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Admission Date: [**2154-2-26**] Discharge Date: [**2154-3-1**]
Date of Birth: [**2084-3-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Aleve
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD with APC of angioectasias
Hemodialysis
History of Present Illness:
(Amended ICU admission HPI)
..
Ms. [**Known lastname 13224**] is a 69yo F with ESRD on HD, CAD, DM, HTN, CHF (EF
60-70%, 3+ MR) and GAVE who presents following an episode of
hematemesis and maroon stools at home. She was recently admitted
to [**Hospital1 18**] [**2-17**] - [**2-22**] after developing "dark" BM that were guaiac
positive. At that time, she was found to be more anemic than
usual and was given IVF and 2u pRBC in the ER, after which she
developed flash pulmonary edema and required intubation and a
short stay in the MICU. She was then scoped and underwent an
Argon plasma coagulation procedure after which she did very
well. Hct upon d/c on [**2-22**] was 31%. At that time, the plan per
GI was to repeat EGD on [**2154-3-7**]. Of note, during her last
hospital stay, she was noted to have lateral TW depressions and
+ troponins which were felt to be due to demand ischemia.
..
Reports that she felt well after discharge until this past
Monday ([**2-25**]), when she reports she had to be taken off of her
dialysis treatment b/c she didn't feel well. She states that she
first felt tingling and pain in her fingers and toes, to the
point where she was unable to put her feet on the ground. She
felt generally weak and tired following dialysis and needed to
be assisted back to her apartment. She spent the evening and
most of the next morning in bed. Her nurse came to assist her
the next day and offered her an oxycodone which she took, but
then vomited what she described as brown liquid w/ white specks
in it. No nausea prior to her vomiting. Her nurse said that it
looked like blood, but denied that it was coffee ground emesis.
After vomiting, Ms. [**Known lastname 13224**] immediately felt better. The nurse
then called the pt's PCP who advised the pt to come to the ER.
15-20 mins later, Ms. [**Known lastname 13224**] then felt the sudden urge to have a
BM and had a liquid maroon stool which was guaiac positive. She
denies any abdominal pain associated w/ the BM. At that point,
EMS arrived and transported her to the ER. On ROS, Ms. [**Known lastname 13224**] [**Last Name (Titles) 13230**]d any lightheadedness, dizziness, CP, SOB, or diaphoresis.
+ persistent burping, but that has actually decreased in
frequency since her last admission. Between her last discharge
and now, she had been eating normally and having normal brown,
formed stools. She has never had an episode of hematemesis
before.
..
In the ED, she was tachycardic but normotensive. Her NG lavage
showed brown fluid that cleared with 200 cc and her rectal exam
revealed guaiac negative brown stool. Her Hct on admsiion was
38% and she received lL of NS and 1u pRBCs. She also received
Anzemet 12.5 mg IV X 1 and pantoprazole 40 mg IV X 1. She was
evaluated by GI and taken for an EGD which showed findings c/w
GAVE. Her angiodysplasias were coagulated w/ an argon laser and
the pt was transfered to the [**Hospital Unit Name 153**] for monitoring of fluid status
and serial Hct's. She remained hemodynamically stable in the
[**Hospital Unit Name 153**] w/o any further episodes of hematemesis or melena, and her
Hct remained stable, so she was transferred to the medical floor
for futher monitoring.
.
Past Medical History:
1. DM type II - c/b nephropathy and neuropathy
2. ESRD - on HD since [**11-30**]
3. CAD - suspected by stress test ([**Doctor Last Name 4001**]) in [**2153-5-22**]: Mild
global hypokinesis. LVEF 43%. Normal myocardial perfusion at the
level of stress achieved.
4. CHF: TTE [**2153-11-1**] showed LVEF 60-70% with 3+ MR and 2+ TR
5. Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB)
- colonoscopy on [**2153-8-7**] -> two nonbleeding polyps in sigmoid
- EGD [**2153-8-7**] -> sig for erythema, edema, and erosion in the
antrum c/w gastritis in addition to erythema in the proximal
bulb c/w duodenitis
- EGD [**12-31**] demonstated GAVE
6. Occult GI bleed [**7-/2153**] with studies as above
7. Gout
Social History:
Pt lives alone in an [**Hospital3 **] community. She has a
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 13222**]. Son lives close by and helps
mother. [**Name (NI) **] ETOH, tobacco, or drugs.
Family History:
[**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. She has no
family history of CAD.
Physical Exam:
PE (on transfer to the floor):
VS: Tm + Tc 98.9, BP 118/62 (127-147/51-101), HR 88 (94-110), RR
20, sats 98% on RA
FS 57
I/O: none recorded yet
GEN: Pleasant, elderly AfAm female in NAD. Moving around bed
very comfortably.
HEENT: NCAT, sclera anicteric, PERRL, EOMI. MMM w/ thrush on
tongue, improved since last admission. Has dark circles around
her eyes, nonpuffy.
NECK: Neck supple, no JVD.
CV: RR, normal S1, S2. III/VI soft systolic murmur heard at
RUSB, II/VI holosystolic murmur heard at LLSB.
CHEST: CTAB, except for few crackles at bases bilaterally.
ABD: Soft, protuberant abdomen, no fluid wave, no ascites; + BS;
obvious ventral hernia, otherwise no masses; no hepatomegaly.
EXT: 2+ radial/PT pulses bilaterally. At tips of index fingers
bilaterally, skin is cool, [**Doctor Last Name 352**]. R index finger has ? necrotic
vs. blood blister on tip. Nontender. No edema. Skin dry, warm,
wrinkled.
NEURO: CN II-XII grossly intact.
Pertinent Results:
Labs on admission:
WBC 7.8, Hct 38.5, MCV 94, Plt 229
(DIFF: Neuts-89.1* Bands-0 Lymphs-7.2* Monos-2.4 Eos-1.2
Baso-0.1)
PT 12.2, PTT 27.1, INR 1.0
Na 139, K 4.9, Cl 98, HCO3 23, BUN 53, Cr 5.9
.
Labs on discharge:
WBC 7.7, Hct 33.5, MCV 93, Plt 239
PT 12.2, PTT 29.8, INR 1.0
Na 139, K 3.9, Cl 104, HCO3 24, BUN 33, Cr 5.0, Glu 78
Calcium 8.1, Phos 3.1, Mg 1.7
calTIBC 161, Ferritin 437, TRF 124*
PTH 81*
.
Urinalysis:
[**2154-2-26**] 08:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-15
Bilirub-SM Urobiln-NEG pH-8.0 Leuks-NEG RBC-0-2 WBC-[**5-4**]*
Bacteri-FEW Yeast-NONE Epi-[**10-14**]
.
Micro:
none
.
Imaging:
EGD [**2154-2-21**]:
- Normal esophagus.
- Stomach: Flat Lesions Multiple angiodysplasias/watermelon
stomach was seen in the antrum compatible with GAVE. An
Argon-Plasma Coagulator was applied for hemostasis successfully.
- Duodenum: Angiodysplasias distributed in a linear pattern was
noted in the first part of the duodenum.
- Impression: Watermelon stomach in the antrum, Angiodysplasias
in the first part of the duodenum, Otherwise normal egd to
second part of the duodenum
.
CXR [**2154-2-26**]: No evidence of CHF or other acute cardiopulmonary
process.
.
EGD [**2154-2-27**]:
Mild erythema in the first part of the duodenum
Angioectasia in the antrum
Erosion in the cardia
Otherwise normal egd to second part of the duodenum
..
Brief Hospital Course:
69yo F with ESRD on HD, CAD, DM, HTN, CHF and h/o UGIB/GAVE, now
presenting with hematemesis and melena.
.
# UGIB: Her NG lavage in the ER was positive, but cleared with
200cc. She was placed on protonix IV for UGIB and 2 large bore
IVs were placed. She was given 1L NS as well as 1u pRBCs. An EGD
was performed which showed bleeding in gastric antrum, likely
due to GAVE. The angioectasias were cauterized with Argon laser
and she had no further episodes of bleeding. Her Hct remained
stable at 36. She was discharged with plans for a repeat
elective EGD and Argon laser cauterization on [**2154-3-7**].
.
# THRUSH: Ms. [**Known lastname 13224**] has thrush, but it appeared improved since
her last hospitalization. She was continued on nystatin swish
and swallow.
.
# CAD: Ms. [**Known lastname 13224**] [**Last Name (Titles) 13231**] has CAD, given that she had a stress
MIBI that showed EKG changes but no perfusion defects at normal
workload. She has no h/o of MI, but does have elevated troponins
at baseline. During her last admission, she experienced lateral
TW depressions as well as a troponin leak felt to be due to
demand ischemia. She was continued on a beta-blocker and statin,
but was not given an aspirin due to her UGIB.
.
# CHF: Her CHF appeared stable during this admission. She had
crackles at her L lung base on exam but no shortness of breath
or hypoxia. She was continued on her regular HD schedule and her
volume status was managed by renal. The team discussed whether
an ACE-inhibitor would be beneficial in her, but it was
discontinued for unclear reasons in [**2145**]. The team decided to
defer this decision to her PCP.
.
# DM II: Her fingersticks were monitored QID and she originally
was on her regular glipizde dose as well as a regular insulin
sliding scale for additional coverage. However, she actually was
hypoglycemic and her glipizide does was held. She was not put on
glipizide upon discharge, as she continued to be hypoglycemic.
.
# ESRD: Ms. [**Known lastname 13224**] has been receiving HD since [**2153-11-25**]. She
was continued on HD per her regular M/W/F schedule. Renal
consulted on her while she was in-house. She was continued on
phoslo and nephrocaps daily.
.
# GOUT: She was continued on allopurinol.
.
# FINGER LESIONS: It was noted prior to discharge that Ms.
[**Known lastname 13224**] has some lesions on the tips of her fingers. Our
differential diagnosis included gout (less likely given
appearance, lack of warmth or effusion), vascular (though has
strong bilateral radial pulses), or a CTD (like lupus or
Raynaud's, though unusual to present for first time at her age).
Further workup was deferred to the outpatient setting as it was
not acute, per the patient.
.
# FEN: She was given a regular [**Doctor First Name **] diet. No IVF were needed. Her
electrolytes were checked daily and were repleted to keep K>4,
Mg>2.
.
# PPX: She was given a PPI for GI prophylaxis, pneumoboots for
DVT ppx, and a bowel regimen to prevent constipation.
.
# ACCESS: Peripheral IV
.
# COMM: with her son, [**Name (NI) **] at #[**Telephone/Fax (1) 13227**]
.
# DISPO: To home with services.
Medications on Admission:
Allopurinol 100 mg PO QD
Atorvastatin 80 mg PO QD
Toprol XL 50mg PO QD
Nystatin 100,000 unit/mL Suspension 10 ML PO QID
Protonix 40mg PO QD
Glipizide 2.5mg PO QD
PhosLo 667mg PO TID
Folic Acid 1mg PO QD
Multivitamin 1 tab PO QD
Vitamin B Complex 1 tab PO QD
Colace 100mg PO BID
Senna 8.6mg PO BID
Tylenol 325-650 PO Q4-6 prn
Oxycodone 5mg PO Q6 prn
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
1. GIB
.
Secondary diagnosis:
1. ESRD on HD
2. Diabetes
3. HTN
Discharge Condition:
Afebrile, Hct stable, BP stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 L
.
Please call your PCP or go to the nearest ER if you develop any
of the following symptoms: fever, chills, chest pain, dizziness,
lightheadhedness, dark, tarry or bloody stools, burning on
urination, abdominal pain or tenderness, or any other worrisome
symptoms.
.
You should take all your medications as prescribed. The only
change in your medications is to take Toprol XL 50mg daily.
.
You should follow-up with the GI department as previously
scheduled for a repeat EGD on [**2154-3-7**].
.
Please have a hematocrit (a measure of your red blood cells)
checked at each hemodialysis session. Per your GI doctors, you
should be transfused for any hematocrit less than 25.
Followup Instructions:
Already scheduled:
Provider: [**Name10 (NameIs) 13228**] [**Name11 (NameIs) 13229**], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2154-3-5**] 12:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2154-3-7**] 8:00
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2154-3-7**] 8:00
.
Please call your PCP [**Last Name (NamePattern4) **] [**11-26**] weeks for f/u from this admission.
.
Please continue dialysis as reccomended by your nephrologist.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
"40391",
"4280"
] |
Admission Date: [**2178-4-1**] Discharge Date: [**2178-4-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84F w/ reported history of COPD, metastatic cancer, and HTN
initially sent to the [**Hospital Unit Name 153**] for evaluation of hypoxia. She was in
her USOH and residing at [**Hospital3 2558**] when transferred for
evaluation of SOB. EMS reported elevated neck veins, blood
pressure of 90/palp and tachypnea w/ sats of 82 on unclear fio2
([**Name2 (NI) 597**]).
.
In ED, she was found to have rectal temp of 101.2, bp 94/71, and
was tachypneic to the 30's while satting 99% on [**Name2 (NI) 597**]. Per
report, she at this time had rales, coarse breath sounds, and
elevated neck veins. She received nebulizers, levaquin, and
solumedrol for ?copd excerbation and ?pna. Initial CXR
demonstrated marked scoliosis but no infiltrate and her chest
CTA was negative for PE but notable for chronic intersitial
changes and ?ingested pill. Her initial labs were notable for
leukocytosis to 14K w/ left shift and mild bandemia, flat
enzymes, and BNP of 1133. Her UA was also suggestive for UTI.
Given the concerns about CHF and rales on exam, she received 20
iv lasix. Overall, through her ER course she received 600 cc
IVF and made 600 cc urine. An ABG checked on presumed [**Name2 (NI) 597**] was
7.38/44/209 with a lacate of 2.6. She was transferred to [**Hospital Unit Name 153**]
for further monitoring.
.
Pt not completely sure why she was transferred to hospital
although she admits to productive pinkish cough of unclear
duration. No definite increased sob or wheezing. No cp/abdominal
pain. No fevers, chills. No changes to bowel/urinary habits.
.
Overnight in the [**Hospital Unit Name 153**], the patient was treated with
levaquin/flagyl but this was changed to unasyn when she was
thought to be at risk for an aspiration event. She remained
afebrile on this regimen overnight. Her mental status cleared
per report and she tolerated PO intake this AM w/out signs of
overt aspiration. She also had several episodes of tachycardia
c/w MAT and received several fluid boluses and a 1x order of
metoprolol. By the time of call-out, she was satting in the high
90s w/ only a 3L NC.
Past Medical History:
1. COPD
2. ?asthma
3. HTN
4. Breast cancer treated at [**Hospital1 2025**] in '80s
5. Metastatic cancer of unclear etiology ?NSCLC per primary
6. kyphoscoliosis
7. s/p pacemaker that was removed, not replaced
8. ?tremor
9. ?CAD
10. sacral decub
Social History:
living at [**Hospital3 2558**], former heavy tobacco
PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] [**Telephone/Fax (1) 59410**], beeper [**Telephone/Fax (1) 103231**]
Contact [**Name (NI) **] (son) [**Telephone/Fax (3) 103232**]
Family History:
n/c
Physical Exam:
97.8 112/50 113 21 100% shovel mask
gen: cachexic elderly female lying in bed, tremulous, oriented
to hospital and the 17th, tachypneic but comfortable
heent: pupils min reactive, eomi, arcus senilus, dry mm, poor
dentition, unable to appreciate jvp
cv: faint heart sounds, s1, s2 tachy but regular, no mrg
appreciated
pulm: poor effot, ?left apical inspiratory crackles, o/w w/
decreased bs, no wheezing
abd: no scars, soft, ntnd, no cvat
ext: mild decreased skin turgor, no edema
Pertinent Results:
ECG: ST at 127, axis 30, qt 360, low limb voltage, [**Last Name (un) **], early
rwave repolarization, Q3, 1mm ST depressions in v4-v6
.
CTA:
1. No PE.
2. Emphysema and chronic interstitial changes.
3. Ovoid high-density focus in the upper esophagus, which may
represent an ingested pill.
.
CXR: There is a new congestive heart failure and Left lower lobe
linear scarring.
