's nausea likely was not due to
insufficient abscess drainage. The patient had another episode
of nausea and vomiting on hospital day 10. Her diet was
gradually advanced and the patient was able to tolerate a
regular diet on discharge. Physical therapy was consulted to
assist the patient with ambulation and she was able to ambulate
independently. Coumadin was restarted and the patient's INR
closely monitored. The patient had a PICC placed so that she
could receive IV antibiotics after discharge.
The [**Hospital 228**] hospital course was complicated by acute renal
failure due to a high Vancomycin level. As her Vancomycin level
trended down, her Cr trended down as well and was stable at
on discharge. The patient had adequate urine output throughout
her admission. She was discharged to home with services in
stable condition.
Medications on Admission:
warfarin 1mg qHS
Protonix 40mg qDay
trazodone 100mg qHS
citalopram 20mg qDay
alprazolam 1mg TID prn
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*20 Capsule(s)* Refills:*0*
7. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
Disp:*120 Tablet(s)* Refills:*2*
8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 3 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Abdominal abscess
Discharge Condition:
Stable
Discharge Instructions:
Call your doctor or seek immediate medical attention if you
experience fever, chills, lightheadedness, dizziness, chest
pain, shortness of breath, severe abdominal pain,
nausea/vomiting, or bleeding, increased drainage, or redness
from drain site.
Activity as tolerated. Try to walk at least three times a day.
You may resume your home medications.
No driving while taking pain medications.
No tub baths or swimming.
Followup Instructions:
Call [**Telephone/Fax (1) 1864**] to schedule an appointment with Dr. [**Last Name (STitle) **]
in [**12-6**] weeks.
|
[
"0389",
"5849",
"99592",
"42731",
"V5861"
] |
Admission Date: [**2202-1-27**] Discharge Date: [**2202-2-15**]
Date of Birth: [**2131-4-24**] Sex: M
Service: MEDICINE
Allergies:
Iodine / Penicillins / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
R internal jugular central line
GJ tube placement
History of Present Illness:
The pt. is a 70 year-old male with irrestectable pan CA who
presented complaints of fever and increased drainage from G/J
tube found to be hypotensive. He had been having fevers at home.
His PCP ordered [**Name Initial (PRE) **] CT torso which per neice report showed b/l PNA
and no intraadbominal process. He was started on levo/clinda
last Thursday. He has had increased difficulty with breathing,
fever, chills and increased drainage from G/J tube.
In the ED BP initially 68/45, HR 95, T 98.8. CXR, KUB done and
labs drawn. Lactate was 1.9. A RIJ was placed and he recieved
vanc/lev/flagl. He was given 4 L of NS with CVP's from [**7-18**]. He
remained hypotensive with MAP of 55-58 and levophed was started.
Has Hx of peritonitis and tumor encasing SMA. Was seen by
surgery who felt no surgical intervention was warrented.
.
ROS
(-)headache, N/V, dysuria, guiac negative per ED report
(+)SOB, diarrhea, productive cough
Allergies: Iodine / Penicillins
Past Medical History:
Past Onc Hx :Orginally presented with elevated liver function
tests in [**7-12**]. ERPC done in [**9-12**] showed biliary stricture with
cytology negative. He had multiple CBD stents and 7 negative
biopsies. A bipsy in [**9-13**] was positive for adenocarcinoma. . He
presented in [**8-14**] with pneumoperitoneum and peritonitis. At that
time he had an exploratory laparotomy and drainage of
intra-abdominal fluid, loop gastrojejunostomy, combined
gastrostomy-jejunostomy tube. He was hospitalized for ~9 days
treated with levo/flagyl and discharged to rehab. He was
re-admitted 5 days later with N/V and treated with IVF and
discharged again to rehab. He does not have an Oncologist and
has been followed by [**First Name8 (NamePattern2) **] [**Doctor Last Name 468**] in Surgery.
.
PMHx
-COPD on home O2
-Type 2 DM
-PUD
-Ventricular ectopy
-Osteoarthritis
-Emphysmea
-Anxiety
Social History:
: Italian-speaking, retired shoe-factory worker. Hx of heavy
smoking; currently a few cigarettes per day. Drinks [**1-11**] glasses
of wine per day; no hx of heavy EtOH use. Lives with his sister
and her husband in [**Name (NI) 1475**]. Is single without children. Very
close with family and especially [**Name (NI) 802**]. Contact/healthcare
proxy: [**Name (NI) **], [**Name (NI) **] [**Name (NI) **], ([**Telephone/Fax (1) 53776**]
Family History:
Negative for pancreatic, colorectal, or any other CA. CAD in
mother, father, and sister. Cerebral aneurysms in sister
Physical Exam:
General: Awake, alert, NAD. thin cahectic man.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD
Pulmonary: Decreased at bases with b/l exp wheezes
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, G/J tube with
erythema and yellow drainage.
Extremities: ppp, trace edema
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. CN II-XII intact . Motor/sensory grossly intact.
To floor:
Vs: T: 98.2, P: 90, R: 24, BP: 107/68, R22 SaO2: 98% on 70% FM
General: Thin cachectic man, NAD.
HEENT: MMM,OP clear,no scleral icterus
Neck: supple, no JVD
Pulmonary: Decreased BS at bases
Cardiac: RRR, nl. S1S2, gmr
Abdomen: Very distended, no-tender, tympanic, soft, normoactive
bowel sounds.
Extremities: no cce.
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3.
Pertinent Results:
[**2202-1-27**] 08:20PM BLOOD WBC-20.1*# RBC-3.29* Hgb-8.5* Hct-24.0*
MCV-73*# MCH-26.0* MCHC-35.6* RDW-15.5 Plt Ct-347
[**2202-2-9**] 06:55AM BLOOD WBC-15.6* RBC-4.62 Hgb-11.6* Hct-35.1*
MCV-76* MCH-25.1* MCHC-33.0 RDW-17.9* Plt Ct-320
[**2202-1-27**] 08:20PM BLOOD PT-14.5* PTT-26.7 INR(PT)-1.4
[**2202-2-2**] 05:25AM BLOOD PT-16.1* PTT-32.8 INR(PT)-1.8
[**2202-1-27**] 08:20PM BLOOD Glucose-124* UreaN-20 Creat-0.7 Na-131*
K-4.1 Cl-98 HCO3-22 AnGap-15
[**2202-2-9**] 06:55AM BLOOD Glucose-84 UreaN-11 Creat-0.6 Na-128*
K-4.6 Cl-93* HCO3-24 AnGap-16
[**2202-1-27**] 08:20PM BLOOD ALT-41* AST-50* CK(CPK)-14* AlkPhos-422*
TotBili-1.1
[**2202-1-30**] 04:33AM BLOOD ALT-20 AST-21 LD(LDH)-181 AlkPhos-292*
TotBili-1.1
[**2202-1-27**] 08:20PM BLOOD Lipase-7
[**2202-1-28**] 02:04AM BLOOD Calcium-6.9* Phos-3.4 Mg-1.6
[**2202-2-9**] 06:55AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.8
[**2202-2-5**] 06:25AM BLOOD calTIBC-101* Ferritn-349 TRF-78*
[**2202-1-28**] 11:11AM BLOOD Cortsol-34.6*
Brief Hospital Course:
Assessment: 70 YOM with known pancreatic CA s/p multiple CBD
stents who presented with sepsis.
==================
Prior to presentation the patient had fevers and was
hypotensive. His PCP ordered [**Name Initial (PRE) **] CT of the torso which showed
bilateral pneumonia and no intra-abdominal process. On
presentation the patient was in septic (spiking fevers and
hypotensive). The patient was started on Levo/Clinda. Despite
this intervention he continued to have increased respiratory
distress.
==================
Course in the ED
In the ED the patient was hypotensive with SBPs in the 60. The
rest of his vitals were stable. Lactate was 1.9. Central access
was obtained and the patient received vanc/lev/flagyl. The
patient received 4L of NS with CVP of [**7-18**] and MAP of 55-58.
Levophed was started. Of note the patient also had increased
drainage of his G/J tube.
==================
In the [**Hospital Unit Name 153**] the patient's hypotension resolved and he was weaned
off of pressors. Surgery replaced his G/J tube with a G tube. TF
were resumed. Throughout his course in the [**Hospital Unit Name 153**] the patient
remained tachypneic and tacchycardic.
.
Prelim blood cultures were identified as growing gram positives.
As a result the patient was maintained on vancomycin. This was
later identified as B. fragilis. The vancomycin was d/c and the
patient was started on metronidazole. The cefepime was d/c 1.26
and levofloxacin started. If the patient became hypotensive or
spike fevers (started to look septic) the plan was to resend
cultures and try a stress dose of steroids.
.
On this regimen of Abx the patient clinically improved. He
remained afebrile and was called out to the floor. On the floor
multiple issues were addressed.
==================
#Nausea - The patient had his G/J tube removed and a G tube
placed on admission. He tolerated this for a short time. There
were no signs of obstruction. He was restarted tube feeds with
out complication but at a slower rate. Ativan for nausea.
.
#Tachpnea - The patient developed hypoxia and dyspnea [**2-11**] COPD
and PNA. He changed his code to DNR/DNI on admission and was
treated w/ abx and supplemetal O2. After an episode of
desaturation to the 80s requiring NRB O2 therapy, his code
status was again addressed and the patient and his family
decided to focus on comfort rather than cure. He completed a
course of abx and was maintained on his nebulizer treatments and
supplemental oxygen for comfort. He was given morphine as well
for respiratory discomfort.
.
#Hyponatremia - The patient has a chronic hyponatremia per OMR
records. He was originally fluid restricted after osms showed
SIADH pathology but this restriction was lifted as his code
status changed.
.
#Anemia - Chronic problem that was stable after transfusion.
.
#Pancreatic cancer - Pt has no oncologist and did not undergoing
treatment. The PCP and family treated his symtpoms as an
outpatient with goal of comfort not cure. The palliative care
team followed the patient throughout his course and was
invaluable in end of life discussions and d/c planning. He was
provided morphine, ativan, and compazine prn for symptomatic
control.
.
# Code Status: The patient was made DNR/DNI on admission and,
after discussion with the patient and family, he was changed to
comfort measures only on the floor and was sent to a skilled
nursing facility with hospice care closer to his family in [**Location (un) **].
.
# Contact: [**Name (NI) **] [**Name (NI) **], ([**Telephone/Fax (1) 53776**]
Medications on Admission:
RISS, albuterol, ipratropium, heparin SC, colace, pancrease,
tylenol, morphine PO, mirtazapine, fluticasone-salmeterol, Vit
D3, MVI, megestrol, CaCO3, MOM, [**Name (NI) 13426**].
Discharge Medications:
1. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN (as
needed).
Disp:*1 bottle* Refills:*1*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 month supply* Refills:*0*
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*1 bottle* Refills:*1*
4. Lorazepam 0.5-1 mg IV Q4H:PRN nausea/anxiety
5. Morphine Concentrate 20 mg/mL Solution Sig: 1-40 mg PO q2-4h
as needed for pain, anxiety, SOB.
Disp:*100 mL* Refills:*1*
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
neb Inhalation Q6H (every 6 hours).
Disp:*2 week supply* Refills:*1*
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Disp:*250 ML(s)* Refills:*1*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*1*
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
Disp:*30 Suppository(s)* Refills:*0*
10. Compazine 5 mg Suppository Sig: One (1) supp Rectal every
4-6 hours as needed for nausea.
Disp:*20 suppository* Refills:*1*
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
Primary: Pancreatic cancer, bilateral lower lobe community
acquired pneumonia
Secondary: Chronic Obstructive Pulmonary Disease, O2 dependent,
Type 2 Diabetes Mellitus, Malnutrition, severe, delirium
Discharge Condition:
Stable
Discharge Instructions:
Please take your meds as directed by the hospice facility. The
patient has terminal pancreatic cancer and has entered hospice
care. The goal of admission to NH is for comfort care.
Followup Instructions:
None
Completed by:[**2202-2-15**]
|
[
"0389",
"486",
"78552",
"2762",
"99592",
"25000",
"2859"
] |
Admission Date: [**2124-12-31**] Discharge Date: [**2125-1-3**]
Date of Birth: [**2057-7-6**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Codeine / Tylenol
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Nausea and Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 67y/o AA female w/ a PMH of DM2, CAD, PVD, CVA, and HTN
who presents to the ER after 3d of nausea, vomiting (NBNB), NP[**MD Number(3) 23674**], constipation, and "chills". She was then noted to be
hypertensive to the 200s/120s. She received hydralazine 30mg iv,
her scheduled labetalol 100po dose, and lopressor 5mg IV x1.
These produced no BP change. She then received labetalol 20mg IV
x1 which lowered the SBP to the 180s for ~1hr after which time
it again rebounded to the 220s. She received a single dose of
lisinopril 40mg PO w/out effect on her BP. During this time
period, the patient noted mild pressure-type substernal CP w/out
radiation or associated SOB, diaphoresis, or palpatations. The
CP was easily reproducible w/ light palpation and the patient
states that it is different from her past anginal pain which is
L-sided non-radiating CP. EKG collected in the ER during her
admission demonstrated STD in V4-6.
.
On admission to MICU the pt had BP in 160's and was weaned off
labetolol drip. This was then restarted when her SBP increased
to >180.
Past Medical History:
1. Diabetes, diagnosed only earlier this year, but given her
history of toe amputation, likely present for much longer than
that.
2. Depression.
3. Hypothyroidism.
4. Hypertension.
5. Spinal stenosis s/p C4-C7 laminectomy
6. CAD, status post MI in [**2121-7-31**].
7. Weakness leading to frequent falls.
8. Hyperlipidemia.
9. PVD s/p aortobifemoral bypass '[**09**] on L adn L toe amputations
Social History:
Patient smokes one-half pack per day. She lives
at home independently with a roommate who helps her with her
everyday needs such as getting dressed and getting washed
Family History:
NC
Physical Exam:
98.6, 186/107, 91, 20, 100%2L
HEENT: EOMI, PERRLA, MMM, O/P clear
CV: RRR, S1/S2 wnl, -M/R/G
Lungs: CTA b/l
Abd: S/NT/ND, +BS, -HSM
Ext: -C/C, chronic edematous changes to the LLE, multiple toe
amputations on the L
Neuro: CN 2-12 grossly intact, decreased strength in the LLE/LUE
compared to the R side, appropriate in conversation
Brief Hospital Course:
MICU Course:
On admission to MICU the pt had BP in 160's and was weaned off
labetolol drip. This was then restarted when her SBP increased
to >180. On day 2 Labetalol was again weaned, this time
successfully (off gtt for > 48 hrs with stable BPs on tx from
ICU), and pt's BPs were controlled on her normal PO regimen. Of
note she had an episode of hypotension in the MICU which
responded to IVF (pt. has a hx of Neuropathy and Gastroparesis
[**2-1**] DM, and the team felt that autonomic neuropathy could be
contributing to labile BPs). STDs seen on EKG were felt to be
[**2-1**] demand, and resolved with BP control, and CEs were neg x 3.
.
She was then transferred to the floor and monitored overnight.
Her pressures were well controlled (SBP 120s-150s) and he had no
further sx of N/V/HA/CP. She was seen by Opthalmology, who
recommended outpatient f/u for a floater she has had
chronically, which was scheduled. In talking with pt. further
she reported that she does not take her medications when she
gets sick, and had not taken her BP meds for a few days prior to
admission. This was felt to be the etiology of her HTN
exacerbation, and a w/u of secondary HTN was not pursued.
Medications on Admission:
aspirin 81'
plavix 75'
lipitor 40'
synthroid 25'
labetalol 100''
protonix 40'
nortryptyline 50'
reglan 10''''
glucophage 500''
trazodone 100''
MVI
tramadol 50''
neurontin 300''''
morphine 15''
cymbalta 20'
Lisinopril 40'
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
5. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
14. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
16. Trazodone 100 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime)
as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
Discharge Condition:
Improved- SBPs 120s-150s
Discharge Instructions:
Please call your doctor or come to the ER if you have any
headaches, nausea, vomiting, changes in your vision, chest pain,
shortness of breath, or any other symptoms that concern you.
It is very important that you take your blood pressure
medication daily.
Followup Instructions:
Primary Care: Provider: [**Name10 (NameIs) 23675**] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2125-1-12**] 2:00
Opthalmology: Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], OD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2125-1-5**] 3:00
Completed by:[**2125-1-4**]
|
[
"4019",
"2859",
"2449"
] |
Admission Date: [**2109-4-1**] Discharge Date: [**2109-4-5**]
Date of Birth: [**2041-10-3**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
headache, confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: [**Known firstname **] [**Known lastname 3123**] is a 67-year-old right-handed man who
presented to the ED after left parietal bleeding. Patient stated
that he was in his usual state of health when he woke up this
morning and went for his doctor appointment due to pain in his
groin. Upon arrival to the front desk he was not feeling right
and he gave a very vague description. He noticed that he was not
able to write his name and his hand writing was not aligned. At
this point he felt confused and inattentive. He was able to
drive
back home, but did no have any recollection of the driving. He
parked the car in the sideway. Next time he remembered he was
lying in the couch with a terrible headache. His wife arrived
between 11am-12pm and found him poorly responsive, mumbling
sounds with very few understandable words,a and not coherent.
She
also mentioned glassy eyes. She decided to bring him to the
closest ED ([**Hospital1 **] Needhan) for evaluation. He had wobbly gait.
Patient underwent a NCHCT which revealed a left parietal
bleeding. He was then transfer to [**Hospital1 18**] [**Location (un) 86**] for further
evaluation.
Patient described his headache as strong left temporal burning
sensation.
ROS:
The pt denied diplopia, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denied focal weakness, numbness,
parasthesiae. The pt denied recent fever or chills. No night
sweats or recent weight loss or gain. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits.
Past Medical History:
Hyperlypidemia- patient was prescribed a statin in the past but
refused to take medicine
Recent admission [**11-2**] to [**Hospital1 **] [**Location (un) 620**] with transient visual
change, thought to be TIA vs migraine
Small MI in [**2085**]
??TIA [**2078**]
Apendicectomy
Tonsillectomy
Bilat arthroscopy knee
right shoulder surgery
Social History:
Married, lives with his second wife.
-EtOh: occasionally
-tobacco: quit smoking 10 years ago, but used to be heavy smoker
-drugs: no IV drugs
Family History:
-mother: heart attack and stroke. Mat GM with heart attack
-father: passed away after heart attack ~68yo. No CA, no
migraines; no epilepsy.
Physical Exam:
Vitals: T:afebrile P:64 R: 15 BP: 150X75mmHg SaO2:
General: Awake, cooperative, NAD.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward with
mild difficulty. Language is fluent with intact repetition and
comprehension. Patient had difficulties in calcualtion: quarters
in $1.75, he first answered wrong and then after thinking hard
he
was able to say 7. Difficulties on [**Location (un) 1131**] the card. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. But clearly had left-right confusion. Finger agnosia.
Abnormal graphesthesia in the right hand. He could not write his
name, clearly inability to write.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally, fundi
normal
III,IV,VI: EOMI, no ptosis. ??nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**5-29**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone; no asterixis or myoclonus.
Right pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 5 5 5 5 5 5
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 2 Flexor
R 2 2 2 2 2 Flexor
-Sensory: Decreased light touch, pinprick, in the right arm
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-Gait: not tested
Pertinent Results:
[**2109-4-1**] 05:40PM BLOOD WBC-6.3 RBC-4.76 Hgb-14.7 Hct-41.5 MCV-87
MCH-31.0 MCHC-35.5* RDW-13.7 Plt Ct-167
[**2109-4-1**] 05:40PM BLOOD PT-12.5 PTT-23.9 INR(PT)-1.1
[**2109-4-1**] 05:40PM BLOOD Plt Ct-167
[**2109-4-1**] 05:40PM BLOOD Glucose-84 UreaN-20 Creat-1.1 Na-139
K-3.8 Cl-103 HCO3-28 AnGap-12
[**2109-4-2**] 04:31AM BLOOD ALT-27 AST-25 AlkPhos-67 TotBili-1.4
[**2109-4-2**] 04:31AM BLOOD %HbA1c-PND
[**2109-4-2**] 04:31AM BLOOD Triglyc-100 HDL-39 CHOL/HD-4.8
LDLcalc-129
EKG: Sinus rhythm. Right bundle-branch block with rightward
precordial R wave transition point consistent with right
ventricular strain or hypertrophy. Compared to the previous
tracing of [**2102-11-24**] there is no diagnostic change.
CT head [**2109-4-1**]
1. Left parietal intraparenchymal hemorrhage slightly larger
compared to six
hours prior. Together with moderate surrounding vasogenic edema,
this causes
local sulcal effacement, without shift of normally midline
structures. Again
as etiology of the hemorrhage has not yet been determined, MRI
is recommended
for evaluation of such, if there is no contra-indication.
2. Large polypoid soft tissue in the right nasal cavity and
right maxillary
sinus, incompletely imaged, and previously seen on [**2108-3-13**].
Also, decreased
mineralization of medial wall of right maxillary sinus, with no
history of
such surgery noted on CareWeb. Findings likely due to
antro-choanal polyp
with bony remodeling. Correlation with direct visualization, and
dedicated
imaging if clinically indicated.
MRI brain, MRA head/neck [**2109-4-1**]
1. Large left parietal lobar hematoma with only mild mass
effect. Evaluation
for an underlying mass is limited in the absence of intravenous
contrast.
Evaluation for an underlying vascular malformation is also
limited in the
absence of intravenous contrast, and because the hematoma is not
fully
included in the field of view of the head MRA (which was
targeted for
evaluation of the circle of [**Location (un) 431**]). If the patient can tolerate
intravenous
contrast, then further evaluation is suggested by a CTA of the
head, and a
follow-up MRI with and without contrast after resolution of
blood products.
Otherwise, follow-up MRI without contrast may be performed.
2. Normal appearance of the circle of [**Location (un) 431**]. Unremarkable neck
MRA, with
limited evaluation of the great vessel origins.
3. Probable right antrochoanal polyp again seen.
CT head [**2109-4-2**]
No change in size or appearance of left parietal IP hemorrhage.
No new
hemorrhage or change in mass effect.
TTE [**2109-4-2**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Left
ventricular systolic function is hyperdynamic (EF>75%). 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 left
ventricular inflow pattern suggests impaired relaxation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No obvious cardiac source
of embolism; however, image quality was suboptimal to exclude
shunting via bubble study. Mild concentric LV hypertrophy.
Preserved biventricular systolic function.
CTA head [**2109-4-3**]:
The intracranial vasculature demonstrates no evidence of
stenosis,
thrombosis, occlusion, large aneurysm, or dissection. There is
no evidence of nidus or draining veins adjacent to the left
parietal hematoma or elsewhere to suggest arteriovenous
malformation. No abnormal arterial structures are identified.
There is no evidence of cerebral venous thrombosis.
MRI HEAD W & W/O CONTRAST [**2109-4-3**]
1. No interval change in appearance of the left parietal
hematoma with no
abnormal enhancement to suggest an underlying mass. Followup as
the blood
products resolved is recommended.
2. Polypoid enhancing soft tissue within the right nasal cavity
which should be correlated with direct inspection.
3. Spiculated hypointensity within the subcutaneous tissues
within the
suboccipital region of unclear etiology, present on prior
examinations, and should be correlated with clinical findings.
Brief Hospital Course:
Patient is a 67-year-old male with history of CAD, angioplasty,
possible prior [**Hospital 44881**] transferred from [**Hospital1 **] [**Location (un) 620**] after he was
found to have a left parietal hemorrhage. Repeat CT head upon
arrival to [**Hospital1 18**] revealed a 4.1 x 2.4 cm bleed in the left
parietal region and the patient was admitted to the neurology
ICU. The patient was admitted to the Neuro ICU for q1h
neurochecks. His systolic blood pressure was maintained 120-160
without requiring antihypertensive agents in the ICU. A repeat
CT head was performed 12 hours after admission which was
unchanged from the initial study. The patient was transferred
to the neurology [**Hospital1 **] on [**4-2**] for further care. An MRI brain and
MRA neck were performed which showed a stable large left
parietal hemorrhage. The post-gadolinium study also showed no
interval change in the appearance of the left parietal hematoma.
As a potential etiology included hemorrhagic transformation of
an ischemic infarct, a TTE was performed which showed no obvious
cardiac source of embolism. The patient's LDL was 129 and HgbA1c
was 5.3%. He was started on simvastatin 10 mg daily. While on
the neurology [**Hospital1 **], he had elevated SBP in the 160's so
amlodipine 5 mg daily was started. After initiation of
amlodipine, his blood pressure normalized. The patient was
evaluated by physical and occupational therapy who recommended
that he could be discharged home with outpatient PT and VNA home
safety evaluation. The following were significant findings on
his discharge neurologic exam: Awake, alert, and oriented times
3. Able to recount events well. Improved simple calculation
ability but still with some difficulty. No apraxia. Normal motor
exam. Normal gait.
Medications on Admission:
Motrin PRN
Tramadol PRN
Discharge Medications:
1. Simvastatin 10 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left parietal hemorrhage
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge neurologic exam: Awake, alert, and oriented times 3.
Able to recount events well. Improved simple calculation ability
but still with some difficulty. No apraxia. Normal motor exam.
Normal gait.
Discharge Instructions:
You were admitted with left parietal hemorrhage. Repeat head CT
scan and MRI showed no interval change in size of the bleed. You
were evaluated with a CTA and MRA of the head which showed
normal intracranial vasculature. Your echocardiogram showed no
cardiac source of embolism.
You have a follow-up appointment scheduled with your PCP, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on Wednesday, [**4-17**], at 11:15 AM. He will refer
you to an Atrius neurologist and schedule a repeat MRI of the
brain with and without contrast in [**7-2**] weeks.
A nurse will visit your home for a home safety evaluation.
You have been provided with prescriptions for physical therapy,
occupational therapy, and speech therapy.
Should you develop any symptoms as listed below or concerning to
you, please call your doctor or go to the emergency room.
Followup Instructions:
1. You have a follow-up appointment scheduled with your PCP, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on Wednesday, [**4-17**], at 11:15 AM. He will refer
you to an Atrius neurologist and schedule a repeat MRI of the
brain with and without contrast in [**7-2**] weeks.
2. A nurse will visit your home for a home safety evaluation.
3. You have been provided with prescriptions for physical
therapy, occupational therapy, and speech therapy.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2109-4-5**]
|
[
"41401",
"2724",
"V4582"
] |
Admission Date: [**2157-10-4**] Discharge Date: [**2157-10-8**]
Service: CARDIOTHORACIC
Allergies:
Gluten
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Referral for resection of mediastinal mass
Major Surgical or Invasive Procedure:
Left VATS converted to left hemi- clamshell thoracotomy with
dissection of mediastinal mass.
Flexible bronchoscopy with therapeutic aspiration of
secretion at the end of the procedure. Placement of fiducial
seed implants.
Past Medical History:
Bilateral L > R glaucoma, celiac spure, hx colitis, hiatal
hernia, Aortic Stenosis (noncritical 1.1 cm^2 valve area),
Mitral Regurgitation, OA, nephrolithiasis, hyponatremia, GERD,
hx UGIB secondary to to Dieulafoy ulcer [**4-2**], hypertension
PSx: ORIF R hip, hiatal hernia
Social History:
Married, lives with wife. Children close by and closely
involved. Drinks 1 drink per day, 10 pack year smoking history,
quit 30 years ago. Remote exposure to asbestos in shipyard. No
radiation exposure.
Family History:
No family history of cancer.
Physical Exam:
T 96.8, HR 69, BP 144/66, RR 18, 97% RA
Gen: No apparent distress, alert and oriented x 3
CV: Regular rate and rhythm with systolic murmur
Resp: Lungs clear to auscultation bilaterally
Chest: Hemi-clamshell incision dressed with Steri-strips, no
erythema, induration, or fluctuance
Abd: Soft/non-tender/non-distended
Ext: No clubbing, cyanosis, or edema
Pertinent Results:
[**2157-10-4**] 09:15AM freeCa-1.16
[**2157-10-4**] 09:15AM HGB-14.5 calcHCT-44
[**2157-10-4**] 09:15AM GLUCOSE-124* LACTATE-1.3 NA+-129* K+-4.0
CL--93*
[**2157-10-4**] 09:15AM TYPE-ART PO2-146* PCO2-40 PH-7.43 TOTAL
CO2-27 BASE XS-2
[**2157-10-4**] 12:23PM PT-12.8 PTT-25.1 INR(PT)-1.1
[**2157-10-4**] 12:23PM PLT COUNT-262
[**2157-10-4**] 12:23PM NEUTS-88.8* LYMPHS-6.6* MONOS-4.1 EOS-0.3
BASOS-0.1
[**2157-10-4**] 12:23PM WBC-10.4# RBC-3.95* HGB-12.4* HCT-35.0*
MCV-89 MCH-31.5 MCHC-35.5* RDW-13.6
Brief Hospital Course:
After undergoing his Left VATS converted to left hemi-clamshell
thoracotomy with dissection of mediastinal mass and flexible
bronchoscopy with therapeutic aspiration of secretion with
placement of fiducial seed implants on [**2157-10-4**], Mr. [**Known lastname 20793**] was
admitted to the SICU still intubated. He was successfully
extubated later that same night without difficulty or
complications. He was given IV medication for pain control and
was initially kept NPO. He was given Lactated Ringers solution
for hydration, and was bolused for hypotension upon admission to
the SICU. His blood pressure responded appropriately. He had a L
chest [**Doctor Last Name **] drain to suction. A chest xray showed no
pneumothorax. Post-operative lab work revealed a sodium that was
low at 126. His fluids were then switched from LR to normal
saline for correction of hyponatremia. The patient was
asymptomatic and had no EKG changes, and also has a reported
history of hyponatremia.
On POD1, his diet was advanced to clears with free water
restrictions because of the hyponatremia. His [**Doctor Last Name **] drain was
placed to water seal and a repeat chest xray again showed no
pneumothorax. Oral pain medications and home medications were
provided.
On POD2, his chest [**Doctor Last Name **] was removed and the chest xray again
showed no pneumothorax. His diet was advanced to regular, gluten
free for his celiac disease. His foley catheter was removed and
he voided without difficulty. He was transferred out of the SICU
to the floor. He remained stable and had no issues on the floor.
On POD 3, he ambulated with nursing staff with a walker. On POD
4, physical therapy saw him and cleared him for discharge to a
rehabilition facility. A rehab bed was identified at the
facility where he lives and he was discharged there in good
condition with instructions to follow up with Dr. [**Last Name (STitle) **] in [**12-1**]
weeks with a chest xray prior to the appointment. Code status
was full code.
Final pathological analysis was still pending at the time of
discharge. A frozen section from the mediastinal mass sent
intra-operatively came back with possible chondrosarcoma.
Medications on Admission:
Atenolol 12.5 QD, Asacol 400mg 2 tabs TID, Multivitamins,
Omeprazole 20 QD, Travoprost 0.004% OU QD, Aspirin 81 mg QD,
Ca-D3 500/200 QD, Citrucel 500 mg QD
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed. Tablet(s)
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Travoprost 0.004 % Drops Sig: [**12-1**] Ophthalmic qPM ().
4. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **]
Discharge Diagnosis:
Mediastinal mass status post resection and fiducial seed
placement.
Discharge Condition:
Good, meeting discharge criteria.
Discharge Instructions:
Call Dr.[**Name (NI) **] office at ([**Telephone/Fax (1) 28276**] if experiencing:
-Fever > 101 or chills
-Increased cough, shortness of breath or chest pain
-Sternal incision develops drainage or increased redness
Follow sternal precaution instructions reviewed by physical
therapy.
No lifting greater than 10 pounds for 4 weeks. No driving for 4
weeks
You may shower. No tub bathing or swimming for 6 weeks
Take stool softners with narcotics.
Followup Instructions:
Call Dr.[**Name (NI) **] office at ([**Telephone/Fax (1) 28276**] to schedule a follow
up appointment 1-2 weeks after discharge. Let them know that you
need to have a chest x-ray done 45 minutes before your
appointment with Dr. [**Last Name (STitle) **].
|
[
"2761",
"V1582"
] |
Admission Date: [**2141-4-17**] Discharge Date: [**2141-4-25**]
Date of Birth: [**2064-11-21**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Injuries after Motor Vehicle Accident
Major Surgical or Invasive Procedure:
Chest tube thoracostomy
History of Present Illness:
76F restrained driver in MVC, car hit wall @ 65 mph at 2 pm on
[**4-17**], air bag deployed. Transferred from OSH after found to have
33% L PTX, multiple rib fx, sternal fx, cardiac contusion.
Denies head trauma, no LOC. At this point her spine has not yet
beencleared.
Past Medical History:
HTN, PVD s/p aortic endarterectomy ([**2131**]), HLD,
hyperthyroidism, ovarian CA ([**2117**]), thrombocytosis ([**2133**]), GERD,
osteopenia, cataracts
Social History:
Married
Retired [**Hospital1 18**] Pathologist
Family History:
Non-contributory
Physical Exam:
Gen: WD/WN, comfortable, NAD.
Neck: Supple.
Lungs: CTA bilaterally, nonlabored breathing; CT in place
Cardiac: RRR.
Abd: Soft
Back: Tender over inferior thoracic spine
Extrem: Warm and well-perfused.
Neuro: AAO x3
Pertinent Results:
[**2141-4-18**] 12:15AM BLOOD WBC-21.3*# RBC-4.49 Hgb-14.3 Hct-44.0
MCV-98 MCH-31.8 MCHC-32.5 RDW-14.8 Plt Ct-365
[**2141-4-18**] 07:22PM BLOOD WBC-19.1* RBC-4.13* Hgb-12.8 Hct-40.0
MCV-97 MCH-31.1 MCHC-32.1 RDW-15.2 Plt Ct-326
[**2141-4-19**] 01:35AM BLOOD WBC-20.2* RBC-4.03* Hgb-13.0 Hct-38.6
MCV-96 MCH-32.1* MCHC-33.5 RDW-15.6* Plt Ct-249
[**2141-4-20**] 02:21AM BLOOD WBC-21.7* RBC-4.29 Hgb-13.9 Hct-41.6
MCV-97 MCH-32.5* MCHC-33.5 RDW-15.5 Plt Ct-324
[**2141-4-21**] 05:05AM BLOOD WBC-17.7* RBC-4.25 Hgb-13.5 Hct-41.7
MCV-98 MCH-31.8 MCHC-32.4 RDW-15.0 Plt Ct-398
[**2141-4-24**] 06:30AM BLOOD WBC-23.4* RBC-3.98* Hgb-13.5 Hct-39.3
MCV-99* MCH-33.8* MCHC-34.3 RDW-14.9 Plt Ct-402
[**2141-4-18**] 12:15AM BLOOD Neuts-94.3* Lymphs-3.3* Monos-1.7*
Eos-0.2 Baso-0.5
[**2141-4-22**] 07:18AM BLOOD Neuts-88.9* Lymphs-5.1* Monos-4.1 Eos-1.5
Baso-0.4
[**2141-4-22**] 07:18AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Spheroc-1+ Ovalocy-NORMAL
Schisto-1+ Burr-1+
[**2141-4-20**] 02:21AM BLOOD PT-11.9 PTT-55.0* INR(PT)-1.0
[**2141-4-18**] 12:15AM BLOOD Glucose-173* UreaN-29* Creat-1.3* Na-141
K-5.3* Cl-108 HCO3-22 AnGap-16
[**2141-4-24**] 06:30AM BLOOD Glucose-107* UreaN-28* Creat-1.3* Na-138
K-4.5 Cl-101 HCO3-28 AnGap-14
[**2141-4-18**] 12:15AM BLOOD ALT-150* AST-175* AlkPhos-92 TotBili-0.7
[**2141-4-20**] 02:21AM BLOOD ALT-74* AST-40 AlkPhos-77 TotBili-1.2
[**2141-4-18**] 12:15AM BLOOD CK-MB-13* cTropnT-0.01
[**2141-4-22**] Radiology RENAL U.S.
IMPRESSION: Essentially normal renal ultrasound.
[**2141-4-18**] Radiology CHEST (PORTABLE AP)
Left chest tube is in place and no definite pneumothorax is
appreciated.
There are several areas of lucency at the left base laterally,
it could
represent pockets of localized pneumothorax.
[**2141-4-18**] Radiology CT T-SPINE W/O CONTRAST
IMPRESSION: 1. T12 compression fracture with retropulsion of the
superior
endplate, causing anterior thecal sac deformity, apparently the
pedicles are
not involved.
2. Moderate anterior wedging of the T8 vertebral body with no
evidence of
retropulsion, the possibility of a subacute fracture or acute
fracture at this
level cannot be completely ruled out.
3. Irregular contour of the spinous processes at T9 and T10
levels with
sclerotic changes, the possibility of acute fractures cannot be
completely
ruled out, if there is any suspicion for spinal cord injury,
ligamentous
injury or other fractures, correlation with MRI of the thoracic
spine is
recommended if clinically warranted.
4. Bilateral lung opacities, likely related with a combination
of atelectasis
and aspiration and also possibly pulmonary contusions.
5. Anterior wedging of the T8 vertebral body, an acute/subacute
fracture in
this vertebral body cannot be completely ruled out.
6. Bilateral wedge renal hypodensities, suggesting multiple
renal infarcts,
laceration or contusion are also considerations. The left
anterior
pneumothorax described on the prior CT of the torso is not
included in this
examination.
Brief Hospital Course:
Dr. [**Known lastname **] was admitted to the TSICU after being transfered to
[**Hospital1 18**] s/p high speed MVC with resulting injuries. She sustained
a pneumothorax in the accident and had a chest tube placed prior
to her transfer to [**Hospital1 18**] with resolution of the pneumothorax on
the 1st follow up film. The tube was subsequently put to water
seal without re-accumultation of the PTX and ultimately reomved
without incident.
She was also diagnosed with a chronic SDH and an acute T12
compression fracture for which Neurosurgery was consulted and
recommended a TLSO when HOB>45 or out of bed (inculding
showering). The brace should be worn as instructed until follow
up with Neurosurgery. Dr. [**Known lastname **] will need to follow up with
neurosurgery 8 weeks post discharge with a non-contrast CT Head
and non-contrast T-spine.
Nephrology was consulted for Dr.[**Name (NI) 103480**] acute renal failure
(baseline Cr 0.6), which was initially thought to be secondary
to contrast nephropathy however her Cr at the sending facility
prior to her CT scan was elevated at 1.3 She will need to
follow up with nephrology as an outpatient 1-2 weeks post
discharge.
Hematology was consulted due to a persistent leukocytosis with
an abnormal peripheral smear. Initially the leukocytosis was
postulated to be the result of a stress response, but given its
persistence and abnormal smear Hematology was consulted. After
their evaluation given the lack of any symptoms and the
possibility that this may be an acute stress response and not a
primary blood dyscrasia they recommended follow up in 1 week
with a CBC with diff prior to that appointment.
Dr. [**Known lastname **] was transfered to the floor where she remained
afebrile with stable vital signs, tolerating a regular diet, and
with adaquate pain control inculding on the day of her
discharge. PT worked with Dr. [**Known lastname **] and recommended rehab.
Medications on Admission:
Toprol, Lipitor
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
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) as needed for
constipation.
6. 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: Do not drink, drive or operate machinery while
taking this medication.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for breakthrough pain: Do not drink, drive or
operate machinery while taking this medication.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
12. Lipitor 10 mg Tablet Sig: 0.5 Tablet PO qpm.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
Discharge Diagnosis:
1) T12 compression fracture
2) Right [**7-18**] rib fractures
3) Left [**12-13**] rib fractures
4) Left Pneumothorax
5) Bilateral Pulmonary Contusions
6) Subacute subdural hematoma
7) Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**] after
sustaining injuries in a motor vehicle accident. A chest tube
was placed to treat your pneumothorax, and was removed prior to
your discharge. You were diagnosed with a compression fracture
of your 12th thoracic vertebral body, and will need to wear the
TLSO brace that you were given while in the hospital anytime the
head of your bed is elevated greater than 45 degress or you are
out of bed (including showering). You will need to use this
brace until your follow up appointment with Neurosurgery in
eight weeks.
Followup Instructions:
Follow up with Neurosurgery in four weeks. Call ([**Telephone/Fax (1) 26566**]
to schedule a follow- up appointment in 8 weeks, with a
Non-contrast
CT scan of the head, and CT of the thoracic spine(without
contrast). The Neurosurgery office is located in the [**Hospital **]
Medical Building, [**Hospital Unit Name 12193**].
Follow up with Nephrology in [**12-10**] weeks to have your renal
function checked to ensure it is recovering. Call for an
appointment ([**Telephone/Fax (1) 10135**]
Follow up with Hematology: Call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9840**] for appointment in 1
week please have a repeat CBC with differential prior to the
appointment [**Telephone/Fax (1) 103481**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"5845",
"5990",
"53081",
"4019",
"2724"
] |
Admission Date: [**2148-12-2**] Discharge Date: [**2148-12-11**]
Date of Birth: [**2084-12-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
64 yo AA male with HIV/AIDS (VL: 570; CD4: 251 on [**11-27**]'[**48**]
currently treated with Combivir and Bactrim SS Mon, Wed, Fri for
ppx as well as a flu shot for [**2147**]-[**2148**]) and COPD on home oxygen
(FEV1/FVC: 34%; FEV1 26%; FVC: 77%) comes in with dyspnea for 6
days. The pt reports development of sob similar to his previous
episodes of COPD/PNA. 2-3days ago, he subsequently developed
cough productive of yellow-green sputum along with subjective
fevers, chills, and diaphoresis. He also developed some
pleuritic chest pain several days ago. The chest pain was
located in the left side of the chest below the nipple line and
occurred with deep inspiration. The pt reports these are all
similar to previous episodes of COPD exacerbation. The pt had
tried nebulizers Q4hours in addition to 2L NC one day PTA
without any improvement. The pt uses oxygen at home 40% of the
time, mostly when he is active. The pt noted inc. DOE even with
the oxygen prior to this episode. The pt does admit to one
episode of vomiting in the ED, which was thought to be secondary
to meds he received in the ED. The pt denies HA, abd pain,
diarrhea.
In the ED, the pt was febrile to 101 rectally, requiring 5liters
oxygen to keep sats >96%. He was given ceftriaxone,
azithromycin, bactrim and solumedrol with continuouos nebs for
PNA vs. COPD flare. He had one episode of emesis in ED. The pt
also received a CTA which ruled out a PE (given the concern for
pleuritic chest pain). ABG in the ED was: 7.44/40/81-->
7.49/40/67. The pt reports improvement in his sob after
receiving solumedrol and nebs in the ED.
Past Medical History:
1. HIV/AIDS: CD4: 251; VL: 570 ([**2148-11-27**])- on combivir and
bactrim
2. COPD: intermittently on oxygen at home, followed by [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 2146**]/[**First Name8 (NamePattern2) 2147**] [**Last Name (NamePattern1) 496**]. FVC: 77%; FEV1: 26%; FEV1/FVC: 34%.
3. GERD
4. HTN
5. CRI
6. h/o GI bleed- w/u negative [**2142**]
7. Leukopenia- followed by [**Doctor Last Name 2148**]- plan is for BM bx
8. Anemia
9. Inguinal hernia
10. Homocysteinemia
11. Chronic back pain- failed spinal cord stimulator, requires
injections from pain management. MR [**9-21**]. Herniated discs.
12. Granulmatous disease in spleen- seen on ct scan
13. Esophagitis- egd [**11-20**]
14. Schatzki's ring- seen on egd [**7-/2143**]
15. SBO obstruction in past
16. H/o of drug use- narcotics contract
PAST SURGICAL HISTORY:
1. Basilar artery clipping [**2134**]
2. Status post several lumbar discectomies in the past.
3. Status post right inguinal hernia repair.
4. Status post right colectomy for benign disease.
Social History:
Disabled. Lives in [**Location 669**] by himself.
EtOH: former heavy etoh, quit [**2135**]
Tob: quit tobacco in [**2135**], 2ppd between [**2100**]-93.
Illicit drugs: smoked crack [**2135**]
Family History:
1. Father: deceased, EtOH
2. Mother: deceased, CVA in 60s
3. Brother: lung cancer
4. Sister: HTN
5. Sister: CVA in 60s
Brothers x7 (now only two), Sister x2 (both still alive)
Physical Exam:
VS in ED: 100.8, 95, 159/95, 21, 98% on neb, 150cc emesis, 200cc
urine in ED
VS in [**Hospital Unit Name 153**]: 91, 126/70, 21, 97% on FM at 7L
Gen: thin, almost cachectic AA male in NAD. Conversing fluently
in full sentences. No accessory muscle use
HEENT: EOMI, anicteric, mmm, op clear
Neck: no retractions, supple, full ROM
Chest: poor air movement posteriorly, soft wheezing bilaterally,
no crackles, no pain on palpation of chest.
CV: RRR, S1, S2, no m/r/g
Abd: soft, suprapubic tenderness, neg [**Doctor Last Name 515**] sign, no rebound,
guarding.
Ext: wwp, no c/c/e, DP +1 bilaterally
Pertinent Results:
EKG: NSR, nml axis, peaked and widened P waves, ?ST elevations
in V3 (vs. artifact)
CXR [**2148-12-2**]: emphysematous changes
CTA [**2148-12-2**]: No PE, +bronchiectasis and emphysema, granulmatous
disease
MIBI: [**11/2142**]: normal
ECHO: [**9-21**]: hyperdynamic EF>75%, trivial MR
[**Name13 (STitle) 2149**] [**11-20**]: normal
EGD [**11-20**]: esophagitis
Labs on Admission
[**2148-12-2**] 05:50AM BLOOD WBC-3.2* RBC-2.94* Hgb-11.0* Hct-31.7*
MCV-108* MCH-37.3* MCHC-34.6 RDW-13.8 Plt Ct-134*
[**2148-12-2**] 05:50AM BLOOD PT-11.7 PTT-27.3 INR(PT)-0.9
[**2148-12-2**] 05:50AM BLOOD Glucose-105 UreaN-14 Creat-0.9 Na-138
K-3.7 Cl-101 HCO3-29 AnGap-12
[**2148-12-2**] 05:50AM BLOOD CK-MB-4
[**2148-12-2**] 05:50AM BLOOD cTropnT-0.03*
[**2148-12-2**] 05:50AM BLOOD LD(LDH)-222 CK(CPK)-144
[**2148-12-3**] 05:15AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.0
Labs on Discharge
[**2148-12-10**] 06:15AM BLOOD WBC-5.6 RBC-2.78* Hgb-9.6* Hct-29.4*
MCV-106* MCH-34.5* MCHC-32.6 RDW-13.5 Plt Ct-286
[**2148-12-10**] 06:15AM BLOOD Plt Ct-286
[**2148-12-10**] 06:15AM BLOOD Glucose-91 UreaN-32* Creat-1.1 Na-137
K-4.2 Cl-101 HCO3-28 AnGap-12
[**2148-12-10**] 06:15AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0
Blood Gases
[**2148-12-2**] 06:09AM BLOOD Type-ART FiO2-40 pO2-81* pCO2-40 pH-7.44
calHCO3-28 Base XS-2
[**2148-12-2**] 08:44AM BLOOD Type-ART O2 Flow-2 pO2-67* pCO2-40
pH-7.49* calHCO3-31* Base XS-6
[**2148-12-3**] 10:43AM BLOOD Type-ART pO2-26* pCO2-55* pH-7.35
calHCO3-32* Base XS-1
[**2148-12-3**] 01:36PM BLOOD Type-ART pO2-99 pCO2-33* pH-7.50*
calHCO3-27 Base XS-2
[**2148-12-3**] 11:12PM BLOOD Type-ART pO2-73* pCO2-40 pH-7.46*
calHCO3-29 Base XS-4
[**2148-12-4**] 01:23PM BLOOD Type-ART pO2-104 pCO2-46* pH-7.43
calHCO3-32* Base XS-4 Intubat-NOT INTUBA
[**2148-12-6**] 05:19AM BLOOD Type-[**Last Name (un) **] Temp-36.6 O2 Flow-2 pO2-44*
pCO2-44 pH-7.44 calHCO3-31* Base XS-4 Intubat-NOT INTUBA
Brief Hospital Course:
A/P: 64yo M with COPD (FEV1 of 26%), HIV/AIDS (VL: 570; CD4: 251
treated with Combivir and Bactrim ppx p/w respiratory distress.
.
#. Respiratory distress: The patient was originally admitted to
the [**Hospital Unit Name 153**]. During this time he was treated for positive
influenza A and COPD exacerbation. He received 5 days of
tamiflu. After a 5 day course in the ICU his respiratory status
improved. Respiratory status stabilzed with supprot over the
course of a 5 day stay in the ICU. He was started on a
prednisone taper.
He was transferred to the medicine floor service. Initially per
PT/OT evals the patient qualified for rehab. However he quickly
improved and his O2 sats were stable on room air. The patient
felt safe to go home with PT and oxygen. He was discharged on a
prednisone taper. He had follow up scheduled with his PCP and
pulmonology.
.
#. HIV: The pt has HIV/AIDS with VL of 570 and CD4 of 251. He
was maintained on Combivir and Bactrim SS Mon, Wed, Fri for ppx
.
#. HTN: The patient was maintained on HCTZ 25 daily
.
#. Pain: The pt has known chronic LBP and is on a narcotics
contract. He was continued on tramadol and Tylenol #3 as well as
tizanidine 2mg [**11-18**] PRN (for spasticity). Given his end stage
HIV has was treated liberally with IV morphine for respiratory
comfort while in the ICU.
.
#. Dispo: The patient was discharged home with PT, supplemental
O2 and instructed to follow up with his health care providers.
.
#. Code Status: DNR/DNI. confirmed by MICU resident, intern and
Pulm fellow.
.
#. Communications:
HCP #1: Son: [**Name (NI) **] [**Name (NI) **] [**Known lastname 2150**]: [**Telephone/Fax (1) 2151**]
HCP #2: Friend: [**Name (NI) 2152**] [**Name (NI) 2153**]: [**Telephone/Fax (1) 2154**]
HCP #3: Sister: [**Name (NI) 2155**] [**Name (NI) 2156**] (moved to VA): [**Telephone/Fax (1) 2157**]
Medications on Admission:
1. Combivir
2. Bactrim- Mon, Wed, Friday
3. Azmacort- 10 puffs [**Hospital1 **]
4. Albuterol nebs and inhaler prn
5. Atrovent nebs prn
6. HCTZ 25 daily
7. Protnix 40 daily
8. Trazadone- 50 qhs prn
9. Doxazosin 2mg qhs
10. Tizanidine 2mg- one to 2 prn
11. tramadol 50 1-2 tabs q4-6 hours prn
12. APAP #3- ONE TID- Narcotics contract
13. Vitamin B12- 2000mcg daily
14. Folic acid
15. Aspirin
16. colace, senna
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
4. Azmacort 100 mcg/Actuation Aerosol Sig: Ten (10) puffs
Inhalation twice a day.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
11. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
15. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. Prednisone 10 mg Tablet Sig: AS DIR Tablet PO DAILY (Daily)
for 4 days: [**2148-12-12**] 30 mg qd
[**2148-12-13**] 20 mg qd
[**2148-12-14**] 10 mg qd
[**2148-12-15**] 5 mg qd.
Disp:*6 Tablet(s)* Refills:*0*
17. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO TID (3 times a day) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. COPD exaccerbation
2. Influenza
Secondary:
1. HIV
2. GERD
3. HTN
4. Chronic back pain
Discharge Condition:
afebrile, satting well on room air
Discharge Instructions:
If you have fevers, chills, shortness of breath, chest pain,
nausea/vomiting, please call Dr [**Last Name (STitle) **] for evaluation or come to
the ED.
1. Take medications as directed
2. You will be on a prednisone taper on discharge for your COPD
3. Use oxygen as needed for you shortness of breath.
Followup Instructions:
Already scheudled:
.
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2148-12-17**] 6:00
.
Pulmonary:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2149-1-3**] 9:10
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2149-1-3**] 9:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2149-5-4**]
|
[
"5859",
"4019"
] |
Admission Date: [**2188-10-21**] Discharge Date: [**2188-11-3**]
Date of Birth: [**2112-12-21**] Sex: F
Service: MEDICINE
Allergies:
Fish Product Derivatives
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Colonoscopy
EGD
History of Present Illness:
History of Present Illness: 75 year old woman on Coumadin and
Plavix, s/p mechanical MVR, h/o GI bleed (ten years ago), now
presenting with black tarry stools overnight, with 2 additional
episodes of melena this morning. Pt was seen in urgent care at
PCP's office today and was guaiac positive. In PCP office she
noted three black tarry stools. During this time, she has no
nausea, vomiting, no epigastric pain, no lightheadedness, and no
chest pain. She has not taken any over-the-counter medications.
She usually takes MiraLax has a bowel movement every few days,
and she has had three bowel movements in less than 24 hours. The
patient has a history of peptic ulcer disease diagnosed in the
mid 90s. She has been maintained on ranitidine 150 mg b.i.d. for
many years.
.
In the ED, initial vs were: T99, P 81, 127/66, RR 16, 100%RA.
Patient was given protonix 40 IV x1, and was seen by GI. GI
recommended NG lavage, which showed brown effluent, no coffee
grounds. Following NGT placement the pt developed brisk
epistaxis, now has packing in place. Repeat hct stable at 40.
Major source of bleeding is now iatrogenic nosebleed. Vitals on
transfer were: 96.4 HR 97 127/63 19 100%RA.
Past Medical History:
CAD: s/p 1 vessel CABG [**2177**]
Valvular dz: s/p mechanical MV replacement [**2177**]
H/o supraventricular tachycardia
TIA's (on plavix)
hypertension
hypercholesterolemia
osteoporosis
migraine headaches with aura
carotid disease
cataracts
s/p hysterectomy [**6-20**]
constipation
History of a significant gastrointestinal bleed secondary
to gastric ulcerations.
Social History:
She does not currently smoke cigarettes, does have a <3 pack
year history, quit in [**2154**]. She is [**Name Initial (MD) **] retired RN, widowed. She
does have a significant other who is being very supportive with
her at this time. She rarely drinks alcohol.
Family History:
Positive for strokes in grandmother and mother.
Physical Exam:
Admission vitals: T:98.2 P:91 R: BP:112/87 SaO2:100 @ RA
Pt [**Name (NI) **]3
HEENT: PREEL, oral moist
Neck: no JVD, supple, no LN
Chest: B/L Bs clear, no wheezing
CVS: S1/S2 regular, thre was click in her apical area, no murmur
Abd: soft, no tender, Bs present
Ext: no pitting edema
Rectum: there is no skin tag, there is black stool in her
rectum, Guaiac test positive
.
Discharge vitals: T: P: RR: BP: O2Sat:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no nasal
bleeding, no conunctival pallor
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, + mechanical murmur
at apex
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: CN2-12 intact, strength intact [**6-17**] U&LE, sensation
intact, DTRs 2+ patellar, gait deferred
Pertinent Results:
EGD [**2188-10-22**]: Impression: Normal mucosa in the esophagus
Mild erosion in the antrum compatible with gastritis
Erythema in the stomach body compatible with NG tube-induced
trauma
Normal mucosa in the duodenum
During this procedure, we did not find activate bleeding.
Small hiatal hernia
Otherwise normal EGD to third part of the duodenum
Recommendations: Because we did not identify the etiology of her
G.I. bleeding during this procedure, she might need colonoscopy
to rule out right colonic bleeding. We will discuss with Dr.
[**Last Name (STitle) 2987**] this afternoon to recommend either regular colonoscopy or
virtual colonoscopy.
Colonoscopy [**2188-10-23**]: Angioectasia in the cecum (thermal
therapy)
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
Recommendations: In patient care
Capsule endoscopy. Serial hematocrits
Brief Hospital Course:
Assessment and Plan: 75 year old woman on Coumadin and Plavix,
s/p mechanical MVR, h/o GI bleed (ten years ago), now presenting
with GI bleeding in the setting of a supratherapeutic INR, c/b
nasal bleeding following NGT placement.
.
# GI Bleed: The pt had three melenotic stools over 24 hrs, but
has stable hct on labs and is otherwise asymptomatic (without
fatigue, shortness of breath with exertion, chest pain, or
orthostasis). NG lavage was negative for any coffee ground
material or bloody contents. EGD did not reveal any source of
bleed. The patient also underwent colonoscopy, revealing a
bleeding AVM, which was coagulated using thermal therapy. She
will need a capsule endoscopy as an out-patient in order to
assess for additional, non-visualized AVM in the small bowel.
She was monitored with serial hematocrits, which trended
downward precipitating transfusion with 1 unit of blood. Her
anti-coagulation with Plavix and Coumadin was held for her
procedures. After, she was re-started on coumadin with a heparin
bridge to therapeutic INR, and her plavix was restarted after
being held for 7 days. Her hematocrit was stable at discharge.
She was discharged once INR was therapeutic.
.
# Nasal trauma: Following NGT placement, pt developed bleeding
from nose that was quite profuse. Packing was placed by ENT
which was dislodged overnight. We suspect that a minor
lac/contusion from NG tube in the setting of elevated INR
precipitated this event. She experienced no further epistaxis
during this admission.
.
# Mechanical MV replacement: Goal INR is 2.5-3.5. The patient is
on a higher dose of Coumadin (5.5mg) to maintain this INR. Per
discussion with cardiology, her anti-coagulation was not
reversed. All anticoagulation was held pending her EGD, and she
was started on a heparin drip afterwards. After her colonoscopy,
she was restarted on Coumadin and a heparin drip was used to
bridge the patient until her INR was therapeutic. At discharge,
her INR was 2.6.
.
# CAD s/p 1 vessel CABG [**2177**]: The patient's beta blocker was
initially held so as not to mask hypovolemia. It was re-started
after the patient's procedures with normal heart rate and
excellent blood pressure control.
.
# TIA's (on plavix): Plavix was restarted after being held for a
total of 7 days after her colonoscopy.
Medications on Admission:
Lipitor 80
Plavix 75
Maxalt ML T 10 prn migraine
Amoxicillin prn dental
Atenolol 12.5
Alendronate 70
EpiPen prn fish
Ambien 10 qhs
Coumadin 5.5 everyday except Sat, on Sat pt takes 4mg
Skelaxin 800 qhs
Zantac 150mg [**Hospital1 **]
meds at hospital:
Maxalt-MLT *NF* 10 mg Oral daily prn migraine
Oxymetazoline 1 SPRY NU [**Hospital1 **]
Lorazepam 0.25 mg IV ONCE MR1
Pantoprazole 8 mg/hr IV INFUSION
Discharge Medications:
1. Rizatriptan 10 mg Tablet Sig: One (1) Tablet PO daily prn ()
as needed for migraine.
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Warfarin 5 mg Tablet Sig: 5.5 mg every day but Saturday, 4mg
on Saturday. Tablets PO Once Daily at 4 PM: 5.5mg every day but
Saturday. On saturday take 4mg. .
5. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
8. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) Intramuscular
once a day as needed for anaphylaxis.
9. Skelaxin 800 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice
a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1) Gastrointestinal bleeding
2) Arteriovenous malformation of cecum
Secondary diagnosis:
1. Coronary Artery Disease status post 1 vessel Coronary Artery
Bypass Graft [**2177**]
2. Valvular disease: status post mechanical Mechanical valve
replacement [**2177**] (on coumadin)
3. History of supraventricular tachycardia
4. Transient ischemic attacks (on plavix)
5. hypertension
Discharge Condition:
Stable, BP --, HR --, no recurrence of GI bleeding after
colonoscopy with thermal therapy, HCT stable at --.
Discharge Instructions:
You were admitted to the hospital for GI bleeding. You had an
EGD, which showed gastritis in your stomach. You also had a
colonoscopy, which showed an AVM (arteriovenous malformation) in
the cecum which was coagulated with thermal therapy to stop the
bleeding. It also showed diverticulosis of the sigmoid colon.
You will need to get a capsule endoscopy as an outpatient. This
will be coordinated by gastroenterology.
* We restarted your Coumadin before discharge. Your INR was
between 2.5 and 3.5 at discharge. You will need to have a follow
up INR check with your regular doctor next week. You should take
your Coumadin as per your prior regimen (5.5mg every day but
Saturday, on Saturday take 4mg).
Please call your doctor or return to the ED if you experience
any:
Recurrence of bleeding
Fainting or lightheadedness
Abdominal or Pelvic Pain
Pain with urination
Fever or Chills
Chest pain or shortness of breath, especially with exertion
Followup Instructions:
You need to follow up with gastroenterology for a capsule
endoscopy as an outpatient and you also need to have an INR
check next week.
You need to schedule the following appointments:
Appointment #1
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**]
Specialty: Internal Medicine
Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg. [**Location (un) 895**]
Phone number: [**Telephone/Fax (1) 250**]
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 3100**]
Specialty: Gastroenterology
Location: [**Last Name (NamePattern1) 439**]. [**Hospital Ward Name **] Bldg. [**Location (un) 858**]
Phone number: [**Telephone/Fax (1) 463**]
Please make appointments to follow up in the above two clinics
upon discharge from the hospital. You also need to have your
INR checked on wednesday, and follow up with the [**Company 191**]
anticoagulation service as you have in the past.
.
Future appts you have scheduled:
1. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2188-11-27**]
9:40
2. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2188-12-31**] 10:10
|
[
"2851",
"V5861",
"V4581",
"4019",
"2720"
] |
Admission Date: [**2175-7-10**] Discharge Date: [**2175-7-15**]
Date of Birth: [**2110-7-17**] Sex: F
Service: NEUROSURG
CHIEF COMPLAINT: Vertigo.
HISTORY OF PRESENT ILLNESS: This is a 64-year-old lady with
a complicated medical history significant for the fact that
she was status post C5-C6 and C6-C7 discectomies with bone
graft and plate placement on [**2175-6-20**]. She presented with
exacerbation of dizziness and the acute onset of vertigo for
four days as well as five minutes of loss of consciousness.
The patient was having dizziness and vertigo ever since her
surgery on [**2175-6-20**]. She was taken to an outside hospital
where workup, including cervical films, failed to determine
any etiology for the syncope and vertigo. She was discharged
home. On admission to [**Hospital1 69**],
the patient continued to have dizziness and vertigo and was
admitted for further investigation.
PAST MEDICAL HISTORY: The past medical history was
significant for the fact that the patient was a diabetic for
the last 25 years. She had C5-C6 and C6-C7 discectomies with
bone graft and metal plate placement on [**2175-6-20**]. She a had
parotid gland tumor resection ten years ago. She had right
rotator cuff surgery. She had a lumbar laminectomy in [**2137**].
She also had an appendectomy in the past. The patient had
hypertension and hypercholesterolemia. She had a
hysterectomy in the past.
MEDICATIONS ON ADMISSION: The patient was on OxyContin,
Vicodin, Lipitor, Glucophage, Amaryl and trandolapril.
ALLERGIES: The patient was allergic to Furadantin, Captopril
and ethylenediamine.
PHYSICAL EXAMINATION: On examination, the patient had a
blood pressure of 118/52, a pulse of 64 per minute, a
respiratory rate of 16 and an oxygen saturation of 99% on
room air. She was interactive. The pulmonary examination
was clear to auscultation bilaterally with no crackles or
wheezes. The cardiovascular examination was a regular rate
and rhythm with no murmurs, rubs or gallops. The abdomen was
soft, nontender and nondistended with positive bowel sounds.
Neurologically, the patient was alert and oriented. Affect
was appropriate. Attention was good. Language was fluent
with normal content. Visual fields were intact. The fundi
were normal. The pupils were normal, round and reactive.