.
LABS on admission:
WBC-14.6*
HCT-43.2 MCV-96
NEUTS-87* BANDS-5 LYMPHS-5* MONOS-3 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0
PLT COUNT-411
.
GLUCOSE-127*
UREA N-14
CREAT-0.5
SODIUM-136
POTASSIUM-5.0
CHLORIDE-100
TOTAL CO2-24
CALCIUM-9.3
PHOSPHATE-3.9
MAGNESIUM-1.8
LACTATE-2.6*
Brief Hospital Course:
A/P: 84F w/ reported history of COPD, CAD, and metastatic cancer
now being evaluated for reported hypoxic resp distress
1. Resp Distress: The patient was sent to the [**Hospital Unit Name 153**] secondary to
hypoxia in the ED requiring a [**Hospital Unit Name 597**]. She was treated empirically
in the ED with lasix for ? CHF, steroids/abx/nebs for ? COPD,
and antibiotics for a ? PNA. She was r/o for PE with a CTA. In
the [**Hospital Unit Name 153**], she was quickly weaned to a nasal canula and continued
on her nebulizer treatments. On the floor, she was afebrile and
w/out definitive evidence of a pneumonia but her antibiotics
were continued empirically. She was continued on her nebulizers
and weaned to RA prior to discharge.
2. Tachycardia: In the [**Hospital Unit Name 153**], the patient was noted to be
tachycardic to the 130s while remaining hemodynamically stable.
Her EKG was c/w sinus tach vs MAT. The patient denied pain but
was mildly febrile at the time. SHe was started on a low dose
betablocker and fluid repleted as she appeared dry on physical
exam. On the floor, she had a recurrence of the same rhythm but
responded well to fluid boluses. Her antibiotics and beta
blocker were continued. She was in NSR with a regular rate at
the time of discharge.
3. UTI: The patient had a dirty UA in the ED and was treated for
this with levaquin. She remained afebrile on the floor and will
complete a 7d course at her facility.
4. ?CAD: She was continued on asa and a low dose bb was started
as above.
5. HTN: Beta blocker was used as above.
6. COPD: management as above
7. ?Metastatic cancer: Per conversations with the son, the
patient has had a work-up at [**Hospital1 2177**] where she was found to have
extensive bony metastases as well as a skull mets w/ ? extention
into the brain. She was given decadron at [**Hospital1 2177**] and offered more
aggressive treatment but became acutely psychotic while on the
steroids and she and her son decided to avoid further treatment
of her malignancy. The patient has a history of breast cancer
that was treated and is presumed to have metastatic disease now
[**12-18**] that primary but no definitive w/u has been done because of
her unwillingness to undergo treatment. She was continued on
her outpatient fentanyl patch for pain control and noted good
relief with this regimen.
8. ?Altered MS: As above, the patient's son notes that she
"hasn't been herself" since she received steroid therapy at [**Hospital1 2177**].
At [**Hospital1 18**], the patient was pleasant and cooperative but not
oriented. This was partially attributed to her underlying UTI
and she was treated as above. There is a question of extension
of her cancer into her brain but this was not worked up.
0. CODE: DNR/DNI in chart
Medications on Admission:
Fentanyl 50 q 72
omeprazole 20 qd
spiriva 18 qd
spironolactone 25 qd
metoprolol 12.5 [**Hospital1 **]
advair 100/50 [**Hospital1 **]
colace
acetaminophen
mvi qd
trazadone 25 qhs
zinc sulfate 220 qd
asa 81 qd
?hctz 25 qd
Discharge Medications:
1. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule inhaled Inhalation once a day.
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
10. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): last day [**4-10**].
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Community Acquired Pneumonia
2. Urinary tract Infection
3. multifocal atrial tachycardia
4. Metastatic Cancer, unknown primary
5. Altered Mental Status
Secondary Diagnosis:
1. COPD
2. Hypertension
3. Breast cancer s/p XRT in [**2151**]
Discharge Condition:
good, mental status at baseline, afebrile
Discharge Instructions:
Please take all medications as prescribed. You were diagnosed
with pneumonia and urinary tract infection and you should take
Levaquin for a 10-day course, last day is [**4-10**].
Call your PCP or come to the ER if you experience any of the
following symptoms: chest pain, shortness of breath, fevers,
chills, painful urination or anything else that concerns you
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 4223**] in the next few
weeks. Call [**Telephone/Fax (1) 59410**] to make this appointment
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2178-6-12**]
|
[
"486",
"5990",
"4019",
"42789"
] |
Admission Date: [**2186-6-14**] Discharge Date: [**2186-6-19**]
Date of Birth: [**2109-6-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 yo M w/ h/o DM, HTN, hypercholesterolemia, NSCLC s/p
resection, progressive on multiple chemo regimen, presents to
the ED with 3 days of worsening N/V/D, found to be fevebrile,
hypotensive, hypoxemic. On [**6-8**] c1w2 of taxotere (3wks on 1wk
off). Tolerated well until 3 days ago when he developed
non-bloody diarrhea after he went out to eat at a restaurant. He
called the fellow on call and was given imodium which he [**Last Name (un) **] w/o
significant relief. Today, pt's wife called to inform Heme/Onc
fellow that Mr. [**Known lastname **] is having n/v, and now unable to keep down
PO fluids. He also c/o chills. Pt was referred to ED for further
evaluation. He reports 4 episodes of non-bilious non-bloody
vomiting today. He denies abdominal pain. + chills
.
In the ED, initial VS T 102.1, HR 102; BP 133/52; RR 20; 93% RA.
He then became hypoxic to 88% (baseline 92%) and hypotensive
with systolic BP in upper 80's/low 90's, blood gas concerning
with 7.37/34/63. Lactate 1.2. Labs remarkable for K 5.6, pt was
given kayexalate. WBC 3.9 (46% neutrophils), Hct 35.6 (down from
40.2 in [**4-1**]). U/A negative, BCx and UCx sent. CXR with interval
progression of NSCLC in the right upper and left lower lobes
with larger more dense masses. Otherwise, relatively stable. The
patient was given Cefepime 2 gm IV once, Zofran, Tylenol,
kayexalate, and given total of 5L NS.
.
The patient currently is asymptomatic. Denies any trouble
breathing. Denies LH or dizziness. Reports normal urine output
at home.
Past Medical History:
- NSCLC: s/p right upper and middle lobectomy ([**11-27**]) and wedge
resection of the left lower lobe([**3-30**]) lung nodule, recurrent
[**2-27**], s/p protocol with Navelbine and Cetuximab, started [**5-30**],
completed 6 cycles by [**10-30**]. Given dz progression started on
tarceva d/c'd in [**12-31**] due to further dz progression.
Subsequently had 2 cycles Alimta, oxaliplatin, and Avastin but
again had dz progression on imaging. ECOG protocol 2501 with
sorafenib started 03/[**2184**].
- Diabetes mellitus type 2
- Hypertension
- Hyperlipidemia
Social History:
He is a retired automotive mechanic and has
taught most recently automotive repair. He is married with one
child. He is a 50-pack-year smoker but quit approximately 35
years ago. He uses alcohol on an irregular basis but has never
drunken to excess.
Family History:
Unremarkable for malignancy but he has a
significant history of cerebrovascular and coronary artery
disease among his relatives.
Physical Exam:
VS: T 97.2; BP 109/52; HR 89; RR 20: sat 89-91 % on 4L NC
Gen - Alert, no acute distress, breathing comfortably
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes slightly dry, no lesions
Neck - no JVD, no cervical lymphadenopathy
Chest - Coarse BS bilaterally, rhonchi, decreased BS LLB, +
expiratory wheezes
CV - regular, nl S1/S2, no murmurs, rubs, or gallops
Abd - Soft, obese, nontender, nondistended, with normoactive
bowel sounds
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**2-6**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Rectal - brown; strongly guaiac positive
Pertinent Results:
[**2186-6-14**]. CTA. IMPRESSION: No filling defect is identified
within the pulmonary arteries to suggest pulmonary embolus.
Again seen are multifocal consolidations throughout bilateral
lungs, corresponding to known bronchioalveolar cell carcinoma.
Compared to the prior CT from [**2186-5-15**], there is dramatic
increase in the extent and the density of the consolidation
which is concerning for significant short-term disease
progression versus superimposed infection.
Brief Hospital Course:
In summary, Mr. [**Known lastname **] is a 76 year old male with NSCLC who was
admitted for post-obstructive pneumonia and dehydration
secondary to diarrhea from chemotherapy.
.
Post Obstructive PNA. Mr. [**Known lastname **] was initially treated in the
MICU, but was then transferred to OMED. He was treated for
pneumonia with Unasyn in the hospital and was sent home on
Augmentin. He was requiring 5L NC of oxygen during the
hospitalization, which was thought to be due to lung cancer,
pneumonia and pulmonary edema after geting 5L of fluid in the
MICU. His oxygen requirments improved with lasix. By
discharge, he was requiring only 2LNC of oxygen.
.
Diarrhea. He was initially admitted with diarrhea, thought to
be due to chemotherapy. He was treated with IVF in the MICU.
His diarrhea resolved without intervention.
.
In addition, he was treated with ISS for type II DM, HCTZ,
Verpamil and Lisinopril for HTN (one hypotension from diarrhea
resolved), and Lovastatin for Hyperlipidemia.
Medications on Admission:
glucophage 1000 mg po bid start [**2179**]
Glipizide 10 mg po bid start [**2179**]
Actos 30mg po daily(changed by his PCP in [**Month (only) **] from 15mg)
Verapamil sr 240mg po daily start [**2173**]
Lisinopril 40 mg po daily
Lovastin 10mg po daily start [**2182**]
Prilosec 20mg po daily
Vitamin C 100u po daily start [**2173**]
Multivitamin po daily start [**2173**]
Hydrochlorothiazide 25mg po daily
Reglan for nausea prn d/c'ed [**2186-2-22**]
Immodium 1-2 tabs po, prn for diarrhea ended [**2186-3-27**]
Gas-X 40 mg po every 6 hours, prn start [**2186-2-22**] ended [**2186-3-27**]
Immodium with Gas-X 1-2 tabs po qid, prn start [**2186-3-28**]
Naproxen 1-2 tabs po qid, prn
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Augmentin XR 1,000-62.5 mg Tablet Sustained Release 12 hr
Sig: Two (2) Tablet Sustained Release 12 hr PO twice a day for 4
days.
Disp:*16 Tablet Sustained Release 12 hr(s)* Refills:*0*
8. Oxygen
Home Oxygen at 2 LPM continuous via nasal cannula conserving
device for portability.
9. Nebulizer
Home nebulizer and supplies.
10. Albuterol-Ipratropium 2.5-0.5 mg/3 mL Solution Sig: One (1)
Inhalation every 6-8 hours as needed for shortness of breath or
wheezing.
Disp:*60 Treatments* Refills:*0*
11. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6549**]
Discharge Diagnosis:
Primary:
- Non small cell lung cancer
- Post-obstructive pneumonia
- Sepsis
Secondary:
- Diabetes mellitus type 2
- Hypertension
- Hyperlipidemia
Discharge Condition:
Stable, requiring oxygen by nasal canula at 2 liters per minute,
ambulating
Discharge Instructions:
You were treated for a pneumonia. Please continue your
antibiotics, Augmentin for four days. Please measure
fingersticks twice daily, and call your doctor if it is greater
than 400. You should contact your primary care physician about
restarting your Actos once your edema is resolved.
.
Please return to the hospital or see your primary care physician
if you have any shortness of breath, fevers, chills or any other
concerns.
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Dr.[**Name (NI) 3279**] office will call you about the
timing of the appointment on Thursday.
.
Please also notify your primary care physician about your
admission to the hospital. You should contact your primary care
physician about restarting your Actos once your edema is
resolved.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"5849",
"25000",
"4019",
"2724"
] |
Admission Date: [**2118-5-14**] Discharge Date: [**2118-5-25**]
Date of Birth: [**2058-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
fevers, hypotension
Major Surgical or Invasive Procedure:
Femoral HD line removal
Temporary femoral HD line placement
Temporary femoral HD line removal
Femoral HD line placement
History of Present Illness:
59M with MMP including ESRD on HD, h/o recurrent line infection
with current femoral tunneled catheter in place, now admitted
with fevers from HD unit. Pt was feeling well until [**5-14**]
morning, when he developed rigors during dialysis-- he was found
to have a fever, and was subsequently given one dose of
vancomycin and gentamicin, and brought to the ED. Of note, pt's
usual HD schedule in MWF, but was changed to T/Th/Sat this week
due to death of his father last week.
.
In [**Name (NI) **], pt was febrile to 103.5, with HR 104, BP 120s/60s.
Bladder scan showed urine in bladder, but ISC unsuccessful. When
seen on the floor early this morning, pt was sleepy and only
awoke for few seconds, then fell asleep again. Unable to obtain
complete history from patient due to somnolence.
.
Of note, pt has had multiple admissions for MSSA line sepsis,
most recently in [**2117-12-24**], during which time a femoral
catheter was removed and replaced in the R groin. He completed a
course of cefazolin in [**Month (only) **], and was seen by ID at that time.
Past Medical History:
- MSSA HD line infection with septic lung emboli [**9-1**] with left
pleural effusion
- h/o Hepatitis B, treated
- Non-ischemic cardiomyopathy, last EF 40-45%
- MI [**2086**] per pt
- CVA [**2086**] per pt (?residual LE weakness)
- ESRD on hemodialysis [**1-25**] HTN. Currently dialyzed through R
femoral line. EDW 80 kg as of [**2118-1-3**].
- Multiple thrombectomies in LUE and R thigh AV fistula
- Graft excision for infected thigh graft [**2117-5-26**]
- Seizure disorder since mid [**2097**] after starting dialysis
- Hungry bone syndrome status post parathyroidectomy
- Pituitary mass
- Anemia of chronic disease
- s/p PEG tube placement [**2117-10-29**]
Social History:
Has 2 PhDs in History and likes to be called "Dr. [**Known lastname 2026**]" only.
Says he walks with a walker at baseline. Says he has no family
that he would like called in case of emergency. Father recently
passed away.
Tobacco - Denies
EtOH - Reports occasional use, but drinks vodka when he does
drink
Illicit drugs - Denies
Family History:
Father - DM
Mother - Deceased age 41 of renal failure
One son - healthy
Physical Exam:
Physical Exam:
General: African American Male lying flat in bed in NAD
HEENT: Sclera anicteric, dryMM, EOMI
Neck: supple, JVP not elevated
Lungs: CTAB
CV: RRR, [**1-29**] SM in axilla, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
back: No ulcers
Ext: AV fistulas both arms, no edema in lower extremities, 2+ DP
pulse bilaterally, fem HD line in place with clean dressing.
NEURO: A+OX3
.
Pertinent Results:
Labs on admission:
CBC
[**2118-5-14**] 05:35PM BLOOD WBC-7.6 RBC-4.87# Hgb-12.2*# Hct-40.3#
MCV-83 MCH-25.0* MCHC-30.2* RDW-17.5* Plt Ct-314
[**2118-5-14**] 05:35PM BLOOD Neuts-84.0* Lymphs-10.5* Monos-3.7
Eos-1.6 Baso-0.4
BMP
[**2118-5-14**] 05:35PM BLOOD Glucose-104* UreaN-41* Creat-6.8* Na-143
K-5.3* Cl-99 HCO3-28 AnGap-21*
LFTs
[**2118-5-14**] 05:35PM BLOOD ALT-39 AST-35 AlkPhos-125 TotBili-0.5
[**2118-5-14**] 05:35PM BLOOD Lipase-66*
Other chemistry
[**2118-5-15**] 05:57AM BLOOD Genta-2.4*
[**2118-5-16**] 03:56AM BLOOD Type-[**Last Name (un) **] pO2-150* pCO2-41 pH-7.38
calTCO2-25 Base XS-0
[**2118-5-14**] 05:35PM BLOOD Lactate-2.0
[**2118-5-16**] 03:56AM BLOOD Lactate-0.8
==================================================
Chest X ray [**2118-5-14**]:
The lungs are low in volume with minimal atelactasis in both
lung bases. The
cardiac silhouette is top normal. The mediastinal silhouette and
hilar
contours are normal. There are small bilateral pleural
effusions. There is a
healed rib fracture on the right.
IMPRESSION:
Small bilateral pleural effusions.
[**2118-5-16**] TTecho:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild to moderate regional left ventricular systolic dysfunction
with near akinesis of the inferior wall and inferior septum and
moderate hypokinesis of the remaining segments (LVEF = 30 %).
The estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2118-1-6**],
the findings are similar (LVEF was overestimated on the prior
study)
[**2118-5-19**] TEecho:
No atrial septal defect is seen by 2D or color Doppler. There is
moderate regional left ventricular systolic dysfunction (EF
30-35%) with inferoseptal wall akinesis and inferior wall
hypokinesis. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. There are filamentous strands on the aortic leaflets
consistent with Lambl's excresences (normal variant). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve.
IMPRESSION: No evidence for valvular vegetation, abscess or
mass. Moderate left ventricular systolic dysfunction. Mild
mitral regurgitation
Radiology Report US EXTREMITY NONVASCULAR RIGHT Study Date of
[**2118-5-16**]
FINDINGS: Transverse and sagittal images of bilateral upper
extremities were obtained. Three nonfunctioning fistula grafts
are identified; one in the right upper arm, one in the left
upper arm, and one in the left forearm. No flow was identified
within these grafts on color Doppler imaging. There is no
subcutaneous fluid collection seen in either arm. No suspicious
soft tissue mass is identified.
IMPRESSION: No collection identified in either arm at the sites
of the old
fistula grafts.
=
=
=
=
=
=
=
=
=
=
=
================================================================
Labs at discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2118-5-25**] 06:05 4.9 3.74* 9.2* 31.5* 84 24.5* 29.1* 17.5*
483*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2118-5-25**] 06:05 711 35* 7.4* 138 4.8 97 27 19
Brief Hospital Course:
# MRSA Bacteremia: Blood cultures obtained on [**5-14**] grew MRSA.
The patient was continued on vancomycin by HD protocol. His HD
line was initially retained despite purulence coming from the
catheter site. However, on hospital day # 2 he developed
hypotension in the setting of receiving lisinopril. He was
transferred to the MICU for concern of sepsis. There his BP was
checked in his legs as he had a history of bilateral UE fistulas
and clots, it was much improved to 110-120s. He was however
tachycardic to 120s, and this improved with IVF. He was 4 liters
positive for his MICU stay. On [**5-16**], his femoral line was
removed by IR. ID was consulted and recommended vancomycin, no
gentamycin. A TTE was negative for vegetation, but the patient
was still febrile as high as 104. An U/S of his bilateral old
fistulae was done and showed no abscess or infected clot. A TEE
was later performed and also negative for vegetations. Renal
followed closely and the patient was given a 24 hr line holiday
before placing a temp line for hemodialysis. He was dialyzed
twice before the temp HD catheter was removed. Blood cultures
were still positive after the temp line was placed. He then had
another 72 hr line holiday. Survelence blood cultures remained
negative. His permanent HD line was placed on [**2118-5-24**]. He will
need to continue his course of vancomycin at HD until [**2118-6-15**]
for a total 4 week course. He will need to follow up in [**Hospital **]
clinic on [**2118-6-2**]. He will need weekly CBC and vanc troughs
drawn and sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD at [**Telephone/Fax (1) 1419**].
.
# ESRD: The patient presented from HD. He had hemodialysis
again on [**5-19**] and [**5-20**], then on [**2118-5-24**] after his new line was
placed. His Lanthanum and Sevelamer were continued. He should
continue to have vancomycin dosed with HD until he completes his
course on [**2118-6-15**].
.
# chronic systolic CHF: The patient showed no signs or symptoms
of volume overload. Hew as continued on ASA 81 mg daily and
digoxin 125 mcg Q every other day. His lisinopril was held
given concern for sepsis and hypotension. He should restart his
home dose lisinopril at discharge. He should continue his
schedule of HD.
.
# Social/father death: The patient's father passed away the week
prior to his presentation and the funeral was held in New
Jersey. The patient stated that he did not want to attend the
funeral. Social work was contact[**Name (NI) **].
.
# Hyperkalemia: The patient was noted to be hyperkalemic at
presentation. EKG was unconcerning. His potassium was
monitored. No Kayexalate was administered.
.
# History of seizures: The patient was continued on his home
dose trileptal and Levetericetam
.
# Hepatitis B: Stable. LFTs were not elevated
.
# History of GI bleed: The patient was continued on his home
dose omeprazole
Medications on Admission:
Acetaminophen 650mg q8hr PRN
Allopurinol 150mg QOD
ASA 81 mg daily
Cefazolin 3gm qFriday
Cefazolin 2gm qMon, qWed
Digoxin 0.125mg PO EVERY SUN, TUE, [**Doctor First Name **], SAT
Levetiracetam 500 mg po TID ON HD DAYS M, W, F
Levetiracetam 500 mg PO BID ON NONHD DAYS Tu, Th, Sat, Sun.
Folic Acid 1 mg po daily
Fentanyl 50 mcg/hr Patch 72 hr
Oxcarbazepine 300 mg po tid on non-HD days (Tu, Th, Sat, Sun).
Oxcarbazepine 300 mg po QID on HD days (M-W-F)
Gabapentin 300 mg PO BID
Sevelamer HCl 1600 mg po tid w/ meals
Omeprazole 40 mg po daily
Heparin 5,000u SC TID
Albuterol nebs PRN
Ipratropium nebs PRN
Discharge Medications:
1. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q HD ().
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
15. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
16. Bisacodyl 10 mg Suppository Sig: Ten (10) mg Rectal once a
day as needed for constipation.
17. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
18. Nepro 0.08-1.80 gram-kcal/mL Liquid Sig: Two [**Age over 90 10973**]y
Seven (237) mL PO twice a day.
19. Outpatient Lab Work
Please have a CBC/diff and vanc trough drawn once a week fpr the
next 3 weeks. Please fax these to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD at
[**Telephone/Fax (1) 1419**]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1459**] Care and Rehabilitation Center
Discharge Diagnosis:
MRSA Bacteremia
Sepsis
Hypotension
ESRD on HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a line infection. Your
blood was found to be growing a bacteria called methicillin
resistant Staph. Aureus. You were treated with antibiotics.
Your line was also removed and a new permanent line was placed.
.
Please continue to take vancomycin for a total of 4 weeks,
ending [**6-15**]. You will need to have your blood checked once a
week and send the results to the [**Hospital **] clinic at fax [**Telephone/Fax (1) 1419**].
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
Please follow-up with your appointments as listed below.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: THURSDAY [**2118-6-2**] at 1:50 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
This is a follow up of your hospitalization. You will be
reconnected with your primary infectious disease physician after
this visit.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2118-6-17**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"40391",
"2762",
"4280",
"412",
"2767"
] |
Admission Date: [**2109-10-7**] Discharge Date: [**2109-10-11**]
Date of Birth: [**2041-11-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Asymptomatic with 3 vessel disease
Major Surgical or Invasive Procedure:
[**2109-10-7**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Diag, SVG to OM, SVG to RCA)
History of Present Illness:
67 y/o asymptomatic male with complex PMH who had a positive
stress test and then referred for cardiac cath. Cath revealed
severe three vessel disease and he was then referred for
surgical revascularization.
Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Hypertension, Hyperlipidemia, Diabetes Mellitus, Peripheral
Vascular Disease, Carotid Artery Disease s/p Left CEA, h/o
Shingles, Left shoulder tendenitis, HOH, s/p Tonsillectomy, s/p
Right hand treatment Dupuytren's contractures
Social History:
Quit smoking [**2098**] after 1.5ppd x 38 yrs. Admits to couple ETOH
drinks/wk.
Family History:
Brother s/p CABG at 50.
Physical Exam:
Admission
VS: 65 20 129/64 Ht5'6" Wt162lbs
Gen: WDWN male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM -JVD
Chest: CTAB
Heart: RRR
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Discharge
VS T 98 HR 74 SR BP 115/58 RR 18 O2sat 95%-RA WT 77.2K
Gen NAD
Neuro nonfocal exam
Pulm CTA-bilat
CV RRR, mo murmur. Sternum stable, incision CDI
Abdm soft, NT/+BS
Ext warm, well perfused. Trace pedal edema bilat
Pertinent Results:
[**2109-10-7**] Echo: PRE BYPASS: The left atrium is normal in 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 thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the aortic arch.
There are complex (>4mm) atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Physiologic mitral regurgitation
is seen (within normal limits). There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS: Normal right ventricular systolic function. The
left ventricle displays very mild mid and distal lateral wall
hypokinesis with preserved overall systolic function. The
tricuspid regurgitation may be slightly worse. The thoracic
aorta appears unchanged.
[**2109-10-7**] 11:25AM BLOOD WBC-13.0*# RBC-2.88*# Hgb-9.0*#
Hct-25.1*# MCV-88 MCH-31.3 MCHC-35.8* RDW-13.6 Plt Ct-197
[**2109-10-7**] 12:00PM BLOOD PT-14.8* PTT-31.3 INR(PT)-1.3*
[**2109-10-7**] 11:25AM BLOOD Plt Smr-NORMAL Plt Ct-197
[**2109-10-7**] 12:00PM BLOOD UreaN-19 Creat-1.0 Cl-111* HCO3-28
[**2109-10-7**] 05:27PM BLOOD K-4.7
[**2109-10-7**] 08:03AM BLOOD Glucose-230* Lactate-1.3 Na-138 K-4.0
Cl-105
[**2109-10-9**] 05:30AM BLOOD WBC-8.7 RBC-3.22* Hgb-10.4* Hct-28.0*
MCV-87 MCH-32.4* MCHC-37.2* RDW-14.2 Plt Ct-161
[**2109-10-9**] 05:30AM BLOOD Plt Ct-161
[**2109-10-10**] 06:00AM BLOOD Glucose-148* UreaN-21* Creat-1.3* Na-133
K-3.8 Cl-97 HCO3-32 AnGap-8
[**2109-9-30**]
09:15a
Other Blood Chemistry:
%HbA1c: 7.8
Radiology Report CHEST (PA & LAT) Study Date of [**2109-10-10**] 8:57 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 61501**]
Reason: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT
/SDA
[**Hospital 93**] MEDICAL CONDITION:
67 year old man s/p cabg
REASON FOR THIS EXAMINATION:
?? ptx- apical on cxr [**10-9**]
Preliminary Report !! PFI !!
No pneumothorax.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Brief Hospital Course:
Mr. [**Known lastname 61502**] was a same day after undergoing pre-operative
work-up after his cardiac cath. On day of admission he was
brought directly to the operating room where he underwent a
coronary artery bypass graft x 4. Please see operative report
for surgical details. In summary he had CABGx4 with a
LIMA-LAD,SVG-Diag,SVG-OM,SVG-RCA. His bypass time was 80 minutes
with a crossclamp time of 66 minutes. He tolerated the operation
well and 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.
On post-op day one he was started on beta blockers and diuretics
and gently diuresed towards his pre-op weight. Later on this day
he was transferred to the telemetry floor for further care. Once
on the floor he had a largely uneventful post-operative course.
On post-op day two his chest tubes were removed. Chest-x-ray
after removal revealed small residual apical pneumothorax, which
remained stable throughout his hospitalization. On post-op day
three his epicardial pacing wires were removed.
During this time his activity level progressed and on POD4 he
was discharged home with visiting nurses.
Medications on Admission:
Plavix 75mg qd, Lipitor 20mg qd, Zetia 10mg qd, Glipizide 10mg
qd, Novolog 70/30 18u qam, 28u qpm, Metformin 1000mg qd, Aspirin
325mg, Niacin 100mg [**Last Name (LF) **], [**First Name3 (LF) **] 3, Lorazepam 0.5mg prn qhs,
Percocet prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Glipizide 10 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:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: 18units QAM/28units QPM units Subcutaneous QAM&PM: 18 units
QAM
28 units QPM.
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. Hydromorphone 2 mg Tablet Sig: 2-6 mg PO Q3-4hrs as needed.
Disp:*50 mg* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**State 2748**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft
x4(LIMA-LAD,SVG-OM,SVG-Diag,SVG-RCA)
PMH: Hypertension, Hyperlipidemia, Diabetes Mellitus, Peripheral
Vascular Disease, Carotid Artery Disease s/p Left CEA, h/o
Shingles, Left shoulder tendenitis, HOH, s/p Tonsillectomy, s/p
Right hand treatment Dupuytren's contractures
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**First Name (STitle) **] in [**1-13**] weeks
Dr. [**Last Name (STitle) **] in [**12-12**] weeks
Completed by:[**2109-10-11**]
|
[
"41401",
"2724",
"25000"
] |
Admission Date: [**2120-8-14**] Discharge Date: [**2120-8-19**]
Date of Birth: [**2059-6-19**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
female with a history of brain tumor. MRI scan showed right
cerebellar mass.
PAST MEDICAL HISTORY: Past medical history includes breast
cancer with lumpectomy in [**2114**], carpal tunnel syndrome, sleep
apnea, gastroesophageal reflux disease.
PAST SURGICAL HISTORY: Previous surgery included lumpectomy
in [**2114**], hysterectomy in [**2114**], thyroid nodule excision.
ALLERGIES: The patient had no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: On physical examination,
this was an obese woman in no acute distress. HEENT was
anicteric. A well-healed incision. Chest was clear to
auscultation. Cardiac revealed S1 and S2, a regular rate and
rhythm. Abdomen was obese, soft, a well-healed midline
incision. Extremities revealed slight edema of the bilateral
lower extremities, nonpitting, easily palpable dorsalis pedis
and posterior tibialis pulses.
HOSPITAL COURSE: The patient was admitted on [**2120-8-14**], status post right suboccipital craniotomy for resection
of cerebellar mass. There were no intraoperative
complications.
Postoperatively, the patient was monitored in the Surgical
Intensive Care Unit where she was awake, alert, and oriented
times three, moved all extremities with good strength. No
drift. Lungs were clear to auscultation. A regular rate and
rhythm.
The patient was transferred to the regular floor on
postoperative day one in stable condition. Her face was
symmetric. Extraocular movements were full. Followed 3-step
commands, awake, alert, and oriented times three. The
patient was seen by Physical Therapy and found to require
three to four days of Physical Therapy treatment prior to
discharge to home. The patient did receive that treatment,
and is now stable for discharge home.
MEDICATIONS ON DISCHARGE: Her medications at the time of
discharge were Decadron taper off over two weeks time,
Percocet one to two tablets p.o. q.4h. p.r.n, Zantac 150 mg
p.o. b.i.d. She is also on Lopressor 50 mg p.o. b.i.d.
DISCHARGE DISPOSITION: Vital signs were stable, and the
patient was afebrile at the time of discharge.
DISCHARGE FOLLOWUP: The patient was to follow up in the
Brain [**Hospital 341**] Clinic in one week for staple removal and follow
up in the Brain [**Hospital 341**] Clinic with Dr. [**First Name (STitle) **].
CONDITION AT DISCHARGE: Her condition was 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: [**2120-8-19**] 10:01
T: [**2120-8-21**] 13:47
JOB#: [**Job Number 3206**]
|
[
"4240",
"53081"
] |
Admission Date: [**2129-9-10**] Discharge Date: [**2129-11-10**]
Date of Birth: [**2052-12-2**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Captopril
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Volume overload
Recalcitratnt Atrial Fibrillation
Chronic Respiratory Acidosis
Major Surgical or Invasive Procedure:
AVR/MAZE
Intubation
Percutaneous jujenostomy tube placement
Percutaneous tracheostomy tube placement.