Extraocular movements were full. Normal facial sensation and
movement were present. Hearing was intact. There were
normal oropharyngeal movement and sensation. The tongue was
midline with no fasciculations.
Motor examination was normal on both the right side and the
left. Strength was grade 5 in all muscle groups. The right
upper extremity examination was limited because of pain.
Pronator drift was absent. Touch was intact bilaterally.
Pinprick, vibration and proprioception were also intact.
Reflexes were bilaterally present and symmetrical. Plantar
reflexes were downgoing. Coordination was good.
LABORATORY DATA: The total white blood cell count was 6500
with a hematocrit of 29 and platelet count of 213,000.
Prothrombin time was 13.1, partial thromboplastin time was
32.4 and INR was 1.1. Chem 7 revealed a sodium of 141,
potassium of 3.7, chloride of 105, bicarbonate of 25, BUN of
11, creatinine of 0.5 and glucose of 176.
IMAGING: The MRI/MRA report showed normal but significant
artifact from cervical hardware. There was no infarct or
stenosis. An angiography done on [**2175-6-11**] showed a left
vertebral dominant system and, upon rotation of the head to
the left, the diameter of the left vertebral artery decreased
by 50%; there was not as significant of a decrease on the
right side. There was no evidence of vertebral dissection.
HOSPITAL COURSE: The patient was admitted to the surgical
intensive care unit for observation after her angiography.
She continued to be investigated for her vertigo. She was
seen by the neurology service. A vascular etiology for the
vertigo was difficult to justify after the findings seen on
the angiography. The patient was started on meclizine. Her
symptoms improved considerably with the meclizine and it was
decided that she could be discharged to home with the
meclizine.
DISPOSITION: The patient was told to follow up with Dr.
[**Last Name (STitle) 6910**], who was her surgeon previously, and also with the
[**Hospital 96499**] clinic. She was told to continue the meclizine
until she was seen by Dr. [**Last Name (STitle) 6910**] and the neurology
service. She was discharged to home in stable condition.
DISCHARGE DIAGNOSIS:
Vertigo, origin uncertain.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7762**]
Dictated By:[**Name8 (MD) 7075**]
MEDQUIST36
D: [**2175-7-15**] 22:20
T: [**2175-7-22**] 09:35
JOB#: [**Job Number 32590**]
|
[
"25000",
"4019",
"2720"
] |
Admission Date: [**2147-4-5**] Discharge Date: [**2147-4-13**]
Service: Medicine
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: This 86 year old female with a
history of inflammatory bowel disease with a recent flare,
status post an admission to [**Hospital6 2018**] in [**2147-2-26**], presents again with recurrent
bright red blood per rectum and an acute anemia with an 8
point hematocrit drop and hypotension. In [**2147-1-26**], the
patient was admitted to [**Hospital6 1708**] for
bleeding and colitis. At that time she had a flexible
sigmoidoscopy which demonstrated mucosal ulceration and
friability to 70 cm, and her stool cultures at that time were
positive for Clostridium difficile. She was discharged to
rehabilitation but returned to [**Hospital6 2018**] for admission from [**2-28**], to [**2147-3-13**],
for bright red blood per rectum and fatigue times one week.
At that time, she was Clostridium difficile negative and a
flexible sigmoidoscopy demonstrated friability, granulation
and ulceration in the rectum and sigmoid colon consistent
with colitis. She was treated with intravenous steroids and
discharged to rehabilitation on intravenous Solu-Medrol. For
this admission she returned with similar complaints of bright
red blood per rectum with multiple stools per day and general
malaise. She denied abdominal pain, nausea and vomiting but
had a near syncopal event when getting out of bed five days
prior to admission. She states that she also had subjective
fevers.
PAST MEDICAL HISTORY: Inflammatory bowel disease, type
unspecified diagnosed in [**2130**]; Clostridium difficile in
[**2147-1-26**]; aortic stenosis diagnosed as moderate to
severe at [**Hospital6 1708**] in [**2147-1-26**] with
a valve area of 0.8 to 0.9, however, repeat echocardiogram at
[**Hospital6 256**] showed only mild atrial
fibrillation, history of biliary sepsis secondary to common
bile duct stone, now status post endoscopic retrograde
cholangiopancreatography on sphincterotomy in [**2146-11-26**],
history of diverticulosis with colonic resection, history of
breast cancer status post lumpectomy and radiation, abdominal
aortic aneurysm repaired in [**2142**], hyperthyroidism, migraines,
gastroesophageal reflux disease, hypercholesterolemia,
chronic anemia, chronic renal insufficiency with a baseline
creatinine of 1.2, hypertension, status post cholecystectomy,
status post right total hip replacement, history of bowel and
bladder incontinence.
ALLERGIES: Tylenol causing nausea.
MEDICATIONS ON ADMISSION: Prednisone 35 mg a day,
Fluconazole, Atorvastatin, Lansoprazole, calcium carbonate
500 mg b.i.d., Nystatin Swish and Swallow 5 mg q.i.d.,
Meclizine 25 mg p.o. q. 6 hours prn, insulin, sliding scale,
subcutaneous heparin, Vancomycin 250 mg p.o. q.i.d.
SOCIAL HISTORY: The patient is a former smoker, quit smoking
30 years ago. The patient rarely drinks alcohol and is only
a social drinker. The patient's code status is full code.
Her health care proxy is her son, [**Name (NI) **] [**Name (NI) **], telephone
#[**Telephone/Fax (1) 111138**].
LABORATORY DATA: On admission white blood cell count 5.5,
hematocrit 25.1, platelets 252, sodium 134, potassium 5.9,
chloride 103, bicarbonate 24, BUN 48, creatinine 1.4, ALT 11,
AST 9, alkaline phosphatase 72, LDH 113, total bilirubin 0.1,
albumin 2.0. Chest x-ray showed clear lungs that are stable,
elevation of the right hemidiaphragm. Abdominal computerized
tomography scan showed pancolic wall thickening, most likely
within the transverse colon but overall decreased in
appearance in the prior study, no evidence of abscess,
pneumobilia and hypodense cysts within the tail of the
pancreas. Electrocardiogram showed normal sinus rhythm,
borderline left axis deviation, slow R wave progression.
HOSPITAL COURSE: 1. Bright red blood per rectum/acute
anemia - On presentation the patient's hematocrit had dropped
from a baseline of 30 to 22, the patient was hypertensive and
required aggressive fluid resuscitation and blood
transfusion. The patient's bright red blood per rectum was
felt to be secondary to a flare of her inflammatory bowel
disease or to recurrent Clostridium difficile colitis. She
was initially treated with bowel rest, intravenous steroids
and oral Vancomycin, however, once two stool samples had
returned as Clostridium difficile negative her Vancomycin was
stopped and the focus of treatment was placed on her flare of
inflammatory bowel disease. The patient was placed on
maximum medical management of her inflammatory bowel disease
which included Solu-Medrol drip, bowel rest with total
parenteral nutrition, Rowasa, and Hydrocortisone enemas,
Mesalamine, both p.o. and p.r. Unfortunately, the patient's
inflammatory bowel disease flare did not respond to maximum
medical management. She continued to have six or more bloody
bowel movements per day. The patient was seen in
consultation by the Surgical Service as her inflammatory
bowel disease had not responded to medical management and it
was felt that definitive therapy would require surgical
intervention. She was seen and evaluated by the Surgery Team
and was transferred to the Surgical Service on [**2147-4-13**]
for a colectomy.
2. Aortic stenosis - There was some question as to the
severity of the patient's aortic valve disease as an
echocardiogram at [**Hospital6 1708**] in [**2147**] showed
severe aortic stenosis with a valve area of 0.8 to 0.9 cm
squared. The patient was seen by Cardiology during this
admission and a repeat echocardiogram was ordered. The
repeat echocardiogram showed a normal left ventricular
ejection fraction of greater than 55% with only mild aortic
valve stenosis. The echocardiogram was reviewed by the
attending cardiologist and it was confirmed that the
patient's aortic valve disease was mild.
3. Bradycardia - During this admission, the patient was
noted to have sinus bradycardia with heartrates in the 40s
and 50s. The patient's PR interval and QTC remained within
normal limits. It was felt by the cardiology consult there
was no acute indication for pacemaker placement. In addition
perioperative beta blockers were held given the patient's
significant bradycardia. Throughout the course of her
admission, the patient remained hemodynamically stable
despite her bradycardia with the exception of the initial 24
hours during which he had acute anemia with hypotension.
4. Oral thrush - The patient was admitted on Nystatin Swish
and Swallow for oral thrush. This was changed during her
Intensive Care Unit admission to oral Clotrimazole, however,
upon examination it appeared that the patient had a cluster
of approximately six to eight acthous ulcers at the tip of
her tongue. There was no evidence of active Candidal
infection. It was recommended that the patient's oral
antifungal [**Doctor Last Name 360**] be discontinued.
5. Diabetes mellitus - The patient was placed on a regular
insulin sliding scale. In addition, the patient had insulin
placed in her total parenteral nutrition.
6. Fluids, electrolytes and nutrition - The patient was
placed on bowel rest for optimal medical management of her
inflammatory bowel disease. Therefore, she required PICC
line placement and initiation of total parenteral nutrition.
The remainder of the hospital course will be covered by the
covering surgical intern.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 9609**]
MEDQUIST36
D: [**2147-4-13**] 20:37
T: [**2147-4-13**] 21:28
JOB#: [**Job Number 111139**]
|
[
"2851",
"4241",
"40391",
"2767"
] |
Unit No: [**Numeric Identifier 70693**]
Admission Date: [**2136-1-25**]
Discharge Date: [**2136-2-4**]
Date of Birth: [**2136-1-25**]
Sex: F
Service: NB
ADDENDUM: This is an interim summary covering from [**1-30**] throughout the date of discharge. Please see prior
dictation for perinatal events.
HOSPITAL COURSE BY SYSTEMS DURING THIS INTERIM PERIOD:
1. RESPIRATORY: Infant remained in the hospital until she
was free of any episodes of apnea or bradycardia for 5
days.
2. CARDIOVASCULAR: There were no cardiovascular issues.
3. FEEDING AND NUTRITION: At the time of discharge,
weighed 2.090 kilograms, was feeding ad lib
demand of NeoSure 24 calories per ounce and was taking
upwards of 180 to 190 cc/kg.
4. HEMATOLOGIC: Infant had a peak bilirubin of 9.1 on
[**1-29**], and her last bilirubin level on [**1-31**]
was 7.4/0.3. She required no treatment.
5. INFECTIOUS DISEASE: There were no infectious disease
issues during this time period.
6. HEARING SCREENING: Was performed and passed on [**1-27**].
7. IMMUNIZATIONS: Hepatitis B vaccine was given on [**1-31**].
DISCHARGE DIAGNOSES:
1. Premature female twin #2 at 35 and [**7-20**]-weeks gestation.
2. Status post apnea and bradycardia of prematurity.
DISCHARGE PLANS: The patient will be followed up at [**University/College **]-
[**Hospital1 **] [**Location (un) 15749**] Center on [**2-7**]. She will be seen
by Dr. [**Last Name (STitle) 39027**]. She will be followed up on [**2-8**] by
the visiting nurse.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], MD
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2136-2-4**] 09:37:08
T: [**2136-2-4**] 10:10:31
Job#: [**Job Number 70778**]
|
[
"V053"
] |
Admission Date: [**2146-6-19**] Discharge Date: [**2146-7-3**]
Date of Birth: [**2146-6-19**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**Known lastname 9035**] is a 35 [**12-30**] week premature twin
number two, born by Cesarean section following an unsuccessful
induction for intrauterine growth restriction of twin I.
PREGNANCY: 34-year-old gravida I, para 0 now II woman with
spontaneous twins. Prenatal screens: B positive, antibody
negative, rubella immune, RPR nonreactive, hepatitis B
surface antigen negative, GBS unknown. Pregnancy complicated
by disparity in fetal growth. Serial assessments confirmed
intrauterine growth restriction of twin A. Eventual decision
for induction at 35 weeks. Induction unsuccessful, and
maternal blood pressure noted to be rising consistently.
Decision for cesarean section, with spinal anesthesia.
Pediatric team present. This twin emerged second, in vertex
position, at about one minute. Suctioned, stimulated and
given blow-by oxygen. Remained persistently dusky. Apgars
were 8 at one minute and 8 at five minutes. Grunting emerged
by four minutes of life, which was persistent. Decision was
made to transfer the infant to the Neonatal Intensive Care
Unit for management of prematurity and respiratory distress.
PHYSICAL EXAMINATION: On admission, birth weight 2610 grams
(70th percentile), head circumference 32 cm (50th
percentile), length 47 cm (60th percentile). Dusky,
good-sized premature male, with grunting and flaring. Round
head, anterior fontanel soft, open and flat. Normal ears and
facies, palate intact, red reflex deferred due to inability
to pry eyes open. Normal neck. Bilateral breath sounds
diminished. No murmur, normal S1, S2. Abdomen soft,
nondistended, no hepatosplenomegaly, testicles descended
bilaterally, normal penis. Anus patent, spine intact,
clavicles intact, hips stable. Active, with good tone and
activity.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant was initially placed on CPAP at
6 cm on admission. A chest x-ray was obtained due to
increased respiratory distress, which revealed a right
pneumothorax. Needle thoracentesis was performed, and 15 cc
of air was extracted. The infant weaned shortly after needle
thoracentesis to nasal cannula. A repeat chest x-ray
revealed a small amount of residual air on the right side.
The infant weaned to room air by day of life two, with oxygen
saturations greater than 95%. Respiratory rate has been in
the 40 to 60 range. Last apnea and bradycardia was on day of
life six. The infant did not receive methylxanthine therapy
this hospitalization.
2. Cardiovascular: The infant has remained hemodynamically
stable this hospitalization, no murmur, heart rate 130 to
150.
3. Fluids, electrolytes and nutrition: The infant was
initially started on 60 cc/kg/day of D-10-W intravenous
fluids. Enteral feedings of Enfamil 20 calories/ounce were
started on day of life two at 80 cc/kg/day given by mouth and
gavage. Feedings were advanced to full enteral feedings of
150 cc/kg/day by day of Enfamil 20 calories/ounce by day of
life number six. The infant tolerated feeding advancement
without difficulty. Last gavage feeding was day of life 11.
Most recent weight 2635 grams, length 47.5 cm, head
circumference 32.5 cm.
4. Gastrointestinal: Maximum bilirubin was total 12.6, with
a direct of 0.4 on day of life five. A repeat bilirubin on
day of life seven was 10, with a direct of 0.6. The infant
did not receive phototherapy this hospitalization.
5. Hematology: Most recent hematocrit on day of life one
was 52.5%. The infant did not receive a blood transfusion
this hospitalization.
6. Infectious Disease: Due to increased respiratory
distress and prematurity, a CBC, differential and blood
culture were sent on admission. The CBC showed a white blood
cell count of 13.3, hematocrit 54.3%, platelet count 338,000,
12 polys, 5 bands. Due to an I:T ratio of 0.29, a repeat CBC
and differential were sent on day of life one, which showed a
white count of 10.2, hematocrit 52.5%, platelets 270,000, 59
polys, 0 bands. Due to a drastic improvement in respiratory
status, with no known sepsis risk factors, the infant was not
placed on antibiotics. Blood cultures have remained negative
to date.
7. Neurology: The infant does not meet criteria for head
ultrasound.
8. Sensory: Audiology: Hearing screen was performed with
automated auditory brain stem responses, he passed in both
ears.
9. Ophthalmology: The infant does not meet criteria for eye
examination.
9. Psychosocial: The parents are involved. [**Hospital1 346**] social work involved with the
family. The contact social worker can be reached at
[**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Former 35 [**12-30**] week premature twin
number two, stable in room air.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], phone
number [**Telephone/Fax (1) 43701**], fax number [**Telephone/Fax (1) 43702**].
CARE RECOMMENDATIONS:
1. Feedings: The infant is currently PO ad
lib, Enfamil 20 calories/ounce, minimum 150 cc/kg/day.
2. Medications: Fer-in-[**Male First Name (un) **] 2 mg/kg/day by mouth,
Poly-vi-[**Male First Name (un) **] 1 cc by mouth once daily.
3. Car seat position screening was performed prior to
discharge. The infant passed.
4. State newborn screening status: State newborn screens
were sent on [**6-23**] and [**2146-7-3**]. Results are
pending.
5. Immunizations: The infant received hepatitis B vaccine
on [**2146-7-2**].
6. Follow-up appointments: Follow-up appointment to be made
with primary pediatrician prior to discharge.
DISCHARGE DIAGNOSIS:
1. Prematurity, 35 2/7 weeks gestation
2. Respiratory distress, resolved
3. Right pneumothorax, resolved
4. Rule out sepsis, resolved
5. Apnea of prematurity, resolved
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 43219**]
MEDQUIST36
D: [**2146-7-3**] 03:04
T: [**2146-7-3**] 04:15
JOB#: [**Job Number 44206**]
|
[
"V290",
"V053"
] |
Admission Date: [**2134-8-12**] Discharge Date: [**2134-8-19**]
Date of Birth: [**2053-11-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
s/p fall- SAH, L acetabular fx, L2+L3 transverse process
fractures, question of T and L spine compression fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 year-old man with history of CAD s/p IMI, afib s/p pacemaker
on coumadin, COPD, laryngeal CA, who was admitted to the TICU
with SAH after a fall, and is now transferred to the MICU for
management of respiratory failure. Briefly, he had a mechanical
fall on [**2134-8-12**] and subsequently sustained a SAH, transverse
process fracture at L2/L3, a compression fracture of
T3/T12/L1/L4, and a left acetabular fracture. His SAH and
fractures were thought to be non-operable per neurosurgery and
ortho, respectively. His course in the TICU was also remarkable
for respiratory distress and ?new hypoxia on the day after
admission (he was 98%2L on the day of admission per review of
the notes), for which he was placed on a face mask, started on
solumedrol, nebs, and azithromycin empirically for a presumed
COPD exacerbation. This was weaned down to 2L NC on the day
prior to transfer and he was satting 98%ra on the morning of
transfer with a plan to go to rehab today.
.
Per report, later this morning around 11 a.m., he was found to
be dyspneic, lethargic and breathing at a rate of 40. He was
placed on a nonrebreather and had O2 satts in the 70s, HR 100s
(afib), SBP 110. ABG was 7.37/47/98/28. He was thought to have
aspirated vs flash pulmonary edema and given lasix 40 mg IV x 1
with good UOP. Of note, his family has been updated and he
agrees to BiPAP but would want to be comfortable if this fails
(after many conversations with patient and family).
.
His hospital course has also been remarkable for delerium
thought to be secondary to sundowning and narcotics, with
geriatrics consulted.
Past Medical History:
AAA repair 4 years earlier
Thyroidectomy 3 years earlier
Advanced COPD
AFib treated with coumadin
CAD and pacemaker placement
Social History:
Lives at home with son. [**Name (NI) **] current alcohol or tobacco use.
Family History:
Unknown
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
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: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
.
[**2134-8-12**] 06:05AM BLOOD WBC-17.9*# RBC-5.01# Hgb-14.6# Hct-44.8#
MCV-89 MCH-29.1 MCHC-32.6 RDW-14.1 Plt Ct-200
[**2134-8-12**] 06:05AM BLOOD Neuts-93.8* Lymphs-3.5* Monos-2.5 Eos-0.1
Baso-0.1
[**2134-8-12**] 06:05AM BLOOD PT-32.5* PTT-35.3* INR(PT)-3.3*
[**2134-8-12**] 06:05AM BLOOD Glucose-150* UreaN-24* Creat-1.8* Na-137
K-4.8 Cl-102 HCO3-25 AnGap-15
[**2134-8-12**] 06:05AM BLOOD CK(CPK)-88
[**2134-8-12**] 06:05AM BLOOD CK-MB-NotDone
[**2134-8-12**] 06:05AM BLOOD cTropnT-<0.01
[**2134-8-12**] 09:01AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.0
[**2134-8-12**] 06:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2134-8-12**] 04:14PM BLOOD Type-ART pO2-43* pCO2-35 pH-7.44
calTCO2-25 Base XS-0
[**2134-8-12**] 06:17AM BLOOD Lactate-1.6
[**2134-8-12**] 04:14PM BLOOD freeCa-1.12
.
.
PERTINENT STUDIES:
.
CT Chest ([**8-12**]):1. Multiple thoracolumbar compression deformities
as described above. 2. Right transverse process fracture of L3
and L4. 3. Emphysema and multiple pulmonary nodules, one of
which is not included in the field of view of the prior
examination, measuring 4 mm. Given risk
factors, a 12-month followup is recommended. 4. Multiple
hepatic cysts. 5. Bilateral renal cysts
CT Head ([**8-12**]):There is asymmetric dense appearance of the right
side of the tentorium and
lateral to it indicating a possible suddural hemorrhage
associated. Close f/u to assess the stability of the above
findings is recommended.
CT C-Spine ([**8-12**]):There is asymmetry in the size of the disc
space at C4/5, wider anteriorly.
(series 400b, im 19). Though this can relate to DJD and disc
bulge, ligamentous injury needs to be excluded given the history
of trauma and no prior studies. MR c spine can be performed for
the same.
LENI ([**8-18**]): LLE: partially occluded clot in greater saphenous,
unchanged from prior; superficial femoral vein proximal
thrombus. Possible thrombus . RLE: interval development of
partially occlusive clot in greater saphenous at junction of
common femoral.
CT Head ([**8-18**]): 1. No evidence of new hemorrhage 2. Stable
appearance of bilateral subdural hemorrhage layering along the
tentorium cerebelli. Interval resolution of subarachnoid
hemorrhage seen in the interpeduncular cistern. 3. Chronic
small vessel ischemic changes.
4. Prominent ventricles and sulci, unchanged.
TTE ([**8-18**]): Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate pulmonary hypertension.
Brief Hospital Course:
Patient was admitted to T/SICU from ER for management of his
injuries s/p mechanical fall, which included SAH, L acetabular
fracture, L2L3 transverse process fractures, and thoracolumbar
compression injuries. Orthopaedics and Neurosurgery were
consulted for these injuries. Orthopaedics recommended
non-operative management of L hip fracture. Patient was to be
touch-down weight-bearing for 6 weeks and to follow-up in the
[**Hospital 13308**] clinic after this course of time. Neurosurgery
recommended normalization of his INR and repeat imaging of his
head in 6hours and 24 hours. No intervention was recommended
for vertebral fractures. His repeat head CTs revealed no
change.
Patient had unstable respiratory status while in the ICU, which
was felt to be d/t COPD flair. He was treated with steroids,
CPAP or BiPAP, and Azithromycin. He experienced some delirium
and sundowning in the unit and geriatrics was consulted and
recommended afternoon haldol rather than standing doses and
tylenol with breakthrough oxycodone rather than morphine
standing.
On HD4 patient had discussion with team regaring desire to be
DNR/DNI and desire for care not to be escalated. Patient was
weaned to 2L NC and transferred to floor. Physical therapy and
occupational therapy evaluated the patient and hospice care was
consulted. Patient had a speech and swallow consult. 1:1
supervision with crushed/pureed foods was recommended.
On HD5 patient became increasingly tachypneic and was
transferred back to the T/SICU for BiPAP. The decision was made
to transfer patient from surgical intensive care unit to medical
intensive care unit.
During his MICU stay, the patient was placed on Bipap for
hypoxic respiratory failure. He was placed empirically on
antibiotics and was given IV steroids for a possible COPD
exacerbation. He remained dyspneic with labored work of
breathing while on Bipap. LENIs were performed, which showed a
new DVT in his lower extremity. He was thus placed on a heparin
drip. He went into AFib with RVR and was started on a diltiazem
drip. He developed increased work of breathing in the setting
of AFib with RVR and eventually expired from cardiopulmonary
arrest.
Medications on Admission:
Nitropatch 0.2 mg per hour
folic acid 1 mg per day
Toprol-XL 12.5 mg per day
Protonix 40 mg per day
Coumadin 2mg per day
Mirtazapine
Levoxyl 50 mcg per day
Testosterone
Vytorin 20/10,
Albuterol inhaler
Combivent inhaler
Fluticasone inhaler
Calcium/vit B-12
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**1-8**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
3. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-12**]
hours as needed for pain.
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p Fall
Subarachnoid hemorrhage
Transverse process fractures L2,3
Compression fracture T3,12; L1,4
Left acetabular fracture
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2134-11-29**]
|
[
"5849",
"42731",
"40390",
"5859",
"2724",
"53081",
"412"
] |
Admission Date: [**2170-1-24**] Discharge Date: [**2170-2-6**]
Service: CCU
ADDENDUM
HOSPITAL COURSE: On the day of discharge, the patient was
restarted on Lasix 80 mg q.Monday, Wednesday, Friday, and 40
mg p.o. q.Tuesday, Thursday, Saturday, and Sunday. We also
asked the rehabilitation facility to check the patient's CBC
and CHEM10 three days after discharge.
The remainder of the discharge medications and discharge
diagnosis remains the same.
FOLLOW-UP: The patient is being discharged to a
rehabilitation facility. She will continue to be followed by
her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11679**]. She will follow-up
with the [**Hospital **] Clinic in six months time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2170-2-6**] 11:00
T: [**2170-2-6**] 11:10
JOB#: [**Job Number 96352**]
|
[
"486",
"4280"
] |
Admission Date: [**2104-3-3**] Discharge Date: [**2104-3-10**]
Date of Birth: [**2038-5-5**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
male with a chief complaint of persistent nausea, vomiting,
and failure to thrive times one week.
The patient has a significant history of biventricular
failure and coronary artery disease, who was recently
discharged from [**Hospital1 69**] on
[**2104-2-15**] for a congestive heart failure exacerbation.
At the time of admission, the patient denies any chest pain,
palpitations, shortness of breath, fevers, chills, bright red
blood per rectum, melena, and diarrhea. He does describe
nausea and vomiting as well as some anorexia for the past
week prior to admission. In general, the patient has had
decreased oral intake and overall failure to thrive for the
last month. The patient denies any sick contacts. The
patient complains of increasing fatigue as well as a 14-pound
weight gain since his discharge on [**2-15**] despite
recently increasing his Lasix dose from 80 mg to 100 mg in
the morning with an additional 80-mg dose in the afternoon,
as well as the addition of Zaroxolyn administered prior to
Lasix.
The patient was seen by his primary care physician
(Dr. [**First Name (STitle) 1104**] and sent to the [**Hospital1 188**] Emergency Department for further evaluation.
On presentation, he was found to have a blood urea nitrogen
to creatinine ratio of 124 to 2.9 which was significantly
increased from his baseline. Therefore, the patient was
admitted for further management of what was felt to be
congestive heart failure exacerbation.
The patient reported that his cardiac history began in [**2086**].
He did well until the middle [**2092**] when he began having
persistently increasing numbers of congestive heart failure
exacerbation. He developed congestive heart failure
intermittently and was hospitalized in [**2103-1-22**] and
then again in [**2103-4-22**]. At this time, he started having
increasing paroxysmal nocturnal dyspnea, dyspnea on exertion,
and peripheral edema. However, the patient was stabilized
with increasing Lasix dosage. He was subsequently admitted
in [**2104-1-22**] with a congestive heart failure
exacerbation and return now with a 14-pound weight gain,
anorexia, nausea, and vomiting.
PAST MEDICAL HISTORY:
1. Biventricular heart failure/congestive heart failure with
an ejection fraction of 20%; thought secondary to ischemic
cardiomyopathy.
2. Severe pulmonic stenosis.
3. Status post pacemaker implantable
cardioverter-defibrillator placement in [**2098**] secondary to
third-degree heart block.
4. Coronary artery disease, status post myocardial
infarction in [**2086**] with cardiogenic shock at the age of 47;
status post cardiac catheterization in [**2102-5-22**] with 50%
proximal left anterior descending artery, severe pulmonary
hypertension, wedge of 14, and global hypokinesis.
5. History of syncopal episodes.
6. Hypercholesterolemia.
7. Insulin-dependent diabetes mellitus since [**2086**] with
secondary neuropathy and cataracts.
8. Obstructive sleep apnea, on home BiPAP times one year.
9. Chronic renal insufficiency.
MEDICATIONS ON ADMISSION: Lasix 80 mg p.o. b.i.d.,
Zaroxolyn 2.5 mg p.o. q.d., captopril (discontinued the week
prior to admission), aspirin 325 mg p.o. q.d., NPH 26 units
in the a.m. and 14 units in the p.m., sublingual
nitroglycerin p.r.n. for chest pain, Protonix 40 mg p.o.
q.d., Pravachol 20 mg p.o. q.d., digoxin 0.125 mg p.o. q.d.,
Isordil 10 mg p.o. t.i.d., K-Dur one tablet p.o. q.d.
ALLERGIES: The patient reports SERAX, AMBIEN, FENTANYL, and
DEMEROL cause him to "feel strange." [**Year (4 digits) **] causes
seizures.
SOCIAL HISTORY: The patient has a distant history of pipe
smoking. He currently lives with his wife and two children
and is a retired security guard. His wife is an Emergency
Department nurse.
FAMILY HISTORY: The patient's brother died of a myocardial
infarction at the age of 47.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 97.4, blood pressure of 116/77, respiratory
rate of 14, saturating 100% on room air. In general, a
rather ill-appearing male, sleeping, lethargic, easily
arousable, in no acute distress. Head, eyes, ears, nose, and
throat revealed mucous membranes were moist. The oropharynx
was clear. Pupils were equal, round, and reactive to light.
Sclerae were anicteric. Cardiovascular examination revealed
soft first heart sound, obliterated second heart sound.
Holosystolic murmur, positive jugular venous distention.
Pulmonary revealed mild bibasilar crackles; otherwise clear
to auscultation bilaterally. The abdomen was distended,
positive bowel sounds, nontender, 2+ pitting edema of the
abdominal wall. Extremities revealed 2+ pitting edema to the
scapulas bilaterally as well as to the bilateral knees.
Neurologically, alert and oriented times three. No focal
deficits.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories at
the time of admission revealed a white blood cell count
of 7.4, hematocrit of 39, platelets of 199. Sodium of 128,
potassium of 3.9, chloride of 83, bicarbonate of 20, blood
urea nitrogen of 124, creatinine of 2.9, blood glucose
of 110. Calcium of 9.1, magnesium of 3.2, phosphate of 7.2.
Digoxin level of 2.8.
RADIOLOGY/IMAGING: A chest x-ray revealed a right pleural
effusion; unchanged, with right-sided atelectasis, dual
chamber pacemaker placed, questionable left lower extremity
opacity, possibly consistent with pneumonia. Stable
cardiomegaly. No increased pulmonary vascular congestion.
Electrocardiogram revealed AV paced at 61 beats per minute
with left axis deviation, QRS of 122 seconds to 200 seconds.
HOSPITAL COURSE: The patient is a 65-year-old male with
severe biventricular failure who was admitted with worsening
renal failure and worsening total body fluid overload thought
secondary to his worsening congestive heart failure.
The patient was initially admitted to the Medicine floor and
then subsequently he was transferred to the Coronary Care
Unit for more intensive hemodynamic monitoring and further
management.
1. CARDIOVASCULAR: The patient was continued on his current
doses of aspirin, Pravachol, and Isordil given his history of
coronary artery disease.
Given that the patient was felt to be significantly fluid
overloaded with poor cardiac output, it was recommended that
a Swan-Ganz catheter be placed and the patient to be placed
on a Milrinone drip. This was performed without
complications once the patient was transferred to the
Coronary Care Unit.
The patient was continued on Lasix which was changed to 40 mg
intravenously b.i.d., and his digoxin was held given elevated
digoxin levels, and captopril was held given his acute renal
failure.
The initial Swan-Ganz placement was performed without
difficulty and demonstrated hemodynamics as follows: Right
atrium 30 mmHg, right ventricle 80/30 mmHg, pulmonary artery
of 80/30 mmHg, wedge of 30 mmHg. Cardiac index of 1.12 with
a cardiac output of 1.9. The patient was subsequently
started on a Milrinone intravenous drip which was renally
dosed given his low creatinine clearance.
The patient continued to demonstrate elevated filling
pressures and a high wedge; however, some benefit of
Milrinone drip was seen by following mixed venous
saturations. The patient's Lasix dose was not felt to be
adequate to promote diaphoresis, and therefore he was
switched to a Lasix drip which was increased to its maximum
dose.
As the patient's blood pressure fell slightly with Milrinone,
a vasopressin was added with subsequent stabilization of his
blood pressure. Given the patient's overall fluid overload
which was not appropriately responding to Lasix therapy, a
Renal consultation was obtained to consider continuous
venovenous hemofiltration.
Over the next few days the patient did not appear to respond
to a Lasix drip with the addition of Zaroxolyn. The
medications were discontinued secondary to his lack of
urinary output. The patient's pacemaker was interrogated by
the Electrophysiology team, and his baseline heart rate was
increased to 80 in an attempt to improve his cardiac output
and cardiac index. As the patient became nearly oliguric, a
femoral vein Quinton catheter was placed, and the patient was
initiated on continuous venovenous hemofiltration.
However, over the next few hospital days, the patient's
cardiac output and cardiac index continued to decrease
despite optimal Milrinone and vasopressin therapy in addition
to continuous venovenous hemofiltration.
The poor prognosis for the patient in view of optimal medical
management was discussed with the patient as well as his
family. The patient's family reported an understanding of
the situation and reflecting on the patient's prior stated
wishes made the patient do not resuscitate/do not intubate.
The patient's subsequently passed away on the following day.
2. RENAL: The patient had a baseline chronic renal
insufficiency with a baseline creatinine of 2.1 which was
increased to 2.9 at the time of admission. A Renal
consultation was obtained at the time of admission to comment
on the appropriateness of initiating hemodialysis given the
patient's overall fluid overload state. An initial attempt
was made to diuresis the patient with a Milrinone, Lasix, and
supportive vasopressin drips; however, as these treatments
failed and the patient became nearly oliguric, a Quinton
catheter line was placed, and the patient was initiated on
continuous venovenous hemofiltration dialysis. In addition,
the patient was maintained on Phos-Lo and Amphojel given his
elevated phosphorous levels, and his electrolytes were
followed carefully on a b.i.d. basis. However, despite
adequate diuresis and hemodialysis the patient continued to
remain oliguric and continued to demonstrate a decrease in
cardiac output and index. The patient was made do not
resuscitate/do not intubate by his family and subsequently
passed away on [**3-10**].
3. PULMONARY: The patient was felt to have a questionable
left lower lobe infiltrate on chest x-ray at the time of
admission. However, the patient had no signs or symptoms
suggestive of a pneumonia on a clinical basis, and therefore
antibiotics were withheld unless the patient had an increase
in a white blood cell count of fever. The patient has a
history of sleep apnea and was continued on BiPAP at night.
The patient was also provided supplemental oxygen therapy as
needed to maintain comfort given his overall fluid overload
status.
The patient had no further pulmonary issues over the
remainder of his hospitalization.
CONDITION AT DISCHARGE: The patient was made do not
resuscitate/do not intubate following a lengthy family
discussion between the patient and the Coronary Care Unit
team on [**3-9**]. The patient subsequently passed away at
6:30 a.m. on [**3-10**]. The family was present in the room
at the time of the death, and an autopsy was refused at that
time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2104-7-23**] 16:35
T: [**2104-7-24**] 10:28
JOB#: [**Job Number 33736**]
|
[
"5849",
"2762"
] |
Admission Date: [**2124-5-13**] Discharge Date: [**2124-5-17**]
Date of Birth: [**2048-2-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 76 year old male with a history of gallstone
pancreatitis complicated by necrotizing pancreatitis and
prolonged hospital stay. He is now s/p CCY with biliary leak,
PTC drain and JP is GB fossa and pigtail drain in right flank.
He was recently D/C'd to rehab. At rehab, he was noted to have a
low grade temp to 100.7 and was hypotensive.
Past Medical History:
Severe Acute pancreatitis [**1-21**]
CAD s/p MI [**30**] years ago, HTN, hyperlipidemia, obesity, OA,
BPH, duodenal ulcer, diabetes
Atrial fibrillation
[**2124-1-21**] ECHO EF 70%
PSH: Open Tracheostomy [**2124-2-4**]; Open G/J tube placement [**2124-2-11**];
Percutaneous Cholecystostomy tube placed on [**2124-2-17**].
[**2124-4-2**] Open subtotal cholecystectomy, PTC
B TKR (most recent R TKR [**2124-1-5**])
Social History:
Retired contractor, living with 2nd wife. [**Name (NI) **] a daughter and 4
sons. Quit smoking 15 yrs. ago. No history of alcohol and
IVDU.
Family History:
Parents - hypertension
Mom - CVA
Physical Exam:
PE:
MS/NEURO: A/O
HEENT: PERRLA, EOMI
CVS: RRR
Resp: CTA-B
Abd: S/NT/ND/+BS
Ext: No. P. Edema
Inc: C/D. right sided W->D gauze packing. Two right sided flank
drains (pigtail and PTC). GJ-tube capped. soft, nontender,
nondistended.
Pertinent Results:
[**2124-5-13**] 12:45AM BLOOD WBC-10.1 RBC-3.05* Hgb-8.9* Hct-27.6*
MCV-91 MCH-29.1 MCHC-32.1 RDW-15.2 Plt Ct-263
[**2124-5-15**] 05:40AM BLOOD WBC-13.8*# RBC-2.83* Hgb-8.4* Hct-25.6*
MCV-91 MCH-29.7 MCHC-32.8 RDW-15.7* Plt Ct-229
[**2124-5-16**] 03:11AM BLOOD WBC-11.1* RBC-2.85* Hgb-8.4* Hct-25.8*
MCV-91 MCH-29.6 MCHC-32.6 RDW-15.1 Plt Ct-231
[**2124-5-13**] 12:45AM BLOOD Glucose-112* UreaN-9 Creat-0.8 Na-137
K-3.5 Cl-101 HCO3-28 AnGap-12
[**2124-5-15**] 05:40AM BLOOD Glucose-9* UreaN-12 Creat-0.7 Na-138
K-3.3 Cl-103 HCO3-24 AnGap-14
[**2124-5-16**] 03:11AM BLOOD Glucose-80 UreaN-11 Creat-0.6 Na-137
K-4.0 Cl-103 HCO3-28 AnGap-10
[**2124-5-13**] 12:45AM BLOOD ALT-11 AST-12 AlkPhos-94 TotBili-0.3
[**2124-5-16**] 03:11AM BLOOD Calcium-7.7* Phos-3.3 Mg-1.9
.
CT ABDOMEN W/CONTRAST [**2124-5-13**] 4:35 PM
IMPRESSION:
1. Big areas of increased opacity involving the lingula, right
upper lobe, and right middle lobe, which are new when compared
to prior chest CT of [**2124-3-11**] and likely represent
developing areas of infiltrate/pneumonia.
2. Multiple intra-abdominal and pelvic fluid collections as
described in detail above, which appear unchanged in size. The
largest of these involving the tail of the pancreas demonstrates
interval development of gas. The remainder are unchanged.
3. Surgical drains as described above, unchanged.
4. Moderate bilateral pleural effusions and bibasilar
atelectasis.
.
CHEST (PORTABLE AP) [**2124-5-15**] 1:15 PM
FINDINGS: In comparison with study of [**5-13**], there is little
overall change. There are again diffuse bilateral opacifications
consistent with pulmonary edema. Retrocardiac opacification most
likely represents atelectasis, though pneumonia can certainly
not be excluded.
.
[**2124-5-17**] 06:45AM BLOOD WBC-9.9 RBC-2.80* Hgb-8.3* Hct-25.5*
MCV-91 MCH-29.4 MCHC-32.4 RDW-15.7* Plt Ct-229
[**2124-5-17**] 06:45AM BLOOD Glucose-74 UreaN-11 Creat-0.7 Na-137
K-3.8 Cl-103 HCO3-29 AnGap-9
Brief Hospital Course:
This is a 76 yo male well know to the surgery service with a
history of necrotizing gallstone pancreatitis, s/p partial Open
Chole [**2124-4-2**]. He had a prolonged hospital course and prolonged
ICU stay. He had a Percutaneous Cholecystostomy tube placed on
[**2124-2-17**] and developed a Cholecystocutaneous fistula. This was
managed with PTC placement.
He was at rehab and developed fever and increased WBC.
A CT Abd showed big areas of increased opacity involving the
lingula, right upper lobe, and right middle lobe, which are new
when compared to prior chest CT of [**2124-3-11**] and likely
represent developing areas of infiltrate/pneumonia.
He was started on Levofloxacin for treatment of pneumonia. He
will complete a 14 day course.
Hypoglycemia: He received NPH and became hypoglycemic and was
somnolent. He received 1 amp of D50%. He was still somnolent and
was transferred to the ICU. The next day he was transferred back
to the floor. The NPH was D/C'd and he was managed with a
sliding scale.
Hypotension: He was hypotensive on [**2124-5-17**]. He received a 500 LR
bolus and responded appropriately. His Lopressor was D/C'd.
GI/ABD: He was tolerating a regular diet. His [**Doctor Last Name 406**] drain with
ostomy appliance was pulled. He had two drains (pigtail abscess
drain, and PTC) in the right side that were capped. The PTC
needs to remain in place and can remained capped. The pigtail
abscess drain was removed and was draining thick sero-sang,
malodorous fluid. An ostomy appliance was placed over the wound
for drainage control. The dressing will need to be changed PRN.
His GJ tube was capped.
Medications on Admission:
Amiodarone 200'', lopressor 25'',lansoprazole 40', simvastatin
40, parosetine 20, olanzapine 5', hep SC, colace, viocase,
albuterol, ipratropium, insulin NPH 35 '',
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol [**Doctor Last Name **]: One (1) Puff
Inhalation Q6H (every 6 hours).
2. Amiodarone 200 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
3. Miconazole Nitrate 2 % Powder [**Doctor Last Name **]: One (1) Appl Topical PRN
(as needed).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Doctor Last Name **]: Two (2)
Puff Inhalation QID (4 times a day).
5. Paroxetine HCl 20 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
6. Simvastatin 40 mg Tablet [**Doctor Last Name **]: 0.5 Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet [**Doctor Last Name **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Docusate Sodium 100 mg Capsule [**Doctor Last Name **]: One (1) Capsule PO BID (2
times a day).
9. Levofloxacin 500 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO Q24H (every
24 hours).
10. Senna 8.6 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO BID (2 times a
day) as needed.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Doctor Last Name **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. Viokase 16 935 mg Tablet [**Doctor Last Name **]: 1-2 Tablets PO four times a
day.
13. Terazosin 10 mg Capsule [**Doctor Last Name **]: One (1) Capsule PO at bedtime.
14. Finasteride 5 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO at bedtime.
15. Ursodiol 300 mg Capsule [**Doctor Last Name **]: One (1) Capsule PO twice a day.
16. Insulin Regular Human 100 unit/mL Solution [**Doctor Last Name **]: Sliding
Scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Month (only) 53281**] Rehabilitation & Nursing Center - [**Location (un) 28318**]
Discharge Diagnosis:
Pneumonia
Hypoglycemia
Hypotension
Discharge Condition:
Good
Discharge Instructions:
You were admitted from rehab with Pneumonia.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please note the changes made in your medications. We are
holding your lopressor and NPH. .
* Continue to increase activity daily
* No heavy lifting (>[**9-27**] lbs) for 6 weeks.
* Monitor your incision for signs of infection
* You may shower and wash. No tub baths or swimming. Keep your
incision clean and dry.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] on [**2124-6-12**]. Please arrive at
9:00am for CT scan and then see Dr. [**Last Name (STitle) 468**] at 11:15am.
Completed by:[**2124-5-17**]
|
[
"486",
"V5867",
"41401",
"4019",
"2724",
"42731",
"412",
"V1582"
] |
Admission Date: [**2153-10-3**] Discharge Date: [**2153-10-4**]
Date of Birth: [**2088-6-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / albuterol
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
AMS, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65M with PMH of paraplegia s/p C5/C7 w/ suprapubic catheter,
MRSA UTI, PE, DVT, and c. diff who presents with one day of
altered mental status and hypotension.
At [**Name (NI) 1501**], pt was noted to be feeling very tired on the morning of
[**10-3**] with his usual neck pain. The staff noticed that he was
more lethargic and had some abdominal distension. They changed
his suprapubic cath. Approx 30 min after transfering to
wheelchair, pt became unresponsive. He was returned to the bed
and became responsive again immediately, was lethargic but
answering questions appropriately, alert and oriented. VS were
afebrile, SBP 74-84/x, HR 50-60, with exam notable for distended
abdomen (nontender), possible L posterior wheeze, and thick
cloudy urine from SPT. BP did not improve with oral fluids. He
was given a dose of levaquin 750mg po.
He was sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital where he presented afebrile,
with eyes closed but answering questions. His urine was
cloudy/white. He was diagnosed with a 7mm basal ganglia bleed by
CT. He is on coumadin and was found to have a recorded INR 3.3
prior to transfer, he received 2000U profilnine iv and 500cc
fluid prior to transfer. By transfer he was awake and alert.
In the ED, his initial vital signs were 96.6 78 114/48 18 97% 2L
Nasal Cannula. The pt c/o [**4-12**] headache and was found to be
arousable by verbal stimuli. BPs ranged from 89-116/48-61. Labs
were largely unremarkable. Imaging was reviewed by neurology,
who felt there was no visible basal ganglia bleed on NCHCT. He
had received Vit K prior to this, and once CT was reread he was
started on heparin gtt to resume anticoagulation. He also
received 2L fluids, ativan, and tylenol, no antibiotics were
started. He was admitted to MICU for management of possible
urosepsis and AMS. Vital signs on transfer were 98.9 87 110/61
16 96%.
On arrival to the ICU, vitals were 113/62, 81, 11, 96%RA. He
describes this morning's incident as an episode of feeling
"funny" shortly after transfer from bed to wheelchair and then
feeling very sleepy. He complained of neck pain similar to what
he has had the last 7 years since his neck injury and headache
which he gets from time to time. He denies photophobia, vision
change. No CP, SOB, fever, chills, nausea, vomiting, or
diarrhea. He reports that for the last few months he has been
experiencing worsening fatigue and sleepiness. He has also had
dizzy spells with transfers to wheelchair on and off. Other new
symptoms over the last few months include memory loss, tremor in
hands, and SOB lying flat. His LEs have been edematous for years
since his accident. He also has redness on his sacrum.
Past Medical History:
MRSA/VRE UTI
C. Diff
Paraplegia [**1-4**] trauma at C5/C7
CVA
Acute respiratory failure [**1-4**] PE, s/p IVC filter
Chronic SFV thrombosis
Hypoxemia
PAF
GERD
Spinal stenosis
Pleural effusion
Cardiomegaly
Phimosis and balanoposthitis
HTN
Anxiety
Sacral decub
OA
groin cellulitis
chronic back pain
BPH
Psychotic disorder NOS
Social History:
Former carpenter who had accident on the job 7 yrs ago with
cervical SC injury. Married, stepson, lives in nursing home.
Former smoker - quit [**7-12**] yrs ago and used to smoke 1.5ppd x
40yrs, former heavy drinker - quit 30 yrs ago, no illicit drugs.
Family History:
Multiple cancers - mother [**Name (NI) **], GF lung, sister [**Name (NI) **], [**Name2 (NI) 39378**]
lung
Aunt with CVD
Physical Exam:
Vitals: afebrile, 113/62, 81, 11, 96%RA
General: Alert, oriented, no acute distress, appears somnolent
when not participating in conversation
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregularly irregular, nl rate, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally with decr breath sounds
at right base, no wheezes, rales, rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: SPT in place, dressed, no edema or erythema, nontender. no
penile redness or discharge
Ext: warm, well perfused, 2+ pulses, 2+ pitting edema in [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 6816**]
Neuro: CN II-XII intact, upper extremeties tremulous with action
and at rest, contractures in the hands bilaterally, increased
tone in UEs. LEs with 0/5 strength, normal sensation. Cognition
appears slow.
Skin: stage I-II sacral decub
Pertinent Results:
ADMISSION LABS
[**2153-10-3**] 05:41PM BLOOD WBC-6.2 RBC-4.42* Hgb-13.4*# Hct-40.3#
MCV-91 MCH-30.4 MCHC-33.4 RDW-15.2 Plt Ct-134*#
[**2153-10-3**] 05:41PM BLOOD PT-22.9* PTT-36.3 INR(PT)-2.1*
[**2153-10-3**] 05:41PM BLOOD Glucose-101* UreaN-18 Creat-0.5 Na-141
K-4.6 Cl-106 HCO3-33* AnGap-7*
[**2153-10-3**] 05:41PM BLOOD Calcium-8.0* Phos-3.9 Mg-2.4
[**2153-10-3**] 05:50PM BLOOD Lactate-1.1
DISCHARGE LABS
[**2153-10-4**] 04:25AM BLOOD WBC-5.5 RBC-4.26* Hgb-12.6* Hct-37.3*
MCV-88 MCH-29.5 MCHC-33.7 RDW-15.2 Plt Ct-123*
[**2153-10-4**] 09:49AM BLOOD PT-13.7* PTT-130.7* INR(PT)-1.3*
[**2153-10-4**] 04:25AM BLOOD Glucose-116* UreaN-13 Creat-0.5 Na-142
K-3.7 Cl-107 HCO3-27 AnGap-12
[**2153-10-4**] 04:25AM BLOOD ALT-14 AST-21 LD(LDH)-160 AlkPhos-58
TotBili-1.6* DirBili-0.2 IndBili-1.4
[**2153-10-4**] 04:25AM BLOOD Albumin-3.6 Calcium-8.0* Phos-2.9 Mg-2.3
MICRO
[**2153-10-3**] URINE URINE CULTURE-PENDING EMERGENCY [**Hospital1 **]
[**2153-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2153-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
IMAGING
[**10-3**] CXR:
Semi-upright portable AP view of the chest was provided.
Overlying EKG leads are present. The lungs appear clear. No
signs of pneumonia or CHF.
Cardiomediastinal silhouette is unchanged with normal heart
size, unchanged. Bony structures are intact.
IMPRESSION: Top normal heart size. Otherwise, unremarkable.
[**10-3**] CT Head (Prelim read)
FINDINGS: Examination is suboptimal due to patient motion. No
intracranial
hemorrhage, edema, mass effect, or vascular territorial infarct.
Stable
appearance of bilateral globus pallidus calcifications.
Ventricles and sulci are age appropriate. There is no shift of
the normally midline structures. Large amount of right and
small amount of left external auditory canal cerrumen. Mastoid
air cells and middle ear cavities are clear. Minimal mucosal
thickening in the ethmoid air cells. The orbits and intraconal
structures are symmetric. IMPRESSION: No acute intracranial
process. Bilateral basal ganglia calcifications.
Brief Hospital Course:
65M with PMH of paraplegia [**1-4**] trauma, recurrent UTI with SPT,
PAF, PE who presents with 1 day of lethargy and hypotension.
ACTIVE ISSUES:
1. Hypotension: Improved. Autonomic dysfunction was considered a
likely contributor given patient's paraplegia and history of
orthostasis. Urosepsis was also considered given UA (mildly
positive in setting of suprapubic catheter) and history of MRSA
and VRE UTI's. [**Hospital3 26615**] urine culture growing GNR and proteus
(no sensitivities at the time of discharge), and patient was
placed on ciprofloxacin. In addition, some of his medications
could be contributing to his low blood pressure, such as
morphine, multiple types of benzodiazepines, baclofen. Please
consider tilt table test as an outpatient to further evaluate
autonomic instability. Please follow up urine culture
sensitivities from [**Hospital3 26615**] and pending urine and blood
cultures from [**Hospital1 18**], as patient may require an antibiotic change
if he grows a resistant organism. It would be important to
simply his pain and anxiety medication regimen.
2. AMS: Improved. Although there was concern for an intracranial
bleed at OSH, CT head here was negative. Polypharmacy in the
setting of numerous sedating medications vs. infection was
determined to be the most likely etiology of AMS. As an
outpatient, please consider further taper of sedating
medications. Patient was started on ciprofloxacin as above.
3. Atrial fibrillation: Patient was maintained on telemetry. His
head CT showed no signs of intracranial bleed, and he was
restarted on his home coumadin dose. His telemetry did show
intermittent bradycardia to the low 50's and occasional pauses,
which were asymptomatic.
4. Chronic pain: Morphine sulfate SR QID was changed to Morphine
Sulfate IR QID given concern for sedation contributing to
hypotension.
CHRONIC ISSUES:
1. Paraplegia: Patient is s/p C5/C7 injury. His neurologic
examinations were stable, and he was continued on his home
muscle relaxants.
2. History of C. diff: Patient has no diarrhea at present
3. GERD: Patient was continued on omeprazole.
4. History of PE: Patient has an IVC filter and is treated with
coumadin. Coumadin was restarted as above.
6. Psychosis NOS: Patient was continued on clonazepam and Prozac
TRANSITIONAL ISSUES:
- Follow up urine culture GNR sensitivities from [**Hospital3 26615**]. If
UCx grows a resistent organism, may need to change antibiotics.
- Follow up blood and urine cultures from [**Hospital1 18**]
- Consider taper of sedating medications
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO DAILY
hold for loose stool
2. Morphine SR (MS Contin) 15 mg PO QID
hold for oversedation or RR <12
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Baclofen 10 mg PO TID
hold for oversedation or RR<12
6. UTI-Stat *NF* ([**Last Name (un) **]-vitC-D mannose-inuln-[**Last Name (un) **]) 3,875 mg/30 mL
Oral [**Hospital1 **]
7. Clonazepam 2 mg PO BID
hold for RR<12 or oversedation
8. Psyllium 1 PKT PO DAILY
hold for loose stool
9. Milk of Magnesia 30 mL PO DAILY: SUN,TUES,THURS,SAT
hold for loose stool
10. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
11. Acetaminophen 650 mg PO BID
12. Gabapentin 300 mg PO TID
hold for oversedation or RR<12
13. Ascorbic Acid 500 mg PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
15. Aripiprazole 10 mg PO DAILY
16. Lorazepam 1 mg PO TID
hold for oversedation or RR<12
17. Docusate Sodium 100 mg PO DAILY
hold for loose stools
18. Fluoxetine 20 mg PO DAILY
19. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 650 mg PO BID
2. Aripiprazole 10 mg PO DAILY
3. Ascorbic Acid 500 mg PO DAILY
4. Baclofen 10 mg PO TID
hold for oversedation or RR<12
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Clonazepam 2 mg PO BID
hold for RR<12 or oversedation
7. Ferrous Sulfate 325 mg PO DAILY
8. Fluoxetine 20 mg PO DAILY
9. Gabapentin 300 mg PO TID
hold for oversedation or RR<12
10. Lorazepam 1 mg PO TID
hold for oversedation or RR<12
11. Milk of Magnesia 30 mL PO DAILY: SUN,TUES,THURS,SAT
hold for loose stool
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Psyllium 1 PKT PO DAILY
hold for loose stool
15. Warfarin 5 mg PO DAILY16
16. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days
17. Docusate Sodium 100 mg PO DAILY
hold for loose stools
18. Morphine Sulfate IR 15 mg PO Q6H
19. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32944**] Village & Rehabilitation Center - [**Location (un) 32944**]
Discharge Diagnosis:
Hypotension
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the [**Hospital1 69**]
for low blood pressure and altered mental status. Your symptoms
were most likely due to an infection of your urine, to autonomic
dysfunction related to your paralysis, or to the medications you
take for pain (which can lower blood pressure). You were started
on an antibiotic for your urinary tract infection and your blood
pressures improved.
Followup Instructions:
Please follow up with the physician at your skilled nursing
facility.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"5990",
"42789",
"53081",
"42731",
"4019",
"V1582"
] |
Admission Date: [**2115-3-9**] Discharge Date: [**2115-3-29**]
Date of Birth: [**2056-8-4**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
with diabetes complicated by end stage renal disease on
hemodialysis, hypertension, who presents with left hip pain,
fever, hyperglycemia. Patient had left hip fracture and was
pinned at [**Hospital3 2576**] in [**1-13**]. However, subsequently since
[**2114-8-12**], patient has been complaining about pain in
her hip and for unclear reasons it increased in severity on
the day of admission. She denies any trauma or fall. She
also reports fever to 101.9 with chills without nausea at
last hemodialysis. She denies rigors, emesis, chest pain,
headache, shortness of breath, cough, sputum, abdominal pain,
recent antibiotics, back pain, vaginal or urinary symptoms.
She also reports that her finger sticks have been elevated
for the past three to four days and she complains of
polydipsia. She sleeps in a chair secondary to her hip pain,
but denies paroxysmal nocturnal dyspnea or orthopnea. She
reports increased swelling in her legs. In the emergency
department serum glucose was 663, potassium 5.9, anion gap 18
with moderate acetone in her blood. She is anuric. She was
given 10 units of insulin and started on an insulin drip and
received normal saline times 1 liter, morphine for hip pain.
Given her fever, elevated white blood cell count and left
shift, she was given vancomycin times 1 gm for presumed line
infection. Chest x-ray was performed which revealed left
pleural effusion greater than right, interstitial edema.
Patient received 2 liters of normal saline only because of
concern about volume overload.
PHYSICAL EXAMINATION: On admission temperature was 97.7,
pulse 93, blood pressure 130/40, respirations 26, 90% in room
air. In general, a middle aged female in no acute distress.
HEENT surgical right, pinpoint on left. No JVP. Mucous
membranes dry. Oropharynx clear. No lymphadenopathy. HC
catheter in right IJ, no erythema or pain. Lungs clear to
auscultation bilaterally except for decreased breath sounds
in bilateral bases. Heart regular rate and rhythm, normal
S1, S2, 3/6 systolic murmur apex. Abdomen soft,
nondistended, nontender, normoactive bowel sounds.
Extremities 3+ edema on right, right lower extremity ulcer.
Left lower extremity with warmth and redness, shortened and
externally rotated, painful to palpation. Neuro exam alert
and oriented times three, grossly nonfocal.
LABORATORY DATA: On admission CBC WBC 18.7, hematocrit 35.0,
platelets 345, 93% neutrophils, 4% lymphs, 3% monocytes, MCV
102, 3+ hypochromic, 1+ anisocytosis, 3+ macrocytosis.
Chem-7 sodium 125, potassium 5.6, chloride 85, bicarb 22, BUN
25, creatinine 2.3, sugar 646, moderate acetones, anion gap
18. Blood cultures pending. PT/INR 14.4/1.4, PTT 32.8. EKG
normal sinus rhythm at 74, normal axis and intervals, [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 6192**] in comparison with EKG on [**2112-2-5**]. T waves are
normalized from flipped in V3 to V6, 1, 2, L, F seen on old
EKG. Chest x-ray left pleural effusion greater than right,
interstitial edema, atelectasis.
HOSPITAL COURSE:
1. Endocrine. The patient was admitted with hyperosmolar
hyperglycemia. She was initially continued on an insulin
drip, was not given any additional normal saline given her
end stage renal disease. Her chem-7 was checked q.three
hours. ABG was checked which revealed pH of 7.39, PCO2 47,
PO2 100. Therefore, patient was switched to her standing
insulin regimen of Lantus in the evening with Humalog p.r.n.
during meals. Lantus was adjusted during her stay as
initially she was hyperglycemic on 13 units q.p.m. However,
she had several episodes of hypoglycemia and so Lantus was
decreased to her standing dose. When she was NPO, Lantus was
halved to 7 units. Her sugars remained stable throughout the
remaining hospital course.
2. Infectious disease. The initial blood cultures revealed
four out of four bottles of methicillin resistant staph
aureus. The presumed etiology included the left hip, line
infection, urosepsis, cellulitis, pneumonia. Patient was
continued on vanco dosed according to levels for less than 15
and was started on levofloxacin to cover for
pneumonia/cellulitis. As the left hip has hardware in it, we
were not able to obtain an MRI. CT scan of the hip was
performed, looking for signs of infection and none were seen.
However, given concern of possible joint infection, an
ultrasound was ordered to evaluate for fluid collection in
the left hip and none was visualized, so no aspiration was
performed. Blood cultures continued to show MRSA; therefore,
a transthoracic echo was performed. Patient was additionally
started on Flagyl for broad spectrum coverage given many
possible sources to cover for possible lower extremity
cellulitis. Transthoracic echo was performed on [**2115-3-13**], and revealed normal left ventricular systolic function
greater than 55%. Mitral valve moderately thickened with no
discrete vegetation, more prominent than seen on prior study
in 3/00. To rule out endocarditis, a transesophageal echo
was performed which revealed no vegetation. Given concern
about possible right IJ PermCath infection, the hemodialysis
catheter was removed on [**2115-3-16**], by the surgical line
service. Daily blood cultures continued to be obtained and
blood culture on [**3-16**] was positive for MRSA. Additionally
a blood culture on [**3-18**] was positive for MRSA. At this
point the leg cellulitis had cleared. She received a 10 day
course of levo and Flagyl for cellulitis/pneumonia which was
completed. She no longer had the hemodialysis catheter so
most likely source of the infection was felt to be the left
hip, given the indwelling hardware. Dr. [**First Name (STitle) 1022**] from
orthopaedics evaluated patient and felt that, although
surgical intervention was high risk, he agreed to do it if
everyone understood the risks. A bone scan was performed
which revealed increased uptake in the left femur, coccyx and
left mid-clavicle. As initially pain control had been the
issue, a sacral decubitus ulcer was not initially identified.
When it was seen, plastic surgery was consulted and graded
it as a stage 3 decubitus ulcer. Patient was taken to the
O.R. on [**2115-3-26**] and the pin hardware was removed. Culture
was taken of the left hip which, at the time of this
dictation, is significant for MRSA. With infectious disease
consult it was determined that patient will continue a six
week course of vancomycin from the date of pin removal to
treat her osteomyelitis. Her blood cultures remained sterile
following the [**3-18**] positive blood culture.
3. Orthopaedics. The patient was initially noted to have an
externally rotated and shortened left lower extremity.
Therefore, concern was raised about possible new hip
fracture. Initially a portable pelvis film was performed
which revealed malalignment of the femur. Orthopaedics was
consulted who initially felt there was no sign of infection
in the left hip. They recommended total hip replacement
after her acute issues of MRSA bacteremia were resolved.
However, given thorough workup for infection source as above,
it was determined that the left hip was the most probable
source of infection. Therefore, patient was brought to the
O.R. on [**2115-3-26**] by Dr. [**First Name (STitle) 1022**]. The two screws were removed.
The hip was turned into internal rotation and mild extension.
The femoral neck fracture was then separated and completed
and the femoral head was removed. Debridement was performed
of the acetabulum as well as the proximal femur. After
irrigation a drain was left in and closed in layers with PDS
and staples for the skin. Orthopaedic surgery continued to
follow patient. Plan is to return to the operating room for
complete repair of the hip once she receives the full six
week course of antibiotics to treat her osteomyelitis.
4. Renal. The patient has end stage renal disease on
hemodialysis. Renal consult was obtained. Patient continued
to receive hemodialysis q.Monday, Wednesday and Friday
initially through her right IJ hemodialysis catheter. On
[**2115-3-19**] a temporary Quinton catheter was placed in the right
femoral vein and this was accessed until it was discontinued
on [**2115-3-27**] when a left femoral tunneled catheter was placed
by interventional radiology.