History of Present Illness:
76 year old female with PMH of Afib, h/o LBBB, CVA-17 years ago,
AS- 0.7 cm mean gradient of 34 and decreased systolic function
with EF of 30% in [**3-17**], presents for AVR and MAze. AS has been
diagnosed during CCU admission [**3-17**] in which patient was
transferred from OSH after presenting in cardiogenic shock with
afib. Was cardioverted/ intubated/ hypotensive and transferred
here on dopa/dobutaime. Cath that adm showed normal coronaries
with elevated blt filling pressures. RA 12 RV: 55/12 PA 55/26
mean: 38 PCWP: 31 CO/CI: 5.2/3.0 SVR: 1123. Pt recovered was
treated unsuccessfully with amio after DCCV failed, was treated
for PNA, was found to have decreased platlets (- hits), had ARF
improving by time of dc, stage II decubitus ulcer. Upon
admission on [**9-10**], patients cr was 2.1 delaying her surgery. ARF
was thought to be secondary to volume overload and decreased
perfusion. Treated with natrecor with improvement in volume
status and serum creatinine. Ultimately, patient had AVR and
Maze done [**2129-9-16**] with placement of 19mm Magna tissue valve. Note
taht echo prior to surgery showed valve area of 0.5 with mean
gradient of 56 and markedly improved LV systolic function to
55-60%. 1+ MR and 2+TR. Post-op patient reverted to AFIB, was
initially diuresed with natrecor and lasix, restarted BB and
ACE and placed on amio drip and coumadin for afib. CR rose over
teeh next week. Swan on [**9-27**] showed CVP: 19, PA 51/24 CO: 2 SVR:
2800 (by thermodilution) then on Natrecor and lasix drip. Repeat
echos ruled out tamponade and showed again mildly decreased EF
-45-50% on [**9-27**]. Patient re-intubated on [**9-28**] for respiratory
distress secondary to CHF. Milrinone added with good effect (CI-
3.2) with some improved renal perfusion. Increased TSH t'ed with
synthroid as recommended by [**Last Name (un) **]. Extubated [**2129-10-1**]. Failed
swallow study [**10-3**]. Met alk treated wuth diamox. DCCV on [**10-4**] to
sinus. Off all ionotropes and pressors as of [**10-7**]. on Natrecor.
Pt continues to go in and out of afib. On zosyn for resistent
UTO from [**10-2**]. Patient now transferred to CCU for further
management of worsening renal function and afib.
Past Medical History:
see above
Social History:
Lives with family. Denies smoking, alcohol or illicits. No
tatoos. Multiple blood transfusions.
Family History:
+DM
+CV
Negative for premature coronary disease. No other obvious
etiology of cardiomyopathy per pt and family.
Physical Exam:
Gen: NAD, A&O X 4
Heent: EOMI, PERRL, MMM
Neck: +JVD to 10cm. Tracheostomy in place c/d/i.
Chest: sternotomy scar
Heart: Irregular rate and rhythm. Normal S1, decreased S2.
+harsh systolic murmur at LLSB with no radiation that varies
with respiration.
Lungs: Decreased, bronchiol breath sounds bibasilarly.
Decreased tactile fremitus bibasilarly. Clear apically.
Abd: PEJ in place. Soft, nt/nd. NABS.
Ext: Stable 2+ pedal edema in arms and legs. L picc line in
place c/d/i.
Neuro: CN 2-12 intact. Motor and sensory grossly intact. Able
to ambulate with help, grossly ataxic.
Pertinent Results:
[**2129-10-10**] TTE: The left atrium is mildly dilated and elongated.
The right atrium is markedly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast (no maneuvers performed). Late bubbles seen in the left
atrium/ventricle suggestive of rapid pulmonary transit or AV
malformations. Left ventricular wall thicknesses and cavity size
are normal. Overall, left ventricular systolic function is
normal (EF > 55%). Right ventricular chamber size and free wall
motion are normal. [Intrinsic right ventricular systolic
function may be more depressed given the severity of tricuspid
regurgitation.] There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. A bioprosthetic aortic valve prosthesis is present.
The transaortic gradient is normal for this prosthesis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. Severe
[4+] tricuspid regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
[**2129-9-16**] Aortic valve pathology: (Aortic) valve leaflets with
fibrosis, myxoid degenerative change and calcification.
[**2129-10-14**] TTE: Mild spontaneous echo contrast is seen in the
body of the left atrium. LAA not visualized (excluded/oversewn
during prior cardiac surgery). No thrombus/mass is seen in the
body of the left atrium. The right atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium or the right atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). No masses or thrombi are
seen in the left ventricle. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated. Right
ventricular systolic function is normal. There is abnormal
(paradoxical) septal motion/position. There are complex (>4mm,
non-mobile) atheroma in the descending thoracic aorta. A
mechanical aortic valve prosthesis is present. The aortic
prosthesis appears well seated, with normal leaflet/disc motion.
No aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Tricuspid
regurgitation is present but cannot be quantified. A catheter is
seen in the RA/RV/PA c/w a Swan-Ganz catheter. There is no
pericardial effusion.
[**2129-10-21**] TTE: Limited views obtained on this study. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Brief Hospital Course:
1. Aortic Stenosis: Valve area 0.7cm squared with mean
gradient 49. Pt admitted to cardiac [**Doctor First Name **] for AVR. Started on
natrecor while waiting for AVR (supratherapeutic INR) to
decrease filling pressures. Had MAZE/AVR [**2129-9-21**] with 19 mm
Magnapericardial tissue heart valve with resolution of gradient
post op. Pt was anticoagulated with heparin during most of her
hospitalizaiton for clot prevention, and will be sent out with
coumadin with INR goal 2.0-3.0.
2. Heart Failure: Pt with chronic NYHA class 4 HF with
preserved EF of 55%. Thus, her heart failure is likely
primarily diastolic failure with superimposed valvular disease
also complicated by chronic AF. Pt remained fluid overloaded
and often went into pulmonary edema. Mrs.[**Known lastname **] is negative 15 L
for her length of stay and her discharge "dry weight" is 62kg.
She required natrecor and IV lasix drips on and off during her
admission. She also required milrinone for 2 weeks during this
admission to maintain her blood pressure. She also had
hypertension during this hospitalization and transiently
required BP control with ACE-inhibitors, beta-blockers, and prn
hydralizine (Mrs.[**Known lastname **] did become quite hypotensive with
ACE-inhibitors and these medications should be avoided in her).
Her swan #'s revealed elevated filling pressures, with pulmonary
arterial hypertension. Interestingly, her PA pressures remained
elevated even with correction of her PCWP, implying possible
underlying primary lung disease. Her most recent swan #'s: PAP
41/22, PCWP 22, CO/CI 6.5/3.76 and SVR 679 (while on milrinone).
Mrs.[**Known lastname **] was intubated and extubated 3 times during this
hospitalization, mainly for pulmonary edema and hypoxic
respiratory failure. She will be discharged with prn lasix to
take in case of wieght gain, although this will now be less of
an issue as she now is s/p tracheostomy and has access to
positive-pressure ventilatory support. She will be d/c'd on
coreg for increased lusotropy, rate control of AF, and slight
reduction in afterload.
3. CAD: Mrs.[**Known lastname **] had no angiographic evidence of coronary
disease as of [**2129-4-7**].
4. Rhythm: Pt also had MAZE procedure [**2129-9-21**] with use of
Atricor system. Unfortunately, she reverted to atrial
fibrillation soon thereafter. She also is s/p numerous
cardioversions that have failed to keep her in NSR. Her rate
during the first 3 weeks of her hospitalization was difficult to
control, intermittently on amiodorone, digoxin and
beta-blockers. The pt did not tolerate AF with RVR secondary to
her stiff, non-compliant ventricles, and this contributed to her
recalcitrant HF. Amiodorone was also used to increase
likelihood of staying in sinus rhythm. She currently is off all
AV nodal blockers and her rate is 60's-70's. It should be noted
that Mrs.[**Known lastname **] became very bradycardic (i.e. 30's-40's) with
digoxin and this medication should be avoided in the patient.
She did not need require pacing for this bradycardia. The
patient was anticoagulated with heparin during her
hospitalization and will be d/c'd on coumadin for stroke
prophylaxis in A-fib. Surface ECG also shows RBBB.
5. Respiratory Failure: The patient was intubated 4 times
during this hospitalization, mainly for hypoxic resp failure due
to pulmonary edema. Each time she was weaned off the ventilator
as she was diuresed. She also grew Proteus from sputum cultures
and was treated successfully for bronchitis with ceftriaxone.
However, the last time extubated she did remain relatively
euvolemic, but then developed hypercapnic respiratory failure,
thought to be [**2-14**] muscle deconditioning and as a compenasation
to diuretic-induced metabolic alkalosis. The pt also had
radiologic evidence of RUL collapse thought to be due to mucus
plugging. She had aggressive pulmonary toilet and chest PT, and
she was able to mobilize most of her secretions. The patient
would periodically tire and become hypercapnic at night, but
could not tolerate BiPAP (used with the goal of nightime resp
muscle rest) for more than one hour at a time due to
discomfort/anxiety. Pulmonary was consulted and the decision
was made to use a tracheostomy for intermittent positive
pressure ventilation.
6. Renal: The pt developed ARF with a peak Cr level of 3.0
thought to be secondary to pre-renal azotemia due to decreased
renal perfusion in setting of low forward-flow heart failure.
Her UTI was considered complicated since it was associated with
indwelling foley, but did not contribute to her ARF. Her Cr
improved to 1.6 on discharge, which is near her baseline of 1.2.
Her discharge GFR is 46 ml/min by the MDRD equation. Her
discharge meds will be renally dosed.
7. Diabetes: Pt was maintained on lantus 8-10U qPM with
humalog sliding scale. Her capillary blood glucose's were
relatively well controlled usually 120's-180's. She did not
develop hyperosmolar coma nor did she become symptomatically
hypoglycemic during this hosptilaztion. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 387**] consult was
obtained to help with her regimen. She will be discharged on
this same regimen of lantus 10U qPM with humalog SS.
8. Hypothyroidism: Pt's home regimen of levothyroxine was
50micrograms/day. Her TSH was noted to be elvated to 24 early
in the admission, so her thyroid replacement was increased to
75micrograms/day levothyroxine. Her TSH was rechecked and
revealed a level of 50, so levothyroxine was then increased to
100micrograms/day with the thought that hypothyroidism may be
complicating her clinical presentation and perpetuating her
hypotension late in the hospital course.
Medications on Admission:
dig 0.125 mg po dialy
lasix 60 mg po daily
coumadin 7.5mg po Mo-Fr
glyburide 5mg po twice daily
metformin 500 mg po twice daily
protonix 40mg po daily
lopressor 50mg po twice daily
lisinopril 10mg po dialy
Discharge Medications:
1. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic QD
(once a day).
Disp:*qs * Refills:*2*
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
7. Insulin Glargine 100 unit/mL Solution Sig: 10 Units
Subcutaneous at bedtime: 10U subcutaneous qPM.
Disp:*qs * Refills:*2*
8. Bimatoprost 0.03 % Drops Sig: Two (2) Ophthalmic every
twelve (12) hours.
Disp:*qs * Refills:*2*
9. Lansoprazole 30 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*
10. Humalog 100 unit/mL Cartridge Sig: One (1) Subcutaneous
once a day: quantity sufficient for sliding scale (see attached
sliding scale).
Disp:*5 * Refills:*2*
11. Promote with Fiber Liquid Sig: One (1) PO once a day:
Tubefeeding: Promote w/ fiber Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50
ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 150 ml water q8h
Disp:*qs * Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Heart Failure from diastolic dysfunction
Chronic Atrial fibrillation
Diabetes
Discharge Condition:
good
Discharge Instructions:
Call your doctor or go to the ER if you have these symptoms:
1. Weight gain
2. Leg swelling
3. Fevers
4. Shaking chills
5. Dizziness or fainting
6. Palpitations
You must be weighed daily. Your discharge weight is 62. Weigh
yourself immediately when you arrive at [**Hospital **] rehabilitation.
If your weight increases by more than 2#, take an extra dose of
lasix 80mg and if your weight does not return to normal, or
continues to increase, call your doctor.
Followup Instructions:
Please call Dr[**Doctor Last Name **] office and schedule follow up in 14-21days
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
Completed by:[**2129-11-6**]
|
[
"4241",
"42731",
"4280",
"5849",
"5990",
"486",
"2875",
"2449",
"25000"
] |
Admission Date: [**2136-5-28**] Discharge Date: [**2136-6-2**]
Date of Birth: [**2088-5-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Penicillins / Ciprofloxacin / Clindamycin
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
CT guided J tube replacement.
History of Present Illness:
48 year old male with history of DM2 complicated by
gastroparesis, GJ tube s/p recent revision, who presents with
nausea, vomiting, found to have hypotension, fever, hematemesis
initially admitted to the MICU for septic shock and ? UGIB now
transferred to the floor today [**2136-5-30**]. On admission, pt was
noted to be febrile, with hyperglycemia and an increased AG
concerning for DKA. He was witnessed to have a "tonic clonic"
seizure and was given 1mg of Ativan. He was started on an
insulin gtt, given IVF, and responded appropriately with closure
of his AG and normalization of his sugars. However, the patient
became hypotensive despite aggressive IVF and required a RIJ
central line and dopamine, which was subsequently changed to
levophed. He also developed coffee ground emesis, and his Hct
dropped from 30 to 22. GI was consulted, and recommended
stopping suction, transfusing 2u PRBCs, giving antiemetics and
IV PPI [**Hospital1 **]. He was admitted to the MICU for UGIB and shock
presumed from sepsis.
.
RECENT HISTORY PER MICU NOTE:
The patient was recently discharged from [**Hospital1 18**] on [**2136-5-11**] after
p/w similar complaints of abdominal pain, vomiting, GJ tube site
drainage and hematemesis. During that admission, his hematemesis
was felt to be from grade D esophagitis and responded to PPI [**Hospital1 **]
and carafate. His GJ tube site was inflamed, but felt to be [**1-12**]
irritation from leakage of stomach contents rather than true
infection. The tube was swabbed and grew polymicrobial flora
felt to be colonization, and a peri-tube u/s showed no fluid
collections. He received a short course of ceftriaxone but this
was stopped after the cultures came back. His abdominal pain was
felt to be [**1-12**] his chronic gastroparesis pain, plus possible
irritation from the GJ tube, and was treated with metoclopramide
and erythro, plus his home pain regimen of oxycontin and
percocet. He had [**12-12**] BCx bottles grow MSSA, which was initially
treated with Vanc but then felt to be a contaminant and so abx
were stopped. Of note, his admit level of phenytoin was <0.6, so
he was given an additional gram IV with a repeat level 3.7. He
had no seizures while in house. On [**5-14**] he presented to
[**Hospital **] Hospital for continued drainage from his GJ tube. Per
his wife (no documentation available) he was started on IV
antibiotics and completed a course of the antibiotics after a
[**4-14**] day stay in the hospital.
.
The pt cont to have nausea and represented on [**5-25**] when he
vomited out his GJ tube and returned to the [**Hospital1 18**] ER. He was
seen by IR and the tube was replaced. He was unable to use the
tube after discharge and anything that was infused into jejunal
tube was aspirated out of the gastric port. He also had severe,
nausea vomiting, and felt dehydrated spending most of the last 3
days in bed due to weakness. He called his GI [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 7306**] [**Last Name (NamePattern1) 62708**] who directed him to the ER for evaluation, hydration
and glycemic control. Per his wife he had been taking all of his
medications at home but she is unclear if he was taking insulin
since he was not eating well.
.
While in the MICU, patient was seen by GI and by psychiatry. GI
felt that the GJ tube was malpositioned, and recommended surgery
consult to place a surgical J tube. Patient also attempted to
leave AMA, and psychiatry was consulted to evaluate patient, and
he was written for haldol. Patient was also seen by neurology
who felt that the seizures patient has been experiencing are
pseudoseizures, and favored no further Dilantin loading.
Patient is now transferred to the medicine service.
Past Medical History:
1) Type 2 Diabetes, complicated by gastroparesis and peripheral
neuropathy x 15 years
2) Left BKA in [**2109**]'s after car accident
3) Esophagitis on EGD [**8-14**]. Last scope here [**10-14**] as follows:
Impression: Linear erosions with exudate in the lower third of
the esophagus compatible with erosive esophagitis. Fluids in
stomach. Mass in the cardia. Mass in the gastroesophageal
junction. Otherwise normal egd to second part of the duodenum.
Recommend repeat EGD.
4) Seizures-[**2-11**] yrs
5) PVD
6) HTN
7) Status post appendectomy for appendicitis in [**2101**].
8) History of DVT "many years ago," with permanent IVC filter
placed.
9) Path: red cell alloantibodies, anti-D and anti-C; should
receive D and C antigen negative red cells for transfusion if
required
Social History:
Lives with his wife and two children. Has smoked 1 PPD >20
years. He has a history of heavy alcohol use which he can't
quantify, but quit about 5 years ago. He used to use illicit
drugs, including heroin, cocaine, LSD. Disabled now since [**09**]'s
after car accident. Works at pig farm for recreation.
Family History:
Sister with [**Name (NI) 4522**] Disease. Father with [**Name2 (NI) 2320**].
Physical Exam:
Tc 99.3 130/60, 77, 13, 96% on RA
Gen: Malnourished male lying in bed.
HEENT: Poor dentition. No elevation in JVP. MMM.
Hrt: RRR. no MRG.
Lungs: CTAB. no RRW.
Abd: Hypoactive bowel sounds, small amount serous drainage from
around the GJ tube. No erythema. Mild tenderness to palpation
over abdomen diffusely.
Extr: L BKA. No edema, non palp dp pulse on rt
Skin: Numerous excoriations over arms, legs, back. None appear
infected. Patient is actively scratching all of his lesions.
Pertinent Results:
LABS:
[**2136-5-28**] 05:27PM GLUCOSE-80 UREA N-22* CREAT-0.6 SODIUM-138
POTASSIUM-3.2* CHLORIDE-100 TOTAL CO2-31 ANION GAP-10
[**2136-5-28**] 05:27PM ALT(SGPT)-9 AST(SGOT)-8 LD(LDH)-100
CK(CPK)-12* AMYLASE-42 TOT BILI-0.2
[**2136-5-28**] 05:27PM LIPASE-24
[**2136-5-28**] 05:27PM CK-MB-NotDone cTropnT-<0.01
[**2136-5-28**] 05:27PM ALBUMIN-3.0*
[**2136-5-28**] 05:27PM FERRITIN-8.4*
[**2136-5-28**] 05:27PM PHENYTOIN-<0.6* VALPROATE-<3.0*
[**2136-5-28**] 05:27PM HGB-7.7* HCT-22.8*
[**2136-5-28**] 02:39PM TYPE-ART PO2-118* PCO2-55* PH-7.44 TOTAL
CO2-39* BASE XS-11 INTUBATED-INTUBATED
[**2136-5-28**] 02:07PM LACTATE-3.0*
[**2136-5-28**] 02:00PM CK(CPK)-13*
[**2136-5-28**] 02:00PM cTropnT-<0.01
[**2136-5-28**] 02:00PM CK-MB-NotDone
[**2136-5-28**] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.033
[**2136-5-28**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Reports:
CT ABDOMEN WITH IV CONTRAST: The lung bases are clear without
evidence of nodules or effusions. There is symmetric thickening
of the esophageal wall measuring 12 mm, most likely consistent
with esophagitis, and this should be clinically correlated. A
G-tube is seen extending to the third portion of the duodenum.
The liver, gallbladder, spleen, adrenal glands, and pancreas are
unremarkable. The left kidney is unremarkable. A hyperdensity in
the right kidney may represent a hyperdense right kidney cyst,
however, cannot be further evaluated on this examination. There
is no free air or free fluid within the abdomen. There are no
pathologically enlarged mesenteric or retroperitoneal lymph
nodes. An IVC filter is collapsed and in unchanged position with
legs of the filter outside of the IVC. The aorta is calcified.
CT PELVIS WITH IV CONTRAST: There is air within the bladder,
likely secondary to the patient's Foley catheter. There is
sigmoid diverticulosis, without evidence of diverticulitis.
There is no free fluid within the pelvis. There are no
pathologically enlarged pelvic or inguinal lymph nodes.
OSSEOUS WINDOWS: Again demonstrate an exophytic lesion arising
from the right iliac crest that is unchanged in appearance
compared to the prior examination. Multiplanar reformatted
images confirm the above findings.
IMPRESSION:
1. Marked symmetric esophageal wall thickening, likely
consistent with esophagitis. This should be clinically
correlated.
2. No evidence of G-tube leak.
3. Right kidney hyperdensity may represent a cyst but can be
evaluated on ultrasound if clinically indicated.
4. Sigmoid diverticulosis without evidence of diverticulitis.
5. IVC filter in unchanged position.
CT head: No acute hemorrhage
CXR: No acute process.
GJ tube placement:
IMPRESSION: Unsuccessful placement of gastro jejunostomy tube
across the pylorus, due to gastroparesis. A gastrostomy tube was
placed instead.
Blood cultures:
[**5-28**]:AEROBIC BOTTLE (Final [**2136-6-1**]):
GRAM STAIN REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 62709**] (CC7D) 1340
[**2136-5-29**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
ANAEROBIC BOTTLE (Final [**2136-6-1**]):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
[**2136-5-28**] 2:00 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2136-6-1**]):
REPORTED BY PHONE TO [**Doctor First Name 62710**] GOOD [**2136-5-30**] 13:25.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
ANAEROBIC BOTTLE (Pending):
Brief Hospital Course:
48yo man with DM2, gastroparesis, GJ tube s/p recent revision,
who p/w n/v, found to have DKA, sepsis, hematemesis and seizure,
now well controlled.
##. Hematemesis: Patient's hematocrit remained stable after
transfusion of 2 units. Likely secondary to esophagitis. GI did
not feel need to repeat endoscopy at this time. Mr. [**Known lastname 6330**]
should continue PPI [**Hospital1 **] for 4 weeks and then can decrease to a
daily PPI.
##. Iron deficiency anemia: He was noted to have Iron deficiency
anemia and treated with IV iron replacement in the hospital. He
will continue on iron replacement as outpatient.
##. Hypotension and fever: Concerning for infection in setting
of positive blood cultures, however blood culture grew out
diphtheroids which infectious disease felt was contamination. No
clear source was ever identified by UA/CXR/CT scan.
##. Seizures: CT head negative on admit. Dilantin and depakote
were subtherapeutic. Neurology consulted and felt that these
were pseudoseizures after witnessing an episode (patient
conscious and talking throughout jerking movement). A bedside
EEG was attempted, but patient refused. Initially, dilantin load
was given and levels were followed closely. He was also
continued on dilantin. Further history from patient revealed
that he did not like to take dilantin or depakote due to side
effects (as demonstrated by levels on admission). After
consulation with neurology, he was changed to tegretol to
hopefully improve compliance. Dilantin and depakote were
discontinued. Of note, during hospitalization, his seizures
were only treated if they lasted longer than 5 minutes or he had
multiple seizures within an hour.
##. Gastroparesis s/p GJ Tube placement. Patient's GJ tube was
found to be out of position. It was replaced by CT guided
intervention on [**2136-6-1**]. He was continued on
Reglan and erythromycin per GI recs for gastroparesis. He
resumed solid diet on [**6-1**] after J tube placement without
events.
##. Depression. Concern was raised during the MICU stay for
suicidal ideation. There was a questionable history of multiple
suicide attempts in past, which was not able to be verified by
the psychiatry resident prior to discharge. Mr. [**Known lastname 6330**] was on 1:1
sitter while in ICU and initially on floor. He was continued on
his celexa. He was no longer suicidal prior to discharge.
Psychiatry was consulted and recommended that the patient follow
up with his outpatient psychiatrist.
##. DM2. ISS. FSQACHS. Blood sugars low initially while patient
NPO because of J tube misplacment.
##. Activity: As tolerated.
##. PPx: During the hospital stay, he was treated with PPI [**Hospital1 **],
pneumoboots for DVT prophylaxis, a bowel regimen and maintained
on seizure precautions.
##. Access: Right IJ triple lumen removed the day of discharge.
##. Comm: wife [**Name (NI) 8771**] [**Name (NI) 6330**] [**Telephone/Fax (1) 62711**]
##. Code: Full after discussion with wife
## pruritis- long standing. Could be due to diabetes, iron
deficiency or some other process. Would treat Iron deficiency
and reassess.
## esophagitis- should have another EGD with biopsy as a screen.
Medications on Admission:
-Lantus 95 U QAM, 55U QPM
-RISS
-Phenytoin 500 mg PO QHS
-Quetiapine 300 mg PO QHS
-citalopram 40 mg PO QHS
-Depakote 500 mg PO QHS
-Oxycontin SR 80 mg PO BID prn
-10mg percocet tid prn
-iron sulfate 325mg tid
-sucralfate 1g qid
-metoclopramide 10mg qid with meals
-[**Telephone/Fax (1) 44137**] 40mg qhs
.
ALLERGIES: Morphine, Augmentin, Ciprofloxacin all cause rash.
Discharge Medications:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
[**Telephone/Fax (1) **]:*30 Capsule(s)* Refills:*6*
2. Quetiapine 300 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
[**Telephone/Fax (1) **]:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
[**Telephone/Fax (1) **]:*1 bottle* Refills:*2*
6. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO Q12H (every 12 hours): 2 week
supply
refills through PCP.
[**Name Initial (NameIs) **]:*56 Tablet Sustained Release 12HR(s)* Refills:*0*
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0*
8. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*1*
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
10. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
[**Name Initial (NameIs) **]:*120 Tablet(s)* Refills:*1*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Name Initial (NameIs) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous QAM.
[**Name Initial (NameIs) **]:*0 0* Refills:*0*
14. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
15. Insulin
Please resume home insulin sliding scale.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Gatroparesis
J tube displacement
Diabetes Mellitus Type 2
Seizure Disorder
Iron deficiency anemia
Depression
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as directed. Your dilantin has been
replaced with Tegretol.
If you have recurrent nausea, vomiting, abdominal pain, fevers
or chills please call Dr. [**Last Name (STitle) 57930**] for urgent evaluation.
Your insulin was restarted at a lower dose. If your blood sugars
remain elevated, please call Dr. [**Last Name (STitle) 57930**] for dose adjustments of
your insulin.
Followup Instructions:
On Monday, please call your primary care physician , [**Last Name (NamePattern4) **].
[**Last Name (STitle) 57930**], to be seen in the office early next week.
You will need a referral to a neurologist for further evaluation
of your possible seizures. You can be seen here at [**Hospital1 18**] if you
would like. If so, please call [**Telephone/Fax (1) 40554**].
You will also need to follow up with Dr. [**First Name (STitle) 2643**] in
gastroenterology regarding your gastroparesis and ongoing need
for gastric and jejunal feeding tubes. Please call his office
MOnday for an appointment.
|
[
"0389",
"78552",
"2762",
"4019"
] |
Admission Date: [**2136-10-24**] Discharge Date: [**2136-12-28**]
Date of Birth: [**2095-9-15**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Transfer for exacerbation of chronic cirrhosis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 41 y/o man w/ a hx of alcoholic cirrhosis c/b ascites,
portal hypertension, and hepatic encephalopathy who presented w/
an exacerbation of his liver failure over the past 2 months. He
also had an episode of s. viridans bacteremia in [**9-7**] that was
treated w/ 4wk of vancomycin and 2wk of gentamycin. He was
admitted to an outside hospital on [**9-5**] w/ bacteremia as above,
[**9-21**] w/ prerenal azotemia, and [**10-20**] w/ complaints of SOB and
fatigue. He was found during his last admission to have a large
R pleural effusion along with elevated LFTs. He was treated
empirically with avelox at the outside hospital and was given
diuretics. A thoracentesis was planned but did not occur [**3-7**]
his elevated INR. He was transferred to [**Hospital1 18**] for further
management of his acute on chronic liver failure and for w/u of
its etiology.
Upon arrival, the patient was mildly confused taking long time
periods to answer questions and needing some redirection to
focus on the question at hand. According to the patient, his
liver function has been declining for approximately the past 3
months. He reports that he has had increasing edema in his LE
despite treatment and that he has been increasingly jaundiced of
late. He states that he has not been able to think as well as
he used to think. He denies any CP, SOB, N/V, diarrhea, HA,
palpatations, or pruritis. He denies any recent viral illness
or sick contacts. [**Name (NI) **] has not traveled recently and has not has
had any of his medications changed recently. He denies taking
any herbal supplements.
Past Medical History:
1. alcoholic cirrhosis c/b ascites and encephalopathy
2. s viridans bacteremia s/p 4wk vanco 2wk gent
3. ARF [**3-7**] aminoglycoside toxicity
Social History:
Pt is married w/ 2 children. He lives in [**Location 5450**] and works
as a salesman for Staples. He has a hx of alcohol abuse w/ his
last drink in [**Month (only) 116**]. He denies smoking, drug use, or tattoos.
Family History:
Pt w/ diabetes in his mother and father. Father died of "kidney
and pancreas problems".
Physical Exam:
Gen: Jaundiced appearing man lying in bed in NAD
HEENT: EOMI, PERRLA, MMM, O/P clear, + icterus
Skin: + jaundice, - rashes
CV: RRR, S1/S2 intact, -M/R/G
Lungs: dullness to percussion w/out BS on the lower half of the
R lung, otherwise CTA
Abd: S/NT, distended, -HSM, +BS, mild asterixis
Ext: -C/C, 2+ pitting edema to the mid-thigh in the LE
Neuro: AAOx2 (not date), patient not able to do serial 7s past
86
Brief Hospital Course:
41 y/o man with h/o alcoholic cirrhosis who presented after
being admitted to an outside hospital with SOB and fatigue. Was
found to have a R pleural effusion and worsening of his LFTs. No
tap was performed [**3-7**] elevated INR.
He had a long hx of cirrhosis with worsening of his condition
over the past several months. He presented w/ encephalopathy and
severe jaundice with unclear cause of sudden decrease in liver
fxn. Possible causes included infection, toxin, thrombosis of
veins. Blood and urine cultures were negative. An US of the
liver w/ doppler revealed a cirrhotic liver without focal
lesions with nearly no flow within the main and left portal
veins, and no detectable flow within the right portal vein.
Massive varices within the abdomen with evidence of splenorenal
shunting. Massive splenomegaly. Small amount of perihepatic
ascites, which was not sufficient
to tap. Nondistended gallbladder with gallbladder wall edema,
indicative of liver disease and right pleural effusion.
Labs were significant for + [**Last Name (un) 15412**] and IgG. He was followed by the
Hepatology service who initiated transplant workup. The
Transplant service was consulted on [**2137-10-27**] and a transplant
workup was completed. CT of the abdomen demonstrated a cirrhotic
liver with no mass lesion demonstrated. Patent but narrow
caliber portal vessels. Thin linear hypodensity within the main
portal vein likley representing some nonocclusive thrombus.
Hepatic veins were patent. Features of portal hypertension
including splenomegaly, moderate amount of intra-abdominal
ascites and portosystemic collaterals were described.
He remained in the hospital for management of worsening liver
failure with hepatorenal syndrome. He became coagulopathic
requiring daily transfusions with platelets, FFP, cryo and PRBCs
per Hepatology recommendation to keep plt>20, inr<4, hct>25,
fibrin >150. Encephalopathy wax and waned. This was managed
with lactulose and rifaximin. He was followed by social work,
psychiatry, nutrition and physical therapy. His MELD score
ranged in the 40s. He did not receive a liver transplant despite
being at the top of the list. He was transferrred to the SICU
with neurology consultation for worsening encephalopathy. He was
intubated. A CT demonstrated a spontaneous subdural hematoma.
He was coagulopathic and due to his contraindication to
transplant, his family met with the team and decided to make him
CMO. He expired on [**2137-12-28**].