5. Neuro. Pain control was difficult in this patient's
case. She was initially given morphine, but became
oversedated and on hospital day one received an injection of
Narcan for respiratory rate less than 10. Subsequently her
medications were changed. Patient was very stable on
OxyContin 40 mg p.o. b.i.d. with oxycodone for break through
pain until postoperatively when she became more confused and
delirious, thought to be secondary to the narcotics given
intraoperatively. Patient remains with tolerable pain with
this regimen. On [**2115-3-23**] patient was complaining of diplopia
and increased confusion. Emergent head CT was performed and
this was negative for bleed. Per Dr. [**Last Name (STitle) 16258**], her PCP, [**Name10 (NameIs) **]
baseline she has waxing and [**Doctor Last Name 688**] mental status which is a
chronic issue. Her finger sticks were normal. Head CT was
negative. Most likely secondary to transient bacteremia.
6. Pulmonary. Bilateral pleural effusions. Repeat chest
x-ray on [**3-24**] showed a small pleural effusion.
7. Heme. Patient with macrocytosis, normal B-12 and folate,
normal TSH. Continue to monitor. She was also noted to be
iron deficient and received iron in hemodialysis.
8. GI. The patient was continued on Protonix and given
stool regimen for narcotics. Liver function tests and
transaminases were checked and were within normal limits
except for elevated alkaline phosphatase which was felt most
likely to be secondary to bone.
[**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17144**]
Dictated By:[**Last Name (NamePattern1) 41557**]
MEDQUIST36
D: [**2115-3-29**] 11:01
T: [**2115-3-29**] 12:24
JOB#: [**Job Number 110754**]
|
[
"40391",
"486"
] |
Admission Date: [**2111-10-21**] Discharge Date: [**2111-10-27**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
s/p fall, unresponsiveness, SDH
Major Surgical or Invasive Procedure:
right craniotomy for evacuation of subdural hematoma
History of Present Illness:
86yo man with PMH significant for labile BP w/ HTN and
orthostatic hypotension presents after a fall and
unresponsiveness. He has had significant orthostasis with
multiple admissions and ED visits for fractures, and notes that
he has fallen perhaps 10 times over the past 2 weeks. He was
last admitted one month ago, at which time he had a normal HCT
and medication alteration. History per his son, he has had two
falls recently that he knows of, once yesterday and then again
today. Yesterday he refused to go to the ED after his fall. His
neighbors called him today and did not get an answer by phone,
and on arrival found him on the ground unresponsive, then
disoriented. He was brought to the ED. Here he had a HCT which
showed a large subdural hematoma with midline shift (see below).
Review of systems is notable for falls, increased drowsiness x 1
week, and some difficulty concentrating. He has also had a
headache x 2 weeks. He has no change in vision or diplopia, no
nausea, vomiting, dysphagia. His son says his neighbors have
noticed occasional strange behavior recently; for example, he
has lost weight and his pants have been falling down without him
noticing. His son is concerned about his safety at home (he
lives by himself).
Past Medical History:
autonomic instability w/ HTN to 220s but orthostatic hypotension
w/ tilt testing showing BP ddrop from 156/83 to 76/44 with tilt
s/p pacemaker placement for bradycardia and syncope [**5-/2110**]
atrial flutter s/p ablation
spinal stenosis
chronic renal insufficiency
depression
s/p cataract surgery
Social History:
lives alone, son is an endocrinologist (see below). h/o tobacco
use, no EtOH
Family History:
not elicited
Physical Exam:
Admission exam:
PE: VS: T99.6, HR 72, BP 220/104->181/94, then SBP 150s, RR 20,
SaO2 96%/RA, pain [**4-3**]
Genl: NAD, comfortable lying in bed
HEENT: cervical collar in place, MMM, OP clear
CV: RRR, nl S1, S2
Chest: CTA bilaterally anteriolaterally
Abd: soft, NTND, BS+
Ext: cool, multiple small lacerations
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. No right left
confusion. No evidence of neglect.
Cranial Nerves:
Pupils postsurgical, equally reactive to light, 2 to 1mm
bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally, no nystagmus.
Sensation intact V1-V3. 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, asterixis, or tremor. No pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF
R 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
Sensation: Intact to light touch throughout, decreased
bilaterally to vibration and proprioception. No extinction to
DSS.
Reflexes: 2+ and symmetric in BUE, 1+ in B patellae, absent
achilles. Toes downgoing bilaterally.
Coordination: finger-nose-finger normal, RAMs normal.
Discharge examination: stable, as above
Pertinent Results:
[**2111-10-26**] 04:00PM BLOOD WBC-6.3 RBC-3.76* Hgb-12.0* Hct-35.1*
MCV-93 MCH-32.0 MCHC-34.3 RDW-13.1 Plt Ct-315#
[**2111-10-24**] 07:50AM BLOOD WBC-7.6 RBC-3.44* Hgb-11.2* Hct-32.1*
MCV-94 MCH-32.5* MCHC-34.8 RDW-13.2 Plt Ct-192
[**2111-10-24**] 04:06AM BLOOD WBC-7.5 RBC-3.29* Hgb-10.6* Hct-30.6*
MCV-93 MCH-32.1* MCHC-34.6 RDW-13.2 Plt Ct-198
[**2111-10-23**] 03:25AM BLOOD WBC-8.0 RBC-3.27* Hgb-10.7* Hct-31.1*
MCV-95 MCH-32.8* MCHC-34.5 RDW-13.2 Plt Ct-219
[**2111-10-21**] 11:27AM BLOOD Neuts-80.6* Lymphs-13.2* Monos-4.7
Eos-1.3 Baso-0.1
[**2111-10-26**] 04:00PM BLOOD Plt Ct-315#
[**2111-10-26**] 04:00PM BLOOD PT-11.7 PTT-25.8 INR(PT)-1.0
[**2111-10-26**] 04:00PM BLOOD Glucose-101 UreaN-24* Creat-1.3* Na-136
K-4.9 Cl-100 HCO3-28 AnGap-13
[**2111-10-24**] 07:50AM BLOOD Glucose-107* UreaN-18 Creat-1.1 K-3.9
Cl-102 HCO3-23
[**2111-10-21**] 11:27AM BLOOD CK(CPK)-181*
[**2111-10-26**] 04:00PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3
[**2111-10-24**] 07:50AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.1
[**2111-10-26**] 04:00PM BLOOD Phenyto-7.3*
[**2111-10-24**] 07:50AM BLOOD Phenyto-4.1*
[**2111-10-22**] 02:15PM BLOOD Type-ART pO2-93 pCO2-42 pH-7.36
calTCO2-25 Base XS--1
[**2111-10-22**] 02:15PM BLOOD Glucose-163* Lactate-1.6
[**2111-10-21**] 02:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
.
.
CT HEAD W/O CONTRAST [**2111-10-21**] 11:56 AM
IMPRESSION: Heterogeneous but relatively low-attenuation
extraaxial collection, layering over the right cerebral
convexity, likely representing a subacute subdural hematoma (or
reflecting underlying profound anemia), with possible small foci
of acute hemorrhage, anteriorly. There is significant mass
effect and associated shift of the midline structures, as
described, with subfalcine and probable early uncal herniation.
No other hemorrhage is identified and there is no acute skull
fracture.
.
.
CT HEAD W/O CONTRAST [**2111-10-23**] 10:43 AM
IMPRESSION: Status post evacuation of the right frontoparietal
subdural hematoma. A small right frontal chronic collection
remains. There is moderate amount of pneumocephalus. A very
small amount of acute blood is seen just deep to the
post-surgical site as well as layering along the tentorium, the
subdural location. Continued followup is needed to document
stability of these tiny amounts of acute blood.
.
.
CT HEAD W/O CONTRAST [**2111-10-24**] 4:46 PM
IMPRESSION: Stable post-surgical changes within the right
cerebral hemisphere from evacuation of subdural hematoma. No new
foci of intracranial hemorrhage are identified.
Brief Hospital Course:
This patient was admitted on [**10-21**] to the neurosurgery service
for his procedure, done on [**10-22**]. He was prepared and consented
as per standard. His procedure (right craniotomy for evacuation
of subdural hematoma) had no intra-operative complications. The
patient tolerated the procedure well, and no drain was left in
place. His skin was closed with staples (to be removed 10 days
from the date of his surgery).
Postoperatively, the patient had difficulty with blood pressure
control (history of severe orthostatic hypotension). His blood
pressures were initially very labile while in the unit. When he
was transfered to the neuro stepdown unit, he remained mainly
hypertensive despite having started his normal antihypertensive
medications. His average SBP ranged from 170-180. Despite his
pressures, his neurological function began to improve post-op
and he was tolerating a regular diet, ambulating and had
adequate pain control. He had no new neurological issues.
On [**10-27**], he was doing well and had no further issues. His Hct
was 35. His dilantin level was therapeutic (around 10 corrected
for a low albumin), and he was discharged to rehab. He should
have his sutures removed [**11-1**] and follow up in neurology clinic
in [**4-30**] weeks with a HCT.
His antihypertensives should not be adjusted without speaking
with Dr. [**Last Name (STitle) **], his primary cardiologist: ([**Telephone/Fax (1) 15500**].
Medications on Admission:
ASA 81mg daily
metoprolol 25mg [**Hospital1 **]
lisinopril 5mg qhs
zoloft 25mg daily
midodrine 2.5mg [**Hospital1 **]
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Lisinopril 5 mg 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. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: asdir
Injection ASDIR (AS DIRECTED): 2u for FS121-160,
4u for FS161-200,
6u for FS201-240,
8u for FS241-280,
10u for FS281-320,
12u for FS>320 and notify MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Subdural hematoma
Status post right craniotomy
Discharge Condition:
Stable
Discharge Instructions:
Take medications as prescribed.
Please follow up with Dr. [**First Name (STitle) **] in several weeks and Dr.
[**Last Name (STitle) 739**] in [**4-30**] weeks. You will need to have your sutures
removed in 10 days.
Call your doctor or go to the emergency room if you have any:
- redness, swelling, or drainage of your wound
- fever or chills
- difficulty thinking, speaking, or swallowing
- loss of consciousness
- chest pain or difficulty breathing
- weakness or tingling of your extremities
- any other concerning symptoms
Followup Instructions:
You need to have your sutures removed [**11-1**]. This can be done in
the neurosurgery clinic [**Telephone/Fax (1) 1669**]. You will need to follow up
with Dr. [**Last Name (STitle) 739**] in [**4-30**] weeks with a head CT prior to the
appointment; the office will call you with an appointment.
Previously scheduled appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2111-12-1**] 2:30
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Date/Time:[**2112-5-13**] 11:45
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
|
[
"5859",
"4019"
] |
Admission Date: [**2150-6-26**] Discharge Date: [**2150-7-6**]
Date of Birth: [**2094-8-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
55 yo male with hx of hep C and EtOH abuse and active IVDU
presents to [**Hospital1 18**] ED with weakness, dizziness and maroon loose
stools.
Major Surgical or Invasive Procedure:
EGD with banding (5 bands) on [**2150-6-27**]
Upper GI endoscopy with banding of esophageal varices.
Nasogastric tube placement.
History of Present Illness:
55M with hx of hepatitis C and etoh abuse presents to [**Hospital1 18**] ED
with 2 days of weakness, dizziness, nausea and maroon loose
stools. Pt states he was in his usual state of health until two
days ago when he started feeling very dizzy, unable to walk. he
states he has fallen several times in the past few days. His po
intake has decreased [**1-22**] nausea although he states he has not
vomited. He did have emesis x 2 last week but he attributes it
to something he ate; it was nonbloody. Pt denies overuse of
NSAIDs, recent etoh use. This has never happened to him before.
.
In [**Name (NI) **], pt found to have SBP in the 90s with HR in the 100s. NG
lavage was positive for maroon blood that did not clear with
saline. He received 6L of NS and 2U PRBCs. He was given 10mg
of SQ Vitamin K. GI was consulted and he was started on
Protonix and Octreotide gtt.
Past Medical History:
- DM
- hepatitis C
- hx of right hand fx s/p surgery
- hx of hernia repair
Social History:
- uses heroin actively (last use, 2 days prior to admission)
- no etoh x 6 hrs, hx of heavy use x 2 years
- smokes a pipe
- works as a cook
Family History:
non-contributory
Physical Exam:
Exam: temp 95.6 (ax), BP 142/53, HR 100, R20, O2 100% on 2L
Gen: shivering, NAD
HEENT: MM dry, pale sclera
CV: tachy but regular, no murmurs
Chest: clear
Abd: +BS, soft, mildly distended, mildly tender in RUQ, liver
edge not palpable; spleen not palpable
Ext: warm, 2+ DP, no edema
Neuro: moving all extremities, AO x 3
Pertinent Results:
Labs on Admission: [**2150-6-26**] 02:30PM BLOOD WBC-16.6*# RBC-1.39*#
Hgb-3.5*# Hct-12.2*# MCV-87# MCH-24.8*# MCHC-28.4*# RDW-18.2*
Plt Ct-323# PT-19.8* PTT-25.4 INR(PT)-1.9* Glucose-415*
UreaN-40* Creat-1.4* Na-141 K-5.0 Cl-103 HCO3-7* AnGap-36*
ALT-22 AST-55* LD(LDH)-246 CK(CPK)-2467* AlkPhos-48 Amylase-40
TotBili-0.2 Calcium-8.3* Phos-6.0* Mg-2.8* ALT-71* AST-132*
LD(LDH)-266* CK(CPK)-1485* AlkPhos-65 TotBili-1.1
Day of Discharge: [**2150-6-28**] 08:52AM BLOOD WBC-11.4* RBC-4.09*#
Hgb-12.0*# Hct-34.1*# MCV-83 MCH-29.4 MCHC-35.2* RDW-15.4 Plt
Ct-81* Glucose-150* UreaN-34* Creat-1.0 Na-142 K-4.5 Cl-113*
HCO3-22 AnGap-12 Albumin-3.0* Calcium-8.0* Phos-2.7 Mg-2.5
ABG pO2-24* pCO2-30* pH-7.18* calTCO2-12* Base XS--17
EGD on [**2150-6-27**]:
4 cords of grade III varices were seen in the lower third of the
esophagus and middle third of esophagus. 5 bands were
successfully placed. Varices at the lower third of the esophagus
and middle third of the esophagus (ligation). Blood in fundus
and cardia.
Abdomen US [**2150-6-27**] :
1. Cirrhotic liver. Moderate amount of ascites. Gallbladder
edema with adjacent ascites. In the presence of diffuse ascites,
the significance of gallbladder edema is uncertain. Please
correlate clinically.
2. Small gallstones.
3. Two right renal cyst.
CXR [**2150-6-26**] : No evidence of pneumonia or CHF. Nasogastric tube
coiled in the distal esophagus.
KUB - [**2150-6-30**] : Ileus
Brief Hospital Course:
55 yo male with h/o Hep C, EtOH abuse, on methadone with active
IVDU who presented with UGIB and lactic acidosis.
.
1) UGIB:
EGD demonstrated 4 cords of grade III varices in lower [**12-23**] of
esophagus and a normal duodenum. 5 bands were successfully
placed. Patient then received a total of 4 units PRBCs and 1
FFP, and Hct remained stable at ~34. Patient was started on IV
protonix and octreotide gtt for 48 hours. Diet was advanced to
liquids and was transferred to the floor. While on the floor,
patient did not have any further episodes of bleeding and was
hemodynamically stable. Patient was scheduled for re-banding
procedure on [**2150-7-10**] with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 437**].
.
2) Cirrhosis and ascites:
Patient presented to the hospital with a history of EtOH abuse
and hepatitis C. Ultrasound showed evidence of cirrhosis. Labs
demonstrated undetectable HCV viral load, although patient was
HCV Antibody positive. To further evaluate etiology of
cirrhosis, patient was tested for qualitative HCV to determine
low levels of HCV, alpha 1 antitrypsin, and Hepatitis B PCR,
which were still pending as of discharge. During the admission,
patient had greatly increased ascites resulting in stomach
discomfort and nausea. For initial treatment of ascites, patient
was started on diuretic therapy on [**2150-6-29**] with spironolactone
and furosemide.
.
3) Klebsiella Bacteremia
During this admission, patient was found to have blood culture
positive for pansensitive Klebsiella and treated with
levofloxicin for 2 weeks. Patient has been afebrile for the
length of his stay and surveillance blood cultures have been
negative.
.
4) Ileus
Patient also developed an ileus on [**2150-6-30**] with greatly
distended bowel, abdominal discomfort, and shortness of breath
which resolved with enemas and NGT placement. Patient slowly
progressed from being NPO to a regular diet.
.
5) Shortness of Breath:
Patient developed acute shortness of breath during admission
secondary to bilateral PEs confirmed on CTA. Patient was
anticoagulated with IV heparin drip and then converted to
lovenox. Patient's SOB was further compounded with abdominal
distension secondary to ileus and fluid overload. Patient was
discharged with lovenox and will be converted to coumadin at
outpatient.
.
6)Lactic acidosis:
Patient's lactic acidosis was likely secondary to reduced
cardiac output in hypotension and quickly resolved after
transfer from MICU to floor.
.
7) Diabetes mellitus:
Patient presented with elevated sugars on admission which was
corrected and then remained under control with insulin sliding
scale.
.
8) Prophylaxis: PPI, pneumoboots
Medications on Admission:
methadone 30mg QD
glipizide
other DM medication (not further specified)
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*50 syringes* Refills:*2*
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Upper gastrointestinal bleed
Klebsiella bacteremia
Bilateral Pulmonary Emboli
Liver cirrhosis
.
SECONDARY:
Diabetes
Discharge Condition:
Good, patient is ambulating, tolerating oral intake, and back to
his baseline condition.
Discharge Instructions:
Please take medications as prescribed. Please seek immediate
medical attention if you develop signs of blood in stools,
vomiting with blood, light-headedness, shortness of breath, or
chest pain.
.
You were started on lovenox for a pulmonary embolism.
.
You are being discharged without your glipizide. Please see your
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**] within one week. Call him at [**Telephone/Fax (1) 2936**]. Please
continue to check your blood sugars at home and bring a log to
your primary care doctor.
Followup Instructions:
Call to schedule appointment with Dr. [**Last Name (STitle) 2903**] [**Telephone/Fax (1) 2936**] to be
seen within one week.
.
Please see Dr. [**Last Name (STitle) **] on Friday [**2150-7-10**] for a rebanding
appointment. Please call liver clinic at [**Telephone/Fax (1) 2422**] for
appointment time for rebanding.
.
Also, please call for follow-up liver clinic for within one
month of discharge. Liver center phone number is [**Telephone/Fax (1) 2422**].
-- Hepatitis C viral load (qualitative) is pending
-- alpha anti-trypsin Ab is pending
.
|
[
"2851",
"5849",
"2762",
"25000"
] |
Admission Date: [**2180-1-24**] Discharge Date: [**2180-1-26**]
Date of Birth: [**2100-11-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
nausea, melena, fatigue
Major Surgical or Invasive Procedure:
cardiac catheterization
upper endoscopy
History of Present Illness:
79 y/o male w/ h/o DM2, HTN, high chol, CAD s/p RCA stent who
presented to OSH c/o melena and overwhelming fatigue. Found to
have STE's in inferior leads and coffee grounds by NG wash. He
was transferred to [**Hospital1 18**] emergently for cath.
Past Medical History:
DM2
HTN
hyperlipidemia
CAD
Social History:
lives with wife
Physical Exam:
T 98.0 BP 80/58 HR 90s RR 20 93% on AC vent
Intubated, sedated
Neck without JVD
Tachycardiac with regular rhythm, normal s1s2, no mrg
Lungs b/l basilar rales
Abdomen soft nt nd nabs
Extremities cool, trace edema
Pertinent Results:
Cardiac Cath:
1. Selective coronary angiography demonstrated two vessel
coronary artery disease in this right dominant circulation with
anomalous LCX origin. The LAD had 80% disease in the distal
vessel. The
D1 was without flow limiting disease. The LCX had an anomalous
origin
from the right cusp and was a small vessel with moderate diffuse
disease. The RCA was a large dominant artery that was totally
occluded
proximally. A previously placed stent was present in the
proximal RCA.
2. Resting hemodynamics from a right heart catheterization while
on
positive pressure ventilation demonstrated elevated right and
left sided
filling pressures with RVEDP=19mmHg and mean PCWP=27mmHg.
Cardiac output
and index were 6.1 L/min and 3.4 L/min/m2 respectively.
3. The patient had an episode of VT that degenerated into VF
requiring
cardioversion with 360J. Lidocaine and amiodarone were
administered.
4. PCI with hepacoat stents in the RCA. From distal to proximal
3.5x18mm, 3.5x33mm, 3.5x33mm, all Hepacoats (See PTCA comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Acute inferior ST elevation myocardial infarction with right
ventricular involvement.
3. Elevated right and left sided filling pressures.
4. VT and VF requiring DC cardioversion.
5. Primary PCI of the RCA with three overlapping Hepacoat
stents.
Brief Hospital Course:
Pt was admitted and found again to have STEMI in inferior leads
with CK in 4000's. He had a NG lavage in the ED which showed
coffee ground that cleared but had an associated Hct drop. He
was taken emergently to cath where he received stents to the
RCA. PCI was complicated by V tach/V fib which responded to
defibrillation. Upon arrival to the unit pt had an episode of v
tach which spontaneously resolved. An upper endoscopy showed a
duodenal ulcer with adherent clot. Epinephrine was injected and
surgery was consulted but he was found not to be appropriate for
surgery. On the day after admission he developed an acute
arrythmia and died.
Medications on Admission:
ibuprophen
Discharge Medications:
N/A
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2180-1-30**]
|
[
"2762",
"5849",
"41401",
"2720",
"4019",
"25000"
] |
Admission Date: [**2150-1-3**] Discharge Date: [**2150-2-7**]
Date of Birth: [**2069-1-30**] Sex: M
Service: SURGERY
Allergies:
Plavix
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Free air
Major Surgical or Invasive Procedure:
Trach and peg
History of Present Illness:
Mr. [**Known lastname **] is an 80 yo M with treatment refractory ITP on
long-term high dose steroids s/p lap splenectomy on [**2149-12-24**],
discharged to home on [**2149-12-28**]. The next day, his visiting nurse
noted that he was unable to rise from the couch. He presented to
[**Hospital3 **] ED and was diagnosed with steroid induced
myopathy and discharged to a rehab facility. At that rehab, he
had a KUB showing an ileus. He then represented to [**Hospital3 **] last night with marked abdominal distention. Repeat
imaging at that time showed free air on CXR and he had a CT
which
showed a large amount of free air, small fluid collection in
LLQ,
marked bowel distention ? SBO vs ileus, and RLL PNA. He was
started on vanc/cipro/flagyl and a surgery consult was obtained.
The surgeons at the outside hospital recommended transfer back
to
[**Hospital1 18**] for management under the patient's recent surgeon at
[**Hospital1 18**],
Dr. [**First Name (STitle) 2819**].
Past Medical History:
PMH:
ITP
A-Fib
CAD-EF 35%
Bullous dermatitis
HTN
Hyperlipidemia, BPH
macular degeneration, degenerative joint disease
Perineal abscess s/p ID
Hyperglycemia 2nd to steroids
PSH:
RCA stent [**2146**]
Hernia repair
Social History:
SH: Live with brother, never married, no children, +tobacco in
20's quite, occasion EtOH, no drugs
Family History:
FH: CAD
Physical Exam:
[**2150-2-2**] 07:04 AM
Vital signs
Tmax: 37.4 ??????C (99.4 ??????F)
T current: 36.4 ??????C (97.6 ??????F)
HR: 83 (83 - 98) bpm
BP: 135/62(90) {135/62(90) - 170/78(115)} mmHg
RR: 15 (14 - 27) insp/min
SPO2: 91%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 97.9 kg (admission): 89 kg
CVP: 9 (1 - 10) mmHg
Total In:
2,080 mL
483 mL
Tube feeding: 960 mL/ 273 mL
IV Fluid: 600 mL/ 50 mL
Total out:
2,355 mL
745 mL
Urine:
2,355 mL
745 mL
Balance:
-275 mL
-262 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 729 (553 - 865) mL
PS : 5 cmH2O
RR (Set): 8
RR (Spontaneous): 13
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 19
PIP: 11 cmH2O
SPO2: 91%
ABG: 7.45/35/91.[**Numeric Identifier 71132**]/27/0
Ve: 9.7 L/min
PaO2 / FiO2: 230
Physical Examination
General Appearance: Cachectic
HEENT: PERRL
Cardiovascular: (Rhythm: Irregular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous : bilateral)
Abdominal: Soft, Bowel sounds present, Tender: Upper quadrants,
Mild distension
Left Extremities: (Edema: 3+), (Temperature: Warm)
Right Extremities: (Edema: 3+), (Temperature: Warm)
Skin: (Incision: Erythema)
Neurologic: (Responds to: Tactile stimuli, Noxious stimuli)
Brief Hospital Course:
Pt is an 80 Y M with ITP on steroids who had un uncomplicated
lap splenectomy on [**12-24**] who was readmitted on [**12-28**] to OSH for
what was thought to be steroid induced myopathy. Readmitted to
[**Hospital1 18**] on [**1-2**] from OSH for abd distention. Imaging at that time
showed free air on CXR and he had a CT which showed a large
amount of free air, small fluid collection in LLQ, Treated for
diverticulitis with bowel rest and NPO. Pt was transfered to
the TICU for resp distress, and subsequent B/L aspergillus PNA,
VRE, ATN and acute renal failure, possible PE, most recently a
retroperitoneal hematoma.
.
Events:
.
[**12-24**] readmitted with diverticulitis,
[**1-8**] CTA chest: No PE. likely a predominantly right upper lobe
pneumonia, CXR: the pre-existing right upper lobe pneumonia
markedly decreased
- doing well. A&O. on 4L NC, sats in high 90s. gentle
diuresis. lasix 20mg once. hct 28-->26-->25-->24. GI consult:
possible infected diverticuli with perf with 2ndary partial SBO
or ischemic colon with perf. no emergent intervention/scope at
this time. conservative treatment with hydration and IV abx,
serial hcts. this AM, pt started to have increased WOB and
tachypnea. another lasix 20mg. pt improved. febrile to 101. pan
cx. APAP PR. s/p splenectomy and chronic steroids thus with
increased risk of infections. last night febrile to 101. APAP
PR. pan cx. primary team wants to consider adding fluconzole
and ID consult. currently on Vanc/Zosyn, to cover HAP and
diverticulitis.
[**1-9**] Fluconazole added, d/w ID. ID also recommended consider add
cipro if continues to spike fevers for double gram neg coverage.
[**1-9**] HCT dropped slightly at noon to 23.6 from 24.6, but was
stable for 9 hours at 23.0. Had another episode of blood per
rectum (red/maroon/clot) at 10pm. Repeat HCT to be checked at
2am.
[**1-10**] 2am HCT drop again to 21.7 w/another bloody/marroon BM,
given dropping hct and active bleeding, transfused x1units
PRBCs, electrolyte abnormalities suggested labs drawn from PICC
contaminated by TPN. Repeat HCT stable at 23.7. Pt intubated for
respiratory distress. Another maroon colored stool, hct stable,
INR 1.5. Bronchoscopy showing purulent fluid in RUL and LLL and
LUL/lingula.
[**1-11**]: started runs of [**7-6**] beats of vtach --> cont vtach. BP
stable. ECG, electrolytes, trops. lidocaine 100mg, Mag 2gms,
lidocaine 100mg, midazolam 2mg, percedex gtt, back on AC on
vent.
[**1-12**] lasix 20mg overnight, to diurese to even. Net -91cc.
[**1-13**]: Febrile in AM, pancx, NGT placed and TF started, failed
decrease in PSV, unable to wean
[**1-14**]: aline. PM Hct 25.3. CT torso per primary team. failed wean
overnight. CT torso: Multiple lower abdominal pelvic air and
fluid collections appear somewhat more organized and slightly
smaller than prior exam. Left lower lobe pneumonia, new since
prior exam.
[**1-15**]: failed weaning
[**1-15**]: ID consult: see below for recs
[**1-16**]: Started Voriconazole, CT chest worse, CT head done (WNL),
unable to wean off vent, needed to increase PSV, HCP consented
for trach/peg in future
[**1-17**]: spiked to 102.1. pan cx. requiring increased vent
support. d/c'd fluconazole. tracheal asp sent for PCP. 2 doses
of lasix to keep him even. minimal output, increased Cr.
intermittent runs of V-tach. BPs stable. today: trach bedside,
peg by IR.
[**1-18**] attempted PICC line placement, but failed. Placed L IJ for
access.
[**1-18**] Bcx from [**1-17**] grew out GPCs in pairs and short chains.
[**1-19**] bedside trach/peg converted to open trach/peg in OR, +VRE,
antibiotics changed, increasing Cr, hypotensive --> neo gtt
started, mixed respiratory and metabolic acidosis unresponsive
to vent changes and cis gtt. bicarb gtt started. hcp passed
away.
[**1-20**]: dead space 74%. started on heparin gtt for persumed PE. no
read on LE U/S. trach with cuff leak. Hct this AM 22. transfused
1 unit. TTE: RV mod dilated, mod [**Last Name (LF) 71133**], [**First Name3 (LF) **] > 55%. UOP improving
slightly, but Cr and lytes worsening. legionella/norcadia urine
Ag neg, Cx pending. increased fats and decreased Dex in TPN.
residuals in the 300s. TFs stopped. reglan given. family meeting
on thursday 1pm with brother.
[**1-21**]: 2 units PRBC for Hct 22. Renal C/s for volume overload,
ATN
[**1-22**]: HD catheter placed, cosyntropin test (initial cortisol
WNL, but poor response to test), started hydrocort 100 IV TID,
TPN stopped, plan to advance TFs, family mtg - DNR/DNI. no CPR,
no shock, no HD, no vasopressors. continue current medical
mgmt, DC coumadin.
[**1-23**]: had another large maroon BM. stat hct 23.3. no change in
mgmnt. TFs held again [**12-30**] high residuals. per ID, d/c'd cipro.
[**1-24**] Transfused 2u PRBc w/ bump from 23.7 to 26.4. Put back on
PSV, tolerating well.
[**1-26**]: Switched to SIMV, Prednisone taper started
[**1-27**] family meeting, continue DNR (no shocks, no compression), no
dialysis, no escalation of care, but continue w/treatment/
abx/medications.
[**1-29**]: resolved metabolic acidosis with normal ABG, family
meeting: no change in care plan.
[**1-30**] stopped heparin given HCT drop and bleeding from PEG site,
CT-torso showed large abdominal ?retroperitoneal bleed. CT-chest
w/ worsening ground-glass opacities/consolidation.
[**2-2**]: US: superficial DVT in cepahlic vein RUE noted
.
Current assessment and Plan:
NEURO: Declined when became azetemic, BUN was up to 170. As his
renal function improved making eye contuct moving extremities,
no priary neurological event
Currently: Mental status poor despite minimal sedation, mild
improvement with resolving uremia. HD CT [**1-16**] neg. Neuro checks
Q4H, Intermittent Haldol/Dilaudid for agitation/pain control.
.
CV: During his VRE bacteremia, hypotensive and requred -pressor
during his course, but as his infection improved he has been
normo tensive and now needs home BP medicaiton. 75 TID of
lopressor tolerating well. Quite a bit of ectomy with runs of
VTACH no hymodynamic instibiliti. He is DNR so if he goes into
lethal run can ot convert out. Was treated with lidocaine.
Currently: Pt has Chronic a-fib - rate controlled with lopressor
increased to 37.5 PO TID, continues to have ectopy and short
runs of VTAC, but remains hemodynamically stable. Holding off on
anticoagulation due to slow drop in Hct
.
PULM: Aspirgillis pneumonia with vorticonizol, On PO fluconazole
which is not neurotoxic. Tached in the OR, remained ventilator
dependent. Currnently:
-Possible PE based on TTE [**1-20**]: RV mod dilated, mod [**Month/Year (2) 71133**]. 75%
calculated dead space. Heparin stopped [**1-30**] due to HCT drop,
active bleeding from PEG site and CT showing retroperitoneal
hematoma.
-Respiratory failure - s/p trach. Daily CXRs. On CPAP 5/5. ABGs
improving. Oxygenating well. Although CT chest on [**1-30**] read as
worsening infection, will continue to assess clinically.
-HAP/VAP: treating with Voriconazole (day 16-on [**1-31**]) for
aspergillius PNA
-Most recent sputum cultures from [**1-31**] and [**2-3**] showed yeast
with gpc which were c/w commensal flora. They were not
enterococcus.
.
GI: During his course pt recieved a PEG and now is on tube
feeds. Currently:
- Abd intermittently diffusely tender as pt occasionally
grimaces to exam. Could be [**12-30**] retroperitoneal hematoma (no
evidence of diverticulitis from CT [**1-30**])
- TFs restarted and tolerating at goal, flexiseal for stool
management, C diff negative so far.
.
RENAL:
-Resolving ARF/ATN with Cr normalizing though pt is uremic
despite adequate urine output, still w/anasarca, grossly volume
overloaded. no dialysis per family mtg. His renal failure has
resolved with his creatinine down to 1.1. Over the last few
days his sodium had increased to 153 but this has improved with
D5W running at 100cc/hr.
HEME:
- Possible PE: Heparin gtt stopped [**12-30**] HCT drop and bleeding.
- Anemia: HCT slowly dropping, checking seral HCT [**Hospital1 **] and
transfusing when clinically indicated. Stool currently brown
though heme positive in past.
.
ENDO: RISS. Restarted steroids; Now on pre-splenectomy
prednisone PO dose.
.
ID: .
-PNA: BAL [**1-15**]: Aspergillus: On Voriconazole (day 16, [**1-31**]).
CT-Chest on [**1-30**] worsening infection, ? radiologic lag vs
evolving infection.
-Bacteremia: BCx [**1-19**] Negative, Surveillance culture [**1-27**] still
NGTD. Blood Cx: [**1-17**] VRE, treated with linezolid for 14 days,
stopped on [**2-1**]. Testing for legionella, PCP, [**Name10 (NameIs) 13607**], all
negative. Continue to f/u BCx.
-ID recs repeat B-glucan/galactomanan to assess treatment.
Voriconazole level 6.78 (therapeutic).
-From [**1-29**] to the 10th he had a rising white count from 10 to
19. He had completed his two week course of linezolid for the
VRE in his blood. However given the gpc in his sputum the
linezolid was continued. It should be continued for another 10
days. He his count has come back down to 15 from 19 and he has
been afebrile during this time.
Medications on Admission:
warfarin 2.5 alternating with 1.5 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd, proscar 5
qd, lasix 40 qd, lantus 7 units qPM, RISS, isosorbide
mononitrate
90 qd, lactinex two pills [**Hospital1 **], toprol XL 50 qd, prednisone 40 qd
(recently reduced from 50 qd), zocor 40 qd, prednisone forte eye
drops one drop OD qd, Vit B3 [**Numeric Identifier 1871**] qweek, MVI qd, dulcolax &
colase qd
Discharge Medications:
1. Prednisolone Acetate 1 % Drops, Suspension [**Numeric Identifier **]: One (1) Drop
Ophthalmic DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid [**Numeric Identifier **]: One (1) PO BID (2
times a day).
3. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Numeric Identifier **]:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
4. Voriconazole 200 mg Tablet [**Numeric Identifier **]: 1.5 Tablets PO Q12H (every 12
hours).
5. Prednisone 20 mg Tablet [**Numeric Identifier **]: 1.5 Tablet PO DAILY (Daily).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID
(3 times a day).
9. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Haloperidol 1-2 mg IV Q4H:PRN agitation
11. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain
12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
13. Linezolid 600mg iv q12
14. Albuterol Inhaler 6 PUFF IH Q4H:PRN wheezing
15. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
intubated
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,
AIRWAY CLEARANCE, COUGH), ACIDOSIS, METABOLIC, .H/O
GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,
GIB), VENTRICULAR PREMATURE BEATS (VPB, VPC, PVC), RESPIRATORY
FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name **]), ALTERED MENTAL STATUS (NOT
DELIRIUM), [**Last Name **] PROBLEM - ENTER DESCRIPTION IN COMMENTS,
IMPAIRED SKIN INTEGRITY, CARDIOMYOPATHY, OTHER, PNEUMONIA,
OTHER, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),
DIVERTICULITIS
Neurologic: Mental status poor despite minimal sedation, mild
improvement with resolving uremia. HD CT [**1-16**] neg. Neuro checks
Q4H, Intermittent Haldol/Dilaudid for agitation/pain control.
Add Tylenol, wean dilaudid as tolerated
Cardiovascular: Chronic a-fib - rate controlled with lopressor
increased to 50 PO TID advance to 75 TID, continues to have
ectopy and short runs of VTAC, but remains hemodynamically
stable.
Pulmonary: Trach, (Ventilator mode: CPAP + PS), Possible PE
based on TTE [**1-20**]: RV mod dilated, mod [**Month/Year (2) 71133**]. 75% calculated dead
space. Heparin stopped [**1-30**] due to HCT drop, active bleeding from
PEG site and CT showing retroperitoneal hematoma.
-Respiratory failure - s/p trach. Daily CXRs. On CPAP 5/5. ABGs
improving. Oxygenating well. Although CT chest on [**1-30**] read as
worsening infection, will continue to assess clinically.
-HAP/VAP: treating with Voriconazole (day 16-on [**1-31**]) for
aspergillius PNA
Gastrointestinal / Abdomen: Abd soft,
- TFs restarted and tolerating at goal, flexiseal for stool
management, C diff negative
Nutrition: Tube feeding
Renal: Foley, -Resolving ARF/ATN with Cr normalizing though pt
is uremic despite adequate urine output, still w/anasarca,
grossly volume overloaded. no dialysis per family mtg. [**Month (only) 116**] need
some hydration with elevated BUN and serum Sodium and creatinine
is almost reached baseline.
Hematology: - stable anemia. 1 unit for Hct=22
- Anemia: HCT slowly dropping, checking seral HCT [**Hospital1 **] and
transfusing when clinically indicated. Stool currently brown
though heme positive in past.
Endocrine: RISS, RISS. Restarted steroids; Now on
pre-splenectomy prednisone PO dose.
Infectious Disease: -PNA: BAL [**1-15**]: Aspergillus: On Voriconazole
(day 16, [**1-31**]). CT-Chest on [**1-30**] worsening infection, ? radiologic
lag vs evolving infection.
-Bacteremia: BCx [**1-19**] Negative, Surveillance culture [**1-27**] still
NGTD. Blood Cx: [**1-17**] VRE, treated with linezolid for 14 days,
stopped on [**2-1**]. Testing for legionella, PCP, [**Name10 (NameIs) 13607**], all
negative. Continue to f/u BCx.
-ID recs repeat B-glucan/galactomanan to assess treatment.
Voriconazole level 6.78 (therapeutic).
.
Wound: Stage 1-2 wound. wound care per nursing.
Lines / Tubes / Drains: Trach, PEG, Foley, right axillary
a-line, LIJ CVL
Wounds:
Imaging:
Fluids: KVO
Consults: General surgery, ID dept
Billing Diagnosis: (Respiratory distress: Failure), Post-op
hypotension, Acute renal failure
Discharge Condition:
Poor
Discharge Instructions:
N: Follow mental status
CV: beta-blockade for rate controlled afib and runs of v-tach.
Resp: Vent - currently requiring minimal support, wean to trach
collar, 2 weeks linezolid for gpc in sputum. Airway and mouth
care.
GI: NovaSource Renal (Full) - [**2150-1-31**] 06:13 PM 40 mL/hour
GU: renal failure resolved, watch creatinine
Glycemic Control: Regular insulin sliding scale
Heme: no anticoagulation for afib secondary to retroperitoneal
hematoma.
ID: prolonged voriconzole and 10 days of linezolid.
Lines:
Multi Lumen - [**2150-1-18**] 06:30 PM
Arterial Line - [**2150-1-19**] 06:09 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Code status: DNR (do not resuscitate)
Followup Instructions:
Follow with Dr. [**First Name (STitle) 2819**] in 3 weeks. Office number ([**Telephone/Fax (1) 10058**]
Completed by:[**2150-2-7**]
|
[
"486",
"5845",
"51881",
"2760",
"99592",
"41401",
"4019",
"42731",
"4280",
"V4582",
"4168",
"V5861"
] |
Admission Date: [**2126-1-11**] Discharge Date: [**2126-1-15**]
Date of Birth: [**2062-6-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2126-1-11**] Coronary artery bypass grafting x4, left internal
mammary artery to left anterior descending coronary artery;
reverse saphenous vein single graft from [**Month/Day/Year 5236**] to first
diagonal coronary artery; reverse saphenous vein single graft
from [**Month/Day/Year 5236**] to the distal right coronary artery; reverse
saphenous vein single graft from [**Month/Day/Year 5236**] to posterior descending
coronary artery.
History of Present Illness:
63M with multiple cardiac risk factors who has experienced DOE x
6 months and recently developed exertional chest discomfort.
Stress test was abnormal and he was referred for cardiac cath
which revealed two vessel coronary artery disease. Surgical
evaluation is requested.
Past Medical History:
Type 2 DM
HTN
Hypercholesterolemia
Osteoarthritis
Past Surgical History
Colon Polypectomy
eye surgery x 2
appendectomy
cholecystectomy
Social History:
Race: Caucasian
Last Dental Exam: 4 months ago
Lives with: wife, has 3 grown children
Occupation: semi-retired,teaches at [**Location (un) **] of So [**State 1727**]
Tobacco: never
ETOH: 1/month
Family History:
Mother with onset of CAD in her 40's, s/p CABG twice. Daughter
diagnosed with hypercholesterolemia at age 5. Brother had MI at
the age of 49
Physical Exam:
Pulse: 69 Resp: 17 O2 sat: 97%RA
B/P Right: Left: 142/56
Height: 5'[**24**]" Weight: 113.4
General: NAD, WGWN, overweight white male, appears stated age
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 x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2126-1-15**] 05:30AM BLOOD WBC-13.9* RBC-4.28* Hgb-8.8* Hct-27.8*
MCV-65* MCH-20.5* MCHC-31.6 RDW-17.2* Plt Ct-163
[**2126-1-11**] 11:35AM BLOOD WBC-18.0* RBC-4.01* Hgb-8.2* Hct-24.9*
MCV-62* MCH-20.5* MCHC-32.9 RDW-16.0* Plt Ct-171
[**2126-1-15**] 05:30AM BLOOD Glucose-117* UreaN-49* Creat-0.8 Na-137
K-4.6 Cl-102 HCO3-26 AnGap-14
[**2126-1-11**] 12:51PM BLOOD UreaN-21* Creat-0.8 Na-142 K-3.9 Cl-109*
HCO3-26 AnGap-11
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 41633**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 41634**] (Complete)
Done [**2126-1-11**] at 10:26:17 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2062-6-29**]
Age (years): 63 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG
ICD-9 Codes: 786.05, 786.51, 424.0
Test Information
Date/Time: [**2126-1-11**] at 10:26 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine: us1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV systolic function.
[**Last Name (NamePattern4) **]: Normal ascending [**Last Name (NamePattern4) 5236**] diameter. Mildly dilated
descending [**Last Name (NamePattern4) 5236**]. Simple atheroma in descending [**Last Name (NamePattern4) 5236**].
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
to moderate ([**11-25**]+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
with normal free wall contractility.
The descending thoracic [**Month/Day (2) 5236**] is mildly dilated.
There are simple atheroma in the descending thoracic [**Month/Day (2) 5236**].
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are moderately thickened. Mild to moderate ([**11-25**]+)
mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is A-Paced, on no inotropes.
Preserved biventricular systolic fxn. No AI. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 18350**]t.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2126-1-12**] 11:17
?????? [**2117**] CareGroup IS. All rights reserved.
Brief Hospital Course:
[**2126-1-11**] Mr.[**Known lastname **] was taken to the operating room and underwent
Coronary artery bypass grafting x4, left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein single graft from [**Known lastname 5236**] to first diagonal
coronary artery/rsvg from [**Known lastname 5236**] to the distal right coronary
artery/rsvg from [**Known lastname 5236**] to posterior descending coronary artery
with Dr.[**Last Name (STitle) 914**]. Please see operative report for further
details. Cardiopulmonary Bypass time=89 minutes. Cross Clamp
time=72 minutes. Pt tolerated the procedure well and was
transferred to the CVICU intubated and sedated. He awoke
neurologically intact and was extubated without incident. All
lines and drains were discontinued in a timely fashion.
Beta-blocker/Statin/Aspirin and diuresis were initiated. POD#1
he was transferred to the step down unit for further monitoring.
Physical Therapy was consulted for evaluation of strength and
mobility. He continued to progress and the remainder of his
hospital course was essentially uneventful. ON POD# 4 he was
cleared by Dr.[**Last Name (STitle) 914**] for discharge to home. All follow up
appointments were advised.
Medications on Admission:
Medications - Prescription
EZETIMIBE-SIMVASTATIN [VYTORIN [**8-/2095**]] - 10 mg-80 mg Tablet - 1
Tablet(s) by mouth daily
INSULIN ASP PRT-INSULIN ASPART [NOVOLOG MIX 70-30] -
(Prescribed
by Other Provider) - 100 unit/mL (70-30) Solution - 56 units
twice a day SQ
LISINOPRIL-HYDROCHLOROTHIAZIDE - 20 mg-25 mg Tablet - 1
Tablet(s)
by mouth daily
METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet -
1
Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth daily
PREDNISONE - 20 mg Tablet - 2 Tablet(s) by mouth twice a day
[**12-13**]
pm and [**12-14**] am (**prophylaxis in setting of shellfish allergy**)
SITAGLIPTIN [JANUVIA] - 100 mg Tablet - 1 Tablet(s) by mouth
daily
Medications - OTC
ACETAMINOPHEN [ACETAMINOPHEN EXTRA STRENGTH] - (OTC) - 500 mg
Tablet - 2 (Two) Tablet(s) by mouth twice a day PRN
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth daily
BLOOD SUGAR DIAGNOSTIC - Strip - as directed twice daily
DIPHENHYDRAMINE HCL - (OTC) - 25 mg Capsule - 2 (Two)
Capsule(s)
by mouth at bedtime PM [**12-13**] pre cardiac cath
RANITIDINE HCL - (OTC) - 75 mg Tablet - 2 (Two) Tablet(s) by
mouth twice a day [**12-13**] PM and [**12-14**] am pre cardiac cath
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
10. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO DAILY (Daily) for 10
days.
Disp:*10 Tablet, ER Particles/Crystals(s)* Refills:*0*
11. insulin aspart 100 unit/mL Cartridge Sig: One (1)
Subcutaneous ACHS: per Sliding scale.
Disp:*qs * Refills:*2*
12. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO once a day:
resume preop regimen.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
coronary artery disease
s/p CABG x4
secondary:
Type 2 DM
HTN
Hypercholesterolemia
Osteoarthritis
Past Surgical History
Colon Polypectomy
eye surgery x 2
appendectomy
cholecystectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema 1+
(B)
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2126-1-29**] at 1:00 pm
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2126-2-12**] at 9:20
Cardiologist:
Please call to schedule appointments in [**11-25**] weeks with your
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**]
**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:[**2126-1-15**]
|
[
"41401",
"4019",
"25000",
"2720"
] |
Admission Date: [**2193-9-14**] Discharge Date: [**2193-10-2**]
Date of Birth: [**2131-3-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 7835**]
Chief Complaint:
Found down [**2193-9-12**]
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
62 yo M h/o hep C (stable in remission), depression/psych dz on
Effexor, Risperdal, Wellbutrin, Sertraline, Remeron, and
methylphenidate, DM on insulin found unconscious on the ground
at 10am of [**2193-9-12**]. Paramedics noted GTC seizure activity and
intubated him in the field for airway protection. Mother spoke
to him night before, said he sounded normal, but unknown how
long he had been lying on the floor. Admission VS included low
grade temp, pulse 109, BP 127/73. Potassium 5.8, Bicarb 16, BUN
49, Cr 4, glucose 324, latate 5, WBC 17. ABG: 7.33/36/312/18.
U/A showed 1000 glucose, 10 ketones, 35 red cells, 10 white,
hyaline casts, 100 prot. Head CT with no acute process. CXR
showed LLL atelectasis/infiltrate.
.
The pt was admitted to [**First Name4 (NamePattern1) 487**] [**Hospital3 91711**] ICU and was given IVF,
Zozyn, and Vanc. Neurology c/s noted that hyperglycemic
acidosis, metabolic derangements, & mult psych meds could have
precipitated seizure/obtundation. Also, couldn't r/o stroke.
Started on phenytoin, asa, EEG unhelpful, MRI when stable.
Patient started to improve and was extubated but never recovered
basline mental status. CXR's no acute process/infiltrate. Renal
fxn improved, Cr 3.2 from 4, CK down from 58,000 to 31,000.
Renal US showed no hydro/stones. liver with fatty infiltration.
.
26 hours later around noon [**2193-9-13**], patient spiked fever to 103,
persisting, ID worried about encephalitis/meningitis, started
empirically on acyclovir/ctx/vanc, with new bld cx. previous
blc/urine cx ngtd. LP not performed.
.
Today [**9-14**], fevers persist and pt noted to be stiff throughout,
increased ms [**Last Name (Titles) **], diaphretic/tachy to low 100s, hypertensive w
SBP 150-160s, tachypneic in 20s, satting at 95% on 60%mask. CPK
began to rise again to 47,000, ? neuroleptic malignant syn -->
started on baclofen. LFTs with high AST>>ALT c/w rhabdo. Uric
acid 16.1 --> 10.9. Last lactate 2.6. Prior to transfer to
[**Hospital1 18**], pt 102.6(was on cooling blanket), 146/55, 77, 17, 95% FM
@ 60%. Sustained good UOP. CXR clear today but limited study.
.
On arrival to the [**Hospital Unit Name 153**], patient remains somnelent/obtunded,
opens eyes initially to his name but unable to stay open, unable
to follow any commands. VS detailed below.
Past Medical History:
HTN
Hep C (in remission)
depresion
GERD
?suicidality
degenerative disk dz
s/p L shoulder [**Doctor First Name **]
s/p card cath at least 5 years ago, negative according to
sister.
Social History:
Air Force veteran, lives w mom, sister helps to take care of
him, takes him out shopping, hx of tobacco abuse but quit. h/o
alcohol abuse per sister.
Family History:
non contributory
Physical Exam:
On Admission
Vitals: 101.4, 86 152/81 24 94% on 4LNC
General: somnelent, obtunded
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: no JVD, LAD, stiff neck but unclear if generalized
Lungs: CTAB
CV: RRR, no murmurs
Abdomen: soft, obese
GU: draining clear brownish urine.
Ext: no edema, very stiff
Neuro: opens eyes briefly to name, retracts to pain, unable to
follow instructions, moving all extrem spontaneously, very stiff
extremities, lower > upper.
Pertinent Results:
On Admission:
[**2193-9-14**] 01:59PM WBC-17.6* RBC-4.37* HGB-12.6* HCT-36.0*
MCV-82 MCH-28.9 MCHC-35.0 RDW-16.2*
[**2193-9-14**] 01:59PM NEUTS-65.9 LYMPHS-24.2 MONOS-8.9 EOS-0.3
BASOS-0.7
[**2193-9-14**] 01:59PM PT-17.6* PTT-24.9 INR(PT)-1.6*
[**2193-9-14**] 01:59PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2193-9-14**] 01:59PM VANCO-<1.7*
[**2193-9-14**] 01:59PM TSH-0.36
[**2193-9-14**] 01:59PM CALCIUM-7.2* PHOSPHATE-4.2 MAGNESIUM-1.4*
URIC ACID-10.6*
[**2193-9-14**] 01:59PM CK-MB-12* MB INDX-0.0 cTropnT-0.11*
[**2193-9-14**] 01:59PM ALT(SGPT)-203* AST(SGOT)-912* LD(LDH)-1725*
CK(CPK)-[**Numeric Identifier **]* ALK PHOS-74 TOT BILI-0.9
[**2193-9-14**] 01:59PM GLUCOSE-110* UREA N-54* CREAT-3.0*
SODIUM-150* POTASSIUM-3.0* CHLORIDE-108 TOTAL CO2-27 ANION
GAP-18
[**2193-9-14**] 02:51PM freeCa-0.87*
[**2193-9-14**] 02:51PM LACTATE-2.9* K+-3.0*
[**2193-9-14**] 02:51PM TYPE-ART TEMP-38.3 O2-94 O2 FLOW-4 PO2-74*
PCO2-31* PH-7.59* TOTAL CO2-31* BASE XS-8 AADO2-569 REQ O2-93
INTUBATED-NOT INTUBA
[**2193-9-14**] 02:52PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2193-9-14**] 02:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2193-9-14**] 02:52PM URINE RBC-165* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2193-9-14**] 03:09PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2193-9-14**] 09:33PM freeCa-0.85*
[**2193-9-14**] 09:33PM GLUCOSE-194* LACTATE-2.5* NA+-147* K+-3.1*
CL--106 TCO2-27
[**2193-9-14**] 10:45PM CEREBROSPINAL FLUID (CSF) PROTEIN-41
GLUCOSE-106
[**2193-9-14**] 10:45PM CEREBROSPINAL FLUID (CSF) WBC-9 RBC-2385*
POLYS-66 LYMPHS-26 MONOS-6 EOS-1 BASOS-1
[**2193-9-14**] 10:45PM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-1360*
POLYS-30 LYMPHS-55 MONOS-15
[**2193-9-14**] 09:33PM TYPE-ART PO2-116* PCO2-27* PH-7.61* TOTAL
CO2-28 BASE XS-6
BLOOD
[**2193-9-15**] 04:26AM BLOOD WBC-12.2* RBC-4.04* Hgb-11.4* Hct-33.6*
MCV-83 MCH-28.2 MCHC-33.9 RDW-16.0* Plt Ct-136*
[**2193-9-18**] 03:41AM BLOOD WBC-10.5 RBC-3.70* Hgb-10.7* Hct-31.8*
MCV-86 MCH-28.8 MCHC-33.6 RDW-15.4 Plt Ct-86*
[**2193-9-23**] 03:33AM BLOOD WBC-10.9 RBC-3.32* Hgb-9.8* Hct-30.2*
MCV-91 MCH-29.6 MCHC-32.5 RDW-19.0* Plt Ct-138*
[**2193-9-26**] 05:11AM BLOOD WBC-6.8 RBC-2.93* Hgb-8.8* Hct-27.1*
MCV-93 MCH-30.0 MCHC-32.4 RDW-19.6* Plt Ct-116*
[**2193-9-20**] 05:00AM BLOOD Neuts-55 Bands-2 Lymphs-31 Monos-7 Eos-2
Baso-1 Atyps-0 Metas-2* Myelos-0 NRBC-1*
[**2193-9-22**] 04:49AM BLOOD Neuts-60.4 Lymphs-26.3 Monos-7.5 Eos-4.9*
Baso-0.8
[**2193-9-26**] 05:11AM BLOOD Neuts-62.1 Lymphs-28.8 Monos-4.7 Eos-3.7
Baso-0.7
[**2193-9-14**] 01:59PM BLOOD PT-17.6* PTT-24.9 INR(PT)-1.6*
[**2193-9-16**] 03:44AM BLOOD PT-16.4* PTT-28.5 INR(PT)-1.4*
[**2193-9-20**] 05:00AM BLOOD PT-18.2* PTT-24.7 INR(PT)-1.6*
[**2193-9-22**] 04:49AM BLOOD PT-14.4* PTT-24.4 INR(PT)-1.2*
[**2193-9-15**] 03:25PM BLOOD Glucose-272* UreaN-50* Creat-2.0* Na-147*
K-3.6 Cl-111* HCO3-25 AnGap-15
[**2193-9-19**] 06:00AM BLOOD Glucose-244* UreaN-38* Creat-1.2 Na-144
K-4.2 Cl-111* HCO3-26 AnGap-11
[**2193-9-21**] 05:15PM BLOOD Glucose-238* UreaN-47* Creat-1.3* Na-151*
K-3.6 Cl-119* HCO3-25 AnGap-11
[**2193-9-23**] 03:33AM BLOOD Glucose-86 UreaN-36* Creat-1.2 Na-147*
K-3.6 Cl-116* HCO3-25 AnGap-10
[**2193-9-26**] 05:11AM BLOOD Glucose-151* UreaN-27* Creat-0.8 Na-141
K-3.8 Cl-112* HCO3-24 AnGap-9
[**2193-9-14**] 01:59PM BLOOD ALT-203* AST-912* LD(LDH)-1725*
CK(CPK)-[**Numeric Identifier **]* AlkPhos-74 TotBili-0.9
[**2193-9-15**] 04:26AM BLOOD ALT-176* AST-794* LD(LDH)-1668*
CK(CPK)-[**Numeric Identifier 91712**]* AlkPhos-63 TotBili-0.7
[**2193-9-16**] 03:04PM BLOOD CK(CPK)-[**Numeric Identifier 91713**]*
[**2193-9-17**] 03:59AM BLOOD CK(CPK)-[**Numeric Identifier 7244**]*
[**2193-9-20**] 05:00AM BLOOD ALT-90* AST-189* CK(CPK)-1652* AlkPhos-71
TotBili-0.5
[**2193-9-23**] 03:33AM BLOOD ALT-64* AST-121* LD(LDH)-429*
CK(CPK)-734* AlkPhos-59 TotBili-0.6
[**2193-9-26**] 05:11AM BLOOD ALT-67* AST-128* LD(LDH)-390*
CK(CPK)-771* AlkPhos-64 TotBili-0.4
[**2193-9-14**] 01:59PM BLOOD CK-MB-12* MB Indx-0.0 cTropnT-0.11*
[**2193-9-18**] 03:41AM BLOOD cTropnT-0.03*
[**2193-9-15**] 03:25PM BLOOD Calcium-7.3* Phos-3.1 Mg-2.3
[**2193-9-21**] 05:15PM BLOOD Calcium-9.3 Phos-2.8 Mg-2.1
[**2193-9-26**] 05:11AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0
[**2193-9-20**] 02:49PM BLOOD Ammonia-97*
[**2193-9-20**] 02:49PM BLOOD Osmolal-330*
[**2193-9-14**] 01:59PM BLOOD TSH-0.36
[**2193-9-23**] 01:20PM BLOOD Type-ART pO2-86 pCO2-30* pH-7.51*
calTCO2-25 Base XS-1
[**2193-9-19**] 08:58AM BLOOD Lactate-2.1*
ARBOVIRUS ANTIBODY IGM AND IGG Results Pending
[**2193-9-24**] Radiology CHEST PORT. LINE [**First Name9 (NamePattern2) **] [**Last Name (LF) **],[**First Name3 (LF) **]
R. Approved
[**2193-9-23**] Radiology CT CHEST W/CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] R.
Approved
[**2193-9-23**] Radiology CT ABD & PELVIS WITH CO [**Last Name (LF) **],[**First Name3 (LF) **]
R. Approved
[**2193-9-20**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] R.
Approved
[**2193-9-20**] Radiology LIVER OR GALLBLADDER US [**Last Name (LF) **],[**First Name3 (LF) **]
R. Approved
[**2193-9-19**] Radiology MR HEAD W & W/O CONTRAS [**Last Name (LF) **],[**First Name3 (LF) **]
R. Approved
[**2193-9-19**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] R.
Approved
[**2193-9-19**] Radiology CT HEAD W/O CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] R.
Approved
[**2193-9-18**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] R.
Approved
[**2193-9-18**] Neurophysiology EEG [**2193-9-18**] [**Last Name (LF) **],[**First Name3 (LF) **] L.
[**2193-9-17**] Neurophysiology EEG [**2193-9-17**] [**Last Name (LF) **],[**First Name3 (LF) **] L.
[**2193-9-16**] Neurophysiology EEG [**2193-9-16**] [**Last Name (LF) **],[**First Name3 (LF) **] L.
[**2193-9-15**] Radiology CHEST PORT. LINE [**First Name9 (NamePattern2) **] [**Last Name (LF) 2437**],[**First Name3 (LF) **]
Approved
[**2193-9-15**] Radiology -76 BY SAME PHYSICIAN [**Name9 (PRE) 2437**],[**Name9 (PRE) **]
Approved
[**2193-9-15**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) 2437**],[**First Name3 (LF) **]
Approved
[**2193-9-15**] Neurophysiology EEG [**2193-9-15**] [**Last Name (LF) 20564**],[**First Name3 (LF) **] C.
[**2193-9-14**] Radiology MR HEAD W/O CONTRAST [**Last Name (LF) 2437**],[**First Name3 (LF) **]
Approved
[**2193-9-14**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) 2437**],[**First Name3 (LF) **]
Approved
[**2193-9-14**] Cardiology ECG [**2193-9-17**] [**Last Name (LF) **],[**First Name3 (LF) **] R.
Brief Hospital Course:
62 M h/o Hep C, HTN, depression on mult psych meds p/w altered
mental status/obtunded, rhabdo, fevers, and increased stiffness
after found down at home, transferred to us from [**Hospital1 487**] for
worsened fever, rigidity, CK. Had indications of rhabdo. His
mental status waxed and waned. Most likely was [**1-23**] NMS. Was
having continuous fevers and worsened obtundation. After gradual
improvement in mental status, he was transferred to the floor.
.
# Altered MS: Initially on admission he had an LP which showed
alot of RBC's. Differential was aseptic vs. blood tap vs.
subarachnoid blood from encephalitis / necrosis. He was placed
on CTX, Vanc, Amp, and acyclovir ([**9-14**]) and started cooling.
Neuro was following while he was in the ICU who believed this is
most likely due to NMS which might take about 14 days to
improve. He was treated with bromocriptine. EEE, West Nile
virus, lyme serology were sent. Lyme and RPR negative. MRI brain
showed mild to moderate cortical atrophy. His Parasite smear and
OSH cultures were negative. PICC line placed [**9-15**]. CSF HSV PCR
was negative and acyclovir subsequently was discontinued ([**9-18**])
along with the other antibiotics ([**9-17**]) given the low suspicion
of bacterial cause. EEG initially showed high epileptiform
activity and valium was started. Subsequent EEG monitoring
showed no seizure activity with gradual taper of valium and
discontinuation on [**9-18**]. On [**9-19**] he was more obtunded with
increased oxygen requirement. Therefore, CT and MRI head were
done which showed no acute changes. Vanc anc cefepime were
started on the same day to cover for presumed HAP given
increased oxygen requirement. CXR didn't show new infiltrates.
Abx dc'ed [**9-25**]. IV acyclovir was restarted [**9-20**] but dc'ed
Lactulose was initiated given concern of hepatic encephalopathy
in setting of HCV and elevated liver enzymes. RUQ ultrasound
showed cirrhosis with trace ascites. His mental status improved.
He received tube feeds starting from [**9-15**] and discontinued after
NG tube was self-removed by him on [**9-26**]. satting 92-93% on RA
while attempting to place an NG tube which eventually failed and
not pursued further. Tolerating apple sauce.
His mental status continued to improve. Recommendation by
Neurology is to continue bromocriptine until [**2193-10-5**] and
continue Keppra for now.
Pt was started on Lactulose and should continue on this
titrating to 3BMs per day to avoid any component of hepatic
encephalopathy.
.
# Hypoxia
Continued oxygen requirement during his stay, but was satting in
90's on RA even during NG tube insertion multiple attempts on
his transfer day. stable. Cultures were have been unremarkable.
Large amounts of mucus were removed [**9-19**] with poor gag reflex.
Suspect due to secretions and AMS with poor cough. He was
treated empirically for PNA.
This improved with improvement in mental status and has been off
oxygen prior to discharge.
.