Medications on Admission:
avelox 400mg
aldactone 25 tid
ambien prn
lasix 20
mvi
folate
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
End Stage Liver Disease secondary to Alcoholic Cirrhosis
Discharge Condition:
expried [**2137-12-31**]
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2137-5-17**]
|
[
"51881",
"486"
] |
Admission Date: [**2168-5-16**] Discharge Date: [**2168-5-25**]
Service: MEDICINE
Allergies:
Vicodin / Darvocet-N 100 / Morphine / Lactose / anti-histamines
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
direct admit for percutaneous arotic valve placement
Major Surgical or Invasive Procedure:
Aortice CoreValve placement
History of Present Illness:
Mrs. [**Known lastname **] is an active [**Age over 90 **] year old woman with a history of
hypertension, hyperlipidemia, previous breast ca and critical
aortic stenosis. She hadsignificant improvement in symptoms
following aortic balloonvalvuloplasty [**1-14**], but has had gradual
progression in symptoms overthe last 2-3 months and is currently
NYHA class [**3-10**] symptoms. She is deemed to be extreme risk for
AVR so is enrolled in the [**Company 1543**] CoreValve protocol for
percutaneous valve placement.
.
She states she has no SOB at rest or during sleep, sleeps with 2
pillows. She is able to ambulate around her home without sig SOB
but gets DOE with 1 flight of stairs and walking more than about
20 feet. SOB resolves with rest. Denies cough, sputum
production, fevers, chills or signs of infection. No recent leg
pain or redness, swelling, or symptoms of claudication.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema,
palpitations, syncope or presyncope. She has a history of falls
but describes these as mechanical only.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
1. Severe Aortic stenosis s/p valvuloplasty x2
2. Dyslipidemia
3. Hypertension
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Past Medical History:
4. Breast CA (left partial mastectomy, on Arimidex) [**2164**]
5. Lactose intolerance
6. Severe osteoporosis
7. Cervical arthritis
8. Carpal tunnel syndrome
9. Blind right eye- R eye prosthesis
10. Cataract in left eye
11. Colon CA s/p bowel resection
12. GERD
13. Multiple falls
Past Surgical History:
- Aortic Valvuloplasty x2. last [**1-14**]
- Left breast partial mastectomy [**2164**]
- Right intertrochanteric hip fracture s/p Open reduction,
internal fixation with DHS construct. [**2162-12-24**]
- Right open carpal tunnel release [**9-8**]
- Left total knee replacement [**2152**]
- Bilateral cataract surgery
- Wide excision of lesion of left lower leg. (non-malignant)
- Partial colectomy for a malignant polyp in [**2134**]
Social History:
Her son is Dr. [**First Name8 (NamePattern2) **] [**Known lastname **], a [**Hospital1 18**] cardiologist.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Independent with ADL's, lives alone.
She is active for her age. She enjoys bridge, [**Location (un) 1131**] and
socializing with her friends
Family History:
father died of MI at 65
Physical Exam:
GENERAL: elderly lady in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. right eye is prosthesis, left
pupil sluggish. Left eye with EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 4/6 systolic murmur radiating to bilat
carotids. No thrills, lifts. No S3 or S4.
LUNGS: Pos kyphosis. Resp were unlabored, no accessory muscle
use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Feet warm
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 1+ Popliteal 1+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 1+ Popliteal 1+ DP 2+ PT 2+
.
Day of discharge:
Right groin with quarter sized hematoma at puncture site, no
ecchymosis or tenderness, no erythema. Positive bruit.
Left groin with mild ecchymosis, no tenderness or hematoma.
CV: RRR, 1/6 systolic murmur at LUSB, no radiation
RESP: crackles left base, clears with cough, no wheezes
ABD: soft, NT
Extremeties: no edema
Pertinent Results:
I. Labs
A. Admission
[**2168-5-17**] 07:30AM BLOOD WBC-4.2 RBC-3.61* Hgb-11.5* Hct-32.7*
MCV-91 MCH-31.8 MCHC-35.2* RDW-13.6 Plt Ct-181
[**2168-5-16**] 11:15AM BLOOD PT-13.0 PTT-29.4 INR(PT)-1.1
[**2168-5-17**] 11:39AM BLOOD Fibrino-326
[**2168-5-16**] 11:15AM BLOOD Glucose-100 UreaN-34* Creat-0.8 Na-137
K-4.1 Cl-101 HCO3-29 AnGap-11
[**2168-5-16**] 11:15AM BLOOD ALT-17 AST-23 CK(CPK)-91 AlkPhos-79
TotBili-0.4
[**2168-5-16**] 11:15AM BLOOD Albumin-3.9
[**2168-5-16**] 11:15AM BLOOD %HbA1c-5.7 eAG-117
[**2168-5-19**] 05:19AM BLOOD TSH-2.0
B. Discharge
[**2168-5-25**] 06:15AM BLOOD WBC-5.0 RBC-3.32* Hgb-10.6* Hct-30.5*
MCV-92 MCH-32.0 MCHC-34.9 RDW-13.4 Plt Ct-175
[**2168-5-25**] 06:15AM BLOOD Plt Ct-175
[**2168-5-25**] 06:15AM BLOOD Glucose-85 UreaN-28* Creat-0.9 Na-135
K-4.2 Cl-101 HCO3-30 AnGap-8
C. Urine
[**2168-5-24**] 10:29PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2168-5-24**] 10:29PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2168-5-24**] 10:29PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
II. Microbiology
[**2168-5-25**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2168-5-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2168-5-24**] URINE URINE CULTURE-PENDING INPATIENT
[**2168-5-17**] Staph aureus Screen Staph aureus
Screen-FINAL INPATIENT
[**2168-5-16**] Staph aureus Screen Staph aureus
Screen-FINAL INPATIENT
[**2168-5-16**] Staph aureus Screen NOT PROCESSED
INPATIENT
[**2168-5-16**] Staph aureus Screen Staph aureus
Screen-FINAL INPATIENT
[**2168-5-16**] Staph aureus Screen NOT PROCESSED
INPATIENT
[**2168-5-16**] URINE URINE CULTURE-FINAL INPATIENT
[**2168-5-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
III. Cardiology
A. Admission ECG
Cardiology Report ECG Study Date of [**2168-5-16**] 3:05:26 PM
Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy with
ST-T wave changes. Since the previous tracing of [**2168-1-19**]
precordial lead
QRS voltage is less prominent.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
66 192 88 [**Telephone/Fax (2) 96201**]8
B. ECHO ([**2168-5-17**])
Pre valve deployment
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. Moderate to severe spontaneous echo contrast
is present in the left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No atrial
septal defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). with normal RV free wall
contractility. There are simple atheroma in the ascending aorta.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is mild valvular mitral stenosis
(area 1.5-2.0cm2). Mild to moderate ([**2-7**]+) mitral regurgitation
is seen. Drs [**Last Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 914**] were notified in person of
the results on [**2168-5-17**] at 930 am.
Post valve deployment
Stented aortic valve seen extending from the LVOT into the
proximal aorta. Trace to mild central aortic insufficiency
present. The peak gradient across the aortic valve is 17 mm Hg
and the mean gradient is 9 mm Hg. Mild mitral insufficiency
seen. Drs [**Last Name (STitle) 914**], [**Name5 (PTitle) **] and [**Name5 (PTitle) **] were notified of the post
deployment findings.
C. C. Cath: final report pending
D. Post-core valve ECHO
The left atrium is normal in size. The left atrium is elongated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). There is a
mild resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. An
aortic CoreValve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Trace to mild aortic regurgitation
is seen. The mitral valve leaflets are moderately thickened.
There is severe mitral annular calcification. There is mild
functional mitral stenosis (mean gradient 6 mmHg) due to mitral
annular calcification. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normally-functioning CoreValve aortic valve
prosthesis. Trace to mild central jet of aortic regurgitation.
Mild symmetric left ventricular hypertrophy with normal global
and regional biventricular systolic function.
IV. Radiology
A. Pre-op CXR
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: 89-year-old female with severe aortic
stenosis, preop
for percutaneous aortic valve replacement.
COMPARISON: [**2165-1-1**], reference also made to the scout from
cardiac CT and
coronary CTA from [**2168-4-7**].
FINDINGS: Frontal and lateral views of the chest are obtained.
Prominent
right hilum is without significant change from the scout view
from [**2168-4-7**],
and likely represents prominent confluence of vessels. No focal
consolidation, pleural effusion, or pneumothorax is seen. The
cardiac
silhouette remains borderline to mildly enlarged and the
thoracic aorta
tortuous. Degenerative changes are seen along the spine.
IMPRESSION:
1. Unchanged prominence of the right hilum, most likely
reflecting vascular
structures.
2. No acute cardiopulmonary process.
### Pending studies: Blood culture x 2 ([**2168-5-24**] and [**2168-5-25**])
Brief Hospital Course:
[**Age over 90 **]-year-old female with critical AS but decent functional
capacity admitted electively for percutaneous aortic valve
replacement.
.
# Critical AS: Patient admitted for corevalve placement that was
successful. She maintained adequate hemodynamics and remained in
normal sinus rhythm without complications at groin site except a
small hematoma as documented on discharge exam. Post-op she was
found to have wide pulse pressure (>100). A CXR at the time
revealed "CoreValve device overlying the LV outflow tract and
proximal aortic root, tip of the internal pacemaker at the level
of the RV, no pneumothorax, pulmonary edema or pleural
effusions". She was extubated on [**5-17**] without difficulty.
Except for an episode of Afib, she did not experience SOB or
lightheadedness or palpitations at rest. She was quickly able to
ambulate on the floor of the ICU without SOB or lightheadedness.
She was transferred to the floor and continued to work with PT.
Telemetry showed a brief episode of 2:1 Wenkebach for which she
remained in the hospital for further observation with no further
subsequent episodes. She was discharged with a KOH monitor.
# HTN: At home, she takes very small [**Month/Year (2) 4319**] of ACEi and BB. She
had significant hypertension post-op and was placed on nitro gtt
which was stopped on [**5-18**] during an episode of afib with
hypotension. After converting to sinus she was treated with
escalating [**Month/Year (2) 4319**] of enalapril and her Metoprolol was stopped.
Given SBP in the 170s-180s, her enalapril was uptitrated to 12.5
mg PO BID with SBP in the 150s on discharge.
# Fever
Patient had a low-grade fever of 100 the day prior to discharge.
A urinalysis was bland, and blood culture was drawn. There were
no focal signs or symptoms of infection except a sore throat.
Her vital signs were stable, and she was afebrile on discharge.
She wanted to leave the hospital, so she was told to report back
to the hospital should she have further fevers.
# RHYTHM: In NSR until [**5-18**] when she developed an episode of
afib in the setting of diuresis. She was hypotensive to the SBP
70s. She was treated with Amiodarone 150mg IV bolus X2 resulting
in conversion to sinus rhythm with the second dose. She was
started on an Amio gtt which was changed to Amiodarone PO. She
was discharged on amiodarone 200 mg PO qD.
# Hyperlipidemia: No recent lipid numbers available, she was
continued on her statin.
# Pump. Preserved EF. DOE and orthopnea thought [**3-9**] tight AS vs
CHF. Has been stable on low dose furosemide. States she follows
low Na diet at home and prepares many meals. She was kept on
strict daily weights and I/Os. She was diuresed for UOP >100
until [**5-18**].
She was continued on clopidogrel, enalapril, atorvastatin,
furosemide, and aspirin 81. Her metoprolol was discontinued.
# Hx of left breast CA, s/p partial mastectomy [**2164**]. Not an
active issue
She was continued on arimidex.
# Transitions of care
- outpatient safety labs for potassium given increased ACEi
dosage
- outpatient follow-up with cardiology and PCP
[**Name Initial (PRE) **] monitoring with KOH given episode of Wenkebach during
hospitalization
Medications on Admission:
Alendronate 70 mgs once weekly
Anastrazole 1 mgs daily
Lipitor 10 mgs qhs
Enalapril 2.5 mgs, 0.5 tabs [**Hospital1 **], 0.25 tab at night prn for high
BP
Furosemide 10 mgs daily
Metoprolol 12.5 mgs daily, 18.75 mg at night
Acetaminophen 325 mgs [**Hospital1 **] prn
Ascorbic acid 500 mgs daily
Calcium citrate-Vit D3 315mgs-200 unit tablet 2 tabs [**Hospital1 **]
Multivitamin 1 tab daily.
Glucosamine chondroiten DS 1 tab [**Hospital1 **]
Preservision one tab [**Hospital1 **]
Discharge Medications:
1. Outpatient Lab Work
Please check chemistry 10 panel within 10 days of discharge
Fax results to PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
Address: [**Location (un) **],[**Apartment Address(1) 77889**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1713**]
Fax: [**Telephone/Fax (1) 96202**]
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*12*
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
4. anastrozole 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. enalapril maleate 5 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for pain.
11. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: Two
(2) Tablet PO twice a day.
12. PreserVision 7,160-113-100 unit-mg-unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Glucosamine Chondroitin MaxStr Oral
16. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Aortic Stenosis s/p CoreValve Placement
Hypertension
Secondary Diagnosis:
Breast cancer
Dyslipidemia
osteoprosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a CoreValve aortic valve replacement to repair severe
aortic stenosis. Subsequent echocardiograms show the valve is
well placed and functioning as expected. You transiently had a
type of heart block, a problem with the electrical system of the
heart which is gone now. You also developed atrial fibrillation
transiently which is also now gone. We want you to wear a "[**Doctor Last Name **]
of Hearts" monitor and send telephone transmissions twice daily
to monitor for any further arrhythmias. Your blood pressure was
high after the CoreValve placement so we increased your
Enalapril to lower your blood pressure. Please refer to the
attached Discharge insruction after aortic valve implantation
for activiy and follow up instructions. Please weight yourself
every day in the morning, call Dr. [**Last Name (STitle) **] if weight increases
more than 3 pounds in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start taking [**Last Name (STitle) **] every day for at least 3 months and
possibly longer. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking [**Last Name (Titles) **]
unless Dr. [**Last Name (STitle) **] or [**Doctor Last Name **] tells you it is OK.
2. Increase your Enalapril to 12.5 mg twice daily to control
your high blood pressure.
3. Start taking Amiodarone to prevent the atrial fibrillation
from returning.
4. Stop taking Metoprolol as the amiodarone will slow your heart
rate as well.
5. Start taking aspirin 81 mg (baby dose) to work with the
[**Name (NI) **] to prevent blood clots.
6. Start taking Fluticasone nasal spray to prevent post nasal
drip. You can stop taking this when your sore throat and cough
improves.
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2168-8-4**] at 10:00 AM
With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2168-8-4**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. [**Telephone/Fax (1) 4586**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: TUESDAY [**2168-8-30**] at 12:50 PM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Address: [**Location (un) **],[**Apartment Address(1) 77889**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1713**]
Appointment: Monday [**6-20**] at 11AM
Department: CARDIAC SERVICES
When: FRIDAY [**2168-6-10**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SURGERY
When: FRIDAY [**2168-6-10**] at 1 PM
With: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2168-6-10**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Campus: WEST Best Parking: [**Hospital Ward Name **] garage
Department: CARDIAC SERVICES
When: FRIDAY [**2168-6-17**] at 11:00 AM and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 12:00
noon
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"4241",
"4019",
"42789",
"42731",
"4280",
"2724",
"53081"
] |
Admission Date: [**2122-5-14**] Discharge Date: [**2122-5-18**]
Date of Birth: [**2052-4-2**] Sex: M
Service: MEDICINE
Allergies:
cefazolin / Penicillins
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
hypotension, Hct drop
Major Surgical or Invasive Procedure:
EGD [**2122-5-15**]
Blood transfusion [**5-14**]
History of Present Illness:
70-year-old man status post kidney transplant now on HD
initially presented with dyspnea and epigastric pain. Patient
reports symptoms began suddenly yesterday while watching TV,
with sudden SOB and mild epigastric discomfort. Pt reports that
at some point today he had mild chest discomfort, similar to
that he has regularly, and took a nitroglycerin. He denies
nausea, vomiting, hematemesis, hematochezia or melena. He
denies history of recent bleeding, dizziness, or light
headedness.
.