# Transaminitis:
Persistently elevated AST and ALT. Evidence of cirrhosis on RUQ
US and CT. History of HepC. Continued laculose empirically for
hepatic encephalopathy.
.
# Hypernatremia
Resolved, likely due to poor access to free water.
.
# ARF/rhabdo: Initially Cr 3.0 on admission, ARF due to
rhabdomyolysis, CPK [**Numeric Identifier 24869**]. He received aggressive IVF hydration
with improvement in CPK and normalization of Cr to 0.7.
.
# HTN: Controlled on Labetalol 200 mg [**Hospital1 **];
.
# DM on insulin:
-on lantus and ISS
.
# Elevated Troponins:
Was not concerning for ACS. Was in setting of ARF, elevated CK
w rhabdo, tachycardia. EKG sinus, normal int/axis, no st
changes.
.
Rehab Issues:
.
#Speech and Swallow recommendations:
1. PO diet: Thin liquids, pureed solids.
2. 1:1 supervision with POs.
3. One sip of liquid at a time.
4. Pills crushed with applesauce.
5. TID oral care.
6. Keppra to be cut and given with applesauce.
.
#Psych recommendations:
-Would utilize behavioral means to reduce delirium (ie. maintain
light/dark cycles, frequent redirection).
-Would not initiate psychiatric medications at this time
(antipsychotics or antidepressants). At least two weeks should
be allowed to elapse after recovery from NMS before rechallenge
with a low-potency antipsychotic.
-In case of behavioral agitation, would refrain from use of
antipsychotic and instead utilize benzodiazepines (ie. Ativan)
or mechanical restraints (ie. posey, wrist restraints).
-Pt. should be followed by rehab psychiatrist, with followup
with outpatient treaters arranged.
Medications on Admission:
Home meds:
Omeprazole 20 [**Hospital1 **]
effexor 125 TID
Risperdal 6 qhs
Wellbutrin 100 [**Hospital1 **]
Sertraline 100 [**Hospital1 **]
Remeron 30 daily
methylphenidate 10 daily
ibuprofen 600 QID
Spironolactone 25
codeine 30 [**Hospital1 **]
Flexeril 10mg TID
Insulin, unknown dose/type
Transfer Medications:
Tylenol
Acyclovir 575mg IV q8h
DuoNeb q6h
ASA 81
Baclofen 10mg [**Hospital1 **]
Ceftriaxone 2g IV BID
Lasix 80 [**Hospital1 **]
Metop 25 [**Hospital1 **]
Zofran prn
Protonix 40 IV daily
Phenytoin 100 IV TID
senna prn
ISS
Lantus 30 u SQ daily
Lactulose 20mg QID
Heparin sq
Colace 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 for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day): titrate to [**1-24**] BMs a day.
9. bromocriptine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): until [**2193-10-5**].
10. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing, SOB.
13. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
15. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever, pain.
16. insulin glargine 100 unit/mL Solution Sig: Forty Five (45)
units Subcutaneous at bedtime.
17. Keppra 500 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours: please cut in 2 and give with applesauce.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Neuroleptic malignant syndrome
Cirrhosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted from another hospital after being found
unconscious at home. You had a syndrome called "neuroleptic
malignant syndrome", which was most likely related to your large
amounts of risperidone which you were taking for your
schizoaffective disorder. You were managed in the intensive care
unit and your psychiatric medications were held. You were
started on a medication called bromocriptine which you should
take until [**10-5**].
You were also found to have cirrhosis of your liver and this
should be followed your PCP or [**Name Initial (PRE) **] Gastroenterologist.
Followup Instructions:
Please follow up with your PCP and Psychiatrist (NP [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 91714**]
[**Hospital1 189**] VA [**Telephone/Fax (1) 91715**]) after discharged from rehab.
|
[
"5849",
"5070",
"2760",
"4019",
"311",
"53081",
"25000",
"V5867"
] |
Admission Date: [**2126-5-8**] Discharge Date: [**2126-5-22**]
Date of Birth: [**2126-5-8**] Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 6930**], twin number two, delivered
at 31-5/7 weeks gestation, weighing 1,525 grams, was admitted
to the intensive care nursery for management of prematurity.
The mother is a 31-year-old gravida 2, para 0, now 2 woman
with conception by in [**Last Name (un) 5153**] fertilization. Estimated date of
delivery was [**2126-7-5**]. Prenatal screens included blood type
A+, antibody screen negative, RPR nonreactive, rubella
immune, hepatitis B surface antigen negative, and group B
Streptococcus unknown. The pregnancy was complicated by a
shortened cervix and preterm labor with admission to [**Hospital1 1444**] about one month prior to
delivery for preterm labor. She was treated with bedrest,
terbutaline and received betamethasone. On the day of
delivery, labor progressed despite tocolysis, with delivery
by cesarean section due to breech position of this twin. The
mother had no fever, did not receive antibiotics prior to
delivery. Membranes were ruptured at delivery. This twin
emerged with spontaneously cry and received free-flow oxygen
with Apgar scores of 7 at one minute and 9 at five minutes.
PHYSICAL EXAMINATION: Admission weight was 1,525 grams (50th
percentile), length 40 cm (30th percentile), head
circumference 29.5 cm (50th percentile). On admission the
overall appearance was consistent with gestational age,
nondysmorphic, anterior fontanel soft, open and flat. Red
reflex deferred. Palate was intact. Respirations were equal
with crackles, diminished bilaterally, with grunting, flaring
and retracting. Heart was regular rate and rhythm without
murmur, 2+ peripheral pulses including femorals. Abdomen was
benign without hepatosplenomegaly or masses; three-vessel
cord. Normal male genitalia with testes descending. Back
normal. Skin slightly mottled and pink. Appropriate tone
and activity level.
HOSPITAL COURSE: 1. Respiratory: The patient was placed on
CPAP of 6 cm of water on admission for grunting, flaring and
retracting; did not require supplemental oxygen. He was
weaned off CPAP to room air on day of life one and has
remained in room air since with comfortable work of
breathing, respiratory rates in the 50s. He has occasional
episodes of apnea and bradycardia, but has not required
caffeine citrate. The last apnea episode was on [**2126-5-22**].
2. Cardiovascular: The patient has been hemodynamically
stable throughout the hospital stay with normal blood
pressure and no heart murmur.
3. Fluids, electrolytes and nutrition: Originally he was
maintained on D10W with maintenance electrolytes added at 24
hours of age. Enterals feeds were started on day of life one
and advanced to full volume feeds on day of life six without
problems. Feeds of premature Enfamil were advanced to 28
calories per ounce with ProMod over several days with
tolerance. At discharge the patient is taking 150 cc per kg
per day divided q. 4 hours with feeds infused over an hour
and a half. Discharge weight was 1,720 grams, length 42.5
cm, head circumference 30 cm.
4. GI: The patient received phototherapy for indirect
hyperbilirubinemia. Peak bilirubin total was 10.4, direct
0.3. Last bilirubin done off phototherapy on [**2125-5-15**] was
total 4.5, direct 0.2.
5. Hematology: Hematocrit on admission was 52.1%. The
patient did not require any blood products during this
admission.
6. Infectious disease: The patient received ampicillin and
gentamicin for 48 hours following delivery for a rule out
sepsis course. Complete blood count on admission showed a
white count of 12.1 with 12 polys, 1 band, 246,000 platelets.
Blood culture was negative.
7. Neurology: A head ultrasound done on day of life eight
was normal. A follow-up head ultrasound is recommended at
one month of age.
8. Sensory: Hearing screening is recommended prior to
discharge. An ophthalmology examination is recommended at
three weeks of age.
CONDITION ON DISCHARGE: Stable 14-day old, now 33-5/7 weeks
corrected age preterm male, growing.
DISPOSITION: The patient is transferred to [**Hospital6 27253**]. His pediatrician is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 38713**], telephone
number [**Telephone/Fax (1) 38714**].
CARE RECOMMENDATIONS:
1. Feeds: Premature Enfamil 28 calories per ounce with
ProMod 150 cc per kg per day. This is achieved by 24
calories per ounce premature Enfamil with four calories per
ounce of MCT and half a tsp of ProMod per 90 cc of formula.
2. Recommend nutrition laboratory studies in one week to
include calcium, phosphorous, alkaline phosphatase and if
still on ProMod, a BUN and creatinine.
3. Medications: Ferrous sulfate 0.15 cc p.o. daily.
4. Car seat position screening recommended prior to
discharge.
5. State newborn screening done on day of life three and
again at time of transfer.
6. Immunizations received: The patient has not received any
immunizations.
7. 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: A. Born at less than 32
weeks. B. Born between 32 and 35 weeks with plans for day
care during RSV season, with a smoker in the household or
with preschool siblings. C. With chronic lung disease.
FOLLOW-UP RECOMMENDED:
1. Ophthalmology examination at three weeks of age.
2. Head ultrasound at one month of age to rule out PVL.
DISCHARGE DIAGNOSES:
1. AGA 31-5/7 weeks preterm male.
2. Twin number two.
3. Respiratory distress likely TTN, resolved.
4. Indirect hyperbilirubinemia, resolved.
5. Apnea of prematurity.
6. Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 36138**]
MEDQUIST36
D: [**2126-5-22**] 13:24
T: [**2126-5-22**] 15:01
JOB#: [**Job Number 48557**]
|
[
"7742",
"V290"
] |
Admission Date: [**2127-11-28**] Discharge Date: [**2127-12-1**]
Date of Birth: [**2053-4-6**] Sex: F
Service:
The patient is a 73-year-old woman with multiple medical
problems who presented with respiratory failure. In the
emergency department she was found to be in hypercarbic
respiratory failure and was intubated and sent to the MICU
where she was started on antibiotics for possible urosepsis.
PAST MEDICAL HISTORY: Coronary artery disease, status post
coronary artery bypass graft, congestive heart failure,
hypothyroidism, chronic obstructive pulmonary disease,
depression, cerebrovascular accident, hypertension, transient
ischemic attack, anemia, [**Known lastname **] Palsy. History of Methicillin
resistant Staphylococcus aureus, multiple urinary tract
infections.
ALLERGIES: Sulfa, Percocet.
SOCIAL HISTORY: Lives at [**Location (un) 93510**]. Health care proxy
is [**Name (NI) **] [**Name (NI) 93511**]. The patient is "Do Not Resuscitate/DNI".
MEDICATIONS
1. Atrovent two puffs four times a day.
2. Plavix 75 mg q day.
3. Aspirin 325 mg q day.
4. Levoxyl 75 mcg q day.
5. Sertuline 50 mg q day.
6. Combivent two puffs q 6 hours.
7. Folate.
8. Diltiazem 120 mg q day.
9. Epo three times a week, 60,000 units.
10. Lopressor 100 mg twice a day.
11. Nephrocaps q day.
12. Zyprexa 5 mg q day.
The patient remained intubated in the MICU. Her mental
status improved. It was decided through health care proxy
that the patient would not want to be intubated. The E-tube
was pulled out. The patient was mentating. She was able to
say goodbye to all of her family. Health care proxy and
patient agreed for comfort only measures, no BYPAP.
The patient was transferred to the floor, placed on Morphine
drip. The patient expired at 4:15 PM on [**2127-12-1**]. Family
was notified of the patient's death.
CAUSE OF DEATH:
1. Hypoxic, hypercarbic respiratory failure.
[**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. [**MD Number(1) 93507**]
Dictated By:[**Name8 (MD) 20317**]
MEDQUIST36
D: [**2127-12-1**] 16:53
T: [**2127-12-1**] 18:19
JOB#: [**Job Number 93512**]
|
[
"0389",
"51881",
"5990",
"78552",
"2762",
"5845",
"496",
"4280"
] |
Admission Date: [**2199-9-25**] Discharge Date: [**2199-10-2**]
Date of Birth: [**2130-3-19**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Patient is a 63 yo woman with PMH of HTN, DM, morbid obesity,
hemorrhagic stroke 2 yrs ago, afib off coumadin who presents
after episode of seizure vs. syncope with family. She and her
husband are in town from CT visiting son and had just gone to a
performance. Following this they went to a restaurant to get a
late night meal, and en route there noted her to be normal in
the car. Once they got to the restaurant, the patient ordered
her meal correctly, but hortly thereafter was not making sense
with her speech. This was around 11 PM. She was speaking actual
words and was not dysarthric but her peech didn't make sense.
They recall that one phrase was something about "ice cream" and
much of her speech was about food. Her son seemed to notice a
slight facial droop around this time and pointed it out to the
patient's husband. This non-sensical speech went on or about 45
minutes without any improvement and the patient seemed ompletely
unconcerned about this. The son asked his father if this sort of
behavior occured frequently with her. They tried asking her if
she had a headache and once she said yes, and another time said
o. Then, suddenly, she threw her head and body back in the
chair, onvulsed at the arms for seconds to a minute, and then
fell to the left. Her husband was able to break her fall and she
did not strike her head. Once on the ground she continued to
convulse briefly and then stopped. At this point she was
gurgling, and not moving. She was not speaking or following
commands.
.
She did have a seizure in the context of her ICH. Her son noted
an event over a year ago where on the phone she suddenly had
non-sensical speech similar to today's. That event resolved
spontaneously.
.
In the ED she was found to have persitent altered mental status
and wasintubated for airway protection. She was evaluated by the
neurology consult service who felt that the symptoms were
concerning for left sided stroke. The evalution was notable for
+UA for UTI. A chest Xray showed concern for widenen mediastinum
which prompted a CTA chest which was negative for dissection. A
CT head was negative for hemorrhage or mass effect. No MRI was
obtained
.
Pt was loaded with dilantin (1g IV x 1) although neuro suggested
1.5g. Pt got pre and post Ct hydration with bicarbonate.
.
ROS: patient cannot offer
Past Medical History:
1. Hemorrhagic stroke 2 yrs ago. Patient had headache and went
to bed. Woke confused and en route to hospital became aphasic.
While there at the hospital coded according to husband and had
to
be intubated. He doesn't know it it was a cardiac vs.
respiratory failure. Following the stroke, she was noted to be
slightly weaker right than left.
2. DM, recent diagnosis
3. Morbid Obesity
4. afib off coumadin
5. OSA on CPAP
6. Depression
7. Diastolic heart failure
8. Hypertension
Social History:
Retired RN. Remote Tobacco. no ETOH. Lives with husband.
Family History:
mother had [**Name2 (NI) **] in late life and lived to 92.
Physical Exam:
VS: T 98.6 BP 130/80 P 50 100% on AC 500x14, peep 5, FiO2 60%
Gen: intubated and sedated
HEENT: left eye echymosis. Pupils 3-4 mm and equally reactive to
light. Thickened right cornea and injected sclera bilaterally
R>L. MMM.
Neck: unable to assess for JVD given size of neck and intubation
Chest: ctab anteriorly without w/c
CV: bradycardic and irregularly irregular, no m/r/g
Abd: obese, s/nd/hypoactive bowel sounds. no appreciable
organomegaly
Ext: no c/c/e. pedal pulses 1+ and equal bilaterally
Skin: no rashes
Neuro: withdraws all four limbs to pain, shifts body with
sternal rub. reflexes 2+ RUE, 1+LUE, 1+ LE bilaterally. + gag
reflex, brain-stem reflexes intact. with propofol weaned was
interactive trying to speak over ventilator, moved all
extremities to command
Pertinent Results:
Urinalysis 21-50 whites, many bacteria, LE, N neg
.
Studies:
CXR - Apparent widening of the upper mediastinum. An aortic
injury cannot be excluded. Consider CT as indicated. Enlarged
cardiac silohuette with evidence of pulmonary edema as
described. ETT tube positioned low (1.3 cm above carina)
.
CT c-spine - Cervical spondylosis with anterior osteophytes are
most prominent at C5/6. no fracture or dislocation identified.
.
CTA chest - No aortic dissection, huge cardiomegaly with
coronary calcifications, Rt pleural effusion, bronchial
thickening with basilar consolidation versus atelectasis, some
diffuse ground glass pattern.
.
MRI/A head/neck: No evidence of hemorrhage, masses, mass effect,
edema or midline shift. Bilateral periventricular white matter
demonstrates hyperintensity on FLAIR and T2-weighted imaging
suggestive of chronic microangiopathic ischemic disease. The
sulci and the ventricles appear normal in caliber,
configuration, and morphology. No hydrocephalus is noted. No
diffusion abnormalities are noted. No areas of abnormal
contrast enhancement are seen. Bilateral sphenoid sinus
demonstrates air-fluid levels suggestive of sinusitis. Mucus
retention cysts are noted in bilateral maxillary sinuses. The
osseous, soft tissue structures and visualized portions of the
orbits are unremarkable.
.
EKG afib with bradycardia (rate 49), normal axis, QTc 540.
diffuse TWI.
.
Bedside EEG: This is an abnormal portable EEG in the waking and
drowsy
states due to intermittent mixed frequency slowing noted broadly
over
the right hemisphere suggesting an underlying area of
subcortical
dysfunction in that region. In addition, the background was
mildly
slowed and disorganized, consistent with a mild encephalopathy,
suggesting bilateral subcortical or deep midline dysfunction.
Medications, metabolic disturbances, and infections are among
the common causes of encephalopathy. There were no epileptiform
features and no electrographic seizures were noted.
.
[**2199-9-25**] 04:07PM GLUCOSE-101 UREA N-14 CREAT-1.0 SODIUM-136
POTASSIUM-2.8* CHLORIDE-99 TOTAL CO2-26 ANION GAP-14
[**2199-9-25**] 04:07PM CALCIUM-8.5 PHOSPHATE-3.7 MAGNESIUM-1.8
Brief Hospital Course:
69 year old woman with history of L-sided hemorrhagic stroke,
DM2, atrial fibrillation, and obesity presenting with acute
altered mental status.
.
#Seizure: Pt admitted with seizure in the setting of presumed
[**Month/Day/Year **]. Symptoms of aphasia/werneke's type speech make L-sided
temporal [**Month/Day/Year **] likely with resultant seizure. The patient was
intubated in the ED due to concern over airway protection and
loaded with dilantin. MRI without stroke. Upon arrival to the
ICU she had full motor strength and was attempting to
communicate over the ventilator which suggested against a large
territory stroke. The patient had an MRI on HD 2 which did not
show stroke, and she was subsequently extubated. Her dilantin
was changed to keppra for ease of administration. Because of
her atrial fibrillation, the [**Month/Day/Year **] was presumed to be a result of
not being anticoagulated. The patient was advised by the
neurology team that she should be on coumadin but the patient
declined and wanted to discuss this with her PCP first, she was
started instead on a full dose aspirin.
With regards to her seizure activity, this was felt to be [**12-21**]
[**Month/Day (2) **] or possibly due to her UTI causing a lowered seizure
threshold. She was started on dilantin, which was changed to
keppra and she was treated with 3 days of augmentin. Carotid
ultrasound was without significant stenosis b/l.
Follow up scheduled with her primary neurologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 75499**] of [**Last Name (un) 3407**] to discuss course of Keppra and to determine
driving restrictions.
.
# Cardiac: Atrial fibrillation with mild bradycardia likely from
atenolol. And after recovery from stroke, hr was stable in
60-80s on atenolol. She also ruled out for MIwith 3x cardiac
enzymes
.
# Pulmonary - Inititally, intubated for airway protection in
setting of change in mental status. Sucessfully extubated
without complication. However, she did have desaturations to 88%
while on NC 2-4L concerning for hypoventilation vs COPD. Chest
CT abnormal with suggestion of possible pulmonary edema and
atelectasis vs RLL infiltrate. Hypozia resolved with gentle
diuresis though she does at times require low level of oxygen
with aggressive physical therapy. She should have an outpatient
chest CT in [**1-20**] months to evaluate for resolution and may need
work up for COPD with PFT's if she has persistent resting
desaturations.
.
# Diabetes Mellitus - New dx previously treated with diet and
exercise. Continue insulin sliding scale with plan deferred to
[**Name8 (MD) 1501**] MD regarding starting oral hypoglycemics.
#OSA: Continue CPAP at 12cm/h2o
.
# UTI: may be responsible for seizure, fully treated with
augmenting.
# Prophy - SQ heparin, PPI
# Code - full
Medications on Admission:
atenolol 50 mg po daily
fluoxetine 20mg po daily
lasix 20mg po daily
prilosec 20mg po daily
lisinopril 5mg po daily
simvastatin 20mg po daily
folate 1g po daily
KCl 10 mEQ po daily
Discharge Disposition:
Extended Care
Facility:
Montowese skilled nursing facility
Discharge Diagnosis:
seizure
[**Name8 (MD) **]
CHF exacerbation
Discharge Condition:
stable
Discharge Instructions:
Please continue physical therapy and be sure to follow up with
your neurologist re: whether to start coumadin. Return to ER
with seizure, weakness or other concerning symptoms.
Followup Instructions:
Chest CT in [**1-20**] months to ensure that infiltrates have resolved.
Please follow up with your primary neurologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 75499**] [**2199-10-9**] at 10:45am at the [**Location (un) 75500**], [**Location (un) **],
[**State 2748**] Phone: ([**Telephone/Fax (1) 75501**]. If family wants to change
appt to the [**Last Name (un) 3407**] office of Dr. [**Last Name (STitle) 75499**] they cal call
[**Telephone/Fax (1) 75502**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2199-10-2**]
|
[
"5990",
"2760",
"32723",
"25000",
"4019",
"4280",
"42731"
] |
Admission Date: [**2181-5-28**] Discharge Date: [**2181-6-23**]
Date of Birth: [**2121-2-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cipro / vancomycin / shellfish
/ Haldol
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Right foot bleeding.
Major Surgical or Invasive Procedure:
Right fifth open ray amputation
Esophagogastroduodenoscopy with clipping of duodenal ulcer
PICC line placement
AV fistula placement
History of Present Illness:
60F with h/o CKD on HD T/T/S, CAD s/p CABG ([**2172**]), STEMI ([**2174**]),
sCHF (EF 35%) s/p AICD placement, IDDM, PVD presents with 1 day
h/o bleeding from chronic right foot ulcer. Pt was sent in from
vascular clinic for evaluation after dressing was changed x3 for
bleeding in clinic and NP from [**Hospital3 2558**] asked to have
ulcer evaluated in ED before returning home. She does endorse
increased pain in the right foot and perhaps some green
discharge from R foot in last week, but isn't sure. Denies
malodor, fever, chills.
.
In the ED, initial vitals were 96.3 80 100/36 16 96% RA.
Podiatry and vascular surgery were consulted in the ED. Podiatry
described the wound on the 5th metatarsal as clean and stable
with sanguinous drainage, likely representing stable, chronic
osteomyelitis of the 5th metatarsal. They debrided the ulcer and
felt it was stable and not newly infected and sent samples for
gram stain and aerobic/anaerobic culture. Debridement led to
significant bleeding which was controlled with pressure and
silver cautery by vascular surgery. Plain film performed which
showed likely osteo in R 5th MTP and phalanx. Because of left
shift and renal failure, they recommended admission and to hold
antibiotics until culture results. VS at transfer: 98 80 107/58
18 94%RA.
.
Of note, the patient was admitted to the [**Hospital1 18**] in [**2181-4-24**] with
hyperkalemia and evidence of AoCRF. She had a temp line placed
for HD after her diuretic adjustment was unsuccesssful. Plan was
to follow up for fistula as outpatient. She was discharged off
all diuretics. Weight at discharge (felt to be dry) 90.6kg.
.
Currently, she is hungry and complains of chronic L stump pain
and pain in R foot.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
Cardiovascular Risk Factors:
+ HTN + HL + DM
# CAD: STEMI in [**2174**] with occlusion of vein graft
INTERVENTIONS:
CABG: [**2172**] with LIMA -> LAD and vein graft to [**Last Name (LF) 11641**], [**First Name3 (LF) **] 25 %
at the time
PERCUTANEOUS CORONARY INTERVENTIONS:
- [**2174**] stents in left anterior descending and [**Year (4 digits) 11641**]
# Systolic CHF - ischemic cardiomyopathy, severely reduced LV
function. ECHO in [**4-2**] with EF 25 - 30%
# PACING/ICD: Right-sided AICD in place ([**2178**]) for primary
prevention given EF
# IDDM, eye and renal manifestations, last HbA1c 9.3% ([**2180-4-23**])
# asthma
# PVD
# s/p left BKA [**2176**]
# s/p right 1st toe amputation [**2176**]
# h/o left intraductal breast cancer - s/p left mastectomy in
[**Month (only) 116**]/[**2173**], now question of right-sided breast cancer, which is
just being followed
# s/p cholecytectomy
Social History:
Hospitalized at [**Hospital1 18**] and/or rehab since [**2180-11-23**].
Otherwise lives in [**Hospital3 **]. Wheelchair-bound. Son [**Name (NI) **]
(nurse) is HCP, daughter [**Name (NI) **] also involved; a third son
[**Name (NI) **] lives in [**Name (NI) 86**].
-Tobacco history: none
-ETOH: rarely
-Illicit drugs: denies, but used marijuana in the past
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VS - Temp 98.3 BP 105/56 HR 79 R 14 O2-sat 93% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
scab in L ear canal with minimal oozing around it
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, II/VI systolic murmur
with no radiation to carotids/axilla
LUNGS - CTAB, no r/rh/wh, moderate air movement, resp unlabored,
no accessory muscle use
ABDOMEN - NABS, firm and distended, no fluid shift, nontender,
no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, 1+ pitting edema in RLE, dopplerable pulse in
RLE, L stump well healed. Ulcer over lateral aspect of 5th
digit, with mostly sanguinous drainage striking through
dressing, no purulence or malodor
SKIN - excoriations noted over trunk, arms, legs
NEURO - awake, A&Ox3, moving all extremities, no asterixis
.
Pertinent Results:
ADMISSION LABS:
[**2181-5-28**] 06:00PM BLOOD WBC-7.9 RBC-3.17* Hgb-8.2* Hct-28.0*
MCV-88 MCH-25.9* MCHC-29.4* RDW-26.4* Plt Ct-219
[**2181-5-28**] 06:00PM BLOOD Neuts-75.4* Lymphs-16.1* Monos-5.8
Eos-1.9 Baso-0.7
[**2181-5-28**] 06:00PM BLOOD PT-16.4* PTT-33.9 INR(PT)-1.5*
[**2181-5-28**] 06:00PM BLOOD Glucose-191* UreaN-31* Creat-3.2*# Na-133
K-3.7 Cl-96 HCO3-24 AnGap-17
[**2181-5-28**] 06:00PM BLOOD Calcium-8.9 Phos-3.7# Mg-1.9
.
PERTINENT LABS:
[**2181-5-31**] 12:11AM BLOOD WBC-10.3 RBC-2.22* Hgb-5.7* Hct-20.2*
MCV-91 MCH-25.8* MCHC-28.3* RDW-28.7* Plt Ct-172
[**2181-6-1**] 07:29AM BLOOD WBC-17.5* RBC-2.74* Hgb-7.4* Hct-25.0*
MCV-91 MCH-27.1 MCHC-29.7* RDW-25.0* Plt Ct-194
[**2181-6-2**] 01:55PM BLOOD Neuts-85.2* Lymphs-8.3* Monos-4.5 Eos-1.5
Baso-0.5
[**2181-6-12**] 05:14PM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-OCCASIONAL
Macrocy-3+ Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL
Target-OCCASIONAL
[**2181-6-2**] 01:55PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-3+
Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-3+ Stipple-1+
How-Jol-OCCASIONAL
[**2181-6-1**] 07:29AM BLOOD PT-29.3* PTT-37.3* INR(PT)-2.8*
[**2181-6-8**] 04:15AM BLOOD PT-14.2* PTT-33.7 INR(PT)-1.3*
[**2181-5-30**] 06:33AM BLOOD ESR-48*
[**2181-5-31**] 10:33AM BLOOD Glucose-75 UreaN-61* Creat-3.5* Na-139
K-5.8* Cl-96 HCO3-19* AnGap-30*
[**2181-6-4**] 02:09AM BLOOD Glucose-173* UreaN-16 Creat-1.0 Na-137
K-3.6 Cl-98 HCO3-28 AnGap-15
[**2181-5-31**] 10:00PM BLOOD Glucose-82 UreaN-40* Creat-2.3* Na-132*
K-4.9 Cl-101 HCO3-15* AnGap-21*
[**2181-5-31**] 10:33AM BLOOD ALT-9 AST-33 LD(LDH)-219 CK(CPK)-39
AlkPhos-132* TotBili-2.0*
[**2181-6-3**] 07:28AM BLOOD ALT-34 AST-153* LD(LDH)-236 AlkPhos-100
TotBili-2.6*
[**2181-5-31**] 12:11AM BLOOD CK-MB-3 cTropnT-0.30*
[**2181-5-31**] 05:02AM BLOOD CK-MB-3 cTropnT-0.32*
[**2181-5-31**] 10:33AM BLOOD CK-MB-5 cTropnT-0.37*
[**2181-5-31**] 10:33AM BLOOD Calcium-8.5 Phos-5.8* Mg-2.2
[**2181-5-29**] 05:33AM BLOOD %HbA1c-6.9* eAG-151*
[**2181-6-5**] 06:07AM BLOOD Cortsol-18.8
[**2181-6-10**] 05:55PM BLOOD Cortsol-39.9*
[**2181-5-29**] 05:33AM BLOOD CRP-58.1*
[**2181-5-31**] 10:42AM BLOOD Type-CENTRAL VE pO2-141* pCO2-43 pH-7.27*
calTCO2-21 Base XS--6 Comment-GREEN TOP
[**2181-6-1**] 07:54PM BLOOD Type-MIX Temp-36.3 O2 Flow-2 pO2-27*
pCO2-48* pH-7.40 calTCO2-31* Base XS-2 Intubat-NOT INTUBA
[**2181-6-6**] 07:55AM BLOOD Type-[**Last Name (un) **] Temp-36.7 pO2-38* pCO2-43
pH-7.37 calTCO2-26 Base XS-0 Intubat-NOT INTUBA
[**2181-5-31**] 10:42AM BLOOD Lactate-10.1*
[**2181-5-29**] 09:11PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2181-5-29**] 09:11PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-2* pH-5.0 Leuks-SM
[**2181-5-29**] 09:11PM URINE RBC-<1 WBC-4 Bacteri-MANY Yeast-NONE
Epi-14 TransE-<1
[**2181-5-29**] 09:11PM URINE CastHy-18*
[**2181-6-6**] 12:23AM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.022
[**2181-6-6**] 12:23AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-SM
[**2181-6-6**] 12:23AM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
[**2181-6-10**] 05:55PM URINE Hours-RANDOM Creat-179 TotProt-740
Prot/Cr-4.1*
.
DISCHARGE LABS:
[**2181-6-16**] 05:30AM BLOOD WBC-9.7 RBC-2.77* Hgb-8.1* Hct-26.7*
MCV-96 MCH-29.4 MCHC-30.5* RDW-24.7* Plt Ct-188
[**2181-6-16**] 05:30AM BLOOD Glucose-131* UreaN-40* Creat-3.5* Na-133
K-4.5 Cl-94* HCO3-26 AnGap-18
[**2181-6-14**] 06:20AM BLOOD ALT-12 AST-19 AlkPhos-113* TotBili-1.3
[**2181-6-16**] 05:30AM BLOOD Calcium-8.6 Phos-4.4 Mg-2.2
[**2181-6-11**] 10:16PM BLOOD Lactate-2.0
.
MICROBIOLOGY:
[**2181-5-28**] 7:03 pm SWAB Source: foot.
GRAM STAIN (Final [**2181-5-28**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2181-5-30**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2181-6-3**]): NO GROWTH.
[**2181-5-30**] SWAB Site: TOE RT 5TH TOE.
GRAM STAIN (Final [**2181-5-30**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2181-6-5**]):
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_______________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- <=0.12 S
MEROPENEM------------- 1 S
OXACILLIN------------- <=0.25 S
PIPERACILLIN/TAZO----- I
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2181-6-5**]): NO ANAEROBES ISOLATED.
Bcx (neg): [**5-28**], [**6-1**], 6/11x2, 6/16x2
Bcx (PEND): [**6-15**], [**6-15**], [**6-16**]
MRSA neg
Fecal cx: NO E.COLI 0157:H7 FOUND.
Urine cx ([**6-6**]): NEG
H.pylori Ab NEG
.
IMAGING:
Foot Xray:
IMPRESSION: Osteomyelitis involving the head of the fifth
metatarsal and base of the fifth proximal phalanx. Subluxation
at the fifth MTP joint.
Abdominal/Pelvis CT:
IMPRESSION:
1. No CT evidence of bowel ischemia without pneumatosis, mural
edema and
patent appearing vessels.
2. Prominent retroperitoneal and pelvic nodes for which
correlation with
prior imaging and medical history is recommended.
3. Fatty liver
Head CT:
IMPRESSION: No acute intracranial process including no evidence
of acute
infarction.
Echocardiogram ([**2181-6-1**]): The left atrium is moderately dilated.
The right atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %); there is a major component of
ventricular interaction with a pressure and volume overloaded
right ventricle. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. The tricuspid valve leaflets are mildly thickened.
Severe [4+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CXR portable [**2181-6-1**]:
Mediastinal and pulmonary vascular engorgement have progressed,
to the
borderline of mild edema. Moderate-to-severe cardiomegaly is
chronic.
Transvenous pacer leads are unchanged in their respective
positions projecting over the right atrium and the defibrillator
lead over the proximal right ventricle. No pneumothorax or
appreciable pleural effusion is present. Dual-channel
supraclavicular left central venous [**Month/Day/Year 2286**] ends in the SVC and
in the region of the superior cavoatrial junction.
CXR portable [**2181-6-3**]:
There is a right-sided AICD with the distal lead tips in the
right atrium and right ventricle. There is a left-sided
vascular catheter with distal lead tip at the distal SVC and
proximal right atrium. There is also a right IJ central line
with the distal lead tip at the distal SVC. Heart size is within
normal limits. There is prominence of the pulmonary vascular
markings consistent with moderate pulmonary edema. There are no
pneumothoraces identified.
CTA [**2181-6-4**]:
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Findings of congestive heart failure including moderate
bilateral pleural effusion, pulmonary edema, cardiomegaly, and
reflux of contrast into a dilated IVC are seen.
3. Ascites is noted in the upper abdomen.
CXR (portable [**2181-6-6**]:
There is moderate cardiomegaly. Transvenous pacer lead tips at
the right
atrium and right ventricle. Right IJ catheter tip is in the
lower SVC. There is no evident pneumothorax. Mediastinal
lymphadenopathy is better seen on prior CT from [**6-4**]. There
is mild vascular congestion. Bibasilar opacities are a
combination of atelectasis and pleural effusion.
Echocardiogram [**2181-6-11**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is top normal/borderline dilated.
There is moderate global left ventricular hypokinesis (LVEF = XX
%). No masses or thrombi are seen in the left ventricle. There
is no ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. There is
abnormal septal motion/position. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened 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. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
ECG ([**2181-5-29**]): Sinus rhythm. P-R interval prolongation.
Intraventricular conduction delay. ST-T wave abnormalities.
Since the previous tracing of [**2181-5-14**], the rate is faster.
Otherwise, unchanged.
ECG ([**2181-6-6**]): Sinus rhythm. P-R interval prolongation. Left
axis deviation. Non-specific intraventricular conduction defect.
Non-specific ST-T wave changes. Compared to the previous tracing
of [**2181-6-5**] there is no significant diagnostic change.
PATHOLOGY:
Fifth toe, right foot, amputation (A):
Bone with chronic osteomyelitis.
Skin and soft tissue with fibrosis.
Brief Hospital Course:
60 year old woman with ESRD on HD, CAD s/p CABG, systolic CHF
(EF 35%) s/p AICD, IDDM, and PVD s/p left BKA who initially
presented with a bleeding ulcer of the 5th digit of her R foot,
underwent amputation, then developed rising lactate,
hypotension, and melena requiring admission to the MICU, and was
subsequently transferred to the floor for treatment for
osteomyelitis.
# Shock/elevated lactate/melena: Given melena and dropping Hct,
shock was thought to be hypovolemic secondary to brisk upper GI
bleed, so the patient was transferred from the vascular service
to the MICU for further management. She was transfused 3 units
of blood and Hct increased from 20 to 29 and remained stable.
She was initially started on peripheral neosynephrine, which was
switched to levophed. At this point, her lactate increased to
10.1, patient became more somnolent, and abdomen became more
firm. There was concern for ischemic colitis, so a stat CT scan
was done, which showed no ischemic or infarcted bowel. Surgery
was consulted and did not feel that surgical intervention was
indicated. Her lactate eventually normalized over the next few
days. On ICU Day 3, her melena increased, Hct dropped back to
22, and her INR remained elevated at 2.8. She was transfused 4
units of PRBCs without adequate increase in Hct. An EGD showed a
nonbleeding duodenal ulcer with new clot which was clipped and
injected with epinephrine. After this, she remained
hemodynamically stable with stable HCTs. She still remained on
levophed and was + 13L. Based on NICOM measurements and CV02,
she seemed to be in cardiogenic shock. Via CVVH, 3-4 L of fluid
were removed per day for several days while on levophed.
Patient's mental status improved and she was able to be weaned
off pressors. She was empirically covered with
linezolid/cefepime for septic shock for seven days, although her
blood cultures did not grow any microbes. On the floor, her SBPs
were 90s-110s and she was mentating well. Hct remained stable
and guiaiac's were negative. She received 2 units of pRBCs on
hemodialysis ([**6-14**], [**6-21**]), per renal protocol. Her hct and blood
pressure on discharge were XXX and XXX, respectively.
# Osteomyelitis of the right 5th toe: ESR and CRP were elevated
and radiographs of the R foot were suggestive of osteomyelitis
involving the head of the fifth metatarsal and base of the fifth
proximal phalanx. Vascular surgery performed a two-step right
fifth open ray amputation. In light of her many antibiotic
allergies, the patient received empiric therapy with IV
gentamicin and cefazolin, then cefepime. Bone biopsies grew
pseudomonas and MSSA so ID recommended a six week course of
meropenem ([**6-13**]->[**7-24**]). She had a RUE PICC placed by IR for
long-term access (the LUE was avoided given plan to place AV
fistula in LUE) and R IJ was removed. Her wound vac was removed
while she was on the floor and per vascular recs, should
continue to get [**Hospital1 **] dressing changes. She will follow-up with
the vascular clinic in 2 weeks. She is set to complete her
course of meropenem on [**7-24**],
# ESRD: CVVH was initiated while the patient was in shock. This
was eventually transitioned back to HD. The patient received HD
as an inpatient on a T/Th/Sat scheduled without difficulty.
Home calcium acetate and nephrocaps were continued. We gave her
metoprolol on days that she did not get HD. She had an AV
fistula placement on her L upper extremity on [**6-22**].
# Leukocytosis:
On [**6-12**], she developed a leukocytosis of 13.0. There was
erythema, induration and yellow crust around her tunneled HD
line concerning for infection thus her lines were cultured and
there was no growth at the time of discharge. Renal also did
not feel that her HD line was infected. Her WBC trended down
and was in the normal range by [**6-16**] and remained within normal
limits for the remainder of her hospitalization. On discharge,
blood cultures ([**6-9**]) were also negative.
# CHF: Nodal blockade agents were held while in the MICU. She
was on levophed and CVVH while in shock. Repeat TTE showed EF
35%, worsening MR, small LV cavity, RV hypokinesis, and
worsening TR (Echo in [**Month (only) 547**] also w/ dilated RV and global free
wall hypokinesis). CTA was negative for PE. This was thought to
be secondary to volume overload. Fluid was removed as noted
above and her digoxin was eventually restarted. We held her
carvedilol given hypotension and gave her metoprolol on non-HD
days.
# CAD: s/p CABG LIMA->LAD and vein graft to [**Month (only) 11641**]. No chest pain
or anginal symptoms were noted during her hospitalization. Her
home aspirin and simvastatin were continued.
# PVD: s/p multiple amputations. Home plavix was continued.
# DM: Initially was on home glargine 15 units QHS + HISS. Her
BSGs remained elevated so the glargine was increased to 20 units
QHS. Home gabapentin was restarted.
# Depression/Anxiety: Patient w/ AMS while in the ICU, head CT
unremarkable, and infectious w/o stable, lytes stable. Felt to
be ICU delirium. She improved on the floor and remained A&Ox3,
appropriate. She experienced episodes of anxiety and her home
antidepressants were restarted (buproprion and venlafaxine). By
discharge, her mood had improved significantly and she reported
feeling less anxious.
# Vision changes: on [**6-20**], patient reported new onset of
difficulty with vision. She was tested at the bedside and found
to have 20/20 near vision with full visual fields. She does
have a history of myopia. She will see an ophthamologist as an
outpatient.
TRANSITIONAL ISSUES:
- Should follow-up with Vascular Surgery
- Wound care for R 5th digit osteomyelitis: dressing changes [**Hospital1 **]
- Antibiotic treatment of R 5th digit osteomyelitis: meropenem
Q24hrs until [**7-24**]
- You are scheduled to have hemodialysis 3x/week
- Please check the following labs
CBC with differential, BUN/Cr (weekly)
AST/ALT (weekly)
Alk Phos (weekly)
Total bili (weekly)
ESR/CRP (weekly)
All laboratory results should be faxed to the Infectious Disease
R.N.s at ([**Telephone/Fax (1) 4591**]. All questions regarding outpatient
parenteral antibiotics should be directed to the Infectious
Disease R.N.s at ([**Telephone/Fax (1) 21403**] or to the on-call ID fellow when
the clinic is closed.
Medications on Admission:
BUPROPION HCL [WELLBUTRIN SR] - (Prescribed by Other Provider) -
100 mg Tablet Extended Release - 1 Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day
DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 0.5
(One half) Tablet(s) by mouth once a day non HD (MWFSun)
GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule - 1
Capsule(s) by mouth once a day
HYDROXYZINE HCL - (Prescribed by Other Provider) - 25 mg Tablet
- 1 Tablet(s) by mouth Q8H
INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - sliding scale
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100
unit/mL Solution - 15 units q HS
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth
VENLAFAXINE ER - (Prescribed by Other Provider) - 37.5 mg Tablet
- 3 Tablet(s) by mouth once a day
ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg Tablet -
1 Tablet(s) by mouth once a day
CALCIUM ACETATE [CALPHRON] - (Prescribed by Other Provider) -
667 mg Tablet - 2 Tablet(s) by mouth TID with meals
SENNA 2 tabs PO BID
TYLENOL 500mg PO Q4H:PRN pain
OXYCODONE 5mg PO Q4H:PRN pain
COLACE 100mg PO BID
NEPHROCAPS 1 tab PO daily
ASPIRIN 325mg PO daily
FEXOFENADINE 180mg PO daily
GUAIFENISIN 10ML PO Q6H:PRN cough
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 100 mg PO QAM
3. Clopidogrel 75 mg PO DAILY
4. Digoxin 0.0625 mg PO EVERY OTHER DAY
(non-[**Telephone/Fax (1) 2286**] days: [**Last Name (LF) 12075**],[**First Name3 (LF) **])
5. Docusate Sodium 100 mg PO BID
6. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Nephrocaps 1 CAP PO DAILY
8. Senna 1 TAB PO BID
9. Simvastatin 40 mg PO DAILY
10. Meropenem 500 mg IV Q24H Duration: 30 Days
give AFTER HD on [**First Name3 (LF) 2286**] days ([**First Name3 (LF) 12075**]). Last Day is [**7-24**]
11. Sarna Lotion 1 Appl TP QID:PRN itching
12. Ascorbic Acid 500 mg PO DAILY
13. Calcium Acetate 1334 mg PO TID W/MEALS
14. Guaifenesin [**5-3**] mL PO Q6H:PRN cough
15. Fexofenadine 180 mg PO DAILY
16. Gabapentin 100 mg PO DAILY
17. HydrOXYzine 25 mg PO Q8H:PRN itching
18. Venlafaxine XR 112.5 mg PO DAILY depression
19. Lidocaine 5% Patch 1 PTCH TD DAILY
Apply to back.
20. Metoprolol Tartrate 12.5 mg PO BID
Give on non-[**Month/Year (2) 2286**] days (TRS, [**Month/Year (2) 1017**])
21. Pantoprazole 40 mg PO Q12H
22. Outpatient Lab Work
Please check the following labs
CBC with differential, BUN/Cr (weekly)
AST/ALT (weekly)
Alk Phos (weekly)
Total bili (weekly)
ESR/CRP (weekly)
All laboratory results should be faxed to the Infectious Disease
R.N.s at ([**Telephone/Fax (1) 4591**]. All questions regarding outpatient
parenteral antibiotics should be directed to the Infectious
Disease R.N.s at ([**Telephone/Fax (1) 21403**] or to the on-call ID fellow when
the clinic is closed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Osteomyelitis
Bleeding duodenal ulcer
Heart failure
Chronic kidney disease
cardiogenic/hemorrhagic shocking requiring pressors
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 91333**],
It was a pleasure participating in your care at [**Hospital1 18**]. You came
in to the hospital for an elective right fifth toe amputation.
After the procedure your blood pressure dropped and you were
found to have a bleeding duodenal ulcer. This ulcer was clipped
and afterwards your blood counts stabilized. You remained in the
ICU because although your blood pressures were low, you had a
lot of fluid in your body, likely due to your kidney disease and
heart failure. The excess fluid was removed by [**Hospital1 2286**]. You
had an AV fistula placement in your left arm near the end of
your stay.
You were also treated for a bone infection in your right foot
with the antibiotic meropenem. You will need to continue taking
meropenem by the PICC line until [**7-24**]. You initially had a
wound vac over the amputated site but this was removed and you
had gauze dressing that was changed twice daily.
MEDICATION CHANGES:
1) Please stop taking aspirin 325mg daily and start taking a
baby aspirin daily (81 mg).
2) Your bedtime glargine was increased from 15 units to 20
units.
3) You should start taking pantoprazole 40 mg by mouth every 12
hours to prevent ulcers from forming in your stomach.
4) You should start taking metoprolol 12.5 mg twice daily on
non-[**Month/Day (4) 2286**] days to protect your heart
5) You should use sarna cream to prevent itching
6) you should use a lidocaine patch to help with your pain
7) You should continue meropenem antibiotics to treat your bone
infection
FOLLOW-UP APPOINTMENTS: please see below
Followup Instructions:
Infectious Disease --
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2181-6-25**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2181-7-17**] 9:30
Vascular Surgery --
Please follow up with Dr. [**Last Name (STitle) **] in two weeks time. The clinic
will call you to schedule this appointment.
Hemodialysis--
Time: [**2181-6-23**] 7:30 am
|
[
"40391",
"2762",
"4280",
"2767",
"V5867",
"V4581",
"2720",
"2859"
] |
Admission Date: [**2117-5-27**] Discharge Date: [**2117-6-18**]
Date of Birth: [**2117-5-27**] Sex: M
Service: NEONATOLOGY
HISTORY: [**Known lastname **] is a 33-6/7 weeks male, twin #2, born at 0307
p.m. on [**2117-5-27**] via C-section for preeclampsia to a 34-
year-old, G1, para 0, now 2, mother with an [**Name (NI) 37516**] of [**2117-7-9**].
Mother's prenatal labs include blood type O+, antibody
negative, RPR NR, rubella immune, Hep-B surface antigen
negative, GBS unknown.
Pregnancy is notable for IVF assisted di-di twin gestation.
Mother's pregnancy was complicated by preeclampsia and preterm
labor. Mother has Crohn disease, did not require medication
during pregnancy. She received complete betamethasone course
prior to delivery. She received no magnesium or other
antihypertensive medications. She had no intrapartum fever,
and no inrtrapartum antibiotic prophylaxis.
At delivery, baby emerged with good tone;
Apgars [**8-12**]. transferred to NICU for prematurity.
Birthweight 2.025 kg (25th-50th%)
HC 31.5 cm (25th-50th%)
Length 44.5 cm (25th-50th%).
Discharge: Age 22 days, PMA 37 wk
Discharge Weight: 2730 gm
PHYSICAL EXAMINATION:
Vital signs on admission: 98.3, HR 130s, RR 40s, BP 83/40 (51),
O2 sat 91-96% room air. Baby's exam was normal including a three-
vessel cord, normal male testes descended, anus patent.
Normal glucose.
HOSPITAL COURSE:
1. RESPIRATORY: Breathed room air. No oxygen supplementation or
other respr support necessary. Mild apnea/bradycardia/ O2
desaturation episodes; no caffeine therapy. He had no
ap/brady/desat episodes 5 days before discharge.
2. CARDIOVASCULAR status wnl (nl BP. no murmur, nl pulses
His blood pressure is 69/48 (59).
3. FLUIDS, ELECTROLYTES AND NUTRITION: initiated feeds after 24
hours of life. Fed via pg until age 18 days; advanced to all po,
ad lib feeds of breast milk or Similac 24 cal/oz. Continue same
feeding regimen at discharge with iron supplementation and
multivitamins.
4. GI: Maximum bilirubin is 6.4/0.2. No phototherapy.
5. HEMATOLOGY: Sepsis screen performed at birth.
WBC 10.4, HCT 58.2, PLTs 390, normal differential.
He had no furtherHct since birth.
6. INFECTIOUS DISEASE: NO ID issues in NICU.
7. NEUROLOGY: appropriate for PMA. No indication for routine
Head ultrasound.
8. AUDIOLOGY screen: passed bilaterally. Hearing screen was
performed with automated auditory brain stem responses.
9. OPHTHALMOLOGY: No indication for ROP screen. positive red
reflex bilaterally and a normal eye exam externally.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY CARE PEDIATRICIAN: [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 38676**], MD
CARE/RECOMMENDATIONS:
1. Feedings at discharge: Breast milk or Similar 24 calorie
or Similac powder. The baby is on ferrous sulfate and
multivitamins. Iron and vitamin D supplementation is
recommended for preterm and low birth weight infants
until 12 months corrected age, especially while taking
predominantly breast milk.
2. Car seat screening passed.
3. State Newborn Screen was normal ([**5-30**]).
4. Immunizations received: Hepatitis B vaccine [**2117-6-3**].
5. Immunizations recommended: 1) Synagis RSV prophylaxis
should be consider from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following 4 criteria: A) born
at less than 32 weeks, B) Born between 32 and 35 weeks
with 2 of the following: Daycare during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school-aged siblings, C) Chronic lung
disease, D) Hemodynamically significant CHD. 2) Influenza
immunization is recommended annually in the fall or 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 rotavirus vaccine. AP 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 APPOINTMENTS:
1. VNA.
2. Pediatrician.
DISCHARGE DIAGNOSES:
1. Prematurity at 33-6/7 weeks, twin gestation.
2. Apnea of prematurity.
3. Status post circumcision.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) 62246**]
MEDQUIST36
D: [**2117-6-17**] 14:37:25
T: [**2117-6-17**] 15:18:03
Job#: [**Job Number 72868**]
|
[
"V053"
] |
Admission Date: [**2102-8-18**] Discharge Date: [**2102-8-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Cardiac catherization.
History of Present Illness:
[**Age over 90 **] year-old woman with a history of HTN who is now transferred
to the CCU with respiratory distress. She initially presented to
the ED on [**2102-8-18**] with one day of chest pain; she wsa found to
have a-fib with RVR to the 120s in the ED and was thought to
have ST elevations in V2-V4 so she was taken urgently to the
cath lab. At cath, she was found to have mild 3-vessel disease
and no intervention was performed. Her pre- and
post-catheterization labs were notable for a creatinine of 2.2
(baseline unknown). She was given a total of 3 L of IV fluids
today due to her elevated creatinine and urine electrolytes
consistent with prerenal azotemia; she reportedly put out only
about 300cc of urine to this throughout the day.
.
Cardiac review of systems cannot be obtained at this time due to
respiratory distress and acuit of the situation.
Past Medical History:
ypertension
.
Cardiac Risk Factors: Hypertension
.
Cardiac History:
Percutaneous coronary intervention, on [**2102-8-18**] anatomy as
follows:
Selective coronary angiography of this co-dominant system
demonstrates moderate three vessel coronary artery disease. The
LMCA
has 30% proximal stenosis. The LAD has moderate luminal
irregularities with serial 40% elsions and mid vessle 50%
stenosis. The mLCx artery has 50% stenosis with streaming
artifact. The LPLV has 70% stenosis. The pRCA has 60% stenosis
with 50% stenosis in the mid vessel. Limited resting hemodynamic
measurement reveals normal central aortic pressure of
122/79mmHg.
Social History:
Social history is significant for the absence of current tobacco
use (quit 20 yrs ago). There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 96.1, BP 110/75, HR 110, RR 36, O2 % unable to check with
pulse oximeter (PaO2 117 on 4L n.c.)
Gen: Elderly hispanic woman in respiratory distress, answering
questions appropriately
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa; dry mucous
membranes.
Neck: Supple with JVP of 12 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Tachycardic, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were markedly labored, with accessory muscle use. Crackles were
noted throughout both lung fields.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: Modertaley cool with mild cyanosis. No clubbing or edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; trace
DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; trace
DP
Pertinent Results:
[**2102-8-18**] 05:45PM BLOOD WBC-9.4 RBC-3.83* Hgb-12.2 Hct-36.9
MCV-96 MCH-31.9 MCHC-33.2 RDW-14.4 Plt Ct-230
[**2102-8-20**] 06:48AM BLOOD WBC-10.2 RBC-3.24* Hgb-10.2* Hct-32.6*
MCV-101* MCH-31.6 MCHC-31.4 RDW-14.8 Plt Ct-152
[**2102-8-18**] 05:45PM BLOOD Neuts-87.1* Bands-0 Lymphs-7.6* Monos-4.3
Eos-0.7 Baso-0.3
[**2102-8-20**] 06:48AM BLOOD Neuts-87* Bands-1 Lymphs-10* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2102-8-20**] 12:01AM BLOOD Fibrino-90*
[**2102-8-20**] 06:48AM BLOOD FDP-320-640*
[**2102-8-20**] 04:00AM BLOOD Glucose-197* UreaN-64* Creat-2.2* Na-143
K-4.1 Cl-99 HCO3-11* AnGap-37*
[**2102-8-19**] 09:10PM BLOOD ALT-113* AST-152* LD(LDH)-833*
AlkPhos-237* Amylase-134* TotBili-2.1*
[**2102-8-18**] 05:45PM BLOOD cTropnT-0.10*
[**2102-8-19**] 09:10PM BLOOD CK-MB-7 cTropnT-0.11*
[**2102-8-20**] 04:00AM BLOOD CK-MB-9 cTropnT-0.09*
[**2102-8-18**] 05:45PM BLOOD Calcium-9.4 Phos-4.4 Mg-2.3
[**2102-8-20**] 04:00AM BLOOD Albumin-2.5* Calcium-6.9* Phos-7.9*
Mg-2.4
[**2102-8-19**] 05:45AM BLOOD Triglyc-47 HDL-60 CHOL/HD-1.9 LDLcalc-45
[**2102-8-20**] 04:00AM BLOOD Hapto-168
[**2102-8-18**] 05:50PM BLOOD Comment-GREEN TOP
[**2102-8-19**] 09:29PM BLOOD Type-ART pO2-255* pCO2-19* pH-7.24*
calTCO2-9* Base XS--17
[**2102-8-20**] 12:45AM BLOOD Type-ART pO2-554* pCO2-27* pH-7.08*
calTCO2-8* Base XS--21
[**2102-8-20**] 02:02AM BLOOD Type-ART pO2-264* pCO2-26* pH-7.18*
calTCO2-10* Base XS--17 -ASSIST/CON Intubat-INTUBATED
[**2102-8-20**] 04:08AM BLOOD Type-ART pO2-156* pCO2-29* pH-7.25*
calTCO2-13* Base XS--12
[**2102-8-20**] 07:21AM BLOOD Type-ART Temp-36.7 FiO2-40 pO2-154*
pCO2-29* pH-7.33* calTCO2-16* Base XS--9 Intubat-INTUBATED
[**2102-8-19**] 08:38PM BLOOD Lactate-14.9* K-4.6
[**2102-8-20**] 12:45AM BLOOD Lactate-16.3*
[**2102-8-20**] 07:21AM BLOOD Glucose-235* Lactate-11.4*
Brief Hospital Course:
Patient had a cardiac catherization without finding occlusive
disease. She tolerated the procedure well. One day following,
the patient was [**Last Name (un) 4662**] the CCU in respiratory distress. Patient
was intubated, and ventilation was stabilized. She had a
progressive lactic acidosis. She eventually had a cardiac
arrested and was unsucessfully coded. On autopsy, patient was
found to have multiple thrombosis, including large pumonary
embolisms.
Medications on Admission:
aspirin 325mg daily
pantoprazole 40mg daily
metoprolol 12.5mg [**Hospital1 **]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary collapse
Discharge Condition:
Expired
|
[
"41071",
"5849",
"5859",
"2762",
"42731",
"0389",
"41401"
] |
Admission Date: [**2190-7-27**] Discharge Date: [**2190-8-2**]
Date of Birth: [**2129-9-8**] Sex: F
Service: ORTHOPAEDICS
Allergies:
doxycycline
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation L4-S1
History of Present Illness:
Ms. [**Known lastname **] has a long history of back and leg pain. She has
undergone a previoius scoliosis fusion and now requires an
extension.
Past Medical History:
PMH/PSH:
-Lumbar spondylosis and stenosis.
-Hypertension
-History of childhood polio
-History of scoliosis s/p rod placements.
-History of right ICA possible source of embolism, right
retinal artery occlusion noted on incidental finding for an eye
exam, question fibromuscular disease, now s/p angiography
revealing no selective carotid artery disease
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2190-8-1**] 05:20AM BLOOD WBC-7.2 RBC-3.58*# Hgb-11.1*# Hct-32.3*#
MCV-90 MCH-31.2 MCHC-34.5 RDW-15.4 Plt Ct-210
[**2190-7-31**] 05:30AM BLOOD WBC-6.8 RBC-2.59* Hgb-8.3* Hct-23.4*
MCV-90 MCH-32.1* MCHC-35.6* RDW-14.9 Plt Ct-163
[**2190-7-30**] 05:43AM BLOOD Hct-27.7*
[**2190-7-30**] 02:52AM BLOOD WBC-10.5 RBC-3.15* Hgb-9.7* Hct-26.7*
MCV-85 MCH-30.7 MCHC-36.2* RDW-15.1 Plt Ct-121*#
[**2190-7-31**] 05:30AM BLOOD Glucose-123* UreaN-3* Creat-0.3* Na-140
K-3.8 Cl-104 HCO3-32 AnGap-8
[**2190-7-30**] 02:52AM BLOOD Glucose-163* UreaN-7 Creat-0.4 Na-134
K-3.3 Cl-99 HCO3-30 AnGap-8
[**2190-7-29**] 03:22PM BLOOD Glucose-138* UreaN-8 Creat-0.4 Na-132*
K-3.7 Cl-101 HCO3-27 AnGap-8
[**2190-7-28**] 09:26PM BLOOD Glucose-174* UreaN-8 Creat-0.5 Na-138
K-3.9 Cl-109* HCO3-24 AnGap-9
[**2190-7-31**] 05:30AM BLOOD Calcium-7.5* Phos-2.2* Mg-2.1
[**2190-7-30**] 02:52AM BLOOD Calcium-7.5* Phos-2.2* Mg-2.0
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2190-8-2**] and taken to the Operating Room for L4-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled L4-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery incurred substantial
bleeding and she was transfered to the SICU for hemodynamic
monitoring. Postoperative HCT was low and she was transfused
with good effect. She was kept NPO until bowel function
returned then diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed on POD#3 from the second procedure. He was
fitted with a lumbar warm-n-form brace for comfort. Physical
therapy was consulted for mobilization OOB to ambulate. Hospital
course was otherwise unremarkable. On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet.
Medications on Admission:
synthroid 125', ASA, Lisinopril 40', multivitamins, metop 50'
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 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. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
5. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
7. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q8H (every 8 hours).
Disp:*90 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
Lumbar disc degeneration and scoliosis
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressings daily
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2190-8-2**]
|
[
"2851",
"2449",
"4019",
"2724",
"53081",
"311"
] |
Admission Date: [**2159-11-17**] Discharge Date: [**2159-11-22**]
Service: SURGERY
Allergies:
Salicylates
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 year old female with CHF, COPD, schizoaffcetive, tardive
dyskinesia presents from OSH with 1 day of nausea and vomiting
and abdominal pain. She is non-verbal, presenting originally
from Nursing home. Was febrile at OSH with elevated WBC and
distended abdomen, NGT placed and CT scan obtained. Ct showed
largely distended gallbladder with stranding and assiciated
small bowel distention likely ileus in setting of
peri-gallbladder inflammation. Received Cipro/Flagyl, foley,
IVF, and was transferred here to [**Hospital1 18**] ED.
Past Medical History:
COPD, HTN, CHF, GL bleed, schizaffcetive psychosis, tardive
dyskinesia, epilepsy, CAD, DJD, uterine CA s/p radiation therapy
complicated by proctitis.
Social History:
Resides at skilled nursing facility. Sister, [**Name (NI) **], is HCP. [**Name (NI) **]
alcohol or tobacco.
Family History:
Non-contributory.
Physical Exam:
Tm103.6/Tc 99 HR 111 BP 117/54 RR 27 02sat 98% 6l NC
GEN: Elderly woman lying in bed in acute distress,
tachypnic,uncomfortable appearing alert to person, no jaundice,
no sceral icteris, MMdry
HEENT: NGT in place, draining bilous output
CARDIAC: tachycardic
LUNGS: decreased BS bilaterally
ABD: distended, tympanic, diffusely tender with no rebound or
guarding
RECTAL: gauaic +
EXTREM: 1+ edema, warm extremities
Pertinent Results:
On Admission:
[**2159-11-17**] 06:05PM POTASSIUM-3.3
[**2159-11-17**] 06:05PM CALCIUM-9.1 MAGNESIUM-1.9
[**2159-11-17**] 10:16AM GLUCOSE-130* UREA N-22* CREAT-0.8 SODIUM-140
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-30 ANION GAP-13
[**2159-11-17**] 10:16AM CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-2.1
[**2159-11-17**] 10:16AM WBC-9.2 RBC-4.35 HGB-12.6 HCT-38.4 MCV-89
MCH-29.0 MCHC-32.8 RDW-14.0
[**2159-11-17**] 10:16AM PLT COUNT-152
[**2159-11-17**] 10:16AM PT-15.8* PTT-31.3 INR(PT)-1.4*
[**2159-11-17**] 05:36AM TYPE-ART PO2-182* PCO2-48* PH-7.40 TOTAL
CO2-31* BASE XS-4
[**2159-11-17**] 05:36AM GLUCOSE-118* LACTATE-1.0 NA+-139 K+-3.0*
CL--98*
[**2159-11-17**] 05:36AM freeCa-1.02*
[**2159-11-17**] 01:32AM LACTATE-1.6
[**2159-11-17**] 12:20AM GLUCOSE-139* UREA N-22* CREAT-1.0 SODIUM-138
POTASSIUM-3.6 CHLORIDE-92* TOTAL CO2-34* ANION GAP-16
[**2159-11-17**] 12:20AM ALT(SGPT)-14 AST(SGOT)-23 ALK PHOS-73 TOT
BILI-0.8
[**2159-11-17**] 12:20AM LIPASE-12
[**2159-11-17**] 12:20AM CARBAMZPN-7.8
[**2159-11-17**] 12:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-9.0* LEUK-TR
[**2159-11-17**] 12:20AM URINE RBC-[**11-30**]* WBC-[**6-20**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2159-11-17**] 12:20AM URINE HYALINE-0-2
[**2159-11-17**] 12:20AM URINE MUCOUS-FEW
.
[**2159-11-17**] OUTSIDE HOSPITAL ABD/PELVIC CT:
1. Distended gallbladder, with fat stranding, suspicious for
acute cholecystitis.
2. Proximal dilated loops of small bowel with decompressed loops
of distal bowel, concerning for small-bowel obstruction with no
definite transition point identified.
3. Cystic structure in the left pelvic area, could be from
ovarian etiology, or peritoneal inclusion cyst (surgical clips
seen in the adjacent area). Pelvic ultrasound can ne done in a
non-urgent setting to evaluate further.
.
[**2159-11-17**] (R)UQ Ultrasound:
Limited scan due to positioning of the gallbladder, and the
patient unable to cooperate; however, dilated gallbladder with
possible cholelithiasis is seen.For more detail, please refer to
CT scan report form the same day.
.
[**2159-11-17**] AP CXR:
As compared to the previous radiograph, the pre-existing left
retrocardiac opacity is unchanged. Also unchanged is the
probable accompanying small left pleural effusion. Otherwise,
the radiograph is unchanged. There is no evidence of pulmonary
edema.
.
[**2159-11-19**] AP CXR:
As compared to the previous examination, the pre-existing
retrocardiac opacity, accompanied by a small pleural effusion
has minimally increased in extent. The nasogastric tube has been
removed. A newly appeared small atelectasis is seen at the right
lung bases. Unchanged size of the cardiac silhouette. No
pneumothorax.
.
[**2159-11-20**] AP CXR:
In comparison with the study of [**11-19**], there are continued low
lung volumes. Retrocardiac opacification with blunting of the
costophrenic angle persists, consistent with atelectasis and
effusion. Minimal basilar atelectasis is seen on the right
medially. Upper lung zones are clear.
.
MICROBIOLOGY:
[**2159-11-17**] Blood Culture x2: No growth to date.
[**2159-11-17**] Urine Cx: No growth - Final.
[**2159-11-17**] MRSA Screen: Negative - Final.
[**2159-11-18**] Blood Culture x2: No growth to date.
Brief Hospital Course:
The patient was transferred from an Outside Hospital (OSH), and
admitted to the General Surgical Service in the TICU on [**2159-11-17**]
for evaluation of the aforementioned problems. The
abdominal/pelvic CT from the OSH was reviewed, which revealed
acute cholecytitis and findings consistent with small bowel
obstruction. She was made NPO, started on IV fluids and empiric
antibiotic therapy with Zosyn, a foley catheter, central IV
access, and A-line were placed, and she was given Morphine IV
PRN for pain with good effect. After discussion regarding her
condition, poor prognosis and high surgical risk between the
patient, her sister [**Name (NI) **] [**Name (NI) **], the [**Hospital 228**] Health Care Proxy
(HCP), and Dr. [**Last Name (STitle) **], the patient was made DNR/DNI. The sister
declined percutaneous drain placement as well. Overall, the
patient was hemodynamically stable.
.
While in the TICU, the patient was given a fluid bolus of 250mL
followed by albumin and lasix to promote diuresis for low urine
output. Metoprolol IV was given PRN for hypertension and
tachycardia. Pain remained well controlled with Morphine IV PRN.
By HD#3, IV fluid was changed to maintenance and Vancomycin IV
was added to antibiotic regimen. Started on sips for comfort.
Urine output remained good. Patient experienced elevated
temperature, but was not re-cultured. Abdominal pain was
somewhat improved on its own.
.
On HD#4, the patient was transferred to the inpatient floor.
DNR/DNI order was continued. She remained on sips, IV fluids,
and IV antibiotics. She remained comfortable with Morphine IV
PRN or acetaminophen. The patient was made comfortable. On HD#5,
the patient was feeling much better. Her diet was advanced to
clears with good tolerability. IV antibiotics were discontinued,
and she was started on a course of oral Ciprofloxacin and Flagyl
for a total of two weeks. Physical Therapy was consulted to
improve activity tolerance. Social Work was consulted to provide
psychosocial support to the patient and family. Labwork and
other invasive interventions were minimized. Ultimately, it was
determined by the family in consultation with the inpatient team
that the patient return to the Skilled Nursing Facility, whence
she came, with Hospice.
.
On HD#6, the patient's diet was advanced to regular with good
intake and tolerability. She required only acetaminophen for
pain. IV fluids, the CVL, and foley were discontinued. She was
subsequently able to void without problem. The patient's sister,
[**Name (NI) **] (HCP) was again consulted regarding the discharge plan,
and concurred.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance, voiding without assistance,
and pain was well controlled. She was discharged back to the
skilled nursing facility with Hospice. The patient and family
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
1. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 3.5 Tablet, Rapid
Dissolves PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever / pain.
4. Ondansetron 4 mg IV Q8H:PRN nausea
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Carbamazepine 300 mg Cap, Multiphasic Release 12 hr Sig: One
(1) Cap, Multiphasic Release 12 hr PO twice a day.
12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for Anxiety, restlessness.
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO once a
day.
14. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
15. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One
(1) neb Inhalation four times a day as needed for shortness of
breath or wheezing.
16. Other: Fleets enema PR as directed qday PRN severe
constipation
Discharge Medications:
1. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 3.5 Tablet, Rapid
Dissolves PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever / pain.
4. Ondansetron 4 mg IV Q8H:PRN nausea
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 12 days.
Disp:*36 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Carbamazepine 300 mg Cap, Multiphasic Release 12 hr Sig: One
(1) Cap, Multiphasic Release 12 hr PO twice a day.
14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for Anxiety, restlessness.
15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO once a
day.
16. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
17. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One
(1) neb Inhalation four times a day as needed for shortness of
breath or wheezing.
18. Other:
Fleets enema PR as directed qday PRN severe constipation
19. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for Breakthrough pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**] health Care Center
Discharge Diagnosis:
Primary:
1. Acute cholecytitis
2. Proximal ileus
3. Sepsis
.
Secondary:
1. CHF
2. COPD
3. Schizoaffective disorder
4. Tardive dyskinesia
5. Possible dementia
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
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 [**5-20**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Follow-up with the surgeon and your Primary Care Provider (PCP)
as advised.
Followup Instructions:
Please call ([**Telephone/Fax (1) 82598**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) **] (PCP) in 2weeks.
Completed by:[**2159-11-22**]
|
[
"0389",
"4280",
"496"
] |
Admission Date: [**2119-10-26**] Discharge Date: [**2119-11-2**]
Date of Birth: [**2093-8-8**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: A 25-year-old male status post
motor vehicle accident in [**2119-6-22**]. Injuries sustained
included an intracranial hemorrhage, subarachnoid hemorrhage,
left temporal contusion, C2 ring fracture, as well as splenic
and hepatic lacerations, pneumothorax. The patient was
admitted on the 5th for a cervical fusion.
PAST MEDICAL HISTORY:
1. Only significant for the injuries related to the motor
vehicle accident in [**2119-6-22**].
2. Splenic rupture status post splenectomy.
3. Pneumothorax.
4. Aspiration pneumonia.
5. Subdural and subarachnoid hemorrhages status post
ventriculostomy.
6. Pelvic fracture.
7. C2 fracture.
8. Multiple rib fractures.
9. Vertebral artery trauma.
10. Tracheostomy.
11. PEG tube.
PHYSICAL EXAMINATION UPON ADMISSION: Alert and oriented,
follows commands. Poor verbal ability. The patient has left
hemiparesis. Is able to wiggle toes on the left side. Does
have a left facial droop. Strength is [**2-24**] right upper
extremity, [**3-26**] right lower extremity, 0/5 left upper
extremity, 0/5 left lower extremity. Reflexes 3+ on the
left, knees, biceps, triceps, and wrist, and normal on the
right. Patient presents a Foley, PEG tube, and a trache
tube.
LABORATORIES: Laboratories are within normal limits.
HOSPITAL COURSE: On [**10-27**], he was taken to the
operating room for a cervical fusion. Postoperative course
was only significant for spiking temperatures. Cultures were
sent and they are still pending. Temperatures resolved on
their own. The patient has been afebrile for the last 24
hours prior to discharge. Neurologically, he remains
unchanged and is stable. He will be discharged to
rehabilitation.
DISCHARGE MEDICATIONS:
1. Dilantin 100 mg po tid.
2. Percocet [**3-31**] mL po q4-6 prn.
3. Docusate 100 mg po bid.
4. Lactulose 30 mL q8 prn.
5. Albuterol 1-2 puffs inhaled q6 prn.
6. Tylenol 325-650 mg nasogastric q4-6 prn.
7. Profenicin 15 mL nasogastric q day.
8. Scopolamine patch one patch q72h.
FOLLOWUP: Followup after discharge will be in [**11-23**] weeks with
Dr. [**Last Name (STitle) 1327**].
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2119-11-1**] 11:49
T: [**2119-11-1**] 12:16
JOB#: [**Job Number 38891**]
|
[
"5990"
] |
Admission Date: [**2193-4-13**] Discharge Date: [**2193-4-25**]
Date of Birth: [**2125-5-9**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname 22559**] is a
67-year-old female with a history of severe mitral
regurgitation, who recently underwent mitral valve
replacement two weeks prior to admission, complicated only by
a brief episode of postoperative bradycardia. The patient
for a visit on the day of admission due to worsening
shortness of breath, cough, and paroxysmal nocturnal dyspnea
with orthopnea since she went home. She was sent to the
Emergency department from [**Hospital **] Clinic via ambulance.
On further questioning through the translator, the patient
reported that she was feeling ill on her day of discharge,
discharge she had developed worsening cough, producing white
phlegm and occasional blood-tinged sputum, but never yellow
or green. She reported that she had not been able to sleep,
and she has not been able to lie flat, and she has been
sitting in a chair at night. She denied any fever, chills,
or any chest pain. She denied any nausea or vomiting, but
she had one episode of frequent loose stools. She denied any
melena or hematochezia. She denied any palpitations.
In the emergency department, the patient was found to have
bibasilar crackles and an elevated jugular vein at
10 cm to 12 cm. A portable chest x-ray result was reported
to show congestive heart failure and right sided pleural
effusion. The patient was given 40 mg IV Lasix with good
output. The patient was given Levofloxacin for questionable
UTI by urine dipstick. Blood cultures were not obtained.
The patient was transferred to [**Hospital Ward Name 121**] 3.
PAST MEDICAL HISTORY:
1. Paroxysmal atrial fibrillation.
2. Mitral regurgitation, mitral valve prolapse status post
mitral valve replacement in [**2193-3-8**].
3. Hypertension.
4. Congestive heart failure.
5. History of dental abscess.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o.q.d.
2. Colace 100 mg one tablet b.i.d.
3. Potassium chloride 20 mEq p.o.b.i.d.
4. Lasix 20 mg p.o.one tablet b.i.d.
5. Percocet 5/325 one to two tablets q.4h. to 6h.p.r.n.
6. Lipitor 20 mg p.o. one tablet q.h.s.
7. Amiodarone 200 mg p.o.q.d.
8. Mavik 4 mg p.o.q.d.
9. Coumadin 1 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient smoked in the past, no alcohol
history. She lives with her sister.
PHYSICAL EXAMINATION: Examination revealed the following:
Heart rate 96 and irregular, blood pressure 124/70,
respiratory rate 22, oxygen saturation 99% on three liters
nasal cannula. GENERAL: The patient is an alert, awake
female looking slightly tremulous and short of breath upon
speaking. Head, eyes, ears, nose, throat: Examination
demonstrated mucous membranes mildly dry, no icterus.
Conjunctiva, pallor found. CARDIOVASCULAR: S1 metalic, soft
1/6 systolic murmur, irregular rhythm.
PULMONARY: Right decreased air entry in the lower chest,
crackles and rubs in mid chest left basilar crackles, no
wheezing, postoperative wound well approximated, no apparent
drainage, no pain over the chest wound. ABDOMEN:
Nondistended, nontender, positive bowel sounds, no mass,
right flank changes with local skin breakdown extending into
the right hip, back, and buttock regions. Possible resolving
hematoma. RECTAL: Rectal examination revealed no
obstipation, guaiac-negative stool. EXTREMITIES: No lower
extremity edema. No calf tenderness. NEUROLOGICAL: The
patient is alert, awake, oriented times three; appears to
answer appropriately to questions, moving all four
extremities, asymmetric.
LABORATORY DATA: Labs upon admission revealed the following:
White count 18.2, hematocrit 27.8, platelet count 781,000, PT
21.6, PTT 39.5, INR 3.2. Sodium 128, potassium 5.3, chloride
92, bicarbonate 25, BUN 17, creatinine 0.8, glucose 165, CK
222, troponin less than 0.3. Urinalysis showed 3 to 5 white
cells plus nitrites. Catheterization results on [**2193-2-26**] revealed the coronary arteries normal,
moderate-to-several mitral regurgitation plus severe mitral
annular calcification and normal ventricular function with a
EF of 64%.
HOSPITAL COURSE:
CARDIOVASCULAR: The patient was maintained on telemetry and
[**Hospital Unit Name **] service. By ECHO, she was subsequently found to have an
approximately 500 cc pericardial effusion, which was drained
percutaneously without any complications. Coumadin was held
prior to procedure and ordered to decrease the INR to less
than two. Also, after the patient's pericardiocentesis she was
cardioverted secondary to her atrial fibrillation; it was
successful. The patient was maintained in normal sinus
rhythm throughout the course of her stay.
RESPIRATORY: The patient also was found to have a right phrenic
nerve paresis, likely temporary as the nerve was not
transected, apparently irritated during the mitral valve
replacement procedure. She was found to have a left-sided
pleural effusion, which was successfully drained by the
pulmonary fellow. Fluid was sent off for analysis and no
infection or malignancy was found.
The patient's symptoms improved. She has a baseline
shortness of breath when she lies down, however, she had no
worsening of shortness of breath, cough, or chest pain
throughout the course of stay.
HEMATOLOGY: The patient was restarted on her Coumadin with a
Coumadin load secondary to her atrial fibrillation history,
as well as prosthetic valve. It was considered crucial that
her INR is at least 2.5 before she is discharged. She was to
follow-up with the [**Hospital 197**] Clinic.
DISCHARGE DIAGNOSES:
1. Mitral valve replacement.
2. Pericardial effusion, status post pericardiocentesis.
3. Left pleural effusion status post right thoracocentesis.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg p.o.q.d. until [**2193-4-29**] and
then 200 mg p.o.q.d.
2. Lipitor 20 mg p.o.q.h.s.
3. Mavik 4 mg p.o.q.d.
4. Coumadin 5 mg p.o.q.h.s.
5. Iron sulfate 325 mg p.o.q.d.
6. Lasix 40 mg p.o.q.d.
7. Captopril 6.25 p.o.t.i.d.
8. Calcium carbonate 500 mg p.o.t.i.d.
DISCHARGE INSTRUCTIONS: The patient is to followup with her
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**5-1**] at 2:30. She
is to followup with Dr. [**Last Name (STitle) 1911**], her cardiologist on
[**5-2**], 4:15 and Dr. [**Last Name (STitle) 1537**], her CT surgeon [**4-30**] at
10 a.m. She was also to call the [**Hospital 197**] Clinic at
[**Telephone/Fax (1) 2173**] for follow up care.
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
[**MD Number(1) **]
Dictated By:[**First Name3 (LF) 22560**]
MEDQUIST36
D: [**2193-4-25**] 15:16
T: [**2193-4-25**] 15:40
JOB#: [**Job Number **]
|
[
"4280",
"5119",
"42731",
"4019",
"2859"
] |
Admission Date: [**2130-9-22**] Discharge Date: [**2130-9-26**]
Date of Birth: [**2049-5-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
aortic insufficiency and coronary artery disease
Major Surgical or Invasive Procedure:
aortic valve replacement(23mm tissue)/Replacement of ascending
aorta/coronary artery bypass graft(LIMA->LAD) [**2130-9-22**]
History of Present Illness:
This 81 year old male has known aortic valve insufficiency and
exertional angina for years, followed with serial echos. he has
recently had increasing symptoms and was catheterized to show
severe insufficiency, 90% LAD and ramus disease along with a
dilated root and LV. He wa referred for elective surgery for
which he was admitted for at this time.
Past Medical History:
aortic insufficiency
coronary artery disease
ascending aortic dilatation
peripheral vascular disease
h/o deep vein thrombophlebitis
Social History:
retired electronics assembler
rare ETOH use
never smoked
Family History:
father died of stroke at 44 years old
Physical Exam:
admission:
Pulse: Resp:14 O2 sat:98%(RA)
B/P Right:140/60 Left: 140/58
Height68": Weight:75kg
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 Gr. 3-4/6 SEM w/ gr.2
diastolic component
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema /Varicosities:
spider veins B LE. Few superficial varicosities LLE
Neuro: Grossly intact
Pulses:
Femoral Right:3 Left:3
DP Right:3 Left:3
PT [**Name (NI) 167**]:3 Left:3
Radial Right:3 Left:3
Carotid Bruit Right: N Left:N
Pertinent Results:
[**2130-9-26**] 05:50AM BLOOD WBC-8.5 RBC-3.22* Hgb-9.8* Hct-29.4*
MCV-91 MCH-30.3 MCHC-33.2 RDW-14.7 Plt Ct-128*
[**2130-9-25**] 02:54AM BLOOD WBC-13.4* RBC-3.11* Hgb-9.6* Hct-28.6*
MCV-92 MCH-30.7 MCHC-33.4 RDW-14.9 Plt Ct-100*
[**2130-9-26**] 05:50AM BLOOD Glucose-123* UreaN-33* Creat-0.9 Na-139
K-4.1 Cl-104 HCO3-26 AnGap-13
Brief Hospital Course:
Following admission he went to the operating [**Last Name (un) **] where valve
replacement,ascending arch replacement and single coronary
artery grafts were performed. See operative note for details.
he weaned from bypass on Nitroglycerin and propofol in stable
condition.
His postoperative CXR revealed a "deep sulcus sign" and a CT was
placed. He was extubated easily and remained stable. He was
begun on beta blockers, diuretics and the nitroglycerin was
weaned off. Physical therapy saw and worked with the patient
for mobility and strength. His CTs were removed uneventfully
and subsequent CXRs were satisfactory.
His pacing wires were likewise removed and his wounds were
healing well at discharge. He was ambulatory and ready for
discharge when sent home.
Instructions were discussed with him, as well as restrictions
and follow up plans.
Medications on Admission:
ASA intermittently(upset stomach),proscar
5mg/D,Cyannocobalamin 500mcg/d,Omega 3
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
ascending aortic aneurysm
aortic insufficiency
coronary artery disease
h/o deep vein thrombophlebitis
Peripheral vascular disease
Discharge Condition:
Good.
Discharge Instructions:
Take medications as directed on discharge instructions.
Do not drive for 4 weeks or while taking any narcotics.
Do not lift more than 10 pounds for 10 weeks.
Shower daily,pat insicions dry.
Do not use lotions, creams, or powders on wounds.
Call our office for temperature >101.5, redness of, or drainage
from the incisions.
Followup Instructions:
Dr. [**Last Name (STitle) 10740**] for 1-2 weeks ([**Telephone/Fax (1) 40144**]).
Dr. [**Last Name (STitle) 7047**] for 2-3 weeks.
Dr. [**Last Name (STitle) **]( [**Telephone/Fax (1) 170**]) for 4 weeks.
Completed by:[**2130-9-26**]
|
[
"4241",
"9971",
"42731",
"41401"
] |
Admission Date: [**2146-5-9**] Discharge Date: [**2146-5-15**]
Date of Birth: [**2062-12-7**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Transfer from outside hosptial after ventricular fibrillation
arrest in setting of bradycardia
Major Surgical or Invasive Procedure:
Cardiac catheterization, Pacemaker placement
History of Present Illness:
Patient is an 83 year old female with coronary artery disease
status post bare metal stent to LCx on [**2146-3-8**], severe MR, COPD,
CHF EF 35-40%, [**Hospital **] transferred from [**Hospital3 **] with recurrent
ventricular fibrillation arrest.
Pt admitted [**Hospital1 18**] [**3-8**] from [**Hospital3 **] (where stress thalium
showed ant/lat ischemia, TTE showed [**1-25**]+MR) for increasing
shortness of breath, had CCath [**3-8**] revealed patent LMCA, mod
diagonal LAD stenosis, 90% proximal lesion in LCx intervened on
with BMS. Pt noted to have severe MR [**1-25**]+, but bc of her PVD,
her age, calcified aorta, MVR felt to be too risky. Pt
discharged to rehab.
Pt admitted mid-[**Month (only) 116**], per report and DC summary, for heart
failure, initiated on Bumex gtt, discharged to rehab (these
records not available to me).
Pt was readmitted to [**Hospital3 **] for "weakness and confusion"
on [**5-3**]. She was treated with ctx for unknown reason and
diuresed. Due to Afib with rapid heart rate, iv dig loaded
[**5-5**], [**5-6**], and [**5-8**] (total 1.125mg). On [**5-8**] pm, 1 episode of
vtach with spontaneous conversion, then 1 episode of v-fib
requiring DC cardioversion, prompting iv amio load and gtt and
then lidocaine (unknown time of start). In AM [**5-9**], 8 episodes
of vfib requiring defibrillation(7:20am - 8:20am), intubated,
reverted to sinus rhythm. HR dropped to mid-30s with BP in 80s,
given atropine and dopamine gtt, both amio and and lidocaine
discontinued. Pt given two doses of digibind for dig toxicity
concern. Pt trasnferred to [**Hospital1 18**] for EP consult and possible
cardiac cath in AM for LCx disease causing ischemia-related
arrythmia.
ROS unable to be obtained at this time due to patient
sedation and mechanical ventilation.
Past Medical History:
- Hip fracture with ORIF in [**1-28**] c/b postop PAF and CHF. Placed
on amiodarone and Lasix
- h/o PAF
- moderate to severe MR (grade [**1-25**] several months ago at NEBH)
- mod pulm HTN
- Left carotid endarterectomy on [**2135-9-24**].
- Coronary artery disease. Angina and chest pain. She gets this
once a month usually resolved after one dose of sublingual
Nitroglycerin
- Congestive heart failure; EF 35-40% in [**2136**]
- Chronic obstructive pulmonary disease
- Hypertension
- Hypercholesterolemia
- h/o R MCA infarct [**2136**]
- PVD
- s/p hysterectomy and appendectomy
- h/o breast CA treated with lumpectomy and tamoxifen
Cardiac Risk Factors: Dyslipidemia, Hypertension
Social History:
The patient lives with her husband and grandson. She is retired
from a factory. The patient has a [**11-24**] pack smoking history of
forty years and quite in [**2136**] s/p CVA. She rarely drinks a glass
of wine with dinner. She has [**Location (un) 86**] VNA services in her home,
along with weekly housekeeping. She has been a rehabilitation
since her last admission.
Family History:
The patient's father died of cancer. The patient's mother died
of coronary artery disease and diabetes mellitus in the [**2117**].
Physical Exam:
On admission:
VS: T 98, BP 120/48, HR 54, RR 12, ac tv 500 f12 98% FiO2 0.40
Gen - elderly female, NAD, responsive to command. answers
questions but not fully appropriately, can repeat her name.
unsure of where she is. Pleasant. Multiple ecchymotic lesions
on upper torso and upper extremities.
HEENT - sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. Temporal wasting.
Neck: Supple with JVP unappreciable.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. Tender to exam at L 3rd ic
space.
Lungs - minimal crackles at bases, wheeze, rhonchi.
Abd - obese, soft, NTND, No HSM or tenderness. No abdominial
bruits. R breast with 2cm by 2cm nodule on underside of breast.
Ext: No c/c/e. No femoral bruits. MSK [**1-26**] bil LE, could not
lift legs off of bed bil symmetric.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
EKG - tele strips available from OSH - periods of polymorphic
vtach and monomorphic vtach.
[**2146-3-9**] - NSR, bl 1st degree av block, prwp
[**2146-5-3**] - tele, irregular, likely afib, hr 110s with exertion
[**2146-5-3**] - aflutter, +lvh by aVL criteria, rate 90
[**2146-5-4**] - afib, vent rate 105, nl axis, st depressions v5-v6
[**2146-5-5**] - nsr, early transition, nl axis, nl intervals
[**2146-5-8**] - nsr, with regular PVC? following each sinus qrs
[**2146-5-8**] - polymorphic VT
[**2146-5-9**] - pvc --> polymorphic vt
[**2146-5-9**] - 'junctional escape' with bradycardia to 41, LAD
TELE here - idioventricular rhythm, no identifiable p-waves.
sinus bradycardia
Cardiac Cath [**2146-5-10**]
COMMENTS:
1. Coronary angiography of this left dominant system
demonstrated no
angiographically apparent flow-limiting coronary artery disease.
The
LMCA had mild luminal irregularities. The LAD had a small
diagonal
branch that had a 70% stenosis. The LCx had mild in-stent
restenosis.
Radi pressure wire was performed across this stenosis and showed
an FFR
of 0.97 after maximal hyperemia with IV adenosine. The RCA was
small
and non-dominant.
2. Limited resting hemodynamics revealed mild systemic arterial
systolic
hypertension at 155/64 mmHg.
3. Successful femoral artery closure with Angioseal VIP.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Mild systemic arterial systolic hypertension.
Echocardiogram [**2146-5-10**]
The left atrium is mildly dilated. The left atrial volume is
markedly increased (>32ml/m2). Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is severe global left ventricular hypokinesis (LVEF = 25 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.]
Transmitral Doppler and tissue velocity imaging are consistent
with Grade II (moderate) LV diastolic dysfunction. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. The mitral valve leaflets
are mildly thickened. There is moderate thickening of the mitral
valve chordae. Moderate to severe (3+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2137-6-24**], the
left ventricle is more dilated with worsened systolic function.
The findings of mildly depressed right ventricular function,
moderate to severe mitral regurigtation are similar.
Brief Hospital Course:
Patient is an 83 year old female with history of paroxysmal
atrial fibrilation, hypertension, hyperlipidemia, severe mitral
regurgitation, and coronary artery disease, who was transferred
from [**Hospital6 2910**] after polymorphic ventricular
tachycarida and fibrillation arrest in setting of bradycardia
and prolonged QTc, status post multiple defibrillations.
.
CARDIOVASCULAR:
# Coronary artery disease: Patient had underwent catherization
on [**2146-3-8**] which showed patent LMCA, moderate diagonal LAD
stenosis, and a 90% proximal lesion in LCx, to which a bare
metal stent was placed. At outside hosptial, her CKs were not
elevated. On admission, repeat cardiac enzymes were negative.
Given concern that ischemia could be contributing to her
arrhythmia and worsening of her mitral regurgitation, she
underwent cardiac catherization on [**2146-5-10**]. There were no
signs of new coronary occlusions, with a stable LCx stented
lesion. Patient was initially treated with ASA 325 mg, however
this was changed to 81 mg enteric coated once she was noted to
have guaiac positive stool. She was also treated with plavix 75
mg, and a statin (on fluvastatin 40 mg as an outpatient,
tolerated atorvastatin 80 mg as in patient). She did not
initially tolerate a beta-blocker (developing bradycardia after
once dose of 12.5 mg), but was restarted on metoprolol at 12.5
mg twice daily following pacer placement. She received 3 days
of antibiotics for procedure prophylaxis, and was monitored on
telemetry during entire admission.
.
# Congestive heart failure, mitral regurgitation: Patient was
admitted with chronic systolic heart failure. Her last echo at
[**Hospital1 18**] was in [**2136**], which demonstrated an ejection fraction of
40%, with other reports demonstrating ECHO 60% more recently. A
repeat transthoracic echocardiogram on [**2146-5-10**] demonstrated an
ejection fraction of 25%, suggestive of interval myocardial
infarction versus variable estimate of mitral regurgitation
leading to variable calculated EF. Patient had been on
significant dose of lasix (80 mg twice daily) as outpt, and
recently treated for congestive heart failure with bumex drip in
setting of severe mitral regurgitation. Was kept on PRN Lasix
boluses and maintained good O2 sats. CXR showed stable L pleural
effusion, stable cardiomegaly. She will require repeat Echo at
3 months.
.
# Rhythm - Pt had had a number of arrhythmias in the week prior
to admission - afib with tachy-brady syndrome upon presentation
to [**Hospital3 **], phase of polymorphic vtach [**5-8**] with reported
vfib arrest s/p defibrillations x10, presented to [**Hospital1 18**] with
idioventricular, narrow complex rhythm with bradycardic rate in
40s, now in sinus rhythm 60s. Of note, pt was on amiodorone on
[**5-3**] to [**5-8**] at [**Hospital3 **], then amio IV loaded on [**5-8**], with
addition of lidocaine. Also, dig loaded over past 4 days. On
dopamine [**2054-5-7**] for positive chronotropy. BB initiated [**5-9**],
but held for bradycardia lasting approx. 30 minutes. It was
thought that bradycardia could represent digoxin toxicity vs.
structural/ischemic heart disease. Pacermaker placed [**5-12**].
Coumadin reinitiated for A-fib. Follow-up appointment on [**5-20**] at 9 am in the device clinic. She will need ongoing
monitoring of her INR for goal 2.0 to 3.0.
.
# HTN - Pt is hypertensive at baseline, initially normotensive
here on low dose dopamine-->SBP in 90s off dopa. Previously
had been on large doses of dilt at rehab and at [**Hospital3 **]. BB
reinitiated for pressure control s/p pacemaker.
.
# HCT drop: From 38-->31 on [**5-10**] to [**5-11**]. Thereafter, daily
HCTs 31-->31-->29-->29 Had diarrhea that was guaiac positive,
non-melenous, C.diff neg x 2. Given PPI [**Hospital1 **], changed ASA to 81
mg EC.
.
# Access - 1 midline, 1 PIV.
.
# Leukocytosis - had wbc 10k at OSH-->12 at [**Hospital1 18**], 85% PMNs,
afebrile, now normalized Did have + UA at OSH with unknown
duration of ctx then. UA with 2 WBCs, no bacteria. UCx neg, BCx
NGTD.
.
# Vaginal Bleeding - in setting of Tamoxifen for Breast CA.
Appointment on [**6-9**] at 4:30 pm with gynecologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], on [**Hospital Ward Name 23**] 8.
.
# R breast lump - underside of R breast, 2cm by 2cm. Hx of
breast CA. Also vaginal bleeding. On tamoxifen. Arranged for
ONC f/u as outpt
.
# ARF - unsure of pt's baseline cr/renal dysfunction, if any.
Cr 1.4-->1.2
.
# Hypothyroidism - continued levothyroxine. Noted to have TSH
0.09 on last admission, unsure if dose changed. TSH normal.
.
# Hyperlipidemia - continue fluvastatin 80mg qd.
.
# Prophylaxis - INR 1.1 currently, pneumoboots, asa, plavix,
ranitidine.
.
# Code - full, discussed with son.
Medications on Admission:
1. Aspirin 325 mg
2. Clopidogrel 75 mg qd
3. Levothyroxine 100 mcg qd
4. Acetaminophen 500 mg q6
5. Diltiazem HCl 360 qd
6. Furosemide 80mg [**Hospital1 **]
7. Tamoxifen 20mg qd
8. Lescol XL 80 mg qd
9. Warfarin 2 mg qd
10. Alprazolam 0.25 mg qhs prn
11. Spironolactone 25 mg qd
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary: Cardiac arrest, Atrial fibrillation,
tachycardia-bradycardia syndrome.
.
Secondary: Hypertension, coronary artery disease
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted due to a heart arrhythmia and respiratory
distress after being transferred from another hospital. You were
given medications and monitored closely for further arrhythmias.
You underwent cardiac catherization to evaluate for any
ischemia. Due to persistently slow heart rhythm, you had a
pacemaker placed.
.
Please contact Dr. [**Last Name (STitle) **] or go to the emergency room if you
experience any chest pain, difficulty breathing, palpitations,
inability to keep down food or drink, fevers, bleeding, or other
concerning symptoms. It has been a pleasure caring for you.
.
The following medication changes have been made:
- Metoprolol 12.5 mg twice a day was started.
- Diltiazem 360 mg daily was STOPPED.
- Spironolactone 25 mg daily was STOPPED.
- Aspirin was decreased to 81 mg daily due to bleeding.
- Alprazolam was STOPPED.
.
You have a follow-up appointment on [**5-20**] at 9 am in the
device clinic to check your pacemaker, in the [**Hospital Ward Name 23**] Building,
[**Location (un) 436**], [**Hospital1 18**] [**Hospital Ward Name 516**]. The office can be reached at
([**Telephone/Fax (1) 2361**].
.
You have an appointment on [**6-9**] at 4:30 pm with a
gynecologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], to evaluate your vaginal
bleeding. The office is located at [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**]
Building, [**Location (un) **], phone number is ([**Telephone/Fax (1) 93312**].
.
Please follow up with your oncologist, to evaluate a right-sided
breast mass noted during your stay that may be new. An
appointment has been made for you [**5-30**] at 11:30 AM at his
office. The number for his office is ([**Telephone/Fax (1) 33521**].
.
Please follow up with your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in the
next 2-4 weeks. Please call his office to arrange follow up upon
discharge from rehabilitation.
Followup Instructions:
You have a follow-up appointment on [**5-20**] at 9 am in the
device clinic in the [**Hospital Ward Name 23**] Building, [**Location (un) 436**], [**Hospital1 18**] [**Hospital Ward Name 5074**]. The office can be reached at ([**Telephone/Fax (1) 2361**].
.
You have a follow-up appointment on [**6-9**] at 4:30 pm with a
gynecologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], to evaluate your vaginal
bleeding. The office is located at [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**]
Building, [**Location (un) **], phone number is ([**Telephone/Fax (1) 93312**].
|
[
"5849",
"41401",
"42731",
"4019",
"2724",
"2449",
"496",
"V4582",
"V5861"
] |
Admission Date: [**2111-4-6**] Discharge Date: [**2111-4-16**]
Date of Birth: [**2035-6-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Atrial fibrillation, atrial flutter; referral from [**Location (un) 3844**]
for cath and ablation.
Major Surgical or Invasive Procedure:
Ablation of atrial flutter
Cardiac catheterization
History of Present Illness:
75F w/ PMH htn, high chol, afib, aflutter, CAD ongoing SOB,
fatigue, and DOE since CABG [**10-26**]. She reports that she has had
worsening fatigue and SOB over the past 3 weeks, including a
recently positive stress test. Plan from discussions with Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 11250**] ([**Location (un) 3844**] cardiologist) is to
admit patient for heparin, check TEE on day of admission, cath
on HD2 by Dr. [**Last Name (STitle) **] followed by ablation by Dr. [**Last Name (STitle) 59545**]. The cath
did not occur because of the events during the ablation
procedure. She was emergently transfered to the CCU after she
became hypotensive during an ablation procedure. Initially,
during the procedure, she became hypotensive to the 60s systolic
with bradycardic to the 30s. A temporary pacer was placed and
dopamine was started. An echocardiogram was negative for
perforation. A permanent pacemaker was subsequently placed
(DDD). Later in the procedure, she complained of back pain and
continued to have transient hypotension. She was intermittently
on dopamine. Post-procedure, she developed abdominal pain in
addition to back pain. An abdominal CT revealed a large left
sided pelvic hematome (8 cm in diameter) that was shifting the
bladder and the sigmoid colon. Given her persistent
hypotension, she was maintained on dopamine and given 1500 cc of
fluids. Her elevated INR to 1.7 was reversed with 2 units of
fresh frozen plasma. She also received a total of 3 units of
packed red cells. After the 3 units of red cells, her
hematocrit remained stable at 30 for 24 hours. She was given a
4th unit of red cells to keep her hematocrit above 30. Her
dopamine was weaned within 24 hours of her bleed.
Past Medical History:
[**12-27**]: TIAs w/ no residual deficits
Afib
CAD s/p CABG [**10-26**]
Hx elevated LFTs w/ neg hep screen and neg liver bx
renal insufficiency
Hyperlipidemia
Prior tx for C diff
Thrush x 3 since '[**08**] after c-scope (polyps removed, guaiac +, w/
Dr. [**Last Name (STitle) 59546**]; f/u scope neg.)
Social History:
widowed, lives w/ daughter x 1.5 years. Since TIAs unable to
drive. Retired. +smoker [**11-24**] ppd x 10yrs, quit [**8-26**]
Family History:
neg for CAD
Physical Exam:
97.2 - 120/86 - 80 - 20 - 100% 2LNC
aaox3, nad, appropriately communicative
+JVD 3cm above clavicle, mmm
irregularly irregular rate and rhythm, no mumurs
moves air moderately well w/o rhonchi/wheeze; mild bibasilar
crackles
bs+, soft nt/nd, no guarding
trace pitting edema bilaterally
.
Reexamination upon transfer from CCU [**4-9**]:
99.0 - 96.8 - 80 paced - 117/67 (117-145/63-83) - 28 (19-28) -
96%ra
24 hour in: 50 PO, 100 IV, 750 PRBCs
24 hour out: 795 urine
Past 12h in: 140IV, 200PO, 360 PRBC
Past 12h out: 500 urine
- aaox3, nad
- right IJ line in place w/o hematoma
- L axillary hematoma, ttp, dressing c/d/i
- Evidence of B groin line insertion w/o bruit or significant
superficial hematoma
- RRR, no m/r/g noted
- CTA B. Moves air moderately well. No focal findings
- Abd soft, non distended. Mild ttp left lateral abd w/o
evidence of mass or ecchymossis
- no edema
Pertinent Results:
[**2109-1-22**] carotid u/s: 25% stenosis at both bifurcations and prox
int carotid arteries.
.
[**2109-11-7**] TEE: No spontaneous echo contrast or thrombus seen in
the body of the L atrium/appendage or the body of the R
atrium/appendage. No ASD, PFO noted. LVEF>55%. Diffuse plaque
noted in the aortic arch and descending aorta. Complex atheroma
noted in the aortic arch and descending thoracic aorta. No AS,
trace AI, mild MR.
.
[**2109-10-29**]: cath at CMC: 100% LAD, 90% of small OMB, 50-60% pRCA,
LVEF 45-50%.
.
[**2109-11-5**]: referred to [**Hospital1 18**] cath lab, unsuccessful PCI
attempting to open LAD-->small localized perforation
.
[**2109-11-12**]: CABG LIMA to LAD, SVG to OM, SVG to PDA of RCA
.
[**2111-2-14**]: Echo non dilated LV w/ mild concentric LVH, posterior
inferior wall HD. LVEF 50%. Biatrial enlargement. Mild-mod MR.
Bicuspid aortic valve w/ no significant aortic stenosis or
insufficiency, mild TR w/ mild pulm hypertension.
.
[**2111-3-10**]: Persantine stress: Decreased uptake in the
anterolateral segment w/o significant reuptake, possibly breast
attenuation. LVEF 54%. Possible ischemia inferiorly and
posterolaterally.
.
[**2111-4-6**] TEE@[**Hospital1 18**]:
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. There are complex (>4mm, non-mobile)
atheroma in the aortic arch and descending thoracic aorta. 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. Mild to moderate
([**11-24**]+) mitral regurgitation is seen. There is no pericardial
effusion.
Compared with the report of the prior TEE study (images
unavailable for review) of [**2109-11-7**], the maximum detected LAA
emptying velocity has increased. The severity of the mitral
regurgitationhas slightly increased.
IMPRESSION: No intracardiac thrombus.
.
Echo [**4-7**] post procedure: The left ventricular cavity size is
normal. Right ventricular chamber size is normal. Right
ventricular systolic function is normal. There is no pericardial
effusion.
.
CXR [**4-6**]: 1. Stable post-operative appearance of the
cardiomediastinal silhouette. 2. Emphysema. 3. Mild
post-operative changes with no evidence of acute interstitial
process.
CXR post pacer [**4-7**]: There has been interval placement of a
left-
sided dual-chamber pacemaker with leads projecting over
appropriate locations. A right-sided internal jugular vein
central venous catheter is seen with the tip at the mid SVC. No
pneumothorax is seen. There is stable atelectasis in the left
mid lung and left base. The right lung is clear.
CXR [**4-8**]: No change.
.
Bilateral groin U/S [**4-7**]: No evidence of pseudoaneurysm or
arteriovenous fistula. No groin hematoma. Inferior margin of
pelvic hematoma seen on CT today is partially imaged.
.
CT abd/pel [**4-7**] (post ablation)
1. Large acute extraperitoneal hematoma in the left pelvis. This
finding was discussed and reviewed with the Cardiology Service
while the patient was still on the scanner. Vascular Surgery was
immediately paged.
2. Distended gallbladder. Stone and sludge are noted in the
gallbladder body.
3. High-attenuation liver suggestive of amiodarone use. Low
attenuation hepatic foci are not fully characterized on this
exam.
.
[**4-9**] B LENI and L UE U/S: neg for DVT
.
Chest CT w/o contrast (amio toxicity eval; d/w Dr. [**Last Name (STitle) **]
1. No definite evidence to support pulmonary amiodarone
toxicity.
2. Small bilateral pleural effusions.
3. Hyperdense liver consistent with patient's known history of
amiodarone toxicity. A few scattered hypodense lesions within
the liver are not adequately characterized on this non-contrast
study. Ultrasound or MRI is recommended for further evaluation.
4. Distended gallbladder. Moderate amount of intraluminal
sludge.
5. Pleural-based calcification in right anterior lung consistent
with prior asbestos exposure.
6. Cardiomegaly and atherosclerosis.
.
[**2111-4-15**] Cath:
1. Selective coronary angiography showed a right dominant
system with
three vessel disease. The LMCA was angiographically without
disease. The
LAD was proximally occluded and filled via the LIMA graft. There
was a
60% stenosis of the LAD proximal to the touch down of the graft.
The D1
was occluded. The LCX was diffusely diseased. The OM1 was a
modest
branching vessel with 99% stenosis and without competitive flow.
The RCA
was the dominant vessel with a proximal 80% and a distal 90%
just prior
to the touch down of the graft.
2. Selectice arterial conduit angiography showed a widely
patent
LIMA-LAD graft.
3. Selective venous graft angiography showed a widely patent
SVG-PDA
and occluded SVG-OM graft.
4. Limited resting hemodynamics showed a mildly elevated left
sided
filling pressure (LVEDP 18 mmHg). There was no gradient across
the
aortic valve.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Mild left ventricular diastolic dysfunction.
3. Patent LIMA-LAD.
4. Patent SVG-rPDA, occluded SVG-OM
Brief Hospital Course:
The patient was admitted for elective ablation and cardiac
catheterization. During there ablation procedure there was some
bleeding noted and the patient was transferred to the CCU (see
below).
CCU Course:
Extraperitoneal Bleed: She was emergently transfered to the CCU
after she became hypotensive during an ablation procedure.
Initially, during the procedure, she became hypotensive to the
60s systolic with bradycardic to the 30s. A temporary pacer was
placed and dopamine was started. An echocardiogram was negative
for perforation. A permanent pacemaker was subsequently placed.
Later in the procedure, she complained of back pain and
continued to have transient hypotension. She was intermittently
on dopamine. Post-procedure, she developed abdominal pain in
addition to back pain. An abdominal CT revealed a large left
sided pelvic hematome (8 cm in diameter) that was shifting the
bladder and the sigmoid colon. Given her persistent
hypotension, she was maintained on dopamine and given 1500 cc of
fluids. Her elevated INR to 1.7 was reversed with 2 units of
fresh frozen plasma. She also received a total of 3 units of
packed red cells. After the 3 units of red cells, her
hematocrit remained stable at 30 for 24 hours. She was given a
4th unit of red cells to keep her hematocrit above 30. Her
dopamine was weaned within 24 hours of her bleed. Given the
size of the hematoma, she will need to be monitored for bowel
ischemia. She has not had a bowel movement yet, but all stools
shoul be guaiaced.
Coronary artery disease: Given her acute bleed, it was decided
not to pursue a cardiac catherization during this admissino.
Her aspirin, plavix, beta-blocker, and ace-inhibitor were held
during the acute episode.
Pacer site hematoma: She also developed a hematoma below her
pacemaker site that extended into her axilla and down her upper
arm.
Atrial Flutter: She underwent a successful atrial flutter
ablation. A permanent pacemaker was placed. She remained
atrial paced throughout the course. Since she doesn't have any
underlying atrial fibrillation, she will not need amiodarone.
Thrombocytopenia: Her platelets trended down post-ablation
procedure. The likely explaination is that she had consumption
from the hematoma. She was not on any medications that could
contribute to the thrombocytopenia. She did not receive any
heparin products during this admission. However, a HIT antibody
was sent and is pending.
.
Floor course:
The patient was stable since coming to the floor on [**4-9**]. She
consistently reported improvement of her shortness of breath.
Her hematocrit remained stable. Her HIT antibody test was
negative and her platelets trended back up. She intermittently
spiked temperatures to Tm 101.3 and was diagnosed with a UTI-
started on bactrim [**4-14**] for 3 days. After further
stabilization, she was afebrile and taken to the cath lab for
further evaluation (see attached report).
She underwent cardiac catheterization on [**4-15**]:
1. Three vessel coronary artery disease.
2. Mild left ventricular diastolic dysfunction.
3. Patent LIMA-LAD.
4. Patent SVG-rPDA, occluded SVG-OM
COMMENTS:
1. Selective coronary angiography showed a right dominant system
with
three vessel disease. The LMCA was angiographically without
disease. The LAD was proximally occluded and filled via the LIMA
graft. There was a 60% stenosis of the LAD proximal to the touch
down of the graft. The D1 was occluded. The LCX was diffusely
diseased. The OM1 was a modest branching vessel with 99%
stenosis and without competitive flow. The RCA was the dominant
vessel with a proximal 80% and a distal 90% just prior to the
touch down of the graft.
She remained stable and afebrile after her catheterization.
Physical therapy evaluated and cleared for d/c home with
services.
Medications on Admission:
metoprolol 50''
coumadin 2.5' last dose 5/13; INR 3.0 [**4-6**] (HD1)
Plavix 75'
Klorcon 20meq 1-2x daily w/ lasix
Lasix 20 1-2x daily depending on edema
Amiodarone 200'
ASA 81'
Zocor 40'
Vit B6'
Fosamax 70 Qwk
Calcium'
Nystatin swish+swallow
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*60 Tablet(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:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO QID (4 times a day) for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
11. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
New Found VNA
Discharge Diagnosis:
Atrial fibrillation
Atrial flutter
Coronary artery disease
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed and keep all follow-up
appointments.
Seek medical attention if you have headaches, lightheadedness,
dizzyness, or any weakness or numbness, or anything else that
you find worrisome.
You should continue physical therapy and go to rehab. Follow
their direction to help you regain your strength.
Activity:
- Do NOT lift anything heavier than 5 pounds with you left arm.
- You should move your shoulder every day.
CALL Your doctor or go to the ER IF:
You have a temperature over 100.5.
Your pain is happening more often or is getting worse even
though you are taking your medicines.
You have new or worsening swelling in your feet or ankles.
You think your medicine is causing problems such as a rash,
itching, or swelling.
You have questions or concerns about your illness or medicine.
SEEK CARE IMMEDIATELY IF: Call 9-1-1 or 0 for an ambulance right
away if you have any of the following symptoms. Never try to
drive yourself to the hospital if you have signs of a serious
health problem.
Your chest discomfort does not go away after resting and taking
your chest pain medicine as directed.
You have new or worsening chest pain, tightness, or discomfort
that lasts longer than 15 to 20 minutes.
You have chest discomfort and feel lightheaded, dizzy, weak, or
faint.
You have chest discomfort and suddenly start sweating for no
reason that you know of.
You have nausea or vomiting with your chest discomfort.
You have new or worsening trouble breathing.
You lose feeling or movement in your face, arms, or legs, or
suddenly feel weak.
You suddenly have trouble thinking clearly, seeing, or speaking.
You cough or vomit blood.
Followup Instructions:
Call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 5909**] for a follow up appointment.
.
Call your primary care doctor for a follow up appointment
([**Last Name (LF) **],[**Known firstname **]-[**Doctor First Name 10588**] [**Telephone/Fax (1) 11254**]).
.
Call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 9530**] for a follow up appointment
(he performed the ablation procedure).
|
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"42789",
"4280",
"2851",
"5990",
"2875",
"4240",
"41401",
"4019",
"V1582"
] |
Admission Date: [**2160-1-25**] Discharge Date: [**2160-1-28**]
Date of Birth: [**2102-6-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 663**]
Chief Complaint:
fever, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 57 yo M with a history of ulcerative colitis and
multiple recent admissions for hypotension who was admitted to
the MICU this morning with hypotension and fever to 101.
Of note, patient has been admitted twice for hypotension in the
past three weeks. His first admission was from [**1-11**] - [**1-18**] it
was thought to be due to sepsis in the setting of a pneumonia,
and he was treated with a full course of levofloxacin. He
followed up with his PCP on discharge on [**1-21**] where he reported
he was still feeling ill and having fevers up to 101 at home.
His BP was noted to be 60/palp and so he was referred to the ED
and admitted. This second admission was from [**1-21**] - [**1-23**]: pt
was treated with IVFs and stress dose steroids (hydrocortisone
and dexamethasone). He had a cortisol AM of 0.9, but appropriate
response of cortisol levels to cosyntropin stimulation test at
30 minutes and 60 minutes (13.4 and 17.5, respectively). His
blood pressures remained stable and he did not have any fevers
prior to discharge; all microbiology testing was negative.
.
Patient woke up on Thursday AM ([**2160-1-25**]) with fever to 101 and
had shaking chills. He had a BP cuff at home and noted his SBPs
were 79-84. He denied any localizing symptoms including
headache, neck stiffness, photosensitivity, cough, sputum, chest
pain, shortness of breath, abdominal pain, increased ostomy
output, dysuria or urinary frequency, joint pain, or new rashes,
or blood in stool or urine. He did have an episode of
unprotected sex 3 months ago. No recent foreign travel or sick
contacts. During his first hospitalization, he describes the
fevers as 'cyclic', occurring every day in the morning between 3
AM and 7 AM. He endorses excellent PO and fluid intake daily. He
called the [**Company 191**] on call physician after noting the hypotension,
who advised him to report to the ED for evaluation.
.
During his MICU stay, the patient received 3 L of NS total (2 L
in the ED and 1 L in the MICU). Blood and urine and cultures are
pending. HIV antibody, viral load, and CMV VL are being checked.
Orthostatics were negative (lying 112/68 HR 74, sitting 115/72
HR 83
standing 104/69 HR 83). His SBPs remained stably in the 90s-100s
and he did not require pressors. Endocrinology informally saw
him and asked for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim off of budesonide and will
officially consult in tomorrow morning.
.
Past Medical History:
Longstanding ulcerative colitis proctocolectomy and pouch anal
stenosis in [**2141**] with subsequentpouch resection and end
ileostomy due to a stricture in the mid pouch and a leak at the
top of the pouch.
B12 deficiency on IM vitamin B-12 injection
Depression treated with Effexor
Olecrenon Bursitis
liver function chronically elevated with an ALT of 84. This can
be related to autoimmune inflammatory bowel disease, or alcohol
intake.
History of spontaneous pneumothorax at age 18, treated with
chest tube
Right thumb tendon injury [**2141**].
Actinic keratoses/seborrheic keratosis
PAST MEDICAL HISTORY
B12 deficiency, depression, olecranon bursitis, elevated ALT,
history of spontaneous pneumothorax at age 18, right thumb
tendon
injury in [**2141**], actinic keratoses, and seborrheic keratoses.
.
ULCERATIVE COLITIS HISTORY
1. Diagnosed in [**2140**].
2. Status post total proctocolectomy and ileal pouch anal
stenosis in [**2141**].
3. Stricture in the mid pouch and a stricture or leak at the
top
of the pouch at the afferent loop. Underwent resection of blind
loop and diverting ileostomy for this in [**2146**] and then a ventral
pouch resection and end ileostomy.
4. [**2148**] recurrent presacral abscesses status post multiple
drainage procedures and occurrence of an intraperitoneal fistula
at the site of prior diverting ileostomy with take down of
fistula. Per Dr.[**Name (NI) 10946**] note, "I should emphasize that
prior to this operation I had all of his prior pathology
reviewed, and although he had been labeled as having Crohn's
disease he in fact truly has ulcerative colitis".
Intraoperatively, there was no evidence of Crohn's.
5. [**2150**] presented with abdominal pain, diarrhea. CT showed
thickening in the distal small bowel, treated with IV Cipro,
Flagyl followed by p.o. Cipro, Flagyl and a small bowel
follow-through that was normal. ANCA serologies reportedly
negative or diagnostically UC at thetime.
8. [**2156**] presented with a cutaneous fistula and found to be a
subcutaneous fistula rather than enterocutaneous fistula.
Underwent ileoscopy that showed a single ulcer in the distal
ileum at 10 cm from the stoma with biopsy consistent with
chronic
active enteritis and focal ulceration of granulation tissue. No
granulomas or dysplasia.
9. Admission in [**11/2159**] for abdominal distention, decreased
ostomy output, and found to have active inflammation of the last
20 cm of his ileum.
Social History:
He is divorced. He has three children age 23, 20, and 19. He
is in touch with his children. He continues to work for the US
Customs Department. He smokes one and a half packs per day.
Family History:
Mother S/P CABG, diabetes. Brother has a diagnosis of mild
rheumatoid arthritis. There is no known thyroid disease,
inflammatory bowel disease, psoriasis, or lupus in the family.
Physical Exam:
VS: 98.7 73 90/64 15 99% on RA
GA: well appearing M AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. ostomy bag with good stool output. no g/rt.
neg HSM.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes. small brown mark on first digit fingernail on
L.
Pertinent Results:
[**2160-1-25**] 01:40PM BLOOD WBC-9.4 RBC-4.33* Hgb-12.9* Hct-39.5*
MCV-91 MCH-29.7 MCHC-32.5 RDW-14.9 Plt Ct-282
[**2160-1-25**] 01:40PM BLOOD Plt Ct-282
[**2160-1-25**] 01:40PM BLOOD Glucose-104* UreaN-19 Creat-1.5* Na-135
K-4.5 Cl-97 HCO3-28 AnGap-15
[**2160-1-26**] 04:48AM BLOOD ALT-31 AST-22 LD(LDH)-141 AlkPhos-68
TotBili-0.4
[**2160-1-26**] 04:48AM BLOOD TotProt-6.0* Albumin-2.9* Globuln-3.1
Calcium-8.1* Phos-3.8 Mg-2.4
[**2160-1-25**] 01:40PM BLOOD TSH-1.7
[**2160-1-26**] 04:48AM BLOOD CRP-37.4*
[**2160-1-25**] 01:47PM BLOOD Lactate-2.6* K-4.3
[**2160-1-26**] 05:12AM BLOOD Lactate-1.7
Discharge Labs:
ESR - xxxxxxxxxxxxxxx
Cortisol Stimulation Results: ([**2160-1-27**])
AM Cortisol: xxxxxxxxxxxxx
30 min Cortisol: xxxxxxxxxxxxxx
60 min Cortisol: xxxxxxxxxxxxx
HIV antibody: xxxxxxxxxxxxxx
HIV viral load: xxxxxxxxxxxxxxxxxxx
Microbiology:
Blood cultures - no growth to date
Urine cultures - no growth to date
RPR - xxxxxxxxxxxxxx
Urine GC/chlamydia - xxxxxxxxxxxxxxxxxx
C. difficile toxin assay ([**2160-1-26**]) -
[**2160-1-26**] 4:02 pm STOOL
**FINAL REPORT [**2160-1-27**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2160-1-27**]):
REPORTED BY PHONE TO K. PROCTOR, R.N. ON [**2160-1-27**] AT 0535.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
Radiology:
TTE ([**2160-1-15**]):
The left atrium and right atrium are normal in cavity size. 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) 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. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion. IMPRESSION: Normal global and regional biventricular
systolic function. No pulmonary hypertension or
clinically-significant valvular disease seen.
CT SCAN OF THE CHEST: ([**2160-1-26**])
There has been interval removal of the right trans-subclavian
PICC line.
There is complete interval resolution of bilateral basal
consolidation with minimal residual nodular atelectasis in the
posterior costophrenic angles. Pleural effusions have
completely resolved. Lung parenchyma is unremarkable except for
previously described centrilobular emphysema in the upper lobes
and minimal bilateral apical scarring, unchanged. Airways are
patent. No mediastinal, hilar, axillary, or internal mammary
adenopathy. No pericardial effusion. Aorta, pulmonary artery,
and great thoracic vessels are unremarkable.
CT SCAN OF THE ABDOMEN: Liver, adrenals, kidneys, pancreas, and
spleen are
unremarkable. The gallbladder is contracted without intra- or
extra-hepatic biliary dilation. No adenopathy or ascites. Bowel
demonstrates no
abnormality.
CT SCAN OF THE PELVIS: The patient is status post colectomy. The
previously described thickening of the terminal ileum proximal
to the ileostomy in the right lower quadrant is no longer seen.
Bladder and prostate are unremarkable. No free fluid in the
pelvis.
No bone lesions.
IMPRESSION: Interval resolution of the bilateral basal
consolidation and pleural effusions. No abnormality in the
chest, abdomen, or pelvis to suggest an infectious focus.
Brief Hospital Course:
A/P: Mr. [**Known lastname 7749**] is a 57 yo M with ulcerative colitis on
budesonide and two recent hospital admissions for hypotension
who presents with asymptomatic hypotension to the 70s at home
and fever to 101 without localizing symptoms, now diagnosed with
C. difficile infection.
# Hypotension: Hypotension likely in part due to early sepsis
(and possibly relative adrenal insufficiency, as below) from C.
difficile infection requiring aggressive IVF resuscitation and
brief MICU admission. Unlikely hypovolemia due to dehydration,
as patient was taking excellent PO fluids at home and
orthostatics performed in the MICU are negative (although
performed after IVFs). No evidence of cardiac etiology of
hypotension (no decreased ejection fraction or heart failure
noted on TTE.)
There was also concern for adrenal insufficiency during last
admission in setting of chronic budesonide use. Patient has had
an appropriate cosyntropin stimulation test during his last
admission, but AM cortisol was quite low which may have been
compromised in the setting of budesonide. The cosyntropin
stimulation test was repeated off of steroids on [**2160-1-27**] and
showed apparently adequate adrenal function. Endocrinology
followed who thought that he still may have some degree of
adrenal inability to respond to stress. For that reason he was
given decadron for two days with plans to then resume his home
dose of budesonide. Fludrocortisone was also started on
discharge.
.
# Fevers: Likely due to C. difficile infection, which is
possible even though patient has a colectomy (can infect the
illeostomy pouch). No evidence of abscess on CT Torso. Patient
has no localizing symptoms other than shaking chills, which may
be supressed in the setting of chronic steroid use. Patient also
with unprotected sexual encounter three months ago, so STD
testing was performed which showed HIV testing and viral load to
be negative syphilis testing (RPR) negative, GC/chlamydia urine
PCR negative. Blood and urine cultures were also without growth.
Patient treated with PO Vancomycin in house and discharged to
complete a 14-day course of PO metronidazole for C. difficile
infection. Fevers resolved prior to discharge.
# Ulcerative colitis: Patient has had an end ileostomy for 20
years. His ulcerative colitis has been fairly stable, but he was
recently having some flares over the summer of [**2159**]. Continued
mesalamine while in house. Budesonide was held in the setting of
the cosyntropin stimulation. He will resume his outpatient
budesonide dose on discharge and follow up with GI.
#Code: FULL CODE
Medications on Admission:
1. mesalamine 500 mg Capsule, SR, 4 capsules [**Hospital1 **]
2. venlafaxine 75 mg Capsule, SR, 4 capsules daily
3. budesonide 3 mg Capsule, SR, 3 capsules daily
4. omeprazole 20 mg daily
Discharge Medications:
1. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Four (4)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. mesalamine 250 mg Capsule, Sustained Release Sig: Eight (8)
Capsule, Sustained Release PO BID (2 times a day).
4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
5. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
6. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
7. budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Clostridium Difficile Infection
Sepsis
Secondary Diagnosis
Ulcerative Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fevers and low blood pressure. You stayed
briefly in the medical ICU because of your blood pressure. You
were discovered to have a gastrointestinal infection known as
'Clostridium Difficile. This will require treatment with
antibiotics. Your adrenal glands were tested to see if an
improper functioning of the adrenals might be the cause of your
low blood pressure. Although one set of tests indicates that
your adrenals are working well, another test was not as clear,
and so we are awaiting further results.
Your doctors have recommended that you get a braclet which
alerts medical providers that you take steroids on a continuous
basis, as this will aid in management should you become ill in
the future.
The following changes were made to your medications.
1. Restart Budesonide 9 mg Daily on [**2160-1-29**]
2. Start taking Metronidazole 500 mg three times a day for 10
days
3. Start taking fludrocortisone 0.1 mg Tablet daily
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], within 1-2 weeks of discharge.
Department: DIV. OF GASTROENTEROLOGY
When: MONDAY [**2160-3-17**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8718**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2160-1-28**]
|
[
"0389",
"99592",
"5849",
"311",
"3051"
] |
Admission Date: [**2184-7-7**] Discharge Date: [**2184-8-12**]
Date of Birth: [**2139-8-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20640**]
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
Cystoscopy
Angiogram of the left kidney
History of Present Illness:
Ms. [**Known lastname 59777**] is a 44 year old female with a history of recently
diagnosed stage IV non-small cell lung cancer metastatic to
brain, adrenals, and kidneys who presents with complaints of
blood when she urinates. She notes that she first noticed this
two days ago. She also notes pain with urination since she
noticed the blood. She ntes it has been the worst between 1 am
and 5 am where she can't leave the BR due to constant need to
urinate. She also urinates several times during the day. Each
time is extremely painful. She notes that since the bleeding
began, the pain has begun to improve but the bleeding has
continued at the same frequency. She denies any vaginal
bleeding, melena, hematochezia, or hematemesis.
In the [**Hospital1 18**] ED, 98.3, 108/70, 96, 18, 100% RA. While in the ED
she was noted to have frank hematuria. Pelvic exam was performed
without evidence of vaginal or cervical bleeding. No obvious GI
bleeding was noted. She was guiaic negative. Labs were
remarkable for Hct drop from 34->20 over 1 month. Coags, WBC,
and plts normal. Electrolytes showed new renal failure with
BUN/Cr 46/2.3 from 14/0.6 1 month prior. K was 6.0, bicarb 17.
U/A revealed >50 RBCs, 21-50 WBCs, LE and nitrite negative, and
no bacteria. She received 30 grams of kayexalate, 10 mg of
dexamethasone, zofran, and morphine. Prior to floor transfer,
she lost her IV access. Bilateral femoral CVLs were attempted
but wire could not be passed. She then had a successful R IJ CVL
placement.
Currently, she feels well. Episode of frank hematuria witnessed
upon arrival to the floor, also notable for stringlike clot. On
ROS, she denies any fevers, chills, chest pain, SOB, DOE. She
does note increased fatigue and recent poor po intake. She also
notes intermittent nausea when taking her medications. She
denies any numbness or tingling, weakness, or confusion. Denies
any muscle or joint pains which the exception of chronic R thumb
pain which improved with steroids and has worsened with taper.
All other ROS negative.
Past Medical History:
# stage IV non-small cell lung cancer metastatic to brain,
adrenals, kidneys (see below)
# h/o intermittent asthma
# h/o tooth infection & extraction between [**2184-2-15**].
# History of subluxation of the metaphalangeal joint in
[**2178-6-17**].