In the ED, initial vital signs were:97.6 76 107/93 18 99%. CXR
was clear. While he was in the ED he became hypotensive to the
80s and received several IVF totalling to 750cc. He had an
episode of melena and coffee ground emesis. He was lavaged
which resulted in bright blood (thought to be traumatic) that
cleared quickly with few coffee grounds, no bile was drawn back.
CTA torso showed no PE or abdominal perforation. EKG also
showed no ST depressions in lateral leads, but troponin 0.06.
Renal was consulted and concerned about K of 6.1 and recommended
urgent dialysis. During his ED stay he received 5mg IV morphine
for epigastric pain, started on a protonix drip. Pt was
transfered to MICU with 2PIVs and stable vital signs.
.
In the MICU, patient reports continued epigastric discomfort,
but no further nausea, emesis, or melena.
.
ROS:
Denies fevers, chills, change in weight, headache, dizziness,
orthopnea/PND or palpitations, urine production, lower extremity
edema, new pains, rash.
Past Medical History:
[**7-/2121**]: Rx allergy: Cephalosporins (cefazolin), s/p graft
embolect
- Subdural Hematoma: ER [**Hospital1 18**] [**6-19**]
- ESRD s/p kidney transplant and rejection, now on hemodialysis
- Glomerulonephritis
- CAD: cardiac cath [**2119-9-26**]: completely occluded LCx
(unchanged since [**2113**]), 50% lesion LAD (vs 30% prior) &
completely stenotic RCA
- Cath [**2119-9-28**] s/p 2 Xience [**Year (4 digits) **] to RCA after rotablation of
heavily calcified artery
- Hyperparathyroidism
- Anemia
- Gout
- Hyperlipidemia
- Hypertension
- Eosinophilia (? 2o Strongloides)
- Multiple lung nodules of unknown etiology
- Hypogonadism
- Obesity
- Bronchospasm
- Hx PPD positive but ruled out for pulmonary TB recently
- chronic SDH s/p [**2119**]
- [**2121-8-25**] Left IJ tunnelled catheter placement
.
PAST SURGICAL HISTORY:
- Cardiac catherization on [**2119-9-28**] s/p 2 Xience [**Year (4 digits) **] to RCA
after rotablation of heavily calcified artery.
- [**2113**] - Left brachial artery to cephalic vein primary AV
fistula.
- [**2114**] - Revision of AV fistula with ligation of side branches
- [**2114**] - Creation of left upper arm arteriovenous graft,
brachial to axillary.
- [**2115**] - Thrombectomy with revision of left arm arteriovenous
(AV) graft
- [**2115-4-11**] Cadaveric kidney transplant, right iliac fossa. (Dr.
[**First Name (STitle) **]
- [**2117-8-13**] - Right upper arm brachial - axillary graft (Dr.
[**First Name (STitle) **]
- [**2119**] - RUE AVG Fistulogram, angioplasty of intragraft
partially occluding clot
- [**2120**] - RUE AVG Thrombectomy, fistulogram, arteriogram, 8-mm
balloon angioplasty of outflow stenoses.
- [**2121**] RUE graft thrombectomy
- [**2121**] [**2121-12-12**] tunneled HD catheter placement and AV fistula
ligation
Social History:
-Tobacco: smoked for a few years as a teenager
-EtoH: denies
-Illicits: denies
-Lives alone w Cat; has three sons that are not very involved in
his life; walks with a cane. Has VNA once a month and meals on
wheels.
-Previously worked as a zoo keeper [**Last Name (NamePattern1) 20122**] Zoo
Family History:
No history of kidney disease, + history for DM, HTN
Physical Exam:
ADMISSION EXAM:
GENERAL - well-appearing gentleman, sedated, in NAD, no
respiratory distress, warm to touch.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, trace edema bilaterally., 2+ peripheral
pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Discharge exam
O: 98.0 136/88 75 18 100%ra
GENERAL - obese latino male in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use. Hematoma on back is
unchanged.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, trace edema bilaterally, 2+ peripheral pulses
(radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission labs
[**2122-5-14**] 02:45PM BLOOD WBC-11.6* RBC-3.17*# Hgb-8.5*# Hct-29.4*#
MCV-93 MCH-26.9* MCHC-29.0* RDW-19.5* Plt Ct-183
[**2122-5-14**] 09:48PM BLOOD WBC-13.6* RBC-2.59* Hgb-7.1* Hct-23.9*
MCV-92 MCH-27.3 MCHC-29.6* RDW-19.4* Plt Ct-168
[**2122-5-14**] 02:45PM BLOOD Glucose-144* UreaN-137* Creat-8.7*#
Na-137 K-6.1* Cl-97 HCO3-20* AnGap-26*
[**2122-5-14**] 02:45PM BLOOD ALT-25 AST-20 AlkPhos-107 TotBili-0.2
[**2122-5-14**] 02:45PM BLOOD Albumin-3.4* Calcium-7.5* Phos-3.1#
Mg-2.9*
.
Cardiac labs
[**2122-5-14**] 02:45PM BLOOD CK-MB-4 cTropnT-0.06* proBNP-4103*
[**2122-5-14**] 09:48PM BLOOD cTropnT-0.05*
[**2122-5-15**] 02:26AM BLOOD CK-MB-3 cTropnT-0.10*
[**2122-5-15**] 09:53AM BLOOD CK-MB-4 cTropnT-0.15*
.
Discharge labs
[**2122-5-18**] 06:30AM BLOOD WBC-8.5 RBC-2.96* Hgb-8.5* Hct-28.1*
MCV-95 MCH-28.8 MCHC-30.3* RDW-19.0* Plt Ct-153
[**2122-5-18**] 06:30AM BLOOD Glucose-119* UreaN-49* Creat-8.1*# Na-135
K-4.4 Cl-94* HCO3-27 AnGap-18
[**2122-5-18**] 06:30AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.3
.
EKG [**2122-5-14**]: Sinus rhythm. Left atrial abnormality with a change
in atrial morphology compared to the previous tracing of
[**2122-1-20**]. There are new ST-T wave changes recorded in leads I
and aVL as compared with prior tracing which may represent
active lateral ischemic process. Followup and clinical
correlation are suggested.
.
EKG [**2122-5-15**]: Sinus rhythm. Compared to the previous tracing of
[**2122-5-15**] there is further improvement inthe inferolateral ST-T
wave abnormalities. Followup and clinical correlation are
suggested.
.
CXR [**2122-5-14**]: No acute cardiopulmonary process. Persistent
increased
interstitial markings in the lungs compatible with chronic
interstitial
disease. Interval resolution of the right mid lung opacity since
prior.
.
CTA [**2122-5-14**]:
1. No evidence of acute pulmonary embolism or acute aortic
dissection.
2. Extensive atherosclerotic disease involving the aorta, major
visceral
arteries and coronary arteries.
3. No evidence of bowel perforation or other acute abdominal
pathology.
4. Scattered colonic diverticulosis without evidence of acute
diverticulitis.
.
EGD [**2122-5-15**]:
Esophagus:
Lumen: A medium size hiatal hernia was seen.
Mucosa: A salmon colored mucosa distributed in a segmental
pattern, suggestive of long segment Barrett's Esophagus was
found.
Stomach:
Mucosa: Localized erythema and erosion of the mucosa with no
bleeding were noted in the antrum. These findings are compatible
with Moderate gastritis.
Duodenum:
Mucosa: Diffuse continuous friability, erythema and congestion
of the mucosa with no bleeding were noted in the duodenal bulb
compatible with Moderate duodenitis.
Excavated Lesions Five ulcers ranging in size from 4 mm to 6 mm
were found in the duodenal bulb. Two of these had visible vessel
in center. 6 cc epinephrine was injected in one and 4 cc in the
other. 2 Endoclips were placed on the the larger ulcer
successfully.
IMPRESSION:
Medium hiatal hernia
Moderate gastritis
Moderate duodenitis
Ulcers in the duodenal bulb
Mucosa suggestive of Barrett's esophagus
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
70 yom with history of ESRD on HD, CAD s/p [**Month/Day/Year **] in [**2120**], p/w
epigastric pain, hematemesis, melena, and dyspnea X 1 day, found
to have duodenal ulcers, s/p clipping and epinephrine, with
course complicated by demand ischemia.
.
# Hematemesis/Melena, GI bleeding, acute bood loss anemia: Pt
with Hct drop to 23.9 from 29.4 on admission. He received 2
units of PRBC transfused on [**2122-5-14**]. He was briefly intubated
for EGD performed on [**5-15**] which showed multiple duodenal ulcers,
two with visible vessels. Both were injected with epinephrine,
and 2 Endoclips were placed on the the larger ulcer
successfully. He was quickly extubated without complication.
HCT remained stable thereafter. His diet was advanced to
clears, and he was maintained on [**Hospital1 **] PPI. Low dose aspirin 81mg
was restarted given his CAD, and decision to restart plavix was
made. His Cardiologist was [**Name (NI) 653**], and [**Name2 (NI) 20207**] a note
from [**2120**]:
.
"This patient has a drug-eluting stent placed in [**2121-1-8**]
for recurrent in-stent restenosis inside a prior drug-eluting
stent from [**2119-9-9**]. He should be on uninterrupted aspirin
for life as well as lifelong clopidogrel (or equivalent
anti-platelet) therapy given the anatomical substrate of a
bilayer of drug-eluting stents that puts him at very high risk
for late and very late stent thrombosis. Late stent thrombosis
carries significant mortality and morbidity risks. The only
circumstance for which we would consider stopping dual
anti-platelet therapy would be intracranial bleeding."
.
He was put back on aspirin 325mg daily and plavix 75mg daily. He
was started on low dose BB, and as he tolerated this well his
home metoprolol succinate 100mg daily was restarted. Because he
is high-risk to bleed, and remains on dual-anti-platelet
therapy, he should have several hct checks in the near future.
His home PPI was also increased.
.
Additionally, an H pylori serology was checked, and came back
equivocal. As this is a potentially reversible risk factor, it
was decided to treat him with PPI, metronidazole x 10 days (he
has PCN allergy), and clarithromycin x10 days.
.
# Hypotension: In the setting of his GIB. This resolved, and he
remained normotensive. We continued to hold his home
antihypertensives in the MICU and these were restarted on the
floor, where his pressures remained stable.
# Demand Ischemia: Pt with EKG on admission showing ischemic
appearing T waves in I and aVL, as well as ST-T wave flattening
in leads V5-V6 andII and aVF. This was concerning for ischemia,
but eventually resolved on subsequent EKG. Thought to be demand
related to the setting of hypotension and anemia. Aspirin 325
and plavix 75 daily were restarted. He was continued on his home
pravastatin 10mg daily, and his LDL was at goal <70. He was
symptomc free on discharge.
.
# Interstitial lung diseae: Initially maintained on IV
methylprednisolone in the setting of his NPO status, and once
diet was advanced he was restarted on home dose of prednisone
30mg, with bactrim PPX. Given his upper GI bleed, his
pulmonologist was [**Name (NI) 653**], and felt that his prednisone could
be lowered to 20mg daily. He will f/u w/ pulmonary on [**5-21**]
.
# CKD on HD: MWF dialysis sessions. Dialysis was deferred on
Friday [**5-15**] given hypotension, but was restarted the following
day. He was continued on sevelemer, calcinet, and nephrocaps,
though sevelemer dose was decreased, and calcium acetate
started, per renal recommendations. Last dialysis sessions was
Monday [**5-18**].
.
# CAD, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **]: As above, initially held ASA, plavix, BB
given that patient was bleeding and hypotensive. He was
maintained on his pravastatin 10mg daily. Eventually, all CAD
meds (see above) were restarted. His aspirin and plavix should
NEVER be stopped, except in setting of truly life-threatening
bleed, given the way this pt is stented puts him at very high
risk for in-stent thrombosis. Per Dr [**Last Name (STitle) **]: "need to balance the
risk and consequences of recurrent GI bleeding vs. the risks and
consequences of stent thrombosis in his RCA. Patients with stent
thrombosis carry a 20-40% mortality and a 30-40% chance of a
large non-fatal MI"
.
# Gout: Continued allopurinol.
.
# Code status: full (confirmed)
===================================
TRANSITIONAL ISSUES
# needs to have hct checked frequently in near future to ensure
no recurrent bleeding
# Repeat EGD 4-6 weeks, per GI.
Medications on Admission:
allopurinol 100 mg qod
B complex-vitamin C-folic acid 1 mg daily
clopidogrel 75 mg daily
metoprolol succinate 100 mg daily
sevelamer carbonate 800 mg 5 tabs tid
pravastatin 10 mg daily
aspirin 325 mg daily
cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
oxycodone 5 mg Tablet q6h prn pain
fluticasone 50 mcg/Actuation Spray daily
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler prn
docusate sodium 100 mg daily
Bactrim DS [**Name (NI) 20208**] (unclear if taking)
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other
day.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
4. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Nasal once a day.
9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation PRN as needed for shortness of breath or
wheezing.
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO M/W/F ().
11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
13. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. 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*
15. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
18. Outpatient Lab Work
[**2122-5-20**]: Hematocrit - Please fax results to Dr. [**First Name (STitle) **].
Phone: [**Telephone/Fax (1) 608**]
Fax: [**Telephone/Fax (1) 4647**]
Discharge Disposition:
Home
Discharge Diagnosis:
duodenal ulcers, gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 20118**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for a gastrointestinal bleed. This was found to be from ulcers
in your stomach. For this, you had an endoscopy, and the
bleeding was stopped. Changes were made to your medications,
which should also help prevent more bleeding.
Your duodenal ulcers may be related to a stomach infection from
Helicobacter pylori. This is a common infection that can
pre-dispose you to ulcers. You will receive 10 days of
antibiotics to treat this infection.
Please have your blood counts (Hematocrit) checked at dialysis
on Wednesday.
You will follow-up with the GI doctors and [**Name5 (PTitle) **] likely need
another endoscopy in 4 - 6 weeks.
The following changes were made to your medications:
** DECREASE sevalamer to 800mg tablets, take THREE (3) tablets
THREE (3) times a day (you had previously been taking 5 tablets
3 times a day)
** DECREASE prednisone to 20mg once daily (you had been on 30mg
once daily)
** START pantoprazole 40mg by mouth twice daily (You will take
this instead of the 20 mg daily dose you were previously taking)
** START calcium acetate 667mg tablet, 1 tablet three times a
day with meals
** START metronidazole 500mg by mouth twice a day for 10 days
[antibiotic]
** START clarithromycin 500mg by mouth twice a day for 10 days
[antibiotic]
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: MONDAY [**2122-5-25**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**], MD [**Telephone/Fax (1) 608**]
Building: 545A Centre St. ([**Location (un) 538**], MA) None
Campus: OFF CAMPUS Best Parking:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2122-6-3**] at 2:30 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], 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
Department: PFT
When: THURSDAY [**2122-5-21**] at 1 PM
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2122-5-21**] at 1 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2122-5-21**] at 2:00 PM
With: DR. [**Last Name (STitle) 11071**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"40391",
"2851",
"V4582",
"2724",
"2767"
] |
Admission Date: [**2178-6-26**] Discharge Date: [**2178-7-3**]
Date of Birth: [**2109-7-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Heparin Agents / Lovenox / Adhesive Bandages
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left fibrothorax.
Major Surgical or Invasive Procedure:
[**2178-6-26**] Left thoracotomy and total pulmonaryn decortication
including parietal pleurectomy, flexible bronchoscopy with
bronchoalveolar lavage.
History of Present Illness:
Mr. [**Known lastname **] is a 68-year-old gentleman who has had bilateral
recurrent pleural effusions. He had a decortication on the right
to address this which
revealed significant fibrothorax and trapped lung. He has had
this same process affecting his left hemithorax and, therefore,
we consented him for decortication to prevent recurrent
effusion. He also has significant dyspnea and it was unclear
whether relief of his fibrothorax may improve his
dyspnea though that was a possibility though not guaranteed.
Past Medical History:
1. Bicuspid aortic valve, status post St. [**Male First Name (un) 923**] mechanical aortic
valve replacement in [**2160**]
2. Atrial fibrillation diagnosed since [**2175-9-17**],
currently on Coumadin therapy
Social History:
Significant for the absence of current tobacco use. daily ETOH
[**1-21**] drinks per day.