# Prior history of obesity.
Past Oncologic history:
Initially presented in [**2-/2184**] with complaints of weight loss,
nausea and vomiting. It seems that her symptoms were initially
mild. She did not have shortness of breath, cough or other
complaints at that time. By [**3-/2184**], she continued to lose
weight and was found to have a potential right-sided dental
abscess. She was treated for that empirically with antibiotics
and continued to have weight loss, diarrhea. It seems that in
the end of [**Month (only) 958**] and beginning of [**5-/2184**], the patient
represented to medical attention with mild shortness of
breath with exertion and chest discomfort. She also had noted
at that point subjective low-grade temperatures and some cough
productive of brown sputum. In [**5-/2184**], she already had a
20-pound weight loss. During the initial presentation, she also
complained of one episode of hemoptysis with production of more
than one teaspoon of blood. Due to the above-mentioned symptoms,
the patient underwent a computer tomography of the chest on
[**2184-5-14**] that disclosed a 2.6 cm cavitary lesion in the
posterior right upper lobe with additional smaller right-sided
pulmonary nodules and extensive right hilar lymphadenopathy with
marked narrowing of the hilar airways and vessels. At that
point, further staging imaging was obtained with a computer
tomography of the torso on [**2184-5-29**] that disclosed the chest
findings as detailed above. There was also right upper lobe
pulmonary interstitial thickening, which was worrisome for
lymphangitic spread. There was a subtle sclerosis of the T4
vertebral body. There was no evidence of extrathoracic disease.
The adrenals had 2 cm masses. There were multiple enlarged
retroperitoneal lymph nodes measuring up to 1.3 cm. An MRI of
head was performed on [**2184-5-29**] and showed multiple areas of
enhancement identifying with surrounding edema in both cerebral
hemispheres as well as in the posterior fossa. The largest
lesion measured 1.5 cm in the left frontal lobe. The patient had
had some intermittent headaches that were thought to be
migraines at that point. However, she had no problems with
motor strength up to the time of initial MRI when she developed
some gait instability and required a cane. She also complained
of intermittent blurry vision. She was diagnosed the etiology
of the brain lesions. A brain biopsy was performed on
[**2184-5-30**]. Multiple fragments were obtained. All showed small
nests of large cell undifferentiated carcinoma throughout brain
lesions. D cells were positive for CK7 and TTF1. Due to the
presence of nonsmall cell lung cancer with brain metastasis and
edema, the patient was referred to neurooncology and radiation
oncology. Whole brain radiation was started on [**2184-6-5**]. The
patient received 3000 cGy to the brain. She was also started on
dexamethasone. Her last day of radiation was [**2184-6-15**]. She has
most recently been on a steroid taper. She is currently in the
planning stages of palliative chemotherapy.
Social History:
Lives in [**Location 1411**] with fiance and three children. The patient
started smoking cigarettes at age 13. ~45-pack-year history. No
history of alcohol use. She has a remote history of prior
intravenous drug use and cocaine use. Originally from Sicily.
Moved to USA in [**2135**]. She worked as a domestic cleaner and had
some exposure to areas affected by asbestos and heavy chemicals.
She currently is out of work and living with family members.
Family History:
Mother, grandfather, and grandmother with DM. Father passed away
at 76 due to "natural causes". Mother is 76. [**Name2 (NI) **] maternal
grandfather had a diagnosis of stomach cancer. Her paternal
grandfather had a diagnosis of prostate cancer.
Physical Exam:
T: 97.6 BP: 138/70, HR: 103, RR: 20 O2 98% RA
Gen: Pleasant, chronically ill appearing female, NAD
HEENT: +Alopecia. MMM. OP clear.
NECK: Supple. JVP low. R IJ CDI
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB
ABD: NABS. Soft, NT, ND. No HSM
EXT: WWP, NO CCE. Full distal pulses
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all
extremities. Normal gait.
Pertinent Results:
[**2184-7-7**] 08:28PM GLUCOSE-111* UREA N-46* CREAT-2.3*#
SODIUM-132* POTASSIUM-6.0* CHLORIDE-99 TOTAL CO2-17* ANION
GAP-22*
[**2184-7-7**] 08:28PM ALT(SGPT)-29 AST(SGOT)-17 LD(LDH)-350*
CK(CPK)-24* ALK PHOS-58 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1
[**2184-7-7**] 08:28PM ALBUMIN-3.4
[**2184-7-7**] 08:28PM OSMOLAL-290
[**2184-7-7**] 08:28PM WBC-9.5 RBC-2.29*# HGB-6.9*# HCT-20.0*#
MCV-87 MCH-30.2 MCHC-34.5 RDW-17.3*
[**2184-7-7**] 08:28PM NEUTS-82.0* LYMPHS-14.6* MONOS-1.5* EOS-1.7
BASOS-0.3
[**2184-7-7**] 08:28PM PLT COUNT-215
[**2184-7-7**] 08:28PM PT-12.4 PTT-23.1 INR(PT)-1.1
[**2184-7-7**] 08:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2184-7-7**] 08:30PM URINE RBC->50 WBC-21-50* BACTERIA-NONE
YEAST-NONE EPI-0
Imaging:
========
CXR ([**7-10**]):
IMPRESSION: Development of focal area of increased density in
the right mid
lung consistent with atelectasis or consolidation. PA and
lateral views may
be helpful for further evaluation.
Renal US [**7-9**]:
1. Multiple bilateral hypoechoic renal masses, consistent with
known
metastases.
2. Doppler ultrasound demonstrates rapid systolic upstrokes,
with impaired
diastolic flow, and elevated resistive indices. The main renal
veins are
patent. These findings most likely reflect increased vascular
resistance
secondary to mass effect of multiple metastatic lesions. There
is no evidence for renal vein thrombosis.
CXR [**7-8**]:
Tip of the new right internal jugular line projects over the low
SVC.
Mediastinal widening and right hilar enlargement due to
adenopathy are stable. No pneumothorax or pleural effusion.
Lungs are grossly clear. Heart size normal.
ECG [**7-7**]: NSR @ 83. Nl axis and intervals. Isolated < 1 mm STE
in aVF. Compared to prior [**2184-5-30**], no sig change.
renal u/s [**7-7**]: Both kidneys enlarged and heterogeneous. Both
contain multiple masses with indistinct borders, some appear
hypervascular. No hydronephrosis. Echogenic lesion in bladder
likely representing blood clot.
Pelvic US [**7-7**]:
CT torso [**6-30**]:
1. Slight decrease in the size of right upper lobe lung nodules.
There has been no substantial change in the appearance of the
hilar and mediastinal lymphadenopathy.
2. Slight increase in the size of the bilateral adrenal lesions.
3. Increase in confluence and increase in size of some of the
bilateral renal lesions. Retroperitoneal and mesenteric
lymphadenopathy as before.
[**6-30**] bone scan:
No evidence of osseous metastatic disease. Abnormal uptake in
the
kidneys bilaterally. Recommend correlation with additional
anatomic imaging, such as ultrasound, as clinically indicated.
Brief Hospital Course:
44F with metastatic NSCLC (brain, bilat adrenals, bilat kidneys)
p/w frank hematuria, anemia, renal failure. The bleeding was
from renal mets and was localized to the L kidney based on blood
seen coming from the L ureter at cystoscopy. The renal failure
was believed to be due to a combination of ATN, mets, and
contrast. Ultimately she was started on HD. The L kidney was
embolized to prevent further bleeding. She is now HD dependent.
Her hospitalization has been further complicated by pneumonia
and adrenal insufficiency.
Ultimately, after a trial of dialysis, the pt opted to be CMO.
However, when she did not pass over a weekend, she considered
this a sign that she could live longer and possbily survive
cancer. A family meeting was convened and an accommodation was
achieved wherein we would restart abx and try to relieve her of
her anasarca using either diuretics or ultrafiltration. That
said, after failing diuretics and prolonged difficulties with
the dialysis catheter, another meeting was convened. Antibiotics
were stopped again and the patient was returned to [**Location 3225**] with
ultrafiltration. During an ultrafiltration treatment, she went
into respiratory failure and passed.
Medications on Admission:
albuterol prn
dexamethasone 1 mg four times daily (decreased [**7-5**], due to drop
to 2 mg daily [**7-12**])
keppra 1000 mg [**Hospital1 **]
lisinopril 10 mg daily
lorazepam 1 mg qhs prn
nystatin swish and spit
protonix 40 mg daily
ranitidine 150 mg [**Hospital1 **]
tylenol prn
Discharge Medications:
none
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary -
Hematuria likely from a bleeding kidney metastasis
Metastatic non-small cell lung carcinoma
Acute renal failure requiring initiation of dialysis
Acute blood loss anemia
Hyperkalemia
Hyponatremia
Discharge Condition:
deceased
Discharge Instructions:
You were admitted to the hospital due to hematuria and low blood
counts. You were given multiple blood transfusions and
eventually your hematuria stopped. You were found to have acute
renal failure and eventually needed to be placed on dialysis.
You developed pneumonia and received antibiotics for that.
Finally, you received your first cycle of chemotherapy.
Please take your medications as ordered.
Call your primary doctor, or go to the emergency room if you
experience fevers, chills, shortness of breath, chest pain,
recurrent hematuria, dizziness, blood in your stool, dark black
stool, or other concerning symptoms.
Followup Instructions:
n/a
Completed by:[**2184-8-12**]
|
[
"486",
"5845",
"2851",
"2761",
"2762",
"5119",
"4019",
"2767",
"49390",
"42731",
"2875"
] |
Unit No: [**Numeric Identifier 74570**]
Admission Date: [**2184-8-6**]
Discharge Date: [**2184-8-9**]
Date of Birth: [**2184-8-6**]
Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname **] was a 3.580 kg product of a 38-
week gestation born to a 36-year-old G2, para 1-0 mother
[**Name (NI) 74571**] labs - The mother's blood type is B+, antibody
negative, RPR nonreactive, rubella immune, and hepatitis B
negative.) EDC was [**2184-8-19**]. Prenatal course was
significant for gestational diabetes treated by diet alone.
The rest of the maternal history and review of systems are
noncontributory. Ms. [**Known lastname **] presented in spontaneous labor
on [**2184-8-6**]. GBS was negative. There was no maternal
fever and no intrapartum antibiotics. The infant was born on
[**2184-8-6**] at 6:40 p.m. by c-section due to repeat.
Apgars were 9 at 1 minute and 9 at 5 minutes. Dextrose sticks
(ranging from first to most recent in newborn nursery) were
38, 42, 29, 42, 43, and 38, feeding some in between. Due to
persistent hypoglycemia and jitteriness, the infant was
brought to the NICU for glucose monitoring.
SOCIAL HISTORY: The mom has a 13-year-old daughter.
PHYSICAL EXAMINATION: Current weight is ________. Current
length is ________. Current head circumference is ________.
On transfer, breath sounds are equal and clear. The heart has
a regular rate and rhythm, normal S1 and S2, and no murmur.
The abdomen is soft and nontender. The anterior fontanelle is
soft, flat, and open. The infant moves all extremities, and
tone is appropriate for gestational age.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory. The infant has been in room air since
birth.
2. Cardiovascular. The infant has been stable
cardiovascularly.
3. Fluids and Electrolytes. The infant's birth weight was
3.580 kg. Weight=3.4kg on [**2184-8-9**] when she was transferred to
newborn nursery. The infant was breastfeeding and supplemented
with feeds in newborn nursery. In the NICU, infant initially
fed Enfamil 20 cal/oz. then Enfamil 24 cal/oz, then Enfamil 26
cal/oz with stable blood sugars. At time of transfer from NICU to
NBN, the infant's blood glucose levels were wnl and stable with
the infant feeding Enfamil 2o ad lib on demand.
4. GI. Bilirubin=8.8/0.3 on [**2184-8-9**].
5. Hematology: no CBC.
6. Infectious Diseases. N/A
7. Neurologic. Infant appropriate for GA.
8. Hearing screen: perform in NBN prior to discharge.
CONDITION when tRANSFERed to NBN: Stable.
DISCHARGE DISPOSITION: Newborn nursery.
PRIMARY PEDIATRICIAN: not identified at time of transfer from
NICU to NBN.
CARE AND RECOMMENDATIONS: Continue ad lib. feedings with
Enfamil 20 cal/oz,
MEDICATIONS: Nonapplicable.
SCREENING: State newborn screening will be sent per protocol
on [**2184-8-9**].
IMMUNIZATIONS RECEIVED: The infant has not received hepatitis
vaccine.
FOLLOW-UP APPOINTMENT SCHEDULE AND RECOMMENDATIONS:
Pediatrician after discharge.
DISCHARGE DIAGNOSES:
1. Infant of a gestational diabetic mother.
2. Hypoglycemia.
3. Hyperinsulinemia.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) 70824**]
MEDQUIST36
D: [**2184-8-8**] 22:26:38
T: [**2184-8-9**] 08:43:42
Job#: [**Job Number 74572**]
|
[
"V053"
] |
Admission Date: [**2168-5-13**] Discharge Date: [**2168-5-27**]
Date of Birth: [**2096-6-7**] Sex: F
Service: SURGERY
Allergies:
Synthroid / Ativan
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Respiratory Failure s/p reanastomosis leak
Major Surgical or Invasive Procedure:
None
History of Present Illness:
H/O diverticulits with perf. Had sigmoid resection with end
colostomy in [**1-23**]. Ostomy reversed 0n [**4-26**]. Readmitted on [**5-2**]
with abdominal pain - CT showed [**Last Name (un) 1236**] leak. Had ex lap with
colostomy. [**5-8**] CT scan showed large abdominal abcess - tapped
with CT guidance for 450 ml. Cxs grew staph epi and
enterococcus. New onset A-Fib started [**5-8**]. Re intubated on
[**5-13**] for PCO2>100 and pH 7. Tx to [**Hospital1 18**] [**5-13**].
Past Medical History:
Diverticulits, OA, HTN, hypothyroid
Social History:
no tobacco no alcohol
Family History:
nc
Physical Exam:
On D/C
Gen: AAOx3, NAD
CV: S1 S2 irreg RR
Chest: CTA B/L good A/E
Abd: Soft, NT, slight distension, ostomy in place and intact, no
guarding or rebound tenderness
Extrem: Slight edema in extremities, much decreased from last
week, no C/C/E, pulses felt 2+
Pertinent Results:
[**2168-5-13**] 06:42PM BLOOD WBC-32.4* RBC-4.28 Hgb-12.6 Hct-39.3
MCV-92 MCH-29.5 MCHC-32.1 RDW-15.4 Plt Ct-257
[**2168-5-14**] 02:19AM BLOOD WBC-25.3* RBC-3.54* Hgb-10.6* Hct-32.3*
MCV-91 MCH-29.8 MCHC-32.7 RDW-15.4 Plt Ct-221
[**2168-5-15**] 02:36AM BLOOD WBC-23.1* RBC-4.08* Hgb-11.9* Hct-35.5*
MCV-87 MCH-29.3 MCHC-33.6 RDW-15.1 Plt Ct-245
[**2168-5-16**] 03:09AM BLOOD WBC-17.2* RBC-4.00* Hgb-11.5* Hct-34.5*
MCV-86 MCH-28.7 MCHC-33.2 RDW-14.8 Plt Ct-219
[**2168-5-17**] 02:03AM BLOOD WBC-16.0* RBC-3.87* Hgb-11.3* Hct-33.7*
MCV-87 MCH-29.1 MCHC-33.4 RDW-15.0 Plt Ct-211
[**2168-5-22**] 04:45AM BLOOD WBC-13.0* RBC-3.65* Hgb-10.6* Hct-32.0*
MCV-88 MCH-29.1 MCHC-33.2 RDW-15.8* Plt Ct-241
[**2168-5-22**] 09:05PM BLOOD WBC-11.5* RBC-3.58* Hgb-10.0* Hct-31.6*
MCV-88 MCH-27.9 MCHC-31.7 RDW-16.0* Plt Ct-253
[**2168-5-13**] 06:42PM BLOOD Neuts-79.8* Lymphs-15.1* Monos-4.3
Eos-0.1 Baso-0.7
[**2168-5-22**] 09:05PM BLOOD Neuts-79.0* Lymphs-14.6* Monos-5.4
Eos-0.9 Baso-0.1
[**2168-5-26**] 05:18AM BLOOD PT-22.8* PTT-33.1 INR(PT)-3.5
[**2168-5-25**] 09:57AM BLOOD PT-22.1* PTT-32.9 INR(PT)-3.2
[**2168-5-24**] 06:43AM BLOOD PT-19.3* PTT-30.7 INR(PT)-2.5
[**2168-5-23**] 06:21AM BLOOD PT-19.6* PTT-57.9* INR(PT)-2.5
[**2168-5-22**] 09:05PM BLOOD Plt Ct-253
[**2168-5-22**] 09:05PM BLOOD PT-18.4* PTT-52.2* INR(PT)-2.2
[**2168-5-22**] 10:54AM BLOOD PT-15.4* PTT-65.2* INR(PT)-1.6
[**2168-5-26**] 09:25AM BLOOD Glucose-152* UreaN-12 Creat-0.5 Na-144
K-3.3 Cl-103 HCO3-35* AnGap-9
[**2168-5-25**] 09:57AM BLOOD Glucose-261* UreaN-12 Creat-0.6 Na-142
K-3.5 Cl-100 HCO3-36* AnGap-10
[**2168-5-24**] 06:43AM BLOOD Glucose-84 UreaN-13 Creat-0.6 Na-144
K-3.9 Cl-104 HCO3-36* AnGap-8
[**2168-5-14**] 02:19AM BLOOD Glucose-137* UreaN-33* Creat-1.0 Na-140
K-3.7 Cl-100 HCO3-35* AnGap-9
[**2168-5-13**] 06:42PM BLOOD Glucose-228* UreaN-31* Creat-0.9 Na-140
K-3.3 Cl-98 HCO3-34* AnGap-11
[**2168-5-18**] 05:00PM BLOOD ALT-12 AST-32 LD(LDH)-278* AlkPhos-525*
Amylase-163* TotBili-0.4
[**2168-5-13**] 06:42PM BLOOD ALT-19 AST-55* LD(LDH)-443* AlkPhos-633*
Amylase-172* TotBili-0.2
[**2168-5-18**] 05:00PM BLOOD Lipase-229*
[**2168-5-13**] 06:42PM BLOOD Lipase-277*
[**2168-5-23**] 04:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2168-5-22**] 09:05PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2168-5-14**] 02:19AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2168-5-26**] 09:25AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8
[**2168-5-25**] 09:57AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.6
[**2168-5-24**] 06:43AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.0
[**2168-5-23**] 04:30PM BLOOD Calcium-8.0* Phos-2.5* Mg-1.6
[**2168-5-14**] 02:19AM BLOOD Calcium-7.9* Phos-0.9* Mg-2.4
[**2168-5-13**] 06:42PM BLOOD Albumin-2.0* Calcium-7.9* Phos-1.0*
Mg-1.9
[**2168-5-24**] 09:45AM BLOOD %HbA1c-8.4* [Hgb]-DONE [A1c]-DONE
[**2168-5-18**] 05:00PM BLOOD TSH-3.9
[**2168-5-18**] 03:30AM BLOOD T4-5.0
[**2168-5-20**] 02:28PM BLOOD Vanco-25.8*
[**2168-5-20**] 12:14PM BLOOD Vanco-13.4*
[**2168-5-18**] 05:05PM BLOOD Type-ART pO2-189* pCO2-37 pH-7.52*
calHCO3-31* Base XS-7 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2168-5-18**] 04:18AM BLOOD Type-ART pO2-176* pCO2-45 pH-7.43
calHCO3-31* Base XS-5
[**2168-5-14**] 05:33AM BLOOD Type-ART Temp-37.2 Rates-16/4 Tidal V-573
PEEP-8 FiO2-50 pO2-53* pCO2-30* pH-7.61* calHCO3-31* Base XS-8
Intubat-INTUBATED
[**2168-5-14**] 02:56AM BLOOD Type-ART Temp-37.2 Rates-16/ Tidal V-550
PEEP-5 FiO2-50 pO2-72* pCO2-39 pH-7.56* calHCO3-36* Base XS-11
Intubat-INTUBATED
[**2168-5-16**] 05:42PM BLOOD Glucose-78
[**2168-5-16**] 03:41PM BLOOD Glucose-187* K-3.2*
[**2168-5-16**] 09:07AM BLOOD Glucose-102
[**2168-5-14**] 11:33AM BLOOD Glucose-71
[**2168-5-14**] 02:56AM BLOOD Lactate-2.6*
[**2168-5-18**] 04:18AM BLOOD freeCa-1.15
Brief Hospital Course:
Tx to [**Hospital1 18**] on [**5-13**]. Repeat CT showed lareg fluid collection
and rain was placed and 1400 ml was drained. She was diuresed
and improved clinically. [**5-16**] - rt thoracentesis with 600 ml of
fluid asp. Extubated on [**5-17**]. Echo showed hyperdynamic, 80%
EF, overall nl. Started on heparin with goal of PTT 60-80. CXR
[**5-17**] showed L pleural effusion and rt base, rt middle lobe
atelect. Tx to floor in stable condition on [**5-18**]. Had episode
of delerium on floor for which hypoxia, metabolic, infectious
cause were ruled out. Physical exam was normal. Delerium
resolved on own over the night. She was diuresed 1-2 L per day
due to massive peri[ph edema. Edmea decreased over time and she
was able to move around with the help of PT. Overnight had
bradycardia to 30's on three occasions. Was asymptomatic and
showed no EKG changes. Was heparinized and put on coumadin with
a goal INR to be between 2-2.5. On [**5-26**] she had a TEE which
showed no clots and was cardioverted successfully. That night
she had bradycardia in the 20's and a-fib, but she was
asymptomatic. Telemetry also showed PVC's. Pt has had issues
with glucose control since this episode started and was on
sliding scale insulin and glargine as inpatient. Suspicious
lung nodule was also incidentally on x-ray. Pt stable for
discharge on [**5-27**] to rehab facility.
Medications on Admission:
Tx from referring hosp:
Insulin
Fentanyl
Imipenum
levothyroxin
heparin sq
morphine
Vanc
Flagyl
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*18 Tablet(s)* Refills:*0*
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*50 Appl* Refills:*0*
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*0*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
6. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Hold
for two days. Goal INR is 2-2.5.
Disp:*30 Tablet(s)* Refills:*0*
7. Levothroid 100 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Renastomosis leak and resp failure
Discharge Condition:
Stable
Discharge Instructions:
Will go to rehab facility.
No telemetry needed.
Continue Vancomycin for 7 more days.
Hold coumadin for 2 days
Keep coumadin level between 2-2.5.
Check INR levels every other day.
Will need sliding scale insulin ordered at rehab facility.
Followup Instructions:
F/U with Dr. [**Last Name (STitle) **] in 2 weeks- ([**Telephone/Fax (1) 1483**]
F/U with thoracic surgery for lung nodule in 2 weeks ([**Telephone/Fax (1) 4044**]
F/U with [**Hospital **] [**Hospital 982**] clinic in 2 weeks ([**Telephone/Fax (1) 4847**]
F/U with Cardiology in 2 weeks ([**Telephone/Fax (1) 2037**]
F/U with Electrophysiology (EP) - 2 weeks ([**Telephone/Fax (1) 8793**]
|
[
"99592",
"42731",
"5119",
"4019",
"2449"
] |
Admission Date: [**2199-7-30**] Discharge Date: [**2199-8-20**]
Date of Birth: [**2199-7-30**] Sex: M
HISTORY: [**Known lastname 12589**] was born to a Gravida 2, Para 0, now 1 mother,
whose pregnancy was uncomplicated prior to her preterm labor
at 33-4/7 weeks. She was blood type A negative and she
received her RhoGAM as prescribed. [**Known lastname 12589**] was admitted
was the 50th percentile for gestational age. Head
circumference was 29 cm which was 25th percentile for
gestational age, and length was 41 centimeters at the 20th
percentile for gestational age.
PHYSICAL EXAMINATION: On admission, [**Known lastname 12589**] was active and
alert. Skin was notable for diffuse petechiae over the
Lungs were clear. Abdomen was soft, nondistended, without
masses. Extremities were well perfused and he was moving
them all equally. The hips were stable. Genitourinary
examination was normal male genitalia with bilaterally
descended testes and patent anus. No dimple. Back was
intact with no defects. Neurologic examination: Anterior
fontanel was open and flat and the child was moving all
extremities well. Head examination: The eyes has bilateral
red reflex. The palate and gums were intact.
DISCHARGE PHYSICAL EXAMINATION: The discharge examination
was the same as the admitting examination, except that there
were no petechiae and [**Known lastname 12589**] had developed a systolic murmur
II/VI heard throughout all heart fields and through the back.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. Respiratory: Stable. No oxygen requirement.
2. Cardiovascular: On day 17 of life, a systolic murmur was
noted; it is intermittent and transmits to the back. Femoral
pulses are intact and equal and four extremity blood
pressures are also equal done today. Right lower extremity
blood pressure was 71/34 with a mean of 39; right upper
extremity was 79/44, with a mean of 59; left lower extremity
was 74/36 and left upper extremity was 75/48. He has had no
evidence of any cardiovascular compromise.
3. Fluids, Electrolytes and Nutrition: Initially, [**Known lastname 12589**]
required gavage feeding. He received caloric supplementation,
with breast milk 30 kcal/oz with ProMod. He tolerated the
feeding well, eventually weaned to
alternating oral and gavage feeds and within the last 48 to 72
hours, all feeding had been oral. He is taking breast milk
24 calories per ounce using Enfamil Powder.
4. Gastrointestinal: [**Known lastname 12589**] suffered from a mild
hyperbilirubinemia on days two, three to four of life during
which he received single phototherapy; this subsequently
resolved. His bilirubin on day two of life was 9.8 and then
the direct was 0.3. On day three of life it was 10.3 with a
direct of 0.3, which has come down to 9.1 and 0.3 for the
direct by day eight of life.
5. Hematologic: The patient's blood type was A positive and
mother was A negative. He was weakly Coombs' positive which
is the likely etiology for his slightly prolonged
hyperbilirubinemia. More importantly, he was noted to be
thrombocytopenic. On day zero of life, his platelet count
was 51,000 and subsequently dropped to 47,000 on day of life one.
He received one dose of IVIG and his platelet
count rose to 73,000, then increased into the normal range for
the rest of his course. On day 20 of life, his platelets had
come up to 723,000.
His blood sample was positive for
anti-GP 1 to 2A antibodies and he was diagnosed with neonatal
alloimmune thrombocytopenia. His mother was
homozygous for the human platelet antigen 5A and father was
heterozygous with human platelet antigen 5A/B. The family
has a 50% chance during their subsequent pregnancy of having
a child with fetal alloimmune thrombocytopenia. The family
is aware. There are no further hematologic issues for [**Known lastname 12589**].
6. Infectious Disease: From an Infectious Disease
standpoint, [**Known lastname 12589**] had a blood culture and CBC drawn on day
zero of life. He was treated with Ampicillin and
Gentamicin until his cultures were 48 hours negative, at
which time, his antibiotics were stopped. His blood
cultures proceeded to have no growth on its final fifth day.
7. Neurologic: From a neurologic standpoint, he had a
normal head ultrasound during his first week of life. Clinically
his neurologic examination has always been normal.
8. Endocrine: From an endocrine standpoint, his neonatal
screen came back for slightly elevated TSH at 17.5; normal
was up to 15 but his thyroxine was within normal range. It
was recommended that this just be followed with a second
neonatal screen.
9. Sensory: A hearing screen performed with automated
auditory brain stem responses was normal.
10. Psychosocial: Parents are involved and understand the
implications for future pregnancies considering the
alloimmune thrombocytopenia.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], phone number
[**Telephone/Fax (1) 35561**]. Fax number is [**Telephone/Fax (1) 44464**].
CARE RECOMMENDATIONS:
1. Feed: At discharge, mother and father have been
instructed to continue to breast feed [**Known lastname 12589**] but when he takes
bottles, to add powder to equal 24 calories per ounce.
2. Medications: He has been discharged on ferinsol.
3. Car seat position test was passed.
4. State newborn screening status: The second newborn
screen has not been sent and needs to be followed up by the
primary care physician.
5. Immunizations - He received Hepatitis B and will continue
with routine immunizations.
6. Follow-up appointment is [**8-21**], Wednesday night,
at 07:00 p.m. with Dr. [**Last Name (STitle) **].
DISCHARGE DIAGNOSES:
1. Neonatal alloimmune thrombocytopenia.
2. Prematurity.
3. Hyperbilirubinemia.
4. Feeding immaturity.
5. Questionable hypothyroidism unlikely with normal
thyroxine but slightly high TSH.
6. Cardiac murmur, consistent with flow. Cardiology follow-up
is recommended if persistent.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 43613**]
MEDQUIST36
D: [**2199-8-20**] 14:28
T: [**2199-8-20**] 14:35
JOB#: [**Job Number **]-24
cc:[**Telephone/Fax (1) 44465**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2127-8-6**] Discharge Date: [**2127-8-14**]
Date of Birth: [**2074-4-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
shortness of breath, fever
Major Surgical or Invasive Procedure:
Large volume paracentesis [**8-9**] and 28.
History of Present Illness:
HPI: 53 year old male with HIV, ESLD (sober for a week), chronic
illness, no medical care, presented with malaise and mild SOB.
Found to have HCT 19, melena ?????? believe to be subacute, low grade
temps (100.3), ascites. Para results pending, already on zosyn.
Transfused 3 units and hemodynamically stable, making urine,
sitting on a medical floor. Requesting transfer to further care.
On [**8-6**] (HD#2) went for EGD to eval melena/suspicion for
varices; unable to tolerate [**1-18**] hypoxia while lying flat and
resting tachycardia to 100-110. Returned to the medical floor
stable, but then hematemesis of 100-150cc bright red blood with
increased tachycardia to 120s and hypoxia requring NRB to keep
sats >=90%.
Bolused 1L [**Hospital **] transferred to ICU, intubated for airway. At
intubation, copious bloody secretions suctioned from ETT.
Octreotide started. On PPI. 2 PIV (bilat antecubs). Transferred
to MICU, intubated in prep for EGD.
ROS: Negative for fevers, chills, nightsweats, chest pain,
shortness of breath, cough, abdominal pain, nausea, vomiting,
diarrhea, melena, hematochezia, hematemesis, dysuria. No
paresthesias or weakness. Otherwise pertinent positives as
above.
Past Medical History:
PMH: HIV+, unclear stage (dx in pts 40s)
Social History:
SH: Drinks 2 large coffee cups of vodka per day. Reports last
drink approx 1 week ago. HIV+ from partner. Off meds for years.
Reports being diagnosed with AIDS. Smokes 1/2-1 PPD. Denies
IVDU.
Family History:
FH: Father with dementia. Mother healthy. [**Name2 (NI) **] alcohol abuse.
Physical Exam:
PHYSICAL EXAM:
VS: T 96.9 BP 157/105 P 122 VENT: AC 450 x12, FiO2 100%;
Sat 99%
GEN: cachectic man
HEENT: prominent temporal wasting, purple-black exudates on
tongue NECK: Supple, no LAD, no appreciable JVD
CV: normal S1S2, no murmurs, rubs or gallops
PULM: CTAB, no w/r/r, fair air movement bilaterally
ABD: + caput medusae, massively distended, normoactive bowel
sounds, no organomegaly, no abdominal bruit appreciated
SKIN: dry, scaling skin on upper trunk, waxy skin on ankles with
bilateral venous stasis changes
EXT: Warm and well perfused, symmetric distal pulses, 2+
bilateral leg edema to the abdomen
NEURO: sedated for intubation; + asterixis prior to intubation
Pertinent Results:
[**2127-8-6**] 11:02PM URINE HOURS-RANDOM CREAT-141 SODIUM-LESS THAN
[**2127-8-6**] 09:19PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.022
[**2127-8-6**] 09:19PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-TR
[**2127-8-6**] 09:19PM URINE RBC-[**11-6**]* WBC-[**2-19**] BACTERIA-NONE
YEAST-NONE EPI-0
[**2127-8-6**] 09:19PM URINE AMORPH-MOD
[**2127-8-6**] 09:15PM GLUCOSE-106* UREA N-38* CREAT-1.5* SODIUM-136
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-25 ANION GAP-9
[**2127-8-6**] 09:15PM estGFR-Using this
[**2127-8-6**] 09:15PM ALT(SGPT)-22 AST(SGOT)-38 LD(LDH)-260* ALK
PHOS-42 TOT BILI-3.2*
[**2127-8-6**] 09:15PM ALBUMIN-1.8* CALCIUM-7.4* PHOSPHATE-3.8
MAGNESIUM-1.7
[**2127-8-6**] 09:15PM WBC-6.3 RBC-3.16* HGB-10.2* HCT-31.7*
MCV-100* MCH-32.2* MCHC-32.1 RDW-22.0*
[**2127-8-6**] 09:15PM NEUTS-65.1 LYMPHS-28.6 MONOS-4.2 EOS-1.5
BASOS-0.5
[**2127-8-6**] 09:15PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2127-8-6**] 09:15PM PLT SMR-VERY LOW PLT COUNT-53*
[**2127-8-6**] 09:15PM PT-18.4* PTT-39.4* INR(PT)-1.7*
[**2127-8-6**] 09:15PM WBC-6.3 LYMPH-29 ABS LYMPH-1827 CD3-93 ABS
CD3-1700 CD4-9 ABS CD4-170* CD8-77 ABS CD8-1413* CD4/CD8-0.1*
Labs from OSH:
WBC 7.8, H/H 8.9/19--->25.6, plts 65
136, 4.6, 108, 23, 32, 1.3, 98
Ca 7.7, Mg 1.7
AST 46, ALT 24, ALK Phos 47, Tbili 3.4, serum albumin 1.2, total
protein 7.0, amylase 97, lipase 28
Ammonia 38
Ferritin 368
Fe 80
TIBC 100
Folate 14
Vit B12 919
TSH 6.6
INR 1.5
UA - dark yellow, cloudy, ph 6, 1+ bili, 2+ blood, 2+ leuk est,
10-20 WBCs, + ammonium urate crystals
Imaging:
[**8-6**]: Abd U/S - large ascites, shrunken liver, patent portal
vein, GB wall thickening, multiple gallstones; splenic
calcifications
Brief Hospital Course:
53 year old male with ESLD, HIV presenting with multiple
complaints transferred to [**Hospital1 18**] with fevers, fount to have UTI
at OSH, now with hematemesis from a gastric ulcer now s/p EGD
with clipping of vessel and [**State **] tube removal.
Pt's condition continued to decline during his hospital
admission. The hematemesis resolved, but all other issues
continued to be problem[**Name (NI) 115**]. [**Name2 (NI) **] developed hypernatremia, had
poor oxygen saturation, and became hypotensive despite repeated
albumin boluses. Pt was made DNR/DNI on [**8-13**] and then was made
CMO the morning of [**8-14**]. He was pronounced dead at 10:45 am on
[**2127-8-14**]. Mother was informed and she declined autopsy.
#. Renal failure: Elevated Creatinine and decreased UOP -
Patient with Cr of 1.6 BL now 2.0 more or less this entire
admission, unknown baseline. Given low muscle mass, this is
quite elevated.
- Previously, urine lytes showed ATN, now, lytes consistent with
pre-renal state
- Will give 500ml of 5% albumin for fluid and albumin resus
- Parancetesis on [**8-13**] with goal to relieve pressure on renal
vasculature which may be contributing to ARF
#. Altered Mental Status - Patient with AMS on arrival, had
improved but now worsening. Unclear if this is AIDS dementia,
uremic, or hepatic encephalopathy
- Now awake, alert, and agitated.
- Will try again with NG lactulose plus lactulose enema as
before
#. ESLD: patient with tense ascites, thrombocytopenia,
coagulopathy. Given history of EtOH abuse, this is the most
likely cause. Chronic Hepatitis also a concern.
-Propranolol 10mg TID PO for varices
-MELD score 18, unlikely candidate for transplant given alcohol
use and likely uncontrolled HIV disease
-US of portal venous system showed blood flow with possible
ileus
-Large vol parancentesis x 2 during admission. Labs of
peritoneal fluid consistent with cirrhosis
# Gaseous distension of colon: Ongoing problem for this Pt.
Etiology unclear.
- Passing gas. Stool more solid now.
- Add back lactulose as tolerated and lactulose enema x 1 today
- [**Month (only) 116**] be contributing to high intraabdominal pressure which may
be complicating ARF
#. Leukocytosis and fever - Patient transferred from OSH with
fevers and +UA, which makes UTI most likely diagnosis. patient
also HIV+ with CD4 count of 170, making opportunistic infection
a concern. Urine cultures X2 negative here.
- BCx results pending
- Paracentesis fluid not c/w SBT. On ceftriaxone for ?UTI from
osh ?????? CTX until [**2127-8-13**]
- As of [**2127-8-13**] WBC rising with mild neutrophilia. Source of
infection unclear. CXR concerning for aspiration. UCx pending.
- Repeating paracentesis on [**2127-8-13**]
#. Hematemesis - From bleeding gastric ulcer. Patient noted to
have 1.5L of frank hematemesis at time of EGD, which prompted
[**State **] tube placement. FDP and D-dimer elevated, along with
decreased haptoglobin and thrombocytopenia. HCT now stabilized.
-discontinued Octreotide
-cont protonix 40mg IV BID
-f/u Hepatology recs
-transfuse for HCT < 25
# Thrombocytopenia ?????? multifactorial. Related to liver disease
and AIDS most likely
- Infused 1 U [**8-12**] with good effect
-transfuse platelets if <50 given recent UGIB
#. HIV - CD count 170 here. will hold on treatment at this time.
[**Month (only) 116**] need PCP prophylaxis now as CD4 count <200.
- started atovaquone
- ID holding HAART for now given poor PO absorption
#. Alcoholism
- Holding CIWA scale for now to be able to eval encaphalpathy
Medications on Admission:
Meds on Admission: from OSH - pt on no meds at home
zosyn 3.375g q6
protonix 40mg IV BID
folic acid 1mg PO daily
MVI 1 po daily
thiamine 100 mg po daily
nicotine patch
metoclopromide 5-10mg IV q6 prn
morphine 2-4 mg IV q3 prn
D5N at 80 per hour
Discharge Disposition:
Home with Service
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2127-8-14**]
|
[
"51881",
"5849",
"2851",
"5990",
"2760",
"2875"
] |
Admission Date: [**2114-11-26**] Discharge Date: [**2114-12-1**]
Date of Birth: [**2062-8-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7616**]
Chief Complaint:
Transfer from OSH for upper gastrointestinal bleeding.
Major Surgical or Invasive Procedure:
Upper endoscopy x 2 with banding of varices x 2 at outside
hospital.
Intubation at outside hospital.
History of Present Illness:
This is a 52y/o male w/ HCV hepatitis, cirrhosis, HCC, s/p
radiofrequency ablation, thrombocytopenia, h/o DT, seizure d/o,
and recurrent cellulitis who is transfered from WXVA after p/w
UGIB. He initially presented on the [**11-19**] with melena and
hematemesis, a Hct drop of 8 points from baseline 35 and a NG
lavage positive for 750cc of dark fluid initially and then 100cc
of BRB. He received 1 units PRBCs was started on octreotide gtt
at that time. He underwent an EGD on day of admission [**11-19**],
demonstrating old blood in the stomach, no active bleeding,
grade 2+ esophageal varices w/one suggestive of a recent bleed.
Six bands were successfully placed. His Hct continued to drop
for the next two days, and he received each day 2 units PRBCs, 4
units FFP, and 6 units of platelets.
However, on the evening of [**11-23**], he developed a recurrent bleed
with a large melanotic stool and a 6-pt Hct drop. He was
restarted on an octreotide gtt, IV PPI, and given 2 U PRBCs, 6
units of platelets, and 2 units of FFP. On [**11-24**] he was
electively intubated for airway protection and underwent a
repeat EGD which showed esophageal varices but no active
bleeding. The varices were banded again. He was then transfered
to [**Hospital1 18**] for [**Last Name (un) **] +/- transplant evaluation on [**11-26**]. He
arrived to the MICU on [**11-26**], intubated and sedated for airway
protection. He was weaned off sedation and also underwent a
paracentesis, which was negative for SBP. He was extubated w/o
complications yesterday. He had no further bleeding episodes and
received 1 U PRBCs and 2 units of platelets while in the unit.
His octreotide gtt was d/c'd today. He had a CT of his
abd/pelvis which demonstrated an ileus, however pt is having
BM's and no n/v, able to tolerate po. An RUQ u/s demonstrated an
old PVT w/o progression since [**Month (only) 216**] of this year.
Past Medical History:
1. Cirrhosis - HCV, grade III esophageal varices,
2. HCV - diagnosed [**2099**], s/p 2 incomplete trials of PEG
IFN/ribavirin, d/c'd for depression and noncompliance, diagnosed
with hepatocellular carcinoma, approximately 4-cm mass. He
underwent radiofrequency ablation of this lesion on [**2114-7-11**].
Repeat CT without lesions.
3. Thrombocytopenia
4. H/o seizure disorder - on Keppra
5. s/p R mastoidectomy - for GSW to head, deaf in R ear
6. H/o PTSD - s/p GSW
7. Depression/anxiety
8. IV drug use from [**2081**] to [**2109**]
9. History of hepatitis B in [**2085**]
Social History:
Lives in [**Location 1268**] by himself in his own apartment. He is
divorced and has an 8-year-old daughter. Currently unemployed,
on [**Social Security Number 59561**]social security. Volunteers at VA. H/o heavy alcohol abuse
[**2078**]-[**2107**], during which he drank a pint to a quart of vodka per
day, sober x 4 yrs. H/o IV heroin use, last use 4yrs ago. +
Tobacco use, 1 ppd x ~40y. H/o incarceration for domestic abuse.
Presently uses <1pp day.
Family History:
Father died at age 62, had a history of emphysema, asthma, COPD,
lung cancer, stroke, alcoholism, hypertension, type 2 diabetes.
Mother and sister with breast cancer. Sister recently passed
away from breast CA.
Physical Exam:
VS: T 95.7, BP 98/64, HR 75, RR 16, SaO2 99%/RA
General: Sitting in chair, chronically-ill appearing male in
NAD, AO x 3
HEENT: NC/AT, PERRL, MMM, O/P clear, poor dentition, mild
icterus
NECK: supple, no LAD
CV: RRR, SEM [**1-15**] heard throughout, best at LLSB
PULM: CTA b/l no w/r/r anteriorly
ABD: NABS, NT, no HM appreciated, distended with tympany to
percussion and dullness at flanks
EXT: 2+ edema, dermatosclerotic changes, no c/c.
NEURO: PERRLA, moving all extremities, 1+ reflexes b/l; no
asterixis
Pertinent Results:
Labwork on admission:
[**2114-11-26**] 03:37PM WBC-9.0# RBC-3.06* HGB-9.8* HCT-28.8* MCV-94
MCH-32.0 MCHC-34.1 RDW-19.7*
[**2114-11-26**] 03:37PM PLT COUNT-39*
[**2114-11-26**] 03:37PM GLUCOSE-133* UREA N-17 CREAT-0.8 SODIUM-143
POTASSIUM-3.8 CHLORIDE-118* TOTAL CO2-21* ANION GAP-8
[**2114-11-26**] 03:37PM ALT(SGPT)-40 AST(SGOT)-56* LD(LDH)-256* ALK
PHOS-71 AMYLASE-30 TOT BILI-4.5*
[**2114-11-26**] 03:37PM LIPASE-28
[**2114-11-26**] 03:37PM ALBUMIN-2.7* CALCIUM-7.5* PHOSPHATE-2.1*
MAGNESIUM-2.0
.
EKG: NSR at 100 bpm. Normal axis and intervals. Unchanged LBBB,
compared to [**7-15**].
.
CXR [**11-26**] - Endotracheal tube is 4 cm above carina. Right
jugular CV line has tip located in region of cavoatrial
junction. No pneumothorax. There are low lung volumes with
probable atelectasis in the left lower lobe but the lungs are
otherwise grossly clear on this suboptimal film. There is slight
gaseous distention of the colon.
.
CT abd [**11-27**] - No evidence of recurrence around RF ablation site
or new hepatic lesions. Interval increase in abdominal and
pelvic ascites. Stable appearance to perisplenic varices and
multiple collateral vessels with increase in gastric and
esophageal varices. Small nonocclusive chronic thrombus within
the main portal vein, grossly stable dating back to [**2114-7-11**]. Otherwise unremarkable hepatic and portal veinous systems.
Cholelithiasis without evidence of cholecystitis. Dilated air
and fluid filled colon with minimal dilatation of small bowel.
No evidence of mechanical obstruction, findings suggestive of
ileus.
.
RUQ u/s [**11-27**] - Cirrhotic liver with no focal liver lesions
identified. Patent intrahepatic portal and hepatic veins with
extrahepatic portal vein not well visualized. Portal
hypertension with patent umbilical vein. Minimal ascites.
Brief Hospital Course:
52 year-old male with HCV/ETOH cirrhosis, HCC s/p radioablation
who is transferred from OSH after two episodes of variceal bleed
for evaluation of [**Last Name (un) **] +/- transplant.
.
1. Upper gastrointestinal bleeding: Secondary to gastric
variceal bleed, status post banding on [**11-19**] and [**11-24**]. No
further bleeding episodes. Hematocrit stable for 72 hours prior
to discharge. Octreotide gtt discontinued [**11-28**]. The patient was
given vitamin K SC x 3 doses. The patient was continued on
propanolol and PPI for prophylaxis. There was no need for IR
evaluation for TIPSS. The patient was given ciprofloxacin to
complete a ten-day course for SBP prophylaxis in the setting of
GIB; paracentesis negative for SBP on [**11-26**]. The patient was
given sucralfate QID for a ten-day course after banding. The
patient will have follow-up endoscopy performed in three weeks.
.
2. Cirrhosis/hepatocellular carcinoma: Complicated by ascites,
variceal bleed, encephalopathy. The patient is status post
diagnostic paracentesis [**11-26**] negative for SBP. The patient's
diuretics were decreased to lasix 20 mg and aldactone 50 mg
daily for rise in creatinine. The patient was continued on
propanolol for prophylaxis. The patient was given ciprofloxacin
for SBP prophylaxis given recent active bleeding. The patient
was given lactulose for encephalopathy. The patient is being
evaluated as an outpatient for liver transplant. MELD score 17
on discharge but patient has known HCC.
.
3. Acute renal failure: Resolving prior to discharge. The rise
in creatinine occurred in the setting of restarting diuretics at
higher doses than previous. Likely pre-renal as responded to
decreasing doses of diuretics.
.
4. Thrombocytopenia: Likely due to splenic sequestration and
liver disease. The patient's platelets remained at baseline.
There was no need for platelet transfusion.
.
5. Seizure disorder: No active issues. The patient was continued
on Levetiracetam and Zonisamide.
Medications on Admission:
MEDS (from [**Hospital1 59561**]) -
Lasix 40 mg qd
Aldactone 100 mg qd
Keppra 1500 mg b.i.d.
Zonisamide 100 mg in the morning and 200 mg at night
Bupriinorphine/naloxone
Clotrimazole 10mg troche
.
MEDS (upon MICU transfer)-
1. Levetiracetam 1500 mg PO bid
2. Pantoprazole 40 mg IV q12
3. Phytonadione 10 mg SC qd
4. Zonisamide 100 mg PO QAM
5. Zonisamide 200 mg PO QPM
6. Ciprofloxacin 400 mg IV q12
7. Sucralfate 1 gm PO qid dissolve
8. Lactulose 30 ml PO bid titrate to 5-6bm/d
9. Furosemide 40 mg IV qd
10. Spironolactone 100 mg PO qd
11. Nadolol 40 mg PO qd
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
3. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
Disp:*300 g* Refills:*2*
8. Propranolol 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*90 Tablet(s)* Refills:*2*
9. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 6 days.
Disp:*24 Tablet(s)* Refills:*0*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
Please draw electrolytes (including BUN/Cr) and liver enzymes
(AST, ALT, Alk P, Tbili, LDH, Albumin, INR) next week and fax
results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 4400**] at the Liver Center.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Variceal bleed status post banding x 2 at outside hospital
.
Secondary:
1. Cirrhosis - HCV, grade III esophageal varices,
2. HCV - diagnosed [**2099**], s/p 2 incomplete trials of PEG
IFN/ribavirin, d/c'd for depression and noncompliance, diagnosed
with hepatocellular carcinoma, approximately 4-cm mass. He
underwent radiofrequency ablation of this lesion on [**2114-7-11**].
Repeat CT without lesions.
3. Thrombocytopenia
4. H/o seizure disorder - on Keppra
5. s/p R mastoidectomy - for GSW to head, deaf in R ear
6. H/o PTSD - s/p GSW
7. Depression/anxiety
8. IV drug use from [**2081**] to [**2109**]
9. History of hepatitis B in [**2085**]
Discharge Condition:
Afebrile, vital signs stable. Hematocrit stable.
Discharge Instructions:
You were hospitalized with bleeding from varices because of your
liver disease. You should take nadolol every day to prevent
future bleeding. You have a repeat endoscopy scheduled in three
weeks as below. Also, please have your labs checked next week
and faxed to the liver clinic as specified in the prescription.
.
Please contact a physician if you experience fevers, chills,
abdominal pain, nausea, vomiting, black stools or blood in your
stools, or any other concerning symptoms.
.
Please take your medications as prescribed.
- You should continue propanolol 40 mg twice daily to prevent
future bleeding.
- You should take protonix 40 mg twice daily to reduce stomach
acid and prevent future bleeding.
- You should continue lasix 20 mg and aldactone 50 mg once daily
to prevent fluid in your abdomen (ascites).
- You should take ciprofloxacin for 5 more days to prevent
infection after bleeding.
- You should take sucralfate for 6 more days to coat your
esophagus after banding.
.
Please keep your follow-up appointments as below. You need to
have a repeat endoscopy as scheduled below.
Followup Instructions:
Repeat endoscopy: Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS
Date/Time:[**2114-12-18**] 8:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2114-12-18**] 8:00
You should arrive at 7:30 am prior to the procedure.
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2115-1-15**] 8:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 7619**]
Completed by:[**2114-12-14**]
|
[
"2875",
"5849"
] |
Admission Date: [**2133-12-24**] Discharge Date: [**2133-12-29**]
Date of Birth: [**2054-4-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Right shoulder pain radiating to chest
Major Surgical or Invasive Procedure:
[**2133-12-25**] Coronary artery bypass grafting x4 with left internal
mammary artery to left anterior descending coronary artery;
reverse saphenous vein single graft from aorta to first obtuse
marginal coronary artery; reverse saphenous vein single graft
from aorta to second obtuse marginal coronary artery; as well as
reverse saphenous vein single graft from aorta to the distal
right coronary artery.
[**2133-12-24**] Cardiac cath
History of Present Illness:
79 year old male who has had right shoulder pain that radiates
to the chest that has been occurring over the last six weeks.
Pain was occurring at rest and with activity and awakened him at
night a few times in the last few days. He had inferolateral ST
depressions with minimal exertion. He took 8 minutes to recover
during stress echo, he was referred to the emergency department
for evaluation and then underwent cardiac catheterization that
revealed coronary artery disease.
Past Medical History:
Hypertension
Colonic adenoma
Diverticulosis
MV insufficiency
Hypercholesterolemia
Pilonal cyst removal [**2078**]
Social History:
Race: caucasian
Last Dental Exam: > 1 year
Lives with: spouse
Occupation: retired but still actively does construction
Tobacco: 25 pack year history quit > 20 years ago
ETOH: Denies
Family History:
noncontributory
Physical Exam:
Pulse: 54 Resp: 19 O2 sat: 99%
B/P Right: 129/68 Left: 154/64
Height: 66" Weight: 188 pounds
General: no acute distress
Skin: Dry [x] intact [x] calluses bilateral knees
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] anterior
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: alert oriented x3 nonfocal
Pulses:
Femoral Right: cath site Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2133-12-24**] Cath: 1. Coronary angiography revealed the following
results. The LMCA was angiographically normal. The LAD revealed
a 100% ostial stenosis and it fills via right to left
collaterals. The LCx revealed a mid 80% and a distal 99%
stenoses. The RCA revealed a mid 100% stenosis and distally
fills via left to right collaterals. 2. Limited resting
hemodynamics revealed a SBP of 127 mmHg and a DBP of 59 mmHg. 3.
R 5Fr femoral artery sheath to be pulled post procedure
[**2133-12-24**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
40-59%
[**2133-12-25**] Echo: Prebypass: No spontaneous echo contrast is seen in
the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The descending thoracic aorta is mildly
dilated. 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. Mild (1+)
mitral regurgitation is seen. There is a small pericardial
effusion. Postbypass: The patient is on a phenylephrine infusion
and is A-paced. Biventricular systolic function continues to be
normal. Mild mitral reguritation and trace aortic regurgitation
persist. The thoracic aorta is intact. Dr. [**Last Name (STitle) 914**] was notified
in person of the results at the time of the study
[**2133-12-28**] 06:15AM BLOOD WBC-3.7*# RBC-3.38* Hgb-10.3* Hct-28.7*
MCV-85 MCH-30.6 MCHC-36.0* RDW-13.3 Plt Ct-159
[**2133-12-28**] 06:15AM BLOOD Glucose-126* UreaN-31* Creat-1.1 Na-139
K-4.2 Cl-100 HCO3-32 AnGap-11
[**2133-12-24**] 03:30PM BLOOD ALT-20 AST-20 AlkPhos-45 Amylase-53
TotBili-1.1
[**2133-12-28**] 06:15AM BLOOD Mg-2.6
[**2133-12-24**] 03:30PM BLOOD VitB12-345
[**2133-12-24**] 03:30PM BLOOD VitB12-345
[**2133-12-24**] 03:30PM BLOOD %HbA1c-5.3 eAG-105
Brief Hospital Course:
Following his cardiac cath on [**12-24**] which showed severe coronary
artery disease he was admitted for surgical work-up for pending
surgery. On [**12-25**] he was brought to the operating room where he
underwent a coronary artery bypass graft x 4. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. Beta blockers and diuretics
were started and he was gently diuresed towards his pre-op
weight. On post-op day one his chest tubes were removed and he
was transferred to the telemetry floor to begin increasing his
activity level. He had intermittent Atrial fibrillation and was
treated with amiodarone with conversion to SR. No Coumadin was
indicated as patient was not in prolonged atrial fibrillation.
Pacing wires removed per protocol. He continued to make good
progress tolerating a full po diet, ambulating in the halls
without difficulty and his incisions were healing well. He was
cleared for discharge to home with VNA on POD # 4. All follow up
appointments were advised.
Medications on Admission:
Medications at home:
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1
(One) Tablet(s) by mouth once a day
SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1
(One) Tablet(s) by mouth at bedtime
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 (One) Tablet(s) by mouth once a day PT HAS
BEEN TAKING TWO TABS DAILY
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. 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*
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] through [**1-2**]; then 400 mg daily [**Date range (1) 89466**];
then 200 mg daily starting [**1-11**] until follow up with
cardiologist .
Disp:*56 Tablet(s)* Refills:*0*
7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
10. potassium chloride 8 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day for 10 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary artery bypass graft x 4
postop A Fib
Past medical history:
Colonic adenoma
Diverticulosis
MV insufficiency
Hypercholesterolemia
s/p Pilonal cyst removal [**2078**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema..................
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on Tuesday [**1-19**] @ 1:30 pm
***Cardiologist: Please get referral to cardiologist from PCP
Primary Care Dr. [**First Name4 (NamePattern1) 1312**] [**Last Name (NamePattern1) 31097**] [**1-28**] @ 4PM
**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:[**2133-12-31**]
|
[
"41401",
"9971",
"5180",
"42731",
"4240",
"4019",
"2724",
"2720",
"2449",
"2875"
] |
Admission Date: [**2106-3-9**] Discharge Date: [**2106-3-25**]
Date of Birth: [**2046-7-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tree Nut
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2106-3-18**]
Coronary artery bypass grafting x3 with a left internal mammary
artery to the left anterior descending artery and reverse
saphenous vein graft to the posterior descending artery and the
diagonal artery
History of Present Illness:
59 year-old male with a history of cardiomyopathy EF 45-50% with
PCM/ICD who presented due to SOB. He awoke in respiratory
distress and called EMS. He was found to have a SBP in 200s, RR
30-40s, rales in bilateral lung fields. He
was given nitropaste and started on CPAP with presumed flash
pulmonary edema. His symptoms improved enroute to the ER. He had
taken his home lasix of 80mg and urinated before EMS arrived. At
baseline he gets short of breath with a flight of stairs. In
the ED he was given lasix 80mg IV x 1 and started on a nitro
gtt. He was continued on CPAP with fiO2 of 50%. He was
diaphoretic on
arrival. He was given vanco and levo for possible PNA. He was
admitted for futher evaluation.
Cardiac Catheterization: Date:[**2106-3-15**] Place:[**Hospital1 18**]
LMCA: non-obstructed
LAD: diffuse mid to distal up to 80% stenosis, proximal 60%
lesion
LCX: RI has a 30% proixmal lesion
RCA: hazy, 85% ostial PDA
RA=17
PCW=30
PA= 46/28
Past Medical History:
-Ischemic and Hypertensive cardiomyopathy,
-chronic systolic CHF s/p BiV pacer-ICD placement [**1-/2100**],
echo-EF 45-50% [**5-15**]
with LVH ([**Company 1543**] [**Hospital1 **]-V/ICD with epicardial LV lead placement
[**2103**])
-Hypertension
-Hyperlipidemia
-Type 2 diabetes mellitus
-Obstructive sleep apnea - on 15 CPAP
-Spinal stenosis, herniated disc (Lumbar spinal stenosis.
Radiculopathy, Neurogenic claudication.,Right L5), s/p fusion
[**7-16**] far-lateral nerve compression)
-s/p tonsillectomy
-nephrolithiasis s/p lithotripsy
-BPH
-Gout
-Sigmoid diverticulosis by CT scan in [**2100**]
-CAD s/p DES D1, [**6-/2104**]
Social History:
Race:Caucasian
Last Dental Exam:1 year ago
Lives with:wife and 2 children
Occupation:retired manager of auto parts wear house.
Tobacco:quit in [**2093**], history of 25 pack-year
ETOH:1-2 beers/wk
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Pulse:90 Resp:16 O2 sat: 95/RA
B/P Right:139/88 Left:146/86
Height:5'4" Weight:192 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]; +IACD with several well
healed scars over left anterior chest
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft, obese [x] non-distended [x] non-tender [x] bowel
sounds +;
Extremities: Warm [x], well-perfused [x] no Edema
Varicosities: None;
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ access site is w/o hematoma Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right:no Left:no
Pertinent Results:
[**2106-3-24**] 04:50AM BLOOD WBC-7.5 RBC-3.41* Hgb-9.8* Hct-29.4*
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.0 Plt Ct-277
[**2106-3-24**] 04:50AM BLOOD Glucose-122* UreaN-28* Creat-1.1 Na-136
K-4.2 Cl-100 HCO3-28 AnGap-12
[**2106-3-23**] 04:35AM BLOOD Glucose-118* UreaN-30* Creat-1.0 Na-138
K-4.2 Cl-100 HCO3-28 AnGap-14
[**2106-3-23**] 04:35AM BLOOD WBC-8.4 RBC-3.45* Hgb-9.5* Hct-28.3*
MCV-82 MCH-27.7 MCHC-33.8 RDW-15.3 Plt Ct-246
[**2106-3-18**] Intraop TEE
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Left ventricular wall thicknesses are normal. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. There is severe global left
ventricular hypokinesis (LVEF = 20 %). Overall left ventricular
systolic function is severely depressed (LVEF= 20 %). The
estimated cardiac index is depressed (<2.0L/min/m2).
Right ventricular chamber size and free wall motion are normal.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. There is moderate aortic valve
stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened.
There is no pericardial effusion.
Post_Bypass:
Patient is on epinephrine infusion. Cardiac output 3.4L/min by
swan ganz method.
There is moderate improvement of LVEF global systolic function.
LVEF 35%
Intact thoracic aorta.
Aortic valve area calculations by continuity is 1.2 cm2 with
peak aortic velocity at 2.1m/sec.
Surgeon informed of the findings.
Other valves similar to prebypass.
Brief Hospital Course:
This is a 59-year-old male with history of cardiomyopathy who
had an ejection fraction of 45-50% and had a biventricular
pacemaker placed about a year or 2 ago. He
presented in respiratory distress and responded to diuresis. He
had an echocardiogram which demonstrated that his left
ventricular function was depressed with moderate to severe
regional systolic dysfunction and ejection fraction about 25%.
His aortic valve showed minimal aortic stenosis. There was also
a mass that was in the left ventricle and it appeared to be
attached to the papillary
muscle suggestive of a fibroblastoma or torn chord. He had a
dobutamine stress echo which showed that the majority of his
heart had viable myocardium except for the inferior wall. He
had a small mitral palpable muscle mass which was suggestive
of a torn chord. Cardiac surgery was asked to evaulate for
surgery. He was brought to the operating room on [**2106-3-18**] where
the patient underwent coronary artery bypass grafting x3 with a
left internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery and the diagonal artery. See operative note
for full 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 on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. A fib was noted to be his rhythm under his
pacemaker and he was loaded with Amiodarone. The patient was
transferred to the telemetry floor for further recovery. He did
have some dizziness and orthostatic hypotension which improved
with albumin. He had scant sternal drainage which had improved
at the time of discharge with no drainage noted for 48 hours.
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 7 the patient was ambulating freely,
tolerating a full oral diet and the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
home with VNA in good condition with appropriate follow up
instructions.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth once a day
CARVEDILOL - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth twice a day
COLCHICINE - (Prescribed by Other Provider) - 0.6 mg Tablet - 1
Tablet(s) by mouth q hs
CYCLOBENZAPRINE - (Prescribed by Other Provider) - 10 mg Tablet
- 1 Tablet(s) by mouth q hs
DILTIAZEM HCL [TAZTIA XT] - (Prescribed by Other Provider) -
300
mg Capsule, Sustained Release - 1 Capsule(s) by mouth once a day
FENOFIBRATE MICRONIZED - (Prescribed by Other Provider) - 200
mg
Capsule - 1 Capsule(s) by mouth q hs
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 2
Tablet(s) by mouth in am and 1.5 tabs at hs
GABAPENTIN [NEURONTIN] - (Prescribed by Other Provider) - 300
mg
Capsule - 1 Capsule(s) by mouth three times daily
GLYBURIDE - (Prescribed by Other Provider) - 2.5 mg Tablet - 2
Tablet(s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
NAPROXEN - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth q 8 hr as needed for prn
NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet,
Sublingual - 1 Tablet(s) sublingually q 5 minutes as needed for
as needed for chest pain
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg
Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a
day
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq
Capsule, Sustained Release - 1 Capsule(s) by mouth once a day
SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 40 mg
Tablet - 1 Tablet(s) by mouth once a day
TERAZOSIN - (Prescribed by Other Provider) - 1 mg Capsule - 1
Capsule(s) by mouth at hs
TERAZOSIN - (Prescribed by Other Provider) - 2 mg Capsule - 1
Capsule(s) by mouth at hs together for 3 mg at hs
VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - 320 mg
Tablet - 1 Tablet(s) by mouth once a day
Metformin 1000mg [**Hospital1 **]
Isosorbide 90mg Daily
Medications - OTC
EC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
MAGNESIUM - (Prescribed by Other Provider) - 250 mg Tablet - 1
Tablet(s) by mouth q hs
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg daily x 1 week, then 200mg daily until further
instructed.
Disp:*60 Tablet(s)* Refills:*2*
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
Disp:*qs * Refills:*0*
8. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
11. colchicine 0.6 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for muscle pain.
Disp:*30 Tablet(s)* Refills:*0*
13. terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
Disp:*90 Capsule(s)* Refills:*2*
14. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 40mg [**Hospital1 **] x 10 days, then resume previous home dose 40mg
am, 30mg pm.
Disp:*60 Tablet(s)* Refills:*2*
16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO Q12H (every 12 hours).
Disp:*60 Tablet, ER Particles/Crystals(s)* Refills:*2*
17. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
18. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule
PO daily ().
Disp:*30 Capsule(s)* Refills:*2*
19. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
20. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
21. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
22. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-7**] Sprays Nasal
QID (4 times a day) as needed for dry nares .
Disp:*qs * Refills:*0*
23. magnesium oxide 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease
s/p CABG x 3
PMH:
-Ischemic and Hypertensive cardiomyopathy,
-CHF s/p BiV pacer-ICD placement [**1-/2100**], echo-EF 45-50% [**5-15**]
with LVH ([**Company 1543**] [**Hospital1 **]-V/ICD with epicardial LV lead placement
[**2103**])
-Hypertension
-Hyperlipidemia
-Type 2 diabetes mellitus
-Obstructive sleep apnea - on 15 CPAP
-Spinal stenosis, herniated disc (Lumbar spinal stenosis.
Radiculopathy, Neurogenic claudication.,Right L5), s/p fusion
[**7-16**] far-lateral nerve compression)
-s/p tonsillectomy
-nephrolithiasis s/p lithotripsy
-BPH
-Gout
-Sigmoid diverticulosis by CT scan in [**2100**]
-CAD s/p DES D1, [**6-/2104**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for 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**
Completed by:[**2106-3-25**]
|
[
"41401",
"5849",
"4280",
"25000",
"2724",
"32723"
] |
Admission Date: [**2148-5-5**] Discharge Date: [**2148-5-14**]
Date of Birth: [**2085-7-3**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2006**]
Chief Complaint:
Right Femur Fracture
Major Surgical or Invasive Procedure:
Femur repair
Colonic decompression
History of Present Illness:
62 yo F with severe mental retardation, afib, and Hodgkin's
disease in remission. She lives in a monitored home for the
developmentally and physically disabled. She is wheelchair-bound
and normally moved by a [**Doctor Last Name 2598**] lift. It is unclear what the
etiology of her injury is. The patient is not able to describe
what happened, and the facility reports no particular incident.
They noted on [**5-3**] that she was having right leg and knee pain.
She had x-rays which showed a right subtrochanteric right
proximal femur fracture.
.
In the ED, initial vs were:97.8 79 132/61 16 97%. On exam
patient is AO to baseline per report. UA with >182 WBC and
moderate bacteria. Urine culture obtained. Patient was given
lorazepam in order to take films. She is ordered for
ciprofloxacin for UTI. Ortho consult called. Admitted to
medicine. Vitals on Transfer: 97.5, 68, 14, 102/55, 94 RA.
.
On the floor, she is alert and conversant. She is pleasant, and
in no acute distress. She does complain of right knee pain, but
mostly when prompted.
Past Medical History:
Hodgkins Lymphoma, in remission since [**2144**]
Atrial fibrillation
Hypertension
Hypothyroid
Osteoporosis
Chronic ileus
Temporary colostomy in [**2128**] for SBO
VRE UTIs
Pericardial effusion s/p window
GERD
Social History:
Lives at [**Location 69885**] Nursing Center. She is non-ambulatory and in
a wheelchair at baseline, and incontinent of bowels and bladder.
She is able to feed herself independently and performed some
ADLs. No history of smoking, alcohol or drugs.
Family History:
Father - CAD, [**Name2 (NI) 499**] and prostate cancer, d 80s
Mother - CVA
M Aunt - ovarian and breast cancer
MGM - liver cancer
Physical Exam:
Vitals: 98.0 104/62 60 20
General: Alert, conversant and able to answer yes/no questions,
but generally agreeable, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended and tympanitic, hypoactive
bowel sounds
Ext: severe pitting edema of bilateral legs and feet, no pain on
palpation of hip or knee, unable to assess range of motion due
to contractures
Skin: warm and dry
DISCHARGE EXAM:
99.1, 138/69, 72, 20% RA
General: Alert, conversant and able to answer yes/no questions,
no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: bibasilar crackles stable from prior exams, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended and tympanitic but reduced
in size compared to several days ago, active bowel sounds
Ext: severe pitting edema of bilateral legs and feet, stable;
thigh incision healing well with no erythema or drainage
Pertinent Results:
ADMISSION LABS:
[**2148-5-5**] 12:40AM BLOOD WBC-5.7 RBC-3.36* Hgb-10.8* Hct-34.5*
MCV-103*# MCH-32.1* MCHC-31.3# RDW-12.9 Plt Ct-188
[**2148-5-5**] 12:40AM BLOOD Neuts-76.1* Lymphs-14.5* Monos-5.2
Eos-3.5 Baso-0.7
[**2148-5-5**] 12:40AM BLOOD PT-12.7* PTT-30.3 INR(PT)-1.2*
[**2148-5-6**] 05:37AM BLOOD ESR-55*
[**2148-5-5**] 12:40AM BLOOD Glucose-129* UreaN-20 Creat-0.6 Na-140
K-4.4 Cl-107 HCO3-28 AnGap-9
[**2148-5-5**] 12:40AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.2
[**2148-5-8**] 05:30AM BLOOD VitB12-369
[**2148-5-6**] 05:37AM BLOOD CRP-76.2*
DISCHARGE LABS:
[**2148-5-14**] 06:16AM BLOOD WBC-4.8 RBC-3.13* Hgb-9.7* Hct-31.1*
MCV-100* MCH-31.2 MCHC-31.3 RDW-17.5* Plt Ct-167
[**2148-5-14**] 06:16AM BLOOD Glucose-113* UreaN-14 Creat-0.3* Na-143
K-3.7 Cl-109* HCO3-30 AnGap-8
[**2148-5-14**] 06:16AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.1
[**2148-5-8**] 05:30AM BLOOD VitB12-369
[**2148-5-9**] 10:40AM BLOOD Lactate-1.5
[**2148-5-9**] 10:40AM BLOOD freeCa-1.15
IMAGING:
CT ABD/Pelv/Thighs Non-Con:
.
FEMUR AP/LAT: Displaced and overriding right femoral
subtrochanteric fracture
.
PELVIS AP: Right-sided subtrochanteric femoral fracture
.
CT LE: Comminuted, markedly angulated and displaced fracture of
the
subtrochanteric femur with involvement of the lesser trochanter.
.
KUB: Chronic, marked colonic dilatation slightly increased from
[**2146-8-9**]. No free air is detected.
.
FEMUR AP/LAT: Multiple views of the right hip and proximal
femur. Status post ORIF of the right proximal femur including
the femoral neck with hooks, plate and screws. The hardware
appears intact. Improved alignment of the comminuted fracture.
No dislocation. Total intraoperative fluoroscopic imaging time
90.8 seconds. Please see operative report for further details.
.
CT A/P: IMPRESSION:
1. In this patient status post right femur fixation surgery,
there are
expected surgical changes and moderate soft tissue edema. No
large hematoma
in the surgical site or retroperitoneal bleed to explain the
patient's
symptoms.
2. Diffuse dilation of the [**Month/Day/Year 499**] measuring up to 16 cm, likely
is ileus.
Recommend correlation with clinical symptoms because there is an
increased
risk of perforation.
.
ABD SUPINE/ERECT: In comparison with the CT scout of [**5-10**],
there is continued and possibly even more prominent extreme
dilatation of a gas-filled [**Date Range 499**]. Although this probably
represents severe post-operative ileus with colonic dilatation
as suggested in the clinical history, the possibility of a
distal obstruction cannot be excluded radiographically.
.
KUB [**2148-5-12**]: In comparison with the study of [**5-11**], there is
again extreme
distention of the visualized loops of bowel. This most likely
represents a
profound adynamic ileus.
.
KUB [**2148-5-12**]: Chronic, marked colonic dilatation is unchanged from
the
preceding radiograph and also seen as far back as CT of [**2146-8-9**].
Brief Hospital Course:
62 yo F with severe mental retardation, afib, and history of
Hodgkin's, admitted with a displaced right proximal femur
fracture.
# Acute Blood Loss Anemia/Hypotension: On post-op day 2 pt was
found to have BP 80/50 on 8 AM vitals with HR in 120s. On
recheck SBP was in 70s. Previous vitals overnight had been
stable with SBP in 120s and HR 70s. Other notable values at the
time were low UOP (220 since midnight) and Hct drop from 31.4 to
26.8 (verified by recheck). EKG was rapid and regular with poor
baseline - either sinus tach or aflutter. No ischemia. Pt was
asymptomatic but had lip pallor. 1L NS was hung wide open and
ortho was asked to evaluate post-op site for internal bleeding.
Ortho did not feel there was high concern for bleeding into
thigh. No other e/o bleeding, such as bloody stool or flank
ecchymosis. BP improved to SBP 90s with fluids but PIV
infiltrated after only a couple hundred mL NS and no other
access could be obtained. Pressures remained in 90s and HR had
increased to 140s so transfer to MICU was initiated. Pt remained
asymptomatic during this period and was alert and talkative. In
the MICU, the patient required 3 units of pRBC's and she had a
non-contrast CT scan of her abdomen and pelvis which extended
into her thighs which did not show any active bleed. Following
her transfusions her crits remained stable and she was called
out to the floor for further management. Her Hct trended up
throughout the rest of admission. There was no evidence of
bleeding from GI tract.
# Right femur fracture s/p ORIF: Found to have right leg pain
with xrays showing a displaced proximal femur fracture. No
mechanism of injury identified by the nursing home, raising
concerns for a pathological fracture, especially in light of
history of Hodgkin's lymphoma. Ortho consulted in the ED and
recommended CT scan then surgery. She was taken for repair on
[**2148-5-7**] which was complicated only by 500mL blood loss
necessitating 2 unit PRBC transfusion for Hct drop from 29 to 24
post-op. Hct subsequently stabilized. Pain well-controlled with
tylenol and pt resting comfortably and denying pain. Biopsy was
taken at the time of surgery to evaluate for malignancy but was
pending at the time of discharge. Pt started on lovenox 40mg
subcutaneous qHS after surgery and should continue this for 1
month. She was started on calcium and vitamin D and is
recommended to start a bisphosphonate after at least month from
surgery.
# UTI: Found to have UTI on admission with pyuria and moderate
bacteria on u/a. Her similar presentation in [**2144**] grew an E coli
sensitive to bactrim, but prior cultures have shown VRE. Started
on bactrim for 7 days. cultures subsequently grew pansensitive
E. coli, including to bactrim. Also grew 10-100K Strep bovis.
Following her hypotension as above, she was broadened to
vanc/cefepime but was switched back to ceftriaxone prior to
call-out to the floor. On floor, CTX was continued for duration
of UTI course, last day [**2148-5-13**].
# S. bovis: organism seen most commonly in pathologic states in
[**Month/Day/Year 499**], such as malignancy or fistula per GI (consulting) and ID
(curbside) but can also be part of normal colonic flora. Pt had
CT A/P which showed no masses that would be concerning for
malignancy. It also showed no evidence of inflammation/conduit
to bladder that would be concerning for fistula. While pt had
bleeding leading to MICU, she never had rectal bleeding that
would be concerning for colonic malignancy and she had a more
likely source of bleeding, which was the recent thigh operation
in which she lost 700cc of blood intraop. suspect that
pathologic state of chronic ileus could be what had led to s.
bovis colonization. If family concerned or new sx develop, can
pursue colonoscopy as outpatient, however, this was not
indicated based on the existing data.
# Atrial Fibrillation: Thought to be related to pericardial and
pleural effusion that occurred in the setting of chemotherapy,
requiring a pericardial window. Was in normal sinus with good
control. Continued amiodarone 100mg [**Hospital1 **] and continued metoprolol
100mg daily.
# Chronic Ileus: This has been an ongoing problem all of her
life, and in the past required a temporary colostomy. She was
controlled on an aggressive bowel regimen at the nursing home,
often turned side to side to relief the gas, and occasionally
rectal tube has been needed. Continued senna, miralax, and
bisacodyl PR in house and added docusate. Having regular BM in
house but abdomen markedly distended (denied pain) so KUB
ordered after surgery in PACU to eval but was mostly unchanged
from prior imaging and shows no free air. CT abdomen and pelvis
showed severely dilated loops of bowel to as large as 16cm yet
patient was without abdominal pain, fevers, white count, or HD
compromise to suggest colitis or megacolon. Patient having bowel
movements. GI performed a colonic decompression by sigmoidoscopy
and temporary placement of rectal tube with frequent
repositioning to help relieve gas. Rectal tube removed after
about 24 hours because pt was stooling around tube (?blockage in
tube), and she continued having BM after removal of tube. Her
abdominal distension improved and she had no abd pain so she was
discharged on a generous bowel regimen. Per GI she can continue
use of rectal prn with frequent positioning at the nursing home
if needed, which was her regimen prior to admission as well.
# Mental Retardation: Appeared at her baseline per her family.
Continued 1:1 sitter from nursing home.
TRANSITIONAL ISSUES:
1. follow up bone biopsy
2. rectal tube prn ileus
3. f/u with ortho in 2 weeks
4. lovenox for one month
5. start bisphosphonate therapy after 1 month post-surgery
Medications on Admission:
Alprazolam 0.25mg TID
Amiodarone 100mg [**Hospital1 **]
Cholecalciferol 1000 units daily
Levothyroxine 75mcg daily
Magnesium 400mg [**Hospital1 **]
Metoprolol 100mg daily
Omeprazole 20mg daily
Potassium chloride ER 20meq, 2 tabs [**Hospital1 **]
Senna 2 tabs qHS
Miralax 17g [**Hospital1 **]
Bisacodyl PR daily
Discharge Medications:
1. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO twice a day.
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO BID (2 times a day).
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
12. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous QPM (once a day (in the evening)).
Disp:*30 syringes* Refills:*0*
13. amiodarone 100 mg Tablet Sig: One (1) Tablet PO twice a day.
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day for 7 days: take standing for 7 days, then OK to use
TID:PRN pain.
Disp:*120 Tablet(s)* Refills:*0*
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
16. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 69885**] Center
Discharge Diagnosis:
Primary Diagnosis:
Right subtrochanteric displaced proximal femur fracture
Urinary tract infection
Chronic ileus
Secondary Diagnoses:
osteoporosis
Hodgkins Lymphoma
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital because you had a fracture in your
femur. You had surgical repair of your femur and a biopsy was
taken to help identify the cause of the fracture. You received a
blood transfusion after surgery due to blood loss. You were
found to have a urinary tract infection while you were here so
you were treated with antibiotics for this. Your abdomen also
became very distended with gas and stool, so a
gastroenterologist was consulted and they performed
decompression of your [**Last Name (un) 499**]. Your distension improved so you
were sent home. Your blood counts were improved at the time of
discharge. You were also found to have low Vitamin B12 so you
were started on a supplement for this.
The following changes were made to your medications:
STARTED:
calcium carbonate 200 mg calcium (500 mg) Tablet twice a day
enoxaparin 40 mg/0.4 mL Syringe One (1) syringe Subcutaneous
every night for one month (last dose [**2148-6-7**])
acetaminophen 500 mg Tablet Two (2) Tablets three times a day
for 7 days, then as needed for pain after that
docusate sodium 100 mg Capsule One (1) Capsule 2 times a day
cyanocobalamin (vitamin B-12) 250 mcg Tablet One (1) Tablet
DAILY
Followup Instructions:
Follow up with your primary care doctor in one week.
**Consider starting bisphosphonate therapy at least month after
fracture repair heals.
Department: ORTHOPEDICS
When: THURSDAY [**2148-5-23**] at 2:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2148-5-23**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
GASTROENTEROLOGY
[**2148-6-19**]
01:30p
[**First Name9 (NamePattern2) 2606**] [**Doctor Last Name 2607**]
RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
|
[
"2851",
"42731",
"53081",
"42789",
"4019",
"2449"
] |
Admission Date: [**2137-7-28**] Discharge Date: [**2137-7-31**]
Date of Birth: [**2077-7-1**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex / Demerol / Codeine /
Penicillins / Propoxyphene
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 60-year-old female with past medical history
significant for Bipolar disorder, borderline personality
disorder, multiple suicide attempts, h/o alcoholism, PTSD, COPD
on home O2, breast cancer s/p lumpectomy who presented to ED via
EMS after being found disoriented and wandering around her
housing complex barefoot with 1 empty and 1 full bottle of
clonazepam. She had 1 empty bottle of clonazepam filled [**7-14**]
with 0 tablets and a 2nd bottle of clonazepam filled with 39
pills (filled yesterday, so 21 tablets gone). She is supposed to
be taking up to 4 pills per day per [**Month/Year (2) **]. Patient states on
further history that she dropped "a bunch" of her clonazepam
tablets fell on the floor. She repeatedly denies any overdose.
She was initially very agitated and unable to give detailed
history. She also c/o pain all over her body pain and was
slightly tremulous at rest. Per patient, she also complained of
having recently run out of her home 02 a "few days ago" which
she takes for history of COPD.
In the ED, initial vital signs were: T 100.1, HR 83, BP 116/86,
RR 20 and O2 sat 99% 2L . She denied fevers, cough, dysuria or
abdominal pains on ROS in ED. She was a limited historian
however, and difficult as she refused FSG and refused attempt at
LP. Despite negative ETOH level she claims she has been drinking
a bottle of wine daily but also made several confusing
statements about timeline of her ETOH use so it is unclear if
she actively using alcohol now. CT head and CXR in ED were both
negative. EKG also showed normal intervals, NSR with no
concerning ST changes. While in ED, she received 1.5L NS IVFs.
2mg Ativan, 5mg Haldol and 50mg Benadryl for agitation which
slowly improved through the afternoon. She was also given 1x
dose 2g Ceftriaxone to cover possible urinary source and
meningitis per ED resident although given no headaches and
normal neuro exam there was limited concern for meningitis as
her AMS improved in the ED.
Given notice of recent TSH of 50 that has been untreated an
endocrinology consult was also called from [**Location **] and patient was
given 200mcg IV levothyroxine. Per report, endocrinology service
did not feel she was in overt myxedema coma but felt her
metabolism of recent drugs likely impaired given her severe
hypothyroidism.
On arrival to [**Hospital Unit Name 153**], initial vital signs were: T 99.3F, BP
107/58, HR 77, RR 22 and O2 sat 98% on 2L NC. She seemed mildly
confused and very easily agitated and refused to answer multiple
questions. In no apparent distress.
Past Medical History:
-h/o cervical fracture ( wears soft collar 24 hours )
-h/o hypokalemia
-history of laxative abuse
-anorexia nervosa
-Bipolar disorder
-Borderline personality disorder
-h/o seizures in setting of alcohol withdrawal
-PTSD
-H/O multiple suicide attempts - cut wrists and multiple drug
overdoses in past
-mild systolic CHF ( EF 45% to 50% ) [**1-/2136**]
-breast cancer s/p lumpectomy (no chemo or radiation therapy)
-H/O Bell's palsy
-[**Name (NI) 3672**] Pt is on 2L oxygen at home. (FEV1 48%; reduced DLCO, but
restrictive physiology on PFTs)
-Fibromyalgia
-Inflammatory osteoarthritis
-attention deficit disorder
-CVA many years ago
-TAHBSO- for cancer in [**2113**]
Social History:
Lives alone in section 8 housing and has visiting nurse 5-6 days
a week. She is married but states she has been separated from
her husband for over 15 years. On [**Year (4 digits) 3710**] now. States she
quit smoking 7 months ago and had smoked 80 pack year history
prior to that. History of alcohol and cocaine abuse in the past.
States she stopped going to AA meetings this year and has been
drinking a bottle of wine daily (although ETOH level not
detected).
Family History:
Mother - CAD, Breast cancer
Father - pancreatic cancer, lung cancer
Physical Exam:
Vitals: T 99.3F, BP 107/58, HR 77, RR 22 and O2 sat 98% on 2L
NC.
General: Alert and oriented to year, person, place. No acute
distress but very easily irritated and mildly tremulous during
exam. Rapid angry speech at times.
HEENT: PERRL. EOMI. Sclera anicteric, dry MM, oropharynx clear.
No thrush. Nares clear, NC in place.
Neck: soft neck brace in place, supple, JVP not elevated, no
LAD, no thyromegaly and no notable thyroid nodules
Lungs: Clear to auscultation bilaterally, mild end expiratory
wheezes at mid fields over backside but no rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: very thin extremities, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: CNs [**3-1**] in tact, face and neck sensation in tact but
patient unwilling to cooperate with rest of neuro exam.
Pertinent Results:
[**2137-7-30**] 11:10AM BLOOD WBC-11.5* RBC-2.99* Hgb-10.3* Hct-32.5*
MCV-109* MCH-34.5* MCHC-31.8 RDW-12.7 Plt Ct-347
[**2137-7-28**] 02:00PM BLOOD WBC-17.2*# RBC-2.94* Hgb-9.9* Hct-29.5*
MCV-100* MCH-33.7* MCHC-33.5 RDW-13.5 Plt Ct-521*#
[**2137-7-28**] 02:00PM BLOOD Neuts-85.5* Lymphs-10.4* Monos-3.5
Eos-0.4 Baso-0.2
[**2137-7-29**] 02:04AM BLOOD PT-11.3 PTT-22.6 INR(PT)-0.9
[**2137-7-30**] 07:20AM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-129*
K-3.9 Cl-99 HCO3-23 AnGap-11
[**2137-7-28**] 02:00PM BLOOD Glucose-116* UreaN-27* Creat-1.1 Na-131*
K-4.5 Cl-92* HCO3-24 AnGap-20
[**2137-7-29**] 02:04AM BLOOD ALT-21 AST-53* AlkPhos-67 TotBili-0.1
[**2137-7-28**] 02:00PM BLOOD ALT-20 AST-43* AlkPhos-69 TotBili-0.2
[**2137-7-28**] 02:00PM BLOOD Lipase-15
[**2137-7-30**] 07:20AM BLOOD Calcium-8.3* Phos-1.9*# Mg-1.7
[**2137-7-29**] 02:04AM BLOOD Albumin-4.0 Calcium-9.9 Phos-3.7 Mg-2.2
Iron-42
[**2137-7-29**] 02:04AM BLOOD calTIBC-241* Ferritn-115 TRF-185*
[**2137-7-28**] 02:00PM BLOOD Osmolal-274*
[**2137-7-28**] 02:00PM BLOOD TSH-28*
[**2137-7-29**] 02:04AM BLOOD T4-6.2 T3-85 calcTBG-1.12 TUptake-0.89
T4Index-5.5 Free T4-1.0
[**2137-7-29**] 02:04AM BLOOD Cortsol-48.9*
[**2137-7-28**] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2137-7-28**] 02:15PM BLOOD Lactate-1.6
ECG [**2137-7-28**]: Sinus rhythm with sinus arrhythmia, likely left
ventricular hypertrophy. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2137-4-6**] findings are
similar.
[**2137-7-28**] CXR PORTABLE AP:
INDICATION: 60-year-old female with altered mental status.
COMPARISON: [**2137-6-5**].
CHEST, AP: The lungs are clear, other than some mild
retrocardiac
atelectasis. The cardiomediastinal and hilar contours are
normal. There are no pleural effusions. No acute fractures are
identified.
IMPRESSION: No acute intrathoracic process
CT HEAD W/O CONTRAST [**2137-7-28**]:
FINDINGS: There is no acute intracranial hemorrhage, large areas
of edema,
large masses or mass effect. [**Doctor Last Name **]-white matter differentiation
is preserved. The ventricles and sulci are normal in size and
configuration. Mucosal thickening/mucous retention cyst is noted
within the left maxillary sinus. Otherwise, the visualized
paranasal sinuses and mastoid air cells are clear. Visualized
soft tissues of the orbits and nasopharynx are within normal
limits.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
60yo F with h/o bipolar disorder, borderline personality
disorder, PTSD, fibromyalgia, multiple suicide attempts, COPD on
home O2, cervical neck fracture (in chronic brace), and severe
OA who presents with altered mental status after questionable
overdose.
Questionable Overdose/AMS: Head CT in ED was within normal
limits and neuro exam also non-focal. No evidence of infection,
the patient also admits to ETOH so her initial presentation
could have been withdrawal and seizure but no witnessed seizure
activity and ETOH serum negative (although w/d obviously still
would be possible in the setting of neg ETOH). The patient was
found to be unresponsive in the setting of an open klonopin
bottle on the floor, although the patient adamantly denied a
suidcide attempt this was still a very likely possibility as she
was on multiple sedating medications and no other organic cause
for change in level of consciousness could be found. In
addition patient improved with time / medication washout.
BIPOLAR DISORDER: The patient was on multiple psychotropic
medications. These were held inpt, risperdal 1mg po qhs was
started back while inpatient. The patient is medically cleared
for discharge to a psychiatric facility.
HYPONATREMIA: She had dilute urine but admits to taking in large
amounts of water, hypothyroidism also a likely contributer. 1
liter free H2O restriction and levothyroxine.
COPD: no active flare. continue low flow 2-3L O2 via nasal
cannula for O2 sats >90% goal, on home O2.
Fever: Unclear etiology. Also has an elevated WBC to 17 with 85%
PMN shift. CXR with no clear infiltrates. She has fairly normal
UA despite complaints of dysuria "off and on". No abdominal pain
but does mention recent diarrhea. Lactate is WNL at 1.6 and
patient has stable vitals throughout hospitalization. 2 days of
afebrile prior to discharge.
Hypothyroidism: Endocrine consulted, continue levothyroxine
50mcg daily and recheck TSH in 6 weeks.
Cervical spine fracture (in chronic brace):
--continue soft neck brace
--pain control with lidocaine patch
--Tylenol PRN (serum tox acetominophen level negative)
Mild systolic CHF: last EF 45% back in [**2136-1-19**]. Written for
home dose of 40mg PO BID lasix. Seems dry on exam and states she
has been having diarrhea for few days. Continue lasix 40mg po
daily and follow up as outpatient.
Contact: sister and HCP [**Name (NI) **] [**Name (NI) 3699**] (h) [**Telephone/Fax (1) 3700**] (c)
[**Telephone/Fax (1) 3701**] other sister BJ (h) [**Telephone/Fax (1) 3702**] (c) [**Telephone/Fax (1) 3703**]
Medications on Admission:
ALBUTEROL SULFATE - 0.83 mg/mL Solution for Nebulization - 1
(One) vial inhaled via nebulizaiton up to 4 times daily as
needed
for shortness of breath or wheezing
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs inhaled 4-5 times a day as needed for shortness of
breath or wheezing
AMPHETAMINE-DEXTROAMPHETAMINE [ADDERALL] - (Prescribed by Other
Provider) - 20 mg Tablet - 1 Tablet(s) by mouth three times a
day
BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg
Tablet - 1 Tablet(s) by mouth q 6hr as needed for prn HA
CLONAZEPAM - (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth four times a day
CVS GENTLE LAXATIVE PILLS - - as directted by physician three
times [**Name Initial (PRE) **] day
ESSENTIAL SOY BY MOTHER SOY [**Name (NI) 3737**] - - 10 cc mixed with
liquid three times a day
FEXOFENADINE - (Prescribed by Other Provider) - 180 mg Tablet -
1 (One) Tablet(s) by mouth once a day
FLUOXETINE - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 40 mg Capsule - 1 Capsule(s) by mouth once daily
FLUTICASONE - 50 mcg Spray, Suspension - 1 to 2 sprays in each
nostril twice a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 (One) inhlations twice a day
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth twice a day
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - 3 patches on neck and 3 on back once a day keep on
for 12 hours, remove for 12 hours
MISOPROSTOL [CYTOTEC] - 100 mcg Tablet - two Tablet(s) by mouth
twice a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth at
bedtime
MORPHINE - 30 mg Tablet Sustained Release - 1 Tablet(s) by mouth
twice a day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 (One) Tablet(s)
sublingually every 5 minutes for 3 doses as needed for chest
pain
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth [**Hospital1 **] 1/2 hour prior to breakfast and dinner
OXYCODONE - 5 mg Capsule - [**1-19**] Capsule(s) by mouth q 6 hr as
needed for pain
PERPHENAZINE - (Prescribed by Other Provider) - 8 mg Tablet - po
Tablet(s) by mouth at bedtime
POTASSIUM CHLORIDE - 10 mEq Tablet Sustained Release - 3 (Three)
Tablet(s) by mouth twice a day
RALOXIFENE [EVISTA] - (Prescribed by Other Provider) - 60 mg
Tablet - 1 Tablet(s) by mouth once a day
RISPERIDONE - (Prescribed by Other Provider; Dose adjustment -
no new Rx) - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime
SULFASALAZINE - 500 mg Tablet - 2 Tablet(s) by mouth twice a day
THICK IT - - Use with all oral liquids to create honey
consistency Patient uses 1 30 ounce can monthly
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - one inhalation once a day
TRAMADOL - 50 mg Tablet - 2 Tablet(s) by mouth qid prn
TRAZODONE - (Dose adjustment - no new Rx) - 100 mg Tablet - 1
Tablet(s) by mouth at bedtime
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply small amount to
rash twice a day
Medications - OTC
ANUSOL HC-1 - 1 % Ointment - 1 suppository rectally at bedtime
day
B COMPLEX VITAMINS - (Prescribed by Other Provider) - Capsule
- 1 Capsule(s) by mouth
BIFIDOBACTERIUM INFANTIS [ALIGN] - 4 mg (1 billion cell) Capsule
- 1 Capsule(s) by mouth once a day
CALCIUM CARBONATE [CALCIUM 600] - (OTC) - 600 mg (1,500 mg)
Tablet - one Tablet(s) by mouth twice a day
CERAMIDES 1,3,[**6-28**] [CERAVE] - Cream - twice a day
CHROMIUM PICOLINATE - (OTC) - 400 mcg Tablet - 2 (Two) Tablet(s)
by mouth once a day
DIPHENHYDRAMINE HCL [SIMPLY SLEEP] - (OTC) - 25 mg Tablet - 2
Tablet(s) by mouth at bedtime
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - 1,000 unit
Capsule - 1 (One) Capsule(s) by mouth once a day
FERROUS GLUCONATE - 324 mg (38 mg Iron) Tablet - 1 Tablet(s) by
mouth twice a day
FOLIC ACID - (Prescribed by Other Provider) - 0.4 mg Tablet - 1
Tablet(s) by mouth once a day
MAGNESIUM OXIDE - 400 mg Tablet - 1 Tablet(s) by mouth once a
day
NUTRITIONAL SUPPLEMENTS [BOOST SMOOTHIE] - Liquid - 6 cans by
mouth once a day dx: severe weight loss, aspiration, and oxygen
dependent COPD and atonic colon
PRAMOXINE-MINERAL OIL-ZINC [ANUSOL] - (Prescribed by Other
Provider) - Dosage uncertain
SIMETHICONE - 80 mg Tablet, Chewable - one Tablet(s) by mouth 3
times a day as needed
SODIUM PHOSPHATES [FLEET ENEMA] - 19 gram-7 gram/118 mL Enema -
[**1-19**] Enema(s) rectally once a day as needed for constipation
VITAMIN E - (OTC) - 1,000 unit Capsule - 1 (One) Capsule(s) by
mouth once a day
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
Oversedation related to medication
Secondary Diagnosis:
Bipolar disorder
Chronic systolic CHF
Discharge Condition:
stable
Discharge Instructions:
You were admitted after being confused and unresponsive, you
have improved with time and witholding of your sedating
psychiatric medications. These will be slowly reintroduced and
titrated so you are being discharged to a psychiatric facility
as you are medically cleared.
Followup Instructions:
Department: NUTRITION
When: WEDNESDAY [**2137-7-31**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3679**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3680**], RD [**Telephone/Fax (1) 3681**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Hospital 1422**]
Campus: EAST Best Parking: Main Garage
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2137-8-7**] at 12:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"2761",
"496",
"2449",
"4280",
"V1582"
] |
Admission Date: [**2150-11-17**] Discharge Date: [**2150-11-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Hypoxia at [**Hospital1 1501**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History and physical is as per ICU team.
.
[**Age over 90 **]-year-old woman from [**Hospital6 459**] with h/o dementia,
aortic stenosis, iron def anemia presented with acute hypoxia.
[**Hospital 100**] Rehab staff noted that patient desated to 79% on room air
with T 98, HR 131, BP 160/84. Her O2 sat improved to 95% on 7L
NC. On exam, had bilateral rales and mottled skin. (Labs from
[**11-5**] revealed WBC 6.1, Hgb 9, BUN 32, Cr 0.8.) She was given
one nebulized treatment and sent to [**Hospital1 18**] for evaluation. EMS
gave her furosemide 40 mg IV x 1--patient has no history of CHF.
.
On arrival to the ED, T 97.7, HR 112, BP 118/58, RR 40, 100% on
NRB. WBC 12.1 with 91%N, 6.5%L, no bands. Hct 25.8 with MCV 94
(?baseline high 20s). INR 1.2. BUN 36 and Cr 1.0. Lactate 3.1.
U/A was negative. CXR revealed RLL/RML infiltrate. She received
levoflox, vancomycin, with metronidazole hanging on transfer to
ICU. Patient's nurse then reported that patient had two "large"
melenotic stools. Rectal exam revealed dark brown
guaiac-positive stool. NG [**Hospital1 103468**] was negative. GI was made
aware, planning to see her in the morning.
.
ROS: not obtained due to patient's dementia
.
Past Medical History:
dementia
aortic stenosis
iron deficiency anemia
Social History:
Lives in [**Hospital1 1501**]. Otherwise, pt unable to give history
Family History:
Non-contributory
Physical Exam:
On ICU admission:
GEN: Elderly woman, tired-looking but in no acute distress, on
NC, conversant comfortably
HEENT: EOMI, PERRL, sclera anicteric, poor dentition
NECK: flat JVP, carotid pulses brisk, no bruits, no cervical
lymphadenopathy
COR: reg rate, [**3-26**] pansystolic murmur best heard throughout
PULM: Bibasilar crackles
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords, DP/PT [**Name (NI) 103469**]
NEURO: oriented to person only. Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
On admission:
[**2150-11-16**] 11:00PM BLOOD WBC-12.1* RBC-2.74* Hgb-7.9*# Hct-25.8*
MCV-94 MCH-28.7 MCHC-30.5* RDW-15.0 Plt Ct-208
[**2150-11-16**] 11:00PM BLOOD Neuts-90.6* Lymphs-6.5* Monos-2.5 Eos-0.3
Baso-0.2
[**2150-11-16**] 11:00PM BLOOD PT-14.1* PTT-31.8 INR(PT)-1.2*
[**2150-11-16**] 11:00PM BLOOD Glucose-223* UreaN-36* Creat-1.0 Na-142
K-3.9 Cl-105 HCO3-23 AnGap-18
[**2150-11-16**] 11:00PM BLOOD CK(CPK)-70
[**2150-11-17**] 04:33AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0
[**2150-11-16**] 11:00PM BLOOD Iron-26*
[**2150-11-16**] 11:00PM BLOOD calTIBC-295 VitB12-340 Folate-GREATER TH
Ferritn-21 TRF-227
[**11-16**] CXR: Small bilateral pleural effusions, with increased
opacity in the right lung base, may reflect atelectasis.
However, developing consolidation cannot be excluded.
[**11-17**] TTE: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with focal hypokinesis of the mid to distal septum, distal
anterior wall and apex. Overall left ventricular systolic
function is mildly depressed (LVEF= 45-50 %). The remaining left
ventricular segments contract normally. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area 0.5 cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild functional mitral stenosis (mean
gradient 4 mmHg) due to mitral annular calcification. 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 moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severe aortic stenosis. Moderate aortic
regurgitation. Mild functional mitral stenosis from annular
calcification. Mild regional left ventricular systolic
dysfunction consistent with mid LAD disease. Moderate pulmonary
hypertension.
Brief Hospital Course:
Pt is a [**Age over 90 **]-year-old woman with h/o dementia, aortic stenosis,
iron def anemia presented with acute hypoxia, found to have
RLL/RML pneumonia.
.
1. Healthcare associated pneumonia: Likely cause of the
hypoxia. Pt was initially covered with zosyn and vanco. Pt was
initially given gentle IVF hydration. Urine legionella was
negative. Urine culture was negative. Blood cultures were
negative. A PICC line was placed and she will complete her
antibiotic course at [**Hospital **] rehab.
.
2. Anemia: reported to have 2 "large" melenotic stools by ED
nurse. [**First Name (Titles) **] [**Last Name (Titles) 103468**] negative for blood. Hct was 23.9 at admission
and dipped down to 19 after IVF. Patient was transfused 2 units
PRBCs in the ICU. For the rest of the patients hospitalization
her Hct remained stable in the mid 20s. Pt does carry a history
of Fe deficieny anemia. Iron supplements were continued. B12
and folate were within normal limits. The patient is DNR/DNI
and the family does not [**Last Name (un) 21405**] to pursue aggresive interventions
such as EGD/colonoscopy at this time.
.
3. Dementia: Continued memantine, seroquel, exelon and
paroxetine.
.
4. Code: DNR/DNI
.
5. Dispo: The patient will be transferred back to [**Hospital 100**] rehab
in stable condition for further care.
Medications on Admission:
ASA 81 mg qday
Fe gluconate 324 mg qday
folate 1 mg qday
memantine 5 mg qday
paroxetine 20 mg qday
quetiapine 25 mg [**Hospital1 **]
rivastigmine 4.5 mg [**Hospital1 **]
Discharge Medications:
1. Vancomycin 500 mg Recon Soln Sig: One (1) gm Intravenous
every twelve (12) hours for 6 days.
2. Memantine 5 mg Tablet Sig: One (1) Tablet PO qday ().
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Rivastigmine 1.5 mg Capsule Sig: Three (3) Capsule PO bid ().
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four
(4) hours as needed for pain or fever.
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: 1-2 Tablets
PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. Zosyn 2.25 gram Recon Soln Sig: One (1) dose Intravenous
every six (6) hours for 6 days.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Healtchcare associated pneumonia.
Anemia.
Discharge Condition:
Good
Discharge Instructions:
-Continue Vancomycin and Zosyn for 6 more days.
-Continue all other meds as prescribed.
-Wean oxygen as tolerated.
-Monitor Hct preiodically as per rehab physician.
[**Name10 (NameIs) **] electrolytes and give free water or D5W if patient has
worsening hypernatremia.
-Return to ED if you experience worsening shortness of breath,
chest pain, fever/chills or other worrisome signs/symptoms.
Followup Instructions:
Patient to be followed at [**Hospital **] rehab.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2150-11-20**]
|
[
"486",
"51881",
"4241"
] |
Service: CARDIOTHOR Date: [**2125-11-30**]
Date of Birth: [**2049-8-20**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old
female with a history of diabetes mellitus, hypertension,
hypercholesterolemia, and positive family history of coronary
artery disease. The patient stated that she had had
occasional bilateral arm heaviness, which occurs both at rest
and with exertion. She denied associated symptoms of
shortness of breath, nausea, vomiting, or diaphoresis. These
symptoms prompted ETT, which was positive. Cardiac
catheterization revealed LAD occluded proximally, right to
left collaterals, left circumflex 80% OM2 70%, OM1 diffuse
distal left circumflex. RCA 70%.
PAST MEDICAL HISTORY:
1. Coronary artery disease, question prior myocardial
infarction.
2. Non-insulin dependent diabetes mellitus.
3. HTN.
4. Hypercholesterolemia.
5. Retinopathy.
6. Bilateral cataracts.
7. Incontinence.
MEDICATIONS:
1. Prinivil 20 mg p.o.q.d.
2. Toprol 50 mg p.o.q.d.
3. Glucophage 500 mg p.o.b.i.d.
4. Glyburide 10 mg p.o.b.i.d.
5. Ocular one drop OU b.i.d.
6. Sublingual nitroglycerin p.r.n.
ALLERGIES: No known drug allergies.
LABORATORY DATA: Admission labs revealed the following:
White count 6.1; hematocrit 34.8; platelet count 189,000;
sodium 138; potassium 4.4; BUN 24; creatinine 1.2; glucose
151.
The patient went to the operating room on [**2125-11-30**].
A CABG times two was performed by Dr. [**Last Name (STitle) **]. LIMA to the
LAD, SVG to the OM1. Bypass time: 51 minutes.
....................38 minutes. The patient was A-V paced
and placed on NeoSynephrine drip.
On postoperative day #1, the patient was extubated and the
NeoSynephrine drip was appropriately weaned.
On postoperative day #2, the patient's Foley catheter and
chest tube were both removed. The patient was tolerating POs
and had good urine output.
On postoperative day #3, cardiac wires were discontinued.
The patient was in stable condition and ready for discharge
to rehabilitation on postoperative day #4.
DISCHARGE LABS: Labs revealed the following: White count
9.0, hematocrit 28.5; platelet count 128,000; sodium 43;
potassium 4.6; chloride 104; bicarbonate 26; BUN 24;
creatinine 1.2; glucose 131; PT 12; INR 1.0; PTT 23.8.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o.b.i.d.
2. Lasix 20 mg p.o.b.i.d. times 7 days.
3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mg p.o.b.i.d. times 7 days.
4. Plavix 75 mg p.o.q.d.
5. Aspirin 325 mg p.o.q.d.
6. Glucophage 500 mg p.o.b.i.d.
7. Glyburide 10 mg p.o.b.i.d.
8. Ocular one drop both eyes b.i.d.
9. Percocet 1 to 2 tablets p.o. q.4 to 6h.p.r.n.
10. Colace 100 mg p.o.b.i.d.
DISCHARGE STATUS: The patient is discharged to a
rehabilitation facility.
FOLLOW-UP CARE: The patient is to followup with Dr. [**Last Name (STitle) **]
in four weeks. The patient is to followup with the primary
care provider and cardiologist in three weeks.
DIAGNOSES: Status post CABG times two.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2125-12-3**] 14:59
T: [**2125-12-3**] 15:02
JOB#: [**Job Number **]
|
[
"41401",
"4240",
"4019",
"2720",
"412"
] |
Admission Date: [**2184-11-1**] Discharge Date: [**2184-11-12**]
Date of Birth: [**2143-1-25**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
Right arm pain
Major Surgical or Invasive Procedure:
Drainage of Right Arm Abscess by Plastic Surgery
History of Present Illness:
41 year-old male with history significant for paroxysmal atrial
fibrillation, active IV drug use, recurrent bacteremia, s/p
spinal fusion surgery and total hip replacement, who is
transferred to general medicine floor from the SICU s/p right
arm debridement for an abscess, also with MRSA bacteremia and
lower back pain. The patient had a complicated medical course
following a fall in [**2179**], including T10-L3 fusion, iliac crest
bone graft, ORIF right femur, and left total hip replacement
complicated by MRSA septic hip requiring further surgical
intervention. Patient also has had recurrent bacteremia,
including uncomplicated enterococcal PICC-associated bacteremia
in [**9-10**]. He was admitted to SICU under the plastics service
[**2184-11-1**] for sepsis and right arm abscess, initially suspected
to be necrotizing fasciitis.
Past Medical History:
1) L THR [**2184-5-20**] (due to traumatic osteoarthritis [**2179**] - fell
off ladder), L hip MRSA prosthetic joint infection with
bacteremia, s/p explant [**6-9**], multiple washouts, spacer
placement,
2) ex-lap with resection of his small bowel,
3) ORIF R femur,
4) T10-L3 fusion, transpedicular decompression, at T12, multiple
laminotomies,
5) right Iliac Crest Bone Graft,
6) h/o polysubstance abuse, etoh, cocaine
7) depression, s/p multiple suicide attempts: cocaine binge,
radial artery laceration/percocet overdose
8) SVT after washouts, responded to dilt
9) h/o GI bleed in the setting of thrombocytopenia from
Vancomycin, improved with stopping Vanco, refused colonoscopy
Social History:
Mom died while pt hospitalized for initial fall.
h/o incarceration
Disability. Tobacco 1.5 ppd, continues to smoke. ETOH, crack
cocaine, opiate use in past. Active IVDU.
Family History:
NC
Physical Exam:
After transfer from SICU to medical floor:
VS: 99.4 132/80 84 16 98% on RA
GEN: alert, lying supine, visibly distressed and moaning from
pain, shouting at medical staff
HEENT: moist mucus membranes
CV: regular rhythm, rate 80s, no murmurs appreciated
RESP: diffuse anterior and lateral wheezing and soft rhonchi;
posterior exam limited due to position
BACK: difficult to assess due to supine position
ABD: soft, nontender, nondistended
EXT: right dorsomedial forearm with open debridement, mostly
wrapped with gauze ; no lower extremity edema
NEURO: limited due to pain
Pertinent Results:
ADMISSION LABS:
[**2184-11-1**]
WBC 18.5 / hct 25.5 / Plt 412
Serum tox - negative for aspirin, EtOH, tylenol, BDPs,
barbiturates, and TCAs
Na 130 / K 3.8 / Cl 97 / CO2 19 / BUN 40 / Cr 2.3 / BG 132
Lactate 1.2
DISCHARGE LABS:
[**2184-11-12**]
WBC 7.9 / Hct 26.8 / Plt 577
Na 140 / K 3.6 / Cl 100 / CO2 29 / BUN 9 / Cr 1.2 / BG 94
MICROBIOLOGY:
[**2184-11-1**] Blood Cx = [**3-6**] MRSA
[**2184-11-1**] Urine Cx negative
[**2184-11-1**] Wound Swab - MRSA, Prevotella
12/2,3,4,5,[**6-10**] Blood Cx negative
[**2184-11-5**] Right Hip Aspirate Cx negative
STUDIES:
UNILAT UP EXT VEINS US RIGHT [**2184-11-1**]
1. No evidence of right upper extremity DVT.
2. Complex fluid and swelling along the right forearm underlying
area of
redness and swelling. Known deep tissue air is better visualized
on recent
radiograph.
FOREARM (AP & LAT) RIGHT [**2184-11-1**]
IMPRESSION: Large amount of subcutaneous and deep soft tissue
air. These
findings are concerning for necrotizing fasciitis.
CHEST (SINGLE VIEW) [**2184-11-1**]
IMPRESSION: Low lung volumes. Mild right pleural thickening vs
trace right
effusion.
TTE (Complete)[**2184-11-2**]
Suboptimal image quality. No echocardiographic evidence of
endocarditis but study limited technically. Normal global
biventricular systolic function. Aortic root dilation.
CT T / L Spine [**2184-11-5**]
1. Prevertebral soft tissue density at L3-4 of uncertain
chronicity as there
is no prior postoperative cross-sectional imaging for
comparison. Infection
cannot be excluded.
2. Limited evaluation of the spinal canal due to streak artifact
from spinal
fusion hardware. CT does not provide intrathecal detail
comparable to MRI.
3. Unchanged L1 vertebral body fracture.
4. Layering right pleural effusion.
TEE [**2184-11-9**]
No echocardiographic evidence of endocarditis.
MR T and L Spine [**2184-11-9**]
1. Fluid collection identified at the L2/L3 intervertebral disc
space,
posteriorly, causing anterior thecal sac deformity, likely
consistent with an
epidural phlegmon, measuring approximately 7 x 28 mm in size.
Associated
inflammatory changes noted at the intervertebral disc space and
vertebral
bodies at L2/L3, which are worrisome for early changes possibly
related with
discitis/osteomyelitis, please correlate clinically. Multilevel
disc
degenerative changes throughout the lumbar and thoracic spine as
described
above, more significant at T6/T7, T7/T8, and T8/T9.
2. Compression fracture at T12 vertebral body is again
identified, apparently
unchanged since the most recent CT, dated [**2184-11-5**] with
mild posterior
retropulsion.
3. Lumbar disc degenerative changes noted at L3/L4 and L4/L5
levels with
narrowing of intervertebral disc spaces, articular joint facet
hypertrophy,
causing bilateral neural foraminal narrowing at L4/L5 level.
4. Status post posterior fixation of the thoracic spine with
laminectomies
from T11 through L1 level.
5. Right pleural effusion and possible left lung basal
consolidation as
described above.
Brief Hospital Course:
41 year old male with recurrent MRSA bacteremia, active IV drug
use, paroxysmal atrial fibrillation, history of spinal fusion
surgery T10-L3 and Left total hip replacement, who presented
with with right arm abscess, MRSA bacteremia and lower back
pain. After the patient was found to have fluid collections
surrounding his spinal hardware that would require Ortho Spine
surgery, he left Against Medical Advice but was accepted by the
Rehab facility on a prolonged antibiotic regimen, with the
understanding that he would return for surgery in a few weeks
when ready.
1. Right Arm Abscess
Patient presented with Right arm pain and swelling s/p injection
drug use. Ultrasound of arm showed no DVT but complex fluid and
swelling along the right forearm. Xray showed large amount of
subcutaneous and deep soft tissue air, concerning for
necrotizing fasciitis. The patient was taken emergently to
surgery by Plastics who noted that there was no necrotizing
fasciitis but drained the abscess. Wound cultures initially
grew MRSA and gram negative rods, so the patient was started in
intravenous daptomycin, clindamycin, and zosyn, per Infectious
Disease team recommendations. The clindamycin was used for a
synergistic effect against MRSA for its ability to reduce the
production of exotoxins by staphylococci. Per ID
recommendations, the clindamycin and the zosyn were discontinued
after a few days. Metronidazole was started on the evening of
[**2183-11-11**] per oral for a total of seven days with prevotella was
found growing from the wound in addition to MRSA.
For control of his Right arm wound post surgically, the Plastics
Surgery team continued to follow the patient. The wound was
dressed with wet to dry dressings and Dakins; the patient should
be started on a wound vac, but he refused this treatment option.
He should be continued on [**Hospital1 **] wet to dry dressing changes and
follow up in [**Hospital 3595**] clinic in [**2184-12-3**].
2. MRSA bacteremia
The patient has a history of recurrent MRSA bacteremia in the
setting of active IV drug use. A transthoracic echo showed no
evidence of vegetations, though the image quality was
suboptimal. The patient initially refused TEE, but eventually
agreed to it; TEE showed no evidence of vegetations as well. He
does have a fluid collection in his left hip, as seen on
imaging, where he has recently had hardware from a hip
replacement and now has an antibiotic spacer.
Patient was initially unable to tolerate imaging of his spine
due to extreme pain with movement, particularly transfers;
initial MRI and CT of lower spine were of poor quality. Patient
was ultimately placed under general anesthesia for an MRI of his
thoracic and lumbar spine, which showed large infected fluid
collections surrounding spinal hardware. The patient requires
surgical removal of his spinal hardware in two surgeries, one to
work on the anterior and one for the posterior sides of the
spine.
The patient refused to have surgery at this time. He prefers to
wait until after [**Holiday **] and the New Year and will have
surgery after that time. He knows and respects Dr. [**Last Name (STitle) 363**], the
Ortho Spine surgeon, well; he would only stay to have the
surgery during this admission if Dr. [**Last Name (STitle) 363**] insisted that this
was the only option. Dr. [**Last Name (STitle) 363**] felt that the patient should
have the surgery sooner than later, optimally during this
admission, but agreed to do the surgery at a later time if the
patient preferred and to send the patient back to Rehab on IV
antibiotics in the meantime; he will follow up with the patient
in his clinic next week. The patient refused to have a CT-guided
drainage of the fluid collection at this time as well; he
preferred to just wait "until the New Year" to have the surgery
by Dr. [**Last Name (STitle) 363**].
The patient has been afebrile for multiple days, so a PICC line
was placed, and the patient will continue on IV daptomycin daily
indefinitely until he has the surgery; the daptomycin should
continue for 6 weeks at minimum. The patient will also continue
on oral metronidazole for five more days to treat the prevotella
in the arm wound. The Rehabilitation facility from which he
came will take him back under strict monitoring for drug abuse.
He will follow up in clinic with Dr. [**Last Name (STitle) 363**] next week and in
Infectious Disease clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] next Friday
[**11-19**]. He will need to have his BUN/Creatinine, CBC with diff,
and CK checked weekly and faxed to Dr.[**Name (NI) 60811**] office.
3. Back Pain
Patient has chronic back pain and is s/p spinal fusion T10-L3;
the pain is likely worsened by the infectious fluid collections
surrounding his spinal hardware. The patient was placed on a
ketamine drip, with the help of the chronic pain team, while on
the surgical service to help manage for pain control in addition
to per oral and intravenous dilaudid, fentanyl patch,
gabapentin, and diazepam. Once the patient was transferred to
the general medical service, the chronic pain team was
officially consulted to help with pain management. The ketamine
drip was weaned slowly, and the dilaudid dose was increased to
8mg every four hours as needed, as the patient stated he was
taking prior to admission. His gabapentin dose was increased
slowly to his apparent home dose of 300mg TID, which can further
be increased slowly to 600mg TID if needed, per chronic pain
team. The diazepam is a home medication, which the patient only
uses once every couple of days for back spasms.
4. Psychiatric Issues
Patient with a reported history of bipolar disorder and suicidal
attempts in the past. Similar to previous hospitalizations, he
was verbally abusive to nursing staff and exhibiting bizarre
behavior, including chewing through his central venous line.
Psychiatry was consulted and recommended clear limits with pain
medicines, avoiding benzodiazepines which could have a
paradoxical effect, and starting seroquel 25 mg TID as needed
for agitation as well as prozac 20 mg daily. The seroquel did
work very well to keep the patient calm but appeared to make him
more sleepy than usual.
After patient was told that he had infected fluid collections
around the hardware in his spine and would need definite
surgical removal of the hardware, he refused surgery. He was
initially upset and agitated, threatening to leave Against
Medical Advice without any explanation as to why he did not want
surgery. The risks of no surgery or delayed surgery were
explained to him, including possible paralysis and possible
death. The patient appeared to understand these risks.
Psychiatry was called again to assess the patient and felt that
he had capacity to make his own decisions; patient was
completely oriented and showed no signs of delirium-- he
understood his options and the possible consequences of his
decision. He expressed again to the medical team that he "just
wanted a break." He was allowed to leave Against Medical Advice
after a PICC line was placed and a plan for IV antibiotics and
close followup was made.
The patient does have a history of active IV drug use and will
need to be monitored very carefully with a PICC line in place
while at the Rehab facility long term.
5. Paraphimosis
After transfer to the general medical service, patient was noted
to have some edema of his foreskin which was pulled back tightly
around his penis. The patient did complain of some pain, but
the head of the penis was still pink. The medical team and the
patient were unable to reduce the paraphimosis. The
paraphimosis was ultimately reduced by Urology.
6. Paroxysmal Atrial Fibrillation
Patient was intermittently treated with IV diltiazem for atrial
tachycardia, likely atrial fibrillation, and responded well to
it. He was started on per oral diltiazem in SICU per cardiology
recommendations and continued on it for the rest of his
hospitalization. Given that his CHADS-2 score was 0, he was
recommended to consider starting aspirin for anticoagulation
once his surgical plan was confirmed.
7. Acute Renal Failure
Patient's baseline renal function was about 0.8-1.0. He was
noted to have an elevated creatinine to 2.0-2.9 on previous
admission for MRSA bacteremia, and he had presented to the
surgical service with an elevated creatinine of 2.3 on this
admission. Acute renal failure was of [**Last Name (un) 5487**] etiology, but
creatinine trended down to 1.2 by the time of discharge.
8. Rash
Patient did have patches of blanching erythematous macular rash
on bilateral lower extremities, asymmetric, while on the floor.
He denied pruritis and pain with the rash, but it slowly
darkened and resolved with a few days. The rash appeared to be a
contact dermatitis.
9. Loose Stool
Patient did have some episodes of loose stools, despite high
narcotic regimen, likely antibiotic associated diarrhea. He did
not have a leukocytosis and has been afebrile, but a C difficile
toxin test was checked and was negative.
Medications on Admission:
Fentanyl patch 50mcg/hr 1 patch Q72H
Valium 5mg QHS and q6-8h prn
Dilaudid 8mg Q4H
Iron 325QD
Gapapentin 300mg TID
Dilt 30mg PO QID
Omeprazole 40mg QD
Lasix 20mg Qd
Colace 100mg QD
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. 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.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Daptomycin 500 mg Recon Soln Sig: Seven Hundred (700) mg
Intravenous Q24H (every 24 hours).
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for agitation / insomnia.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 5 days.
10. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for For back spasms only (use seroquel for
agitation.
11. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
12. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day): please hold for diarrhea.
15. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
16. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
20. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain, fe [**Last Name (un) **].
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
Primary Diagnosis:
MRSA Bacteremia
Infected Spinal Hardware
Right Arm Abscess
Secondary Diagnoses:
Chronic Pain
Paroxysmal Atrial Fibrillation
Depression
Discharge Condition:
alert, oriented x3
pain controlled
Discharge Instructions:
Mr. [**Known lastname **],
You were admitted to the hospital because you had a bad
infection in your right arm which had gone also to your
bloodstream. You were started on antibiotic treatment for this
infection. You were found to have infected fluid collections in
the hardware in your spine; this hardware needs to be surgically
removed as soon as possible. You did not wish to have this
surgery at this time, so you decided to sign out of the hospital
Against Medical Advice. As you are aware, delaying surgery
could increase your risk for worsened infection in your spine;
if the fluid collections get larger, you could become paralyzed.
There is also the risk that the infection could again spread to
your bloodstream and infect other parts of your body, including
your heart; there is the risk that you may die before coming
back for surgery. Prior to discharge, you understood these
risks and signed the paper to leave Against Medical Advice, as
the medical team strongly felt that you should not leave the
hospital at this time. It is very important for you to continue
on the intravenous antibiotics prescribed to you by the medical
and infectious disease teams in the hospital until you are able
to have the surgery.
You should return for followup in Ortho Spine clinic next week.
Please do not inject any more IV drugs because this puts you at
risk for another infection.
You will be continued on IV antibiotics through a PICC line at
Rehab.
The following important changes have been made to your
medications:
- You are STARTING the antibiotic Daptomycin intravenously daily
indefinitely, which should be continued at least until you have
the surgery to remove the infected hardware in your spine
- You were STARTED on fluoxetine, which is an antidepressant
which will take a few weeks to start to help
- You were STARTED on metronidazole antibiotic for your Right
arm wound to be continued for five more days
- You were also STARTED on diltiazem per oral 30mg four times
per day to control your heart rate. This medication can later be
changed to a once daily medication by your primary care doctor
Please seek immediate medical attention if you begin to
experience fevers/chills, if you become incontinent of urine or
stool, if your legs become weaker, or if you experience any
other symptoms concerning to you.
Followup Instructions:
It is extremely important that you keep all of your followup
appointments because you have a very bad infection around your
spine.
Please be sure to follow up in Ortho Spine clinic next week with
Dr. [**Last Name (STitle) **]
[**2184-11-17**] at 4pm
[**Hospital Ward Name 23**] Building, [**Location (un) **]
[**Telephone/Fax (1) 3573**]
Please also follow up in Infectious Disease Clinic.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2184-11-19**] 11:30
Please follow up in Plastic Surgery clinic in [**2184-12-3**]; you
should call the following number to make the appointment.
[**Telephone/Fax (1) 3009**]
|
[
"5849",
"42731",
"311",
"3051",
"40390",
"5859"
] |
Admission Date: [**2114-11-2**] Discharge Date: [**2114-12-17**]
Service: VASCULAR
CHIEF COMPLAINT: Ruptured aneurysm.
HISTORY OF PRESENT ILLNESS: The patient had the onset of
acute pain and near syncope and was admitted to an outside
hospital and then transferred here after the diagnosis of
ruptured aneurysm was made. The patient underwent emergent
surgery.
HOSPITAL COURSE: The patient was emergently taken to the
Operating Room and underwent an abdominal aortic repair,
open. He was transferred to the Intensive Care Unit for
continued care.
On [**2114-11-7**], the patient underwent a split primary
closure and a G-tube placement. Attempt to wean was tried on
[**11-8**] without success.
The patient developed fever and was pancultured. He grew
yeast from his sputum. He was begun on
Levofloxacin and Fluconazole. On [**2114-11-10**], he was
placed on PAP.
His right central line was changed to a triple-lumen catheter
on [**11-12**]. On [**11-15**], he was extubated. Physical
Therapy began to evaluate the patient and treated him on a
daily basis.
Speech and Swallow evaluated the patient, and he had positive
signs of aspiration with liquids. He was continued NPO, and
TPN was continued.
The patient was begun on G-tube feeds and transferred to the
VICU on [**2114-11-17**]. He had some episodes of
hypernatremia requiring additional intravenous fluids. He
underwent a video swallow on [**11-21**] which demonstrated
aspiration, and he had an inability to cough. He was
continued NPO, and nutrition was supported with TPN and
G-tube feedings.
The patient returned to the Intensive Care Unit on [**11-23**] secondary to respiratory insufficiency, chronic renal
insufficiency with acute renal failure. He was begun on
Vancomycin, Zosyn and Flagyl at this time. He required
transfusion, 1 U packed cells, and on [**11-26**], he was
transferred back to the VICU.
A repeat video swallow was done on [**11-28**], which the
patient failed. On [**12-4**], the patient became febrile,
tachycardiac, with question of pulmonary embolus.
Intravenous Heparin was started empirically.
A swallow the day before noted that the patient continued to
aspirate, although pureed solids and thin liquids were
instituted.
The patient remained septic requiring
ventilatory
support and required additional antibiotics for his MRSA
pseudomonas pneumonia.
On [**12-7**], the patient continued to be persistently
afebrile. CT of the abdomen was obtained which showed fluid
around the left kidney.
The patient was instituted on Ceftazidime for pseudomonas
pneumonia. He showed improvement after the Ceftazidime was
instituted and transferred back to the VICU on [**2114-12-10**].
Hematology was consulted because of his pancytopenia. They
felt this was all secondary to poly-pharmacology, and with
adjustment of his medications, his pancytopenia improved.
Tube feeds, half-strength Nepro 50 cc/hr was instituted.
On [**12-17**], his antibiotics were discontinued. He was
begun on p.o. clears only. He continued to be monitored for
aspiration. He was followed by Physical Therapy and
discharged in stable condition.
DISCHARGE MEDICATIONS: Ipratropium multidose inhaler 8 puffs
q.4 hours p.r.n., Insulin sliding scale, the patient is on
tube feeds, artifical tears 1-2 drops O.U. p.r.n.,
................. 20% nebulizers q.4-6 hours p.r.n.,
Albuterol nebulizers 1 q.4 hours, Acetaminophen 325-650 mg
q.4-6 hours p.r.n., Metoprolol 25 mg b.i.d., Pantoprazole 40
mg q.d., tube feeds half-strength Nepro at 50 cc/hr, check
residuals q.4 hours and hold for residuals greater than 150,
the patient is to receive 125 cc of water q.6 hours.
DIET: Consistence of pureed, thin liquids was begun.
DISCHARGE DIAGNOSIS:
1. Ruptured aortic aneurysm, status post open repair, with
delayed primary closure of the abdominal wound.
2. G-tube placement for nutritional support.
3. Respiratory failure requiring prolonged intubation status
post extubation.
4. ................. pneumonia times three, treated.
5. Hyponatremia, treated.
6. Aspiration of thin liquids, improved.
7. Pancytopenia secondary to multiple medications.
8. Pseudomonas pneumonia, on Ceftazidime.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2114-12-17**] 12:54
T: [**2114-12-17**] 12:56
JOB#: [**Job Number 34379**]
|
[
"0389",
"5845"
] |
Admission Date: [**2171-4-3**] Discharge Date: [**2171-4-27**]
Date of Birth: [**2106-1-18**] Sex: F
Service:
This is a discharge summary addendum covering the dates [**4-25**] through [**2171-4-27**].
The patient continued to improve clinically during the last
two days of her hospital course. However, she did develop
some erythema and tenderness at the site of her PICC line on
the right arm. This was evaluated by a right upper extremity
ultrasound which showed thrombophlebitis of the right
cephalic vein surrounding the catheter, with no evidence for
deep venous thrombosis. It was recommended that the PICC
line be changed. In addition, because thrombus had developed
at the site of the PICC line, we started the patient on
Lovenox 30 mg subcutaneously twice a day, and discontinued
her heparin 5000 units subcutaneously twice a day to prevent
further clot formation at the site of the new line. The new
line was placed by the Interventional Radiology service. It
is a midline suitable for use with linezolid and tobramycin,
however, the patient should not receive other antibiotics or
medications through this line without first checking with
Pharmacy to see if this line is appropriate.
The patient will have a follow-up MRI on [**2171-5-15**], at
10:15 A.M. at the fourth floor of the [**Hospital Ward Name 23**] Center for
follow up. The Infectious Disease service will follow up
with her in clinic as well.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 7896**]
MEDQUIST36
D: [**2171-4-26**] 22:10
T: [**2171-4-27**] 00:12
JOB#: [**Job Number 42247**]
|
[
"486",
"42731"
] |
Admission Date: [**2187-9-17**] Discharge Date: [**2187-9-20**]
Date of Birth: [**2151-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 15287**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
36M with DMI and gastroparesis recently admitted for DKA (d/c'd
on [**2187-8-29**]) now with nausea/vomiting that started last night.
Emesis is coffee-ground. Pt denies any abd pain, chest pain,
dizziness, blood in stool, dark stools, cough, fever or chills.
Pt last BM last night. ESRD on HD (M,W,F), missed appt today d/t
symptoms. Reports glucose this morning was 211. Feels nauseaous
In the ED, initial VS were: T-96.0 P 103 BP 224/122 R18 100% RA
Pt was found to have AG of 29 with an initial glucose of 209. Pt
was started on insulin drip and 1 L of NS bolus. Pt received 2
doses of zofran and ativan for nausea. LFTs and lipase were
negative in the ED and EKG did not show any signs of ischemia.
Pt gap started to close on insulin drip.
On arrival to the MICU, the patient continues to complain of
mild nausea. He otherwise feels well. Pt denies any chest
pain, abdominal pain, fever, chills, or cough.
Past Medical History:
- Type I diabetes: since age 19, complicated by gastroparesis,
retinopathy (laser treatment), DKA, chronic kidney disease
- ESRD, on HD MWF, started [**9-4**]; currently on transplant list
- s/p left brachiocephalic AV fistula created on [**2186-7-18**]
s/p angioplasty of the arterial anastomosis, mid cephalic
and cephalic arch, complicated by an extravasation and
mid-fistula hematoma (still usable)
- [**Doctor Last Name 9376**] syndrome
- Hypertension
- Asthma
- HLD
- chronic multifactorial anemia, on Epo, h/o pRBC transfusion x2
Social History:
Lives with his parents. Denies tobacco use, alcohol use, or
illicit drug use
Family History:
Father with CAD/MI, HLD, type II DM. Mother with thyroid cancer
Physical Exam:
Admission:
Vitals: T:afebrile BP:189/110 P:91 R: 18 O2:98 on RA
General: Alert, oriented, no acute distress; appears mildly
uncomfortable
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear,
EOMI, PERRL
Neck: supple, no LAD
CV: Tachycardic S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, mildly tender to palpation in epigastrium; no
rebound or guarding
GU: no foley
Ext: AV fistula in left upper extremity with thrill; warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Discharge:
Vitals: Patient was afebrile, normotensive, non-tachycardic,
non-tachypneic, 98% on room air
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: RRR, transmitted flow murmur from fistula, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, nontender, no rebound or guarding
Ext: AV fistula in left upper extremity with palpable thrill and
audible bruit, warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
Admission:
[**2187-9-17**] 06:45PM BLOOD WBC-9.5# RBC-4.02* Hgb-11.5* Hct-36.4*
MCV-90 MCH-28.6 MCHC-31.6 RDW-15.2 Plt Ct-218
[**2187-9-17**] 06:45PM BLOOD Glucose-209* UreaN-88* Creat-12.4*#
Na-138 K-5.0 Cl-95* HCO3-20* AnGap-28*
[**2187-9-17**] 06:45PM BLOOD Lipase-58
[**2187-9-17**] 11:36PM BLOOD cTropnT-0.07*
[**2187-9-17**] 06:45PM BLOOD ALT-18 AST-25 AlkPhos-116 TotBili-0.7
[**2187-9-17**] 08:43PM BLOOD Type-[**Last Name (un) **] pO2-77* pCO2-48* pH-7.32*
calTCO2-26 Base XS--1 Comment-GREEN TOP
Pertinent:
[**2187-9-19**] 02:30AM BLOOD Glucose-213* UreaN-36* Creat-7.0* Na-133
K-4.3 Cl-96 HCO3-29 AnGap-12
[**2187-9-18**] 05:18PM BLOOD Glucose-91 UreaN-27* Creat-6.1*# Na-138
K-4.0 Cl-97 HCO3-33* AnGap-12
Discharge:
[**2187-9-20**] 06:00AM BLOOD WBC-6.3 RBC-3.70* Hgb-10.7* Hct-33.5*
MCV-91 MCH-28.9 MCHC-31.9 RDW-15.0 Plt Ct-172
[**2187-9-20**] 06:00AM BLOOD Glucose-160* UreaN-29* Creat-5.6*# Na-138
K-4.4 Cl-97 HCO3-30 AnGap-15
[**2187-9-20**] 06:00AM BLOOD Calcium-8.9 Phos-5.8* Mg-2.1
Brief Hospital Course:
Brief Course:
36M with type I DM and gastroparesis recently admitted for DKA
(discharged on [**2187-8-29**]) who presented with nausea and coffee
ground emesis and DKA. He was treated with insulin drip and
received dialysis in house.
Active Issues:
#DKA: Likely secondary to witholding his insulin in the setting
of not eating due to nausea and vomiting from gastroparesis.
Anion gap was 29 on presentation with glucose of 209.
Electrolytes were initially checked q 4 hours and repleted when
needed until the gap was closed. Patient was started on insulin
drip and transitioned to subcutaneous insulin after his gap had
closed with 2 hour overlap. Patient is tolerating good PO and is
discharged on his home insulin regimen.
#Gastroparesis: Complication of type I DM. Likely the cause of
his nausea and vomiting. Patient's outpatient GI doctor has seen
the patient in the hospital. He was continued on eythromycin and
metoclopramide and given zofran and prochlorperazine prn for
nausea.
#Coffee ground emesis: Had similar episode in [**Month (only) 1096**], and EGD
at that time was largely normal. No more episodes while in
hospital and hematocrit was stable. Maintained active type and
screen. Possibly due to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear from vomiting. PUD,
gastritis also in differential. Placed on PPI. Tolerating good
PO.
#ESRD: Chronic secondary to diabetes, on hemodialysis MWF. The
patient is currently on the dual pancreatic/kidney transplant
list. He missed his Monday dialysis session because it was the
day he came into the hospital, so he was dialyzed while in the
hospital on Tuesday and Wednesday. He will continue his
scheduled dialysis along with nephrocaps and sevelamer.
#HTN: Normalized after dialysis. Pt states that BP is usually
elevated prior to dialysis. He was continued on his home
clonidine patch, labetolol and lisinopril without issues.
Transitional Issues:
1. Code status: Full
2. Communication: Patient
3. Medication changes: None
4. Pending studies: None
5. Follow up: PCP, [**Name Initial (NameIs) **]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTUES
2. Metoclopramide 10 mg PO QIDACHS
3. Nephrocaps 1 CAP PO DAILY
4. Omeprazole 20 mg PO DAILY
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. Labetalol 200 mg PO TID
7. Lisinopril 10 mg PO DAILY
8. Erythromycin 250 mg PO TID
9. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using Novolog Insulin
Discharge Medications:
1. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTUES
2. Erythromycin 250 mg PO TID
3. Labetalol 200 mg PO TID
4. Lisinopril 10 mg PO DAILY
5. Nephrocaps 1 CAP PO DAILY
6. sevelamer CARBONATE 2400 mg PO TID W/MEALS
7. Metoclopramide 10 mg PO QIDACHS
8. Omeprazole 20 mg PO DAILY
9. Glargine 5 Units Breakfast
Glargine 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
DKA
ESRD on dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 14782**],
You were admitted for DKA. You were treated with IV insulin and
transistioned back to your home insulin regimen. Your nausea
resolved and you were able to tolerate food.
We have made no changes to your medications. Please follow up
with your doctors as described below and continue dialysis at
your previous schedule.
Followup Instructions:
Name: [**Doctor Last Name **] [**Last Name (NamePattern4) 85503**], MD
Specialty: Endocrinology
When: Tuesday [**9-25**] at 1pm
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6104**] Np
Specialty: Primary Care
When: Tuesday [**10-2**] at 2pm
Location: [**Hospital1 641**]
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 644**]
Completed by:[**2187-9-20**]
|
[
"40391",
"V5867",
"49390",
"2724"
] |
Admission Date: [**2197-9-4**] Discharge Date: [**2197-9-7**]
Date of Birth: [**2124-12-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 72F with a PMH s/f ESRD on HD MWF, CVA's, seizure
disorder with a declined mental status (A+Ox1), who is
presenting to the MICU with hypotension after dialysis. Today
during dialysis the patient became unresponsive 45 minutes into
the session with a systolic blood pressure in the 60s. She was
given 2.5L of fluids and BP responded immediately as did her
mental status. She was sent to the ED for further work-up.
.
In the ED, the patients initial vitals were 97.7, 145/59, 66,
100% on 2L NC. A finger stick blood glucose was 133. She did not
have any fevers, leukocytosis, or elevated lactate. A CXR showed
a right pleural effusion. She has a history of traumatic cardiac
tamonade during a dialysis line placement in [**7-/2197**], so a
bedside echo was performed, which did not show any signs of
tamponade. She continued to have episodes of hypotension with
systolic BP's in the 70s, which would resolve spontaneously
without fluids.
Past Medical History:
1. ESRD on HD since [**2189**]
2. Diabetes mellitus II: [**8-13**] A1C of 5.2%
3. Hypertension
4. Hyperlipidemia: [**4-11**] LDL of 49
5. Peripheral [**Month/Year (2) 1106**] disease
6. Diastolic CHF, EF 70%
7. Chronic upper extremities DVTs
8. CVA x2
9. Seizure d/o s/p CVA
[**99**]. h/o MRSA line sepsis/klebsiella bacteremia, coag neg staph
bacteremia
11. h/o Osteomyletis (L3-L4 vertabrae) '[**92**]
12. h/o Pelvic fx
13. h/o psoas abscess
PAST SURGICAL HISTORY:
1. s/p Right BKA
Social History:
Lives at [**Hospital3 **] Home in [**Location (un) 583**], MA. Daughter is
next of [**Doctor First Name **]: [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 94263**]. No tobacco, EtOH, drug
use.
Family History:
Non-contributory
Physical Exam:
T=97.2... BP=132/54... HR=70... RR=15... O2=100% 2L
.
.
PHYSICAL EXAM
GENERAL: elderly african american female, lying on her right
side, refusing to be examined, un-cooperative with history or
physical.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Small reactive pupils bilaterally. Neck supple.
Cardiac: RRR, no murmurs, will not allow me to auscultate or
take a blood pressure
LUNGS: Refusing exam, only able to listen over left lung, no
abnormalities
ABDOMEN: NABS. Soft, NT, ND.
EXTREMITIES: R BKA, Left aKA, stump c/d/i
SKIN: ~5cm superficial sacral decubitus ulcer
NEURO: Unable to tell me her name, place or year. Follows simple
commands intermittently. Moving all four extremities. Not
cooperative with neuro exam.
Pertinent Results:
ADMISSION LABS
[**2197-9-4**] 02:25PM BLOOD WBC-5.2 RBC-3.65* Hgb-12.3 Hct-38.4
MCV-105* MCH-33.6* MCHC-31.9 RDW-19.0* Plt Ct-259
[**2197-9-4**] 02:25PM BLOOD Neuts-62 Bands-0 Lymphs-24 Monos-10 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2197-9-4**] 12:50PM BLOOD PT-23.0* INR(PT)-2.2*
[**2197-9-4**] 02:25PM BLOOD Glucose-110* UreaN-30* Creat-4.6* Na-137
K-5.0 Cl-102 HCO3-25 AnGap-15
[**2197-9-4**] 02:25PM BLOOD cTropnT-0.07*
[**2197-9-4**] 02:25PM BLOOD Albumin-3.2* Calcium-7.9* Phos-3.6 Mg-2.3
[**2197-9-4**] 02:31PM BLOOD Glucose-102 Lactate-1.3 K-6.1*
CHEST X-RAY ([**2197-9-6**])
AP BEDSIDE CHEST. The heart is upper limits of normal. There is
central
[**Month/Day/Year 1106**] congestion and interstitial edema. Small right and
probably left
effusions layering in semi-erect position with possible
superimposed right
pleural thickening. Sternal wire sutures. Left subclavian line
with tip in
mid SVC. Allowing for technical differences there is no change
from similar exam two days ago ([**2197-9-4**]).
IMPRESSION: No short interval change. CHF and/or fluid overload.
Brief Hospital Course:
Ms. [**Known lastname **] is a 72F with a PMH s/f ESRD on HD, CVA with seizure
disorder and declining mental status who presented with
hypotension.
.
#. Hypotension: Occured transiently after dialysis, and
immediately responded to fluids. No fevers, leukocytosis,
lactate, tamponade physiology on echo, or signs of bleeding.
Likely a result of hypovolemia after dialysis combined with
autonomic dysreflexia. All antihypertensives were held and
midodrine was started with good response. Patient has remained
normotensive and will be discharged with this regimen. She will
need close follow up with primary renal team per D/C
instructions
.
#. Right pleural effusion: Appears chronic based on past CXRs.
Patient remained afebrile and without supplementa oxygen
requirement.
.
#. Pericardial effusion: Although prior history of this,
currently there is no tamponade physiology on bedside
echocardiogram done in the ED. No further intervention is
required.
.
#. Sacral decubitus ulcer: Chronic, noted at admission. Wound
care consult was called.
.
#. Mental status: Based on prior neuro notes, this appears to be
her baseline. Recent head CT with old strokes, and nothing acute
on [**8-30**].
.
#. ESRD: Patient tolerated HD on above regimen, defer further
management to outpatient renal team.
.
#. DM: continue home insulin regimen
.
#. CVA: Continue coumadin per outpatient regimen.
.
#. HTN: Not active as above
.
#. Seizures: continue home regimen of keppra
Medications on Admission:
ISS
Remeron 15mg daily
Bisacodyl
NGT transdermal ointment 1" q6H prn SBP>150
Dilaudid prn
Aluberol prn
Cinacalcet 30mg every other day
Ranitidine 150mg daily
[**Month/Year (2) **] 81mg daily
Lactulose [**Hospital1 **]
Coumadin: unclear dose, was not discharged on this
Metoprolol tartrate 37.5mg TID
Keppra 500mg daily, give after dialysis if possible
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): Hold for SBP >130.
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
9. Insulin Regular Human 100 unit/mL Solution Sig: As directed
per insulin sliding scale units Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 94271**] nursing home [**Location (un) **]
Discharge Diagnosis:
Hypotension
Discharge Condition:
Stable
Alert and oriented to self only
Intermittently responds to questions
BP 130-160/50-60
HR in the 60s
Satting well on room air
Discharge Instructions:
You were admitted with low blood pressure, which we think is due
to autonomic dysreflexia. We started a new medication called
midrodine to help keep your blood pressure normal, and stopped
your antihypertensives.
.
Please take all of your medications as directed
.
Please return to the emergency room if you experience any loss
of consciouness or abnormally elevated blood pressures.
Followup Instructions:
Provider: [**Last Name (NamePattern5) 9155**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2197-11-15**] 2:00
|
[
"40391",
"25000",
"4280"
] |
Admission Date: [**2131-6-11**] Discharge Date: [**2131-6-28**]
Date of Birth: [**2046-6-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
L facial tumor
Major Surgical or Invasive Procedure:
Left facial resection and graft placement
PEG feeding tube placement
History of Present Illness:
CC: invasive advanced basal cell cancer causing discomfort
closing her mouth; some drooling of food because of the
retraction of her lips; difficulty in closing her eyes; some
tearing because of retraction of her lower eyelid and some pain
and discomfort in the cheek area itself and this ligament of her
face.
.
HPI: 85 year old woman with dementia and advanced erosive basal
cell
carcinoma involving the left cheek, nasal cavity, palate, and
lateral facial region. She was admitted for surgical resection
and will need a prosthesis and by a prosthodontist to have a
preliminary prosthesis made that will eventually shell the
defect and provide her some cosmesis.
Past Medical History:
Hypertension, anemia, renal failure, hypothyroidism,
hyperlipidemia, paranoid, dementia, and chronic psychosis.
Excision of left-sided facial carcinoma and type 2 diabetes, and
history of prior alcohol abuse.
Social History:
From the family, she says she and her husband
estranged from her family. Her husband recently died and they
used to travel all over the country in a trailer and they never
had a permanent place of residence. She is now in a
rehabilitation facility called Roscommon On The Parkway. No
other social history could be elicited from her. She does not
remember if she smokes or does have a history of alcohol abuse.
Family History:
None
Physical Exam:
VS: 96.2 128/84 HR 69 RR20 O2sat 95% on RA
General: Alert, oriented, mild respiratory difficulty with
audible wheeze, difficult to understand when she speaks.
HEENT: Sclera anicteric, dry MM, large defect on left cheek
extending to left orbit. Slight erythema at wound edge. no odor,
no sloughing tissue. Lips sutured midline.
Neck: supple, JVP 2-3 cm above clavicle
Lungs: mild crackles at bases bilaterally
CV: regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds
hypoactive, no rebound tenderness or guarding, no organomegaly,
Gtube without dressing, ~10 in out of abd, clean dressing, no
erythema.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis,
edema
Neuro: moving all extremities
Groin: minimal erythematous satellite lesions extended to
buttocks crease, labial folds
.
Pertinent Results:
Admit labs:
[**2131-6-11**] 04:00PM BLOOD WBC-17.8* RBC-4.08* Hgb-12.4 Hct-36.5
MCV-90 MCH-30.3 MCHC-33.9 RDW-12.8 Plt Ct-250
[**2131-6-11**] 04:00PM BLOOD Glucose-222* UreaN-17 Creat-0.9 Na-137
K-4.6 Cl-107 HCO3-22 AnGap-13
[**2131-6-11**] 04:00PM BLOOD Calcium-7.4* Phos-3.2 Mg-1.4*
[**2131-6-14**] 04:50AM BLOOD TSH-0.58
[**2131-6-14**] 04:50AM BLOOD T4-8.1 T3-52*
Cardiac enzymes:
[**2131-6-17**] 08:23AM BLOOD CK-MB-3 cTropnT-2.40*
[**2131-6-15**] 09:10PM BLOOD CK-MB-4 cTropnT-2.28*
[**2131-6-15**] 06:39PM BLOOD CK-MB-5 cTropnT-1.95*
[**2131-6-15**] 03:30AM BLOOD CK-MB-6 cTropnT-1.22*
[**2131-6-14**] 04:50AM BLOOD CK-MB-14* MB Indx-3.1 cTropnT-0.95*
UA
[**2131-6-23**] 09:12PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2131-6-23**] 09:12PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.024
[**2131-6-23**] 09:12PM URINE RBC-6* WBC-25* Bacteri-FEW Yeast-FEW
Epi-1 TransE-<1
Discharge labs:
[**2131-6-26**] 07:30AM BLOOD WBC-12.6* RBC-3.18* Hgb-9.7* Hct-30.5*
MCV-96 MCH-30.6 MCHC-31.9 RDW-16.2* Plt Ct-503*
[**2131-6-26**] 07:30AM BLOOD Glucose-310* UreaN-34* Creat-1.1 Na-139
K-4.9 Cl-98 HCO3-30 AnGap-16
[**2131-6-22**] 05:45AM BLOOD ALT-16 AST-19 AlkPhos-55 TotBili-0.4
[**2131-6-26**] 07:30AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0
URINE CULTURE (Final [**2131-6-25**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
YEAST. ~5000/ML. SECOND MORPHOLOGY.
Blood Culture:
Blood Culture, Routine (Final [**2131-6-22**]): NO GROWTH.
Blood Culture, Routine (Final [**2131-6-22**]): NO GROWTH.
Studies:
Portable CXR [**2131-6-22**]
FINDINGS: Patient's positioning compromises the quality of the
film as well as comparison with prior radiographs. However,
bilateral perihilar haziness with upper redistribution secondary
to mild pulmonary vascular congestion seems unchanged. The right
hemidiaphragm is elevated. A left lower lobe radiopacity is
stable from prior radiographs and likely represents moderate
atelectasis. No evidence of pneumothorax. Mild cardiomegaly is
stable.
IMPRESSION: Unchanged mild pulmonary edema. Bibasilar
atelectasis, left
worse than right.
Chest CT:
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There is no
axillary,
mediastinal, or hilar lymphadenopathy. The pulmonary arteries
are well
opacified. There are no filling defects. A small left pleural
effusion is
identified. There is atelectasis in the right lower lobe. There
is left
lower lobe consolidation. A small amount of pericardial fluid is
noted. There are no lung nodules or masses. An NG tube is
identified.
Limited views of the upper abdomen demonstrate a normal
gallbladder, liver, and spleen. A 1.2 cm nodule in the left
adrenal gland measures 16 Hounsfield units, is thus
indeterminate but most consistent with an adenoma. A 3.5 cm
hypodense lesion in the right kidney at mid pole measures 13
Hounsfield units and is consistent with a cyst.
On bone windows there is loss of height of T12 and L1 and T9.
This is of
indeterminate age.
IMPRESSION:
1. No evidence of PE.
2. Consolidation in the left lower lobe concerning for
pneumonia. Small
pleural effusion.
3. Compression deformity of several lower thoracic vertebral
bodies and of L1 are of indeterminate age.
Abd Xray [**2131-6-22**]
FINDINGS: One supine portable view of the abdomen is provided. A
G-tube is
seen within the stomach. The bowel gas pattern shows some mildly
dilated
loops of small bowel consistent with an ileus. There are
multiple
calcifications noted, most predominantly within the aorta. The
lung bases
appear clear. There is no evidence of free air.
IMPRESSION: Bowel gas pattern consistent with an ileus.
PATHOLOGY: [**2131-6-11**] Maxillary Tissue
1. Left medial palatal margin (A):
Negative for carcinoma.
2. Left medial lip margin (B):
Negative for carcinoma.
3. Left inferior periorbital margin (C):
Atypical cells present; cannot exclude carcinoma.
Note: The atypical cells in the initial frozen section are
suspicious for carcinoma. The focus does not appear in the
permanent section of the remaining frozen tissue.
4. Left medial periorbital margin (D):
Negative for carcinoma.
5. Left superior medial periorbital margin (E):
Negative for carcinoma.
6. Left proximal inferior orbital nerve margin (F):
Small cluster of atypical basaloid cells within soft tissue
consistent with basal cell carcinoma, see note.
Note: There is a small focus at the edge of the permanent
section of the remaining frozen tissue. The focus did not
appear in the original frozen section which was diagnosed as
negative for carcinoma. The focus is within fat. The nerve is
uninvolved. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] has reviewed this case and concurs
with the diagnosis.
7. Additional margin, left inferior periorbital (G):
Small cluster of atypical basaloid cells consistent with basal
cell carcinoma, see note.
Note: There is a small focus at the edge of the permanent
section of the remaining frozen tissue. The focus did not
appear in the original frozen section which was diagnosed as
negative for carcinoma. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] has reviewed this case and
concurs with the diagnosis.
8. Coronoid process of left mandible (H-I):
Portion of bone and muscle; negative for carcinoma.
9. Posterior portion of left inferior turbinate (J):
Nasal mucosa; negative for carcinoma.
10. Total maxillectomy, left (K-AK):
-Basal cell carcinoma, infiltrative type, present at inferior
orbital rim margin (slides K, L, AH) see note.
-Hypertrophic actinic keratosis, not seen at the examined
specimen margins.
Note: There is perineural invasion (best observed in slide R)
and extension of tumor to underlying bone (best observed in
slides AD, AF). The tumor extends from the overlying epidermis
near the ulcer. In the superficial areas the tumor shows more
typical features of basal cell carcinoma including larger
nodules with peripheral palisading. As the tumor infiltrates
deeper, the cells are more pleomorphic with loss of palisading,
and some areas show infiltration of smaller nests with a marked
sclerotic stroma. There are focal areas showing an adenoid
pattern.
Brief Hospital Course:
This is an 85 yo F h/o HTN, DM, dementia with psychosis, basal
cell carcinoma admitted for surgical resection of basal cell
carcinoma of the left face. Surgical resection and Gtube
placement was performed [**6-11**] with post-op course complicated by
hypercapnia, aspiration PNA, tachycardia, hypernatremia, and
ARF.
Operative and post op course
Pt was admitted for surgical resection of large left facial
tumor. She underwent a resection of left facial tumor; partial
orbitectomy; partial palatectomy soft tissue face and cheek;
partial rhinectomy; local tissue rearrangment left eye. She
tolerated the procedure well, and was extubated, and brought to
the recovery room in stable condition. In the recovery room the
pt was desating to 80s% on room air, although remained stable
the entire time. On face mask and 12L her sat was 96%. cxr in
the PACU did not reveal pleural effusions, or any other acute
lung pathology. post-op labs were unchanged and wnl, except for
abg which was significant for a respiratory acidosis (PaCO2 61)
likely related to anesthesia. However, that pt was unable to
maintain saturation on room air, decision was made to send pt to
the ICU. Overnight in the ICU the pt remained npo with 100%
saturdation on non-rebreather. On POD#1, pt was weaned from
supplemental oxygen to room air. On room air saturdation was 92%
(baseline preop 94%). Pt was restarted on home medications,
continued on Unasyn, and tube feeds were started. In addition,
pt tolerated sips for comfort without coughing. On POD#2 pt was
transferred to the medical service after which she underwent the
following complications throughout her MICU and hospital stay:
hypercapnia, aspiration PNA, GIB, tachycardia, hypernatremia,
and ARF.
These problems were managed over the course of a prolonged
hospitalization to the point she was relatively stable with the
main underlying problems being poor airway control with high
aspiration risk and PEG tube management. Plan for discharge on
[**6-25**] when she had a minor aspiration event with respiratory
distress without hypoxia. That evening she also pulled her PEG
tube out. Goals of care were readdressed the following day with
the health care proxy who decided patient should be made DNR/DNI
and focus on comfort measures only and to avoid PEG tube
replacement.
Continued issues for this patient include:
1) Persistent aspiration risk: Patient must remain at atleast 45
degree angle to prevent aspiration. Pt allowed to have sips or
small bites of pureed solids for comfort if she requests. She is
written for concentrated liquid medications and suppositories as
routes of medication. She is written for morphine to be used
for respiratory distress.
2) Skin care: Patient has a hole at her G tube site which is
draining any oral intake and some gastric secretions also.
Barrier cream should be applied to the site twice daily with
good skin care. Pegs around the G tube site should fall off on
their own in [**2-23**] weeks, earlier removal may result in a
peritonitis.
3) Face care: Daily to qod facial cleansing with small
quantities of normal saline.
4) Pain control: Patient is written for round the clock tylenol
and prn morphine.
5) GOC: Patient is Comfort Measures Only and Do not hospitalize.
5) HCP: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 89691**] X123
.
Medications on Admission:
1. Alendronate 70mg weekly (sunday)
2. Citalopram 20mg daily
3. Ergocalciferol 50,000 units monthly
4. Erythromycin (0.5%) ointment 5mg/gm left eye daily
5. Glipizide XL 5mg daily
6. Labetalol 400mg PO BID
7. Levothyroxine 50mcg daily
8. Lisinopril 10mg daily
9. Olanzapine 2.5mg daily
10. Miralax 17gm/dose daily
11. Simvastatin 20mg nightly
12. Acetaminophen 650mg q6hrs
13. Aspirin 81mg daily
14. Calcium carbonate 500 mg (1250mg) tablet [**Hospital1 **]
15. Carboxymethylcellulsoe 1% drops 1 drop OS QID
16. Dextra 70-hypromellose 1 drop every 2 hours while awake
17. Colace 100mg [**Hospital1 **]
18. Mg hydroxide 400mg/5mL 30ml twice weekly Wed/Fri
19. Mg oxide 800mg daily
20. MVI
21. Senna 1 tablet nightly
22. Lacrilube one drop OS [**Hospital1 **]
Discharge Medications:
1. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QHS (once a day (at bedtime)).
2. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-19**]
Drops Ophthalmic Q1H (every hour).
3. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q6H (every 6 hours) as needed for
discomfort/agitation.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
discomfort from constipation.
5. acetaminophen 650 mg Suppository Sig: One (1) suppository
suppository Rectal every six (6) hours.
6. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
Five (5) mg PO q2h as needed for pain or respiratory distress.
7. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Ten
(10) mg PO q2h as needed for severe pain or respiratory
distress.
Discharge Disposition:
Extended Care
Facility:
Roscommon on the Parkway - [**Location 1268**]
Discharge Diagnosis:
Primary Diagnosis
Basal Cell Carcinoma
Supraventricular tachycardia secondary to B-blockade withdrawal
Pneumonia
Secondary Diagnoses
Chronic kidney disease
Hypothyroidism
Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 17926**],
It was a pleasure to take care of you. You were admitted to the
hospital for surgery to remove a cancer on your face. After the
surgery, you had a number of post surgical complications
including an arrythmia, a pneumonia, and a yeast infection on
the body. After all of this your health care proxy decided to
focus on comfort based care for management of your symptoms.
You had a feeding tube put in to protect your airway, but you
continued to pull it out and it was decided that we not replace
it. Your family decided that it may be best to focus on comfort
based care instead of aggressive medical treatments.
A number of medications have been changed. Please see the new
attached list.
Followup Instructions:
not needed
Completed by:[**2131-6-28**]
|
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"5070",
"51881",
"41071",
"2760",
"5849",
"9971",
"2762",
"40390",
"5859",
"2449",
"2724",
"42789",
"41401",
"4280"
] |
Admission Date: [**2169-6-17**] Discharge Date: [**2169-6-27**]
Date of Birth: [**2092-11-3**] Sex: M
Service: MEDICINE
Allergies:
Neosporin / Latex
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
fever, delta MS, incontinence
Major Surgical or Invasive Procedure:
PICC line placement [**2169-6-21**]
History of Present Illness:
HPI obtained from wife due to change in pts mental status. 76
yo with poorly differentiated lung carcinoma (likely small cell)
on etoposide and carboplatin, recurrent sternal wound
osteo/infection requiring debridements and flaps, s/p CABG in
[**2166**], CAD s/p MI and CABG, DMII, HTN, COPD who presents after
being discharged from [**Hospital1 **] rehab yesterday with
fever. The pt was admitted to [**Hospital1 18**] in [**4-17**] and underwent
sternal wound debridement on [**2169-4-26**] with tx for MRSA infection.
He was then sent to rehab on 6 weeks of Vancomycin and a Vac
dressing (recently d/c'd). The pt went home [**6-15**] and was without
complaints until [**6-16**] when his wife took his temp and noted it to
be 105. The wife gave him 2 tylenol at that time and noted him
to have "shaking chills". He then became incontinent of urine
and became "short" with her. His wife notes that he becomes
confused every time he has a fever, and states he was admitted
in [**3-20**] with fever and confusion. She also notes he was
intermittently febrile at rehab as well as 2 days prior to his
discharge. He denied cough, SOB, ab pain, d/c, n/v to his wife
prior to admission. The pt states that during other
febrile/delta MS episodes in the past, she has never seen him
this somnolent.
.
The pt was seen by thoracic surgery in the ED and it was felt
the pt has a chronic chest fistula. He received Linezolid 600
mg IVx1, lopressor 50 mg po x1, ativan 1mg pox1, levoflox 500 mg
IVx1, and flagyl 500 mg IVx1. CT of the chest showed no
drainable collections.
.
Of note, the pt started etoposide and carboplatin while at rehab
on [**2169-5-9**]. His first cycle was complicated by neutropenic
fever, although he was receiving neupogen daily. The pt
reportedly had insomnia and sundowning at OSH with a negative
head CT.
Past Medical History:
Onc Hx per OMR:
In [**1-16**] pt was in the doctor's office for routine checkup and
was noted to have hemoptysis at that time. He therefore had a
chest x-ray that showed a right upper lobe mass which was
followed by a CAT scan that showed a 2.2 x 1.9 cm right upper
lobe nodule as well as a
7.5 x 4.4 x 6-cm soft tissue lesion in the anterior right chest
wall anterior to the right clavicle, also diffuse moderate
emphysema. This was followed by a PET scan on [**2169-3-2**], which
revealed an FDG-avid nodule in the right upper lobe with a
maximal SUV of 24.6 that measured 2.2 x 1.9 cm, also a right
hilar 9 mm lymph node with an SUV of 8.9 as well as increased
activity in the sternal area in the surgically created muscle
flap at the patient's sternal resection site. He then underwent
mediastinoscopy on [**2169-3-6**] with bronchial washings, which
were negative, and also had an I&D and sternal debridement. He
was presumed to have nonsmall cell lung cancer and went in for a
fiducial placement in the right upper lobe mass for CyberKnife.
At the same time they did an FNA of the nodule which was
consistent with poorly differentiated carcinoma with features of
small cell. Pt was started on etoposide and carboplatin in [**4-17**]
with last dose [**2169-6-1**].
--CAD - IMI in [**2165**], s/p CABGx4 in [**2166**], which was complicated
by
mediastinitis and sternal osteomyelitis and MRSA wound
infection. sternal wound infection
requiring sternal debridement and omental flap
reconstruction. He subsequently developed multiple sinus
tracts emanating from osteo.He had a pec flap repair on [**5-16**].
--incisional hernia -- s/p repair and recurrence
--COPD/emphysema on home night time O2
--T2DM - controlled by meds and diet
--HTN
--hypercholesterolemia
--GERD
--anemia - monthly procrit
--hyperlipidemia
--prior right frontal lobe and left caudate infarct
--h/o confusion, fever, urinary incontinence on admission [**3-20**]
Social History:
Married for 52 years; taken care by wife at home. Former
smoking of cigar x 20yrs, and 10ppy hx of cigarettes; quit 30
years ago. No EtOH.
Family History:
FH: no h/x of cancer or CAD
Physical Exam:
PE:
Vitals: T 102.6 P 115 BP 120/78 R 24 Sat 96% 3LNC
GENERAL: overweight elderly male, lying on his side, A and
Ox2-->somnolent, not answering most questions
HEENT: bilateral esotropia, PERRL, conjunctivae
noninjected/anicter
NECK: No LAD, supple
CARDIOVASCULAR: Tachycardic. No murmurs, rubs, or
gallops
LUNGS: Clear to auscultation bilaterally with distant breath
sounds; noted by resident to have Cheynne [**Doctor Last Name **] respirations
ABDOMEN: Soft, nontender, protuberant, normoactive bowel sounds
with a reducible ventral hernia.
EXTREMITIES: no c/c/e, wwp, 1+ dp/pt pulses bilaterally, R PICC
line site without erythema
STERNUM: 2 sinus tracts (one on each chest wall) which are non
erythematous, no purulence, nontender, no fluctuance, no warmth,
good granulation tissue
NEURO: a and ox2
Pertinent Results:
[**2169-6-17**] 06:02PM TYPE-ART PO2-73* PCO2-34* PH-7.43 TOTAL
CO2-23 BASE XS-0
[**2169-6-17**] 06:02PM GLUCOSE-139* LACTATE-1.0 NA+-134* K+-4.0
CL--103 TCO2-23
[**2169-6-17**] 06:02PM freeCa-1.19
[**2169-6-17**] 04:33AM LACTATE-1.2
[**2169-6-17**] 12:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.039*
[**2169-6-17**] 12:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2169-6-17**] 12:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2169-6-16**] 10:05PM LACTATE-1.3
[**2169-6-16**] 10:00PM GLUCOSE-112* UREA N-20 CREAT-1.0 SODIUM-135
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-22 ANION GAP-16
[**2169-6-16**] 10:00PM ALT(SGPT)-34 AST(SGOT)-21 ALK PHOS-81
AMYLASE-32 TOT BILI-0.3
[**2169-6-16**] 10:00PM LIPASE-24
[**2169-6-16**] 10:00PM ALBUMIN-4.0
[**2169-6-16**] 10:00PM WBC-3.7* RBC-3.88* HGB-10.9* HCT-31.6* MCV-82
MCH-28.1 MCHC-34.5 RDW-17.6*
[**2169-6-16**] 10:00PM NEUTS-58 BANDS-1 LYMPHS-17* MONOS-20* EOS-4
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2169-6-16**] 10:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
[**2169-6-16**] 10:00PM PLT SMR-NORMAL PLT COUNT-249#
.
CT Chest [**2169-6-16**]:
FINDINGS: The soft tissue mass in the posterior segment of the
right upper lobe previously measuring 3.2 x 1.8 cm is almost
completely resolved, now 0.5 x 1 cm with a fiducial marker in
it. Right hilar adenopathy seen just below the first mass (I
2:23) has resolved.
A 1 x 0.8 cm right middle lobe nodule, 3:36, is new. A 1.3x1.3
cm LLL nodule with calcification within it is stable or even
smaller. Bilateral basal atelectasis, left greater than right,
is grossly stable. Prominent centrilobular emphysema involves
mostly the upper lobes.
The patient had CABG and sternectomy for osteomyelitis. The
omental flap contains new areas of induration adjacent to the
previous fluid collection in the sternotomy bed which is now a
large thick walled cavity with a far wider connection to the
surface, perhaps due to debridement. It still has a long extent
long contiguity with pericardium but there is no pericardial
effusion or other fluid collection in the mediastinum. The
presternal lymph nodes are stable.
Heterotopic bone formation around the sternal excision margins
is stable. Several, enlarged mediastinal lymph nodes measuring
up to 1 x 2 cm, are stable. Some of the bilateral asbestos
pleural plaques are calcified. There is no pleural effusion.
The imaged portion of the abdomen does not reveal any pathology
within the liver, kidneys, spleen, pancreas and adrenals.
Several large gallstones are stable, with no evidence of
cholecystitis.
IMPRESSION:
1. Almost complete resolution of right lung mass and hilar
adenopathy.
2. New right middle lobe nodule, could be tumor or infection.
3. Unchanged left lower lobe nodule and bilateral lower lobe
atelectasis.
4. Large, infectious cavity in the sternal bed, with large
percutaneous fistula or tract formation.
.
MRI Chest [**2169-6-20**]:
FINDINGS: There has been no significant change from prior chest
CT dated [**2169-6-16**]. The patient is status post sternectomy with
flap repair. Two large fistulae tracks are identified within the
anterior chest wall at the sternectomy defect. There is
significant soft tissue enhancement in this region, consistent
with underlying infection. However, the pericardial fat remains
normal in signal and this anterior chest wall infection does not
appear to communicate with the mediastinum.
A few subcentimeter lymph nodes are seen inferior to the two
fistulae. Limited imaging through the upper abdomen demonstrates
no significant abnormality. The aorta is normal in caliber, with
mild atherosclerotic disease. Visualized portions of the great
vessels are unremarkable.
IMPRESSION: No significant change from prior CT examination
dated [**2169-6-16**]. Two large fistulae within the anterior chest wall
at the sternectomy defect with significant soft tissue
enhancement consistent with infection. No communication to the
pericardium or mediastinum.
Evaluation of the reformatted images on a separate workstation
were valuable in delineating the anatomy.
.
PICC line placement [**2169-6-21**]:
PROCEDURE/FINDINGS: The procedure was performed by Dr. [**First Name (STitle) 379**] [**Name (STitle) **]
and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12166**]. Dr. [**Last Name (STitle) 12166**], the attending radiologist, was
present and supervising throughout the procedure.
The patient was placed supine on the angiographic table. The
left arm was prepped and draped in the standard sterile fashion.
Ultrasound confirmed the left basilic vein was patent and
compressible. 5 cc of 1% lidocaine were applied for local
anesthesia. Under ultrasonographic guidance, a 21-gauge needle
was used to access the left basilic vein. Ultrasound films were
taken before and after the venous access was achieved. A 0.018
guide wire was advanced through the needle under fluoroscopic
guidance with the tip in the superior vena cava. The needle was
exchanged for a 4-French peel-away sheath. The length of the
PICC line was measured at 46 cm depending on the [**Last Name (STitle) **] on the
wire. After inner dilator was removed, a double-lumen PICC line
was placed over the wire under fluoroscopic guidance with the
tip in the superior vena cava. The peel-away sheath and the wire
were removed. Two lumens were flushed and the line was secured
with skin with StatLock. The patient tolerated the procedure
well and there were no immediate complications.
IMPRESSION: Successful placement of a 46-cm, double-lumen PICC
line through left basilic vein with the tip in the superior vena
cava. The line is ready to use.
.
Brief Hospital Course:
Briefly, this is a 76 yo with poorly differentiated lung
carcinoma (likely small cell) on etoposide and carboplatin,
recurrent sternal wound osteo/infection with MRSA requiring
debridements and flaps, s/p CABG in [**2166**], CAD s/p MI and CABG,
DMII, HTN, COPD who presented after being discharged from [**Hospital1 15454**] rehab the day prior to admission with fever and
mental status changes. On arrival to the floor the pt was tachy
to 110s, somnolent, noted to have some Cheynne [**Doctor Last Name **]
respirations, febrile to 102.6. Pts PICC line was attempted to
be pulled, however it started to heavily bleed and attempt was
stopped. Pt was started on broad spectrum abx with Vanc, Ceftaz,
and Flagyl. He was taken for US of his RUE to eval his PICC
line, and head CT. ABG:7.43/34/73 with lactate 1.0 on 3L NC.
The pt was transferred to the ICU overnight for neurologic
monitoring. His fever diminished on the night of admission, his
delta ms resolved, and he was transferred back to the floor the
following day.
.
#Fever: The pt was admitted with fever of 102.6, RR 24, tachy to
110s, concerning for impending sepsis. His SBP however was
stable in the 120s with a lactate of 1.0. Given the pts
somnolence and mental status changes, the pt was tranferred to
the ICU as per above on the night of admissin. DDX included
sternal wound infxn, UTI, line infxn, PNA, meningitis. CT of
torso and CXR were unrevealing of any clear source of infxn but
large soft tissue collection in anterior chest was visualized
and read as a possible abscess vs iatrogenic tract formation.
The pt was seen by Thoracics who felt the pts sternal fistulas
are not infected. Pt received Vancomycin and Levo/flagyl in ED.
Given his mental status changes, the pt was started on
Vanc/Ceftaz (to cover pseudomonas) and Flagyl on the floor.
These were discontinued the day after admission. The pts PICC
line was pulled on admission. Head CT was negative for any acute
change on admission. In the ICU, the pts mental status rapidly
improved overnight to alert and oriented x 3 the following day.
The pt also became afebrile overnight in the ICU. On transfer
to the floor, the pt was continued on Vancomycin only to cover
for possible soft tissue MRSA infection. Infectious disease was
consulted for assistance in the pts workup. MRI of the pts
sternum was ordered and revealed soft tissue enhancement in the
anterior chest wall. ID was consulted and recommended 4 more
weeks of vancomycin. The pt had already received 10 days of
Vanc at the time of discharge. Radiology confirmed that the pts
soft tissue infection was draining through his fistula.
Although the pts wound cx was growing pseudomonas
(pansensitive), this was felt to be a colonizer (according to
ID) given pt has been afebrile on Vancomycin. The pt remained
afebrile from HD#2 on.
.
# Diarrhea: The patient developed soft brown stool post
chemotherapy with transient resolution on [**6-26**]. Diarrhea
returned on [**6-27**]. Etoposide is known to cause diarrhea, however
given several days post chemotherapy, concern was raised for
possible hospital aquired infectious colitis. Pt WBC was also
elevated, though likely [**3-16**] to filgastrim(GCSF. His stool was
sent for C dificile antigen and the results are pending at the
time of discharge. These results need to be followed up on. If
diarrhea continues, would recommend resending the C dificile
antigen test.
#Mental Status Changes: Per pts wife, pt becomes confused with
incontinence whenever he has a fever. He was admitted in [**3-20**]
with fever and confusion as well. Sources included infection as
discussed above. There was no evidence of intracranial
hemorrhage or mass effect on CT of the head on admission. Remote
infarcts in the right frontal and left caudate lobes were noted.
His mental status drastically improved the day after admission
when his fever had dissipated. The pt remained a and ox3 from
HD#2 on.
.
#Tachycardia: This was likely related to infection. The pts
tachycardia resolved on HD#2
.
#HTN: Given the pts initial presentation, his lopressor 25 mg po
bid, cozaar 100 mg po qd were initially held. These were
restarted sequentially on HD2 and 3 as his blood pressure
tolerated.
.
#DMII: On admission the pts metformin 1000 [**Hospital1 **] was held given
his recent contrast given on [**6-16**] for CT. He was covered with
HSSI, qid FS. His glyburide was also held given the pt was
confused and not eating. These medications were restarted HD
#3.
.
#CAD: The pt was continued on [**Last Name (LF) 17339**], [**First Name3 (LF) **]. On admission his
lopressor/cozaar were held in the setting of possible impending
sepsis.
.
#Small cell cancer in R lung: The pt received
carboplatin/etoposide during this admission from [**Date range (1) 66873**]
without any side effects. Pt has been on carboplatin/etoposide
in the past. His CT shows resolution of the 2 R lung masses,
although there is a new RML nodule which denotes a mixed
response. The pt is to be on neupogen for 10 days following
[**Date range (1) 3454**] (started [**6-24**]).
.
#COPD: Pt has history of 86% of predicted FEV1/FVC on PFT's in
past. Also has decr TLC for unknown reasons. The pt was
continued on advair diskus and ipratropium
.
#Anemia: Pt has baseline anemia with hct 25-30. Received 2
units PRBC on [**6-13**] at his rehab. He was continued on his epogen
and iron supplements. The pts hct slowly dropped back down to
26 so he received 1 unit of PRBC on [**6-24**] with his hct rising up
to 29.
.
#FEN: diabetic/cardiac diet.
.
#Contact: Wife, [**Name (NI) **], cell [**Telephone/Fax (1) 97060**], home [**Telephone/Fax (1) 97061**]
.
#CODE STATUS: DNR/DNI
Medications on Admission:
Toprol XL 50', Metformin 1000'', Colace 100", Zetia 10', [**Telephone/Fax (1) **]
10', Atrovent prn, Spiriva 10', Cozaar 100', [**Telephone/Fax (1) **] 81', Advair
250/50'
Discharge Medications:
1. Atorvastatin 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO BID (2
times a day): please hold if diarrhea.
3. Ferrous Sulfate 325 (65) mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID
(2 times a day).
4. Epoetin Alfa 10,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday): 10,000 unit
injection.
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Telephone/Fax (1) **]:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
7. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
8. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) unit
Injection ASDIR (AS DIRECTED): For Fingerstick of: 150-200 give
2 units; 201-250 give 4 units; 251-300 give 6 units; 301-350
give 8 units; 351-400 give 10 units.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
12. Metformin 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet [**Telephone/Fax (3) **]: One
(1) Packet PO BID (2 times a day).
15. Glyburide 5 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO DAILY (Daily).
16. Losartan 50 mg Tablet [**Telephone/Fax (3) **]: Two (2) Tablet PO DAILY (Daily).
17. Vancomycin 500 mg Recon Soln [**Telephone/Fax (3) **]: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours).
18. Heparin Flush (10 units/ml) 3 ml IV PRN catheter care
10 ml NS followed by 3 ml of 10 Units/ml heparin (20 units
heparin) each lumen Daily and PRN. Inspect site every shift.
19. Filgrastim 480 mcg/1.6 mL Solution [**Age over 90 **]: Four [**Age over 90 11578**]y
(480) mcg Injection Q24H (every 24 hours) for 7 days: [**Date range (1) 66820**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Small Cell Lung Cancer
Chronic anterior chest wall fistulas with underlying soft tissue
infection
Discharge Condition:
stable, afebrile
Discharge Instructions:
Please take all medications as prescribed. Call your doctor or
return to the ER for fever, worsening chest pain associated with
your wounds, confusion, or any other concerning symptoms.
Followup Instructions:
1) Please call Dr.[**Name (NI) 3279**] office on Monday [**7-3**] at [**Telephone/Fax (1) 97062**] to set up appointment for next chemotherapy which would be
in approximately 2 weeks from discharge if all goes well.
2)Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 8495**] TAN Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2169-7-21**] 11:00 AM. Please call for directions.
3) Please present for a repeat Chest CAT SCAN Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2169-7-19**] 1:00 PM; [**Location (un) **] [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 5074**] [**Hospital3 **]
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
|
[
"4280",
"496",
"V4581",
"53081"
] |
Admission Date: [**2131-1-8**] Discharge Date: [**2131-1-13**]
Date of Birth: [**2060-1-23**] Sex: F
Service: [**Doctor Last Name **] Medicine
HISTORY OF PRESENT ILLNESS: This is a 70 year old female
with a history of atrial fibrillation with rapid rate that
was refractory to medical therapy, that was ablated and had a
pacemaker placed. History of chronic obstructive pulmonary
disease, history of esophageal cancer, status post
esophagectomy and history of left breast cancer, status post
mastectomy was recently discharged from [**Hospital3 **]
after pacemaker placement to the [**Hospital6 32395**] Home on
[**2131-1-6**]. She did well there but then one day prior
to admission developed nausea, vomiting and diarrhea. The
vomiting was bilious without blood or coffee grounds. She
had a slightly low blood pressure of 80/50 and was slightly
short of breath with an oxygen saturation of 93% on 2 liters
and so was brought to the Emergency Room. She was admitted
to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease on home oxygen and
metered dose inhalers.
2. Chronic pulmonary nodules, question pulmonary
hypertension versus chronic pulmonary embolism never been
diagnosed.
3. Diastolic dysfunction.
4. Atrial fibrillation with rapid rate, status post
atrioventricular junction ablation, and pacemaker placement
in [**2130-12-9**]. Normal thyroid function. Echocardiogram
at an outside hospital per report showed [**Hospital1 **]-atrial
dilatation, trace mitral regurgitation and an ejection
fraction of 33%.
5. Esophageal cancer, status post resection and
chemotherapy.
6. Left breast cancer, status post mastectomy.
7. Psoriasis.
8. Anxiety/depression.
9. Status post left total knee replacement.
10. Status post right ankle fusion for fracture.
11. Status post mastectomy as needed above.
MEDICATIONS ON ADMISSION: Atrovent 1 to 2 puffs q.i.d.;
Fosamax 70 mg p.o. q.d.; Trusta 25 mg p.o. q.d.; Remeron 50
mg p.o. q.d.; Imodium 2 mg p.o. q. 6 hours prn; Colace 100 mg
p.o. b.i.d.; Zantac 150 mg p.o. b.i.d.; Lasix 20 mg p.o. q.
day; Toprol XL 200 mg p.o. q. day; Digoxin 0.125 mg p.o. q.
day; Verapamil 120 mg p.o. b.i.d.; Coumadin 7.5 mg p.o. q.d.;
Fragmin 6000 units subcutaneously b.i.d. until Coumadin is
therapeutic.
ALLERGIES: Penicillin causes a rash.
SOCIAL HISTORY: Lives alone in Chelsae without immediate
family but currently at Leespoint Nursing Center after
pacemaker placement for rehabilitation. No smoking, alcohol
or illicit drug use.
PHYSICAL EXAMINATION: On admission, she was pale and
ill-appearing but oriented times three with dry mucous
membranes. Her blood pressure was 91/56, heartrate 81,
respiratory rate 23 sating 100% on 3 liters of nasal cannula.
She had pupils that were equal and reactive to light with
cataracts. She was anicteric. Her lungs had coarse sounds
with bilateral crackles at the bases. Heart was regular with
no murmurs. Her abdomen was soft with well healed scars and
no hepatosplenomegaly. She had bowel sounds. She had 1 to
2+ pitting edema bilaterally. Her pacemaker site looked good
on her upper chest. On neurological examination her cranial
nerves were intact.
LABORATORY DATA: Laboratory data on admission included a
white count of 13.3, hematocrit 25.8 down from 33 at
[**Hospital3 **] on [**12-26**]. Platelet count was
198. Baseline BUN and creatinine were 20 and .7 but here was
32 and 2.0, sodium was 128, potassium 4.5, chloride 87 and
bicarbonate 23. Glucose was 239. She ruled out for
myocardial infarction. Her urinalysis was negative.
Chest x-ray revealed a pacemaker and question of a left
retrocardiac density, collapse versus consolidation as well
as perhaps mild pulmonary edema.
HOSPITAL COURSE: She was diagnosed with hypotension
secondary to hypovolemia. She was resuscitated with 2 units
of packed red blood cells and intravenous fluids. She was
found to be guaiac positive in the Emergency Room. The
differential included Clostridium difficile versus
gastroenteritis. Her Clostridium difficile was negative
times two. Given the guaiac positive stools, she received
gastrointestinal workup. After the 2 units her hematocrit
stabilized and she had no further decrease. Her creatinine
improved with hydration with intravenous fluids back to her
baseline. Her respiratory status improved with diuresis and
a steroid taper for presumed chronic obstructive pulmonary
disease flare as she was quite wheezy during admission. She
remained afebrile and her rhythm remained paced. She had had
a number of aspiration events in the past and so a video
swallow was obtained which revealed a mild to moderate
oropharyngeal dysphagia complicated by reduced bolus control
with formation that resulted in aspiration of thin liquids.
She was upgraded to a thin liquid, ground solid diet with her
pills whole or crushed in purees and aspiration precautions
including tucking chin to chest for all bites and sips,
alternating between solids and liquids and clearing the
throat and swallowing during the middle and end of the meal.
From the standpoint of her congestive heart failure
exacerbation she diuresed well with Lasix. From the
standpoint of her chronic obstructive pulmonary disease, she
improved with nebulizers around the clock and steroid taper.
From the standpoint of her question of gastrointestinal
bleed, she received an esophagogastroduodenoscopy and
colonoscopy. Her esophagogastroduodenoscopy revealed diffuse
gastritis and a pulsating extrinsic bulge in the esophagus,
suggestive of a thoracic aortic aneurysm. Her
esophagogastroduodenoscopy was otherwise normal. The cause
of her guaiac positive stool was found on colonoscopy which
revealed two solitary rectal ulcers with no acute bleeding.
Cold forceps biopsies were performed. The gastroenterologist
stated that they would follow up with her in three weeks with
regards to the results of the biopsies. Given that she was
on anticoagulation only for atrial fibrillation, they
recommended holding anticoagulation until they saw and after
the results of the biopsy determine if she needs a repeat
endoscopy. They also recommended a computerized tomographic
angiogram of the chest to evaluate for thoracic aortic
aneurysm. She received this examination which revealed no
evidence of aortic aneurysm or dissection, although she had
diffuse aortic atherosclerotic disease. It was consistent
with her diagnosis of congestive heart failure as she had
pulmonary edema and bilateral pleural effusions. It was also
consistent with her history of esophagectomy as her stomach
lay in her thoracic cavity. Incidental note was made of an
avid area of arterial enhancement within the caudate lobe of
the liver which most likely was a vascular shunt. The
recommendation per Radiology was that further evaluation with
ultrasound or magnetic resonance imaging scan on a
nonemergent basis is recommended if clinically warranted.
She has no clinical symptoms or concerns for such a finding.
Given her stable hematocrit and finding for the source of the
bleeding, she was prepared for discharge.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSIS:
1. Chronic obstructive pulmonary disease with exacerbation
2. Congestive heart failure exacerbation secondary to
diastolic dysfunction
3. Atrial fibrillation, status post pacemaker placement
4. Gastrointestinal bleed from solitary rectal ulcers
5. Gastroenteritis
6. History of left breast cancer
7. History of esophageal cancer
8. Psoriasis
MEDICATIONS ON DISCHARGE:
1. Combivent 1 to 2 puffs every q. 6 hours
2. Trazodone 25 mg q.h.s.
3. Remeron 15 mg q. day
4. Colace 100 mg p.o. b.i.d.
5. Protonix 40 mg q. day
6. Furosemide 40 mg q. day
7. Albuterol/Atrovent nebulizers prn
8. Prednisone taper
9. Calcium and Vitamin D
10. Fosamax 70 mg p.o. q. week
11. Coumadin will be restarted after she follows up with
Gastroenterology
FOLLOW UP INSTRUCTIONS:
1. Follow up with primary care physician in about one week,
you will need an outpatient echocardiogram to further
evaluate cardiac function. You will also need an ultrasound
of liver if clinically warranted.
2. Will be contact[**Name (NI) **] by Gastroenterology to follow up on
biopsy results and need for further endoscopy as well as to
restructure anticoagulation.
3. Continue with aspiration diet.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2131-1-13**] 08:58
T: [**2131-1-13**] 09:16
JOB#: [**Job Number 32396**]
|
[
"5849",
"4280",
"42731"
] |
Admission Date: [**2201-3-7**] Discharge Date: [**2201-3-8**]
Date of Birth: [**2150-2-18**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
STEMI, CARDIOGENIC SHOCK
Major Surgical or Invasive Procedure:
PCI
Thrombectomy
Impella Placement
Central [**Doctor First Name **] Line Placement x 2
History of Present Illness:
51 yo M with 3V CAD, previously stented to LAD at OSH in setting
of MI, presents from [**Location (un) **] with CP, nausea and SOB similar
(but worse) to prior MI. Initially EKG within normal limits, but
was having ectopy, eventually EKG showed anterior ST elevations
and he was given aspirin, heparin, plavix and IIb/IIIA, his BP
dropped to the 100s he was given neosynpephrine.
.
He was transfered to [**Hospital1 **] for catheterization. He was taken
immediately to the cath lab, initially not intubated. Pt vomited
early but no clear aspiration noted. An IABP pump was placed. He
was found to have an acute in stent thrombosis, successfully
cleared. Pt developed VF arrest, CPR was initiated, he was
shocked to brady rhythm for which he was given 3mg of atropine.
Nadir ABG revealed 6.96/52/236, HCO3 13, Lactate 10. He was
intubated and
initially there was some small amounts of red frothy return from
the ETT. IABP was replaced by Impella and required high doses of
levophed and dopamine. Oxygenation worsened down to 70s and PEEP
increased to 18 with improvement of O2 to 80s. Did not respond
to increased tidal volumes to 750 and RR to 28, so pt paralyzed.
Received total of 400mg IV lasix and began improving oxygenation
with urine output. Pt started on amio with reduction of ectopy.
.
ROS unable to be obtained due to intubation/sedation.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, Diabetes
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: LAD stenting in
[**Location (un) 5622**]
3. OTHER PAST MEDICAL HISTORY: DM
HTN
HL
Morbid obesity
CAD s/p stenting in [**Location (un) **]
no known lung disease
Social History:
married with children and adoptive children. Unknown t/e/d
Family History:
unknown
Physical Exam:
GENERAL: WDWN, intubated.
HEENT: NCAT. Sclera anicteric. Dilated Pupils.
NECK: Supple with JVP of *** cm.
CARDIAC: Distant, uncharacterizable heart sounds
LUNGS: vetned + BS bilaterally, anterior exam only and
clear.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Cool, blue extremities with 7 second cap refill in
feet, [**3-11**] in hand
Pertinent Results:
CBC
[**2201-3-7**] 08:10AM BLOOD WBC-18.5* RBC-5.19 Hgb-15.2 Hct-46.1
MCV-89 MCH-29.2 MCHC-32.9 RDW-14.2 Plt Ct-340
[**2201-3-7**] 03:00PM BLOOD WBC-40.3*# RBC-5.12 Hgb-14.9 Hct-46.7
MCV-91 MCH-29.0 MCHC-31.8 RDW-14.5 Plt Ct-496*
[**2201-3-7**] 10:01PM BLOOD Hgb-14.2 Hct-43.0 Plt Ct-403
INR
[**2201-3-7**] 08:10AM BLOOD PT-13.8* PTT-150* INR(PT)-1.2*
[**2201-3-8**] 03:54AM BLOOD PT-24.1* PTT-74.4* INR(PT)-2.3*
CHEM
[**2201-3-7**] 08:10AM BLOOD Glucose-198* UreaN-16 Creat-1.4* Na-138
K-4.9 Cl-104 HCO3-21* AnGap-18
[**2201-3-8**] 03:54AM BLOOD Glucose-479* UreaN-31* Creat-3.7*# Na-135
K-6.0* Cl-102 HCO3-12* AnGap-27*
CARDIAC
[**2201-3-7**] 08:10AM BLOOD CK-MB-17* MB Indx-6.6* cTropnT-0.07*
[**2201-3-7**] 03:00PM BLOOD CK-MB-GREATER TH cTropnT-22.9*
[**2201-3-7**] 10:01PM BLOOD CK-MB->500
[**2201-3-7**] 03:00PM BLOOD ALT-255* AST-864* CK(CPK)-[**Numeric Identifier 85991**]*
AlkPhos-78 TotBili-1.1
[**2201-3-7**] 10:01PM BLOOD CK(CPK)-[**Numeric Identifier **]*
[**2201-3-8**] 03:54AM BLOOD CK(CPK)-[**Numeric Identifier 85992**]*
ABG
[**2201-3-7**] 08:28AM BLOOD Type-ART pO2-68* pCO2-38 pH-7.29*
calTCO2-19* Base XS--7 Intubat-NOT INTUBA
[**2201-3-7**] 09:28AM BLOOD Type-ART pO2-236* pCO2-52* pH-6.96*
calTCO2-13* Base XS--21 Intubat-INTUBATED Vent-CONTROLLED
[**2201-3-8**] 04:07AM BLOOD Type-ART pO2-117* pCO2-34* pH-7.19*
calTCO2-14* Base XS--14
Brief Hospital Course:
Pt arrived in cardiogenic shock requiring escalating doses of
pressors (dopa, levo and vasopressin). He had an impella placed.
His wife flew in from PA.
A family meeting was held where goals were outlined. The wife
was clear that the patient would not want to live on a
ventillator; she and her children agreed that we would try to
support him and see if he could turn around.
Mr. [**Known lastname **] was anuric, profoundly acidemic, febrile to 104; he
had ischemic digits and his backside was entirely unperfused. He
was in lactic adisosis and diabetic ketoacidosis. His rhythm was
a sinus tachycardia to 150, later in RBBB and when most
acidotic, a ventricular/junctional rhythm. He was dependent on
122 units/hour insulin and a bicarb drip with regular boluses.
He had three seperate blood draws with MB fractions greater than
500.
As his rhythm deteriorated, with his wife in the room, a
decision was reached to withdraw care. His children gave their
farewells and his pressors were stopped. He passed immediately
thereafter.
Medications on Admission:
unknown
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2201-3-8**]
|
[
"51881",
"41401",
"V4582",
"2724",
"4019"
] |
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