Family History:
There is no family history of premature coronary artery disease
or sudden death. +grandfather with MI and DM
Physical Exam:
VS: T 97.6 HR 88 Afib SBP 116/64 Sats: 97% RA
General: walking in halls in no distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: irregular, good click
Resp: decreased breath sounds on right, faint crackles LLL
GI: benign
Extr: warm no edema
Incision: Left thoracotomy site clean mild erythema around
margin, cool no discharge
Neuro: non-focal
Pertinent Results:
[**2178-6-30**] WBC-4.2 RBC-2.65* Hgb-9.1* Hct-27.2 Plt Ct-153
[**2178-6-29**] WBC-5.6 RBC-2.80* Hgb-9.6* Hct-28.5* Plt Ct-143*#
[**2178-6-26**] WBC-5.6# RBC-4.55* Hgb-15.9 Hct-47.0 Plt Ct-118*
[**2178-6-29**] Glucose-137* UreaN-16 Creat-1.0 Na-139 K-3.8 Cl-102
HCO3-29
[**2178-6-26**] Glucose-138* UreaN-22* Creat-0.9 Na-139 K-3.9 Cl-106
HCO3-25
[**2178-6-29**] Calcium-8.7 Phos-2.8 Mg-2.2
Culture Pleural Fluid [**2178-6-26**] no growth
CXR:
[**2178-7-2**] There is a minimal millimetric apical medial
pneumothorax. Signs of tension are not present. Small left basal
pleural
effusion that is unchanged. Also unchanged is the right-sided
pleural
effusion. The preexisting rib fracture is less well recognized
than on the
previous exam. The size of the cardiac silhouette is unchanged.
[**2178-6-29**] 1. Persistent small bilateral pleural effusion, mild
left basal atelectasis and costal pleural thickening, but no
pneumothorax.
[**2178-6-27**] IMPRESSION: Left lower lobe new retrocardiac opacity
consistent with interval development of atelectasis that might
be accompanied by pleural effusion. Interval improvement of
subcutaneous air. The left fifth posterior rib fracture is most
likely post-surgical.
[**2178-7-3**] 06:20AM BLOOD WBC-4.8 RBC-2.94* Hgb-10.2* Hct-30.1*
MCV-102* MCH-34.6* MCHC-33.8 RDW-15.0 Plt Ct-226
[**2178-7-3**] 06:20AM BLOOD Plt Ct-226
[**2178-7-3**] 06:20AM BLOOD PT-18.3* INR(PT)-1.7*
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2178-6-26**] for Left thoracotomy and
total pulmonary
decortication including parietal pleurectomy, flexible
bronchoscopy with bronchoalveolar lavage. He was transferred to
SICU intubated.
Pulmonary: He was extubated on [**2178-6-27**]. He required aggressive
pulmonary toilets and nebs and diuresis. His oxygen saturation
on 1 Lites high 90's which dropped to the high 89's with
ambulation. His oxygenation improved over the course of his
hospitalization, RA saturations 97% RA He continued on his home
CPAP at night.
Chest tubes: 3 28 french chest-tubes: basilar, posterior &
anterior apical remained on suction until [**2178-6-30**] then placed
to water-seal. The drainage was serousanguiounous. They were
removed on [**2178-7-2**]. He was followed by serial chest films which
revealed atelectasis/sm effusion.
Cardiac: He was hypotensive immediately postop with a good
response to neo and volume. He was started on his home
medications for atrial fibrillation.
Heme: We was restarted on his fondaparinox on [**2178-6-28**] for his
mechanical valve. He chest tube drainaged was monitored for
bleeding which none occurred. He was then restarted on his
warfarin [**2178-6-30**] for a goal INR 2.0-3.0
Renal: Administered lasix with 1.8 Liter output. Renal function
remained normal.
FEN: Electrolytes were repleted as needed. He tolerated a
regular diet.
Pain: His epidural was managed by acute pain with good pain
control which was removed on [**2178-6-27**]. His pain was well
controlled via Dilaudid PCA converted to PO pain medication.
Disposition: Plan home with VNA. He will follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
atenolol 25 mg daily, folic acid 1 mg daily, furosemide 20 mg
[**Hospital1 **], probenecid 500 mg [**Hospital1 **], isosorbide mononitrate 30 mg daily,
warfarin 5/2.5 mg alternating.
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Probenecid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO as directed: Goal
INR 2.0-3.0.
9. Fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily): stop when INR > 2.0.
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Left fibrothorax
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops drainage
-Chest tube site remove dressing Saturday and cover with a
bandaid until healed
-You may shower on Saturday. No tub bathing or swimming for 6
weeks
-No driving while taking narcotics
-Walk 4-5 times a day for 10 mins increased to goal of 30 mins
daily
Warfarin: Take Fonadarinux until INR 2.0 or greater
Warfarin continue home dose as previous
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**7-16**] 2:00 pm on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment
Follow-up with Dr. [**Last Name (STitle) 2912**] [**Telephone/Fax (1) 25005**] for further warfarin
doses. INR Goal 2.0-3.0. Please have your Blood drawn on
Monday and call Dr.
[**Last Name (STitle) 2912**] for further warfarin doses.
Completed by:[**2178-7-3**]
|
[
"5180",
"2875",
"42731",
"V5861"
] |
Admission Date: [**2141-7-9**] Discharge Date: [**2141-7-28**]
Date of Birth: [**2095-10-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p trauma
Major Surgical or Invasive Procedure:
[**2141-7-14**]: Inferior vena cava filter placement; Closed treatment,
pelvic ring fracture with manipulation, axis application of
uniplanar external fixator to the pelvis.
[**2141-7-19**]: Placement of tracheostomy tube
[**2141-7-20**]:
1. Removal of external fixator.
2. Open reduction of the anterior symphyseal disruption.
3. Open reduction internal fixation right sacroiliac joint.
[**2141-7-27**]:
Percutaneous gastrostomy
History of Present Illness:
This patient is a 45 year old male who was transferred from OSH
s/p MCC.
From outside hospital after a high-speed motorcycle accident
where he was struck by a motor vehicle, reportedly thrown
approximately 40 feet. He was found with a GCS of 3
intubated on the scene, hypotensive on arrival to outside
hospital, given blood and found to have a open book pelvic
fracture. Reportedly, his blood pressure improved with
pelvic binding, but according to med flight, his blood
pressure was in the 60s to 70s en route
Past Medical History:
Hyperlipidemia
Social History:
Lives with spouse and has 3 children
Family History:
non-contributory
Physical Exam:
On admission:
Constitutional: Intubated, critically ill
HEENT: Pupils equal, round and reactive to light
C. collar in place
Chest: No crepitus
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, positive fast exam
GU/Flank: No costovertebral angle tenderness
Extr/Back: No gross long [**Doctor Last Name 534**] deformity
Skin: Multiple abrasions throughout
Neuro: Revised sedated
On discharge:
Vitals: T: 99.0 P: 94 BP: 118/70 R: 18 O2sat: 99% trach mask
GEN: Alert, interactive. NAD. Follows commands.
HEENT: Atraumatic, PERRLA. Tongue appearance consistent with
thrush infection. Tracheostomy tube in place.
CV: RRR
PULM: CTAB
ABD: Soft, nontender, nondistended. PEG tube in place.
Skin: Multiple well-healed abrasions
Pertinent Results:
[**2141-7-9**] 03:30AM WBC-15.7* RBC-4.70 HGB-14.9 HCT-43.9 MCV-93
MCH-31.7 MCHC-33.9 RDW-14.4
[**2141-7-9**] 03:30AM PLT COUNT-178
[**2141-7-9**] 03:30AM PT-13.7* PTT-40.1* INR(PT)-1.3*
[**2141-7-9**] 03:30AM FIBRINOGE-82*
[**2141-7-9**] 03:30AM ASA-NEG ETHANOL-163* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2141-7-9**] 03:30AM LIPASE-177*
[**2141-7-9**] 03:30AM UREA N-15 CREAT-1.5*
[**2141-7-9**] 03:34AM GLUCOSE-156* LACTATE-4.5* NA+-141 K+-3.6
CL--111* TCO2-20*
[**2141-7-9**] 04:32AM TYPE-ART PO2-201* PCO2-38 PH-7.22* TOTAL
CO2-16* BASE XS--11
[**2141-7-9**] 05:45AM GLUCOSE-138* UREA N-15 CREAT-1.2 SODIUM-143
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-15* ANION GAP-23*
[**2141-7-9**] 05:45AM CALCIUM-6.6* PHOSPHATE-5.2* MAGNESIUM-1.8
[**2141-7-9**] 05:45AM CK-MB-22* MB INDX-2.1
[**2141-7-9**] 05:45AM CK(CPK)-1046*
CT HEAD W/O CONTRAST Study Date of [**2141-7-9**] 3:37 AM
No acute intracranial hemorrhage or mass effect
CT ABD & PELVIS/CHEST WITH CONTRAST Study Date of [**2141-7-9**] 3:38
AM
IMPRESSION:
1. Grade 3 liver laceration with active extravasation resulting
in
intraperitoneal hematoma. As a result, the IVC is collapsed and
the adrenals are hyperenhancing consistent with
hypovolemia/hypoperfusion.
2. Stranding of the small bowel mesentery, with fluid seen
between leaves of a mesentery and small foci of active
extravasation concerning for mesenteric injury. Enteric injury
is not excluded, though no free air is seen.
3. Diastasis of the pubic symphysis, disruption of the right
sacroiliac joint and right sacral fracture, with multiple foci
of active extravasation within the pelvis resulting in a large
pelvic hematoma.
4. Non-displaced posterior rib fractures of the first and
second ribs and left third rib, without mediastinal hematoma or
evidence of great vessel injury.
5. Left L2 and L3 spinous process fractures and T4 and T5
spinous process avulsion fractures.
6. Partially visualized right acromion and scapular fractures.
CT C-SPINE W/O CONTRAST Study Date of [**2141-7-9**] 3:38 AM
There is levoscoliosis with reversal of cervical lordosis.
There is asymmetry in the atlanto-occipital joints, right being
slightly wider than the left. there is also mild widening of the
lateral atlanto-axial joints on both sides; however, symmetric.
[**2141-7-10**] TTE:
IMPRESSION: Right ventricular cavity enlargement with free wall
hypokinesis c/w possible RV contusion or other primary RV
process. Normal left ventricular cavity size with preserved
global and regional systolic function. Normal ascending aortic
diameter.
[**2141-7-28**] 05:46AM BLOOD WBC-6.7 RBC-3.34* Hgb-10.5* Hct-31.8*
MCV-95 MCH-31.3 MCHC-32.9 RDW-15.5 Plt Ct-388
[**2141-7-28**] 05:46AM BLOOD Glucose-112* UreaN-16 Creat-0.8 Na-140
K-4.0 Cl-103 HCO3-30 AnGap-11
[**2141-7-28**] 05:46AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.2
[**2141-7-23**] 12:17 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2141-7-26**]**
GRAM STAIN (Final [**2141-7-23**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2141-7-25**]):
THIS IS A CORRECTED REPORT ([**2141-7-26**]).
STAPH AUREUS COAG +. MODERATE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
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.
ERYTHROMYCIN PREVIOUSLY REPORTED WITH AN MIC OF 0.5
MCG/ML
([**2141-7-25**]).
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Brief Hospital Course:
The patient was transferred to the trauma ICU under the Acute
Care Surgery service for close monitoring. He remained in the
ICU until [**2141-7-26**] when he was stable both hemodynamically and
from a respiratory standpoint, at which time he was transferred
to the surgical floor. He is medically stable and ready for
discharge on [**2141-7-28**]. His hospital course is summarized by
systems below:
Neuro: He was intubated and sedated. He was intermittently
paralyzed in order to optimize vent synchronization. Once his
sedation was weaned, he slowly became more responsive
mental-status wise. He responded appropriately to his family and
eventually to nursing. He was started on standing serquel which
was changed to prn as his agitation improved. At the time of
discharge he is alert, interactive and following commands.
On his admission c-spine CT scan, widening at the
atlanto-occipital joint was noted. He remained in c-collar and
neurosurgery was consulted, who recommended that he remain in
the hard c-collar for 1 month.
Pulm: He was intubated and mechanically ventilated. He had
increasing vent requirements and a CT scan showed ARDS. He was
started on ARDS protocol for vent settings and his oxygenation
improved. He was also treated for a VAP, with cultures initially
growing MSSA & proteus. Repeat sputum culture also showed MSSA.
He continued on a high PEEP due to his ARDS and he was started
on a lasix gtt in order to improve oxygenation. He continued to
diurese well. He was weaned off of the vent until he tolerated
trach mask for almost 24 hours starting on [**7-24**]. On transfer to
the floor his oxygenation was stable on trach mask. His MSSA
pneumonia is being treated with levofloxacin with the course to
be completed on [**2141-8-3**]. He remains afebrile with a normal WBC
count.
CV: He was on pressors initially when he was hypotensive in the
ICU. There was concern for continuing abdominal bleed or occult
bowel injury but CT torso did not show evidence of active bleed.
He was eventually weaned off pressors and remained stable. Echo
on [**7-10**] showed EF >55%, RV cavitary enlargement w/ wall
hypokinesis. He remained off pressors since [**7-14**]. His vital
signs are currently stable at the time of discharge.
GI: He was kept NPO/IVFs. A dobhoff was placed and he received
nutrition through tube feeds. On [**2141-7-27**] he had a PEG placed and
he was started on TF the next day. Given his improved mental
status a speech and swallow evaluation was performed on [**7-28**] and
he was cleared for a ground solid and thin liquid diet.
GU: His UOP was monitored. He received multiple boluses of
fluids for resuscitation. His foley catheter remained in place
with adequate urine output. It was removed on [**7-28**] prior to
transfer to rehab.
Heme: He was transfused pRBCs as needed for a dropping hct. He
received 10u pRBC on arrival for active extravasation in his
abdomen. He went to IR for embolization of his abdominal bleeds,
no extravasation was seen in the pelvis but liver bleed was
embolized. His hematocrit continue to trend downward and a
repeat CTA revealed no active bleed. He received a total of 16u
of pRBCs while in the ICU. On the floor he remained without
active signs of bleeding a stable hematocrit.
MSK: His pelvis was wrapped for stabilization, initially. He had
an ex-fix on [**7-14**] and ORIF on [**7-20**]. Physical therapy worked
with him during his ICU course and did passive range of motion
exercises. He was eventually allowed to have LLE full weight
bearing and RLE touchdown weight bearing after his ORIF.
ID: He had severe ARDS as well as a VAP with cultures growing
MSSA and proteus. He was on an 7 day course of
vanc/cipro/cefepime (stopped on [**7-18**]). He was restarted on vanc
on [**7-23**] for GPCs growing in sputum. The vanc was changed to PO
levofloxacin on [**7-25**] in order to transition the patient to PO
medications. He was noted to have thush infection when on the
ventilator in the ICU and was started on nystatin at that time.
Prophylaxis: He had a IVC filter placed on [**7-14**]. He received
subQ heparin as well once his hematocrit remained stable. His
anticoagulation was later changed to lovenox 40 mg daily per
orthopedics recommendations.
On [**7-28**] he is afebrile with stable vital signs. His mental
status continues to improve. His respiratory status is stable.
He has no active signs of bleeding. He is being discharged to
rehab with follow up in [**Hospital 2536**] clinic, ortho clinic, and
neurosurgery clinic.
Medications on Admission:
? cholesterol medication, unknown
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H fever, pain
2. Albuterol-Ipratropium [**4-7**] PUFF IH Q4H:PRN wheezing
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Metoprolol Tartrate 25 mg PO BID
7. Senna 1 TAB PO BID Constipation
8. Levofloxacin 750 mg PO DAILY Duration: 7 Days
last dose [**2141-8-3**]
9. Enoxaparin Sodium 40 mg SC DAILY
10. Nystatin 500,000 UNIT PO Q8H thrush
11. OxycoDONE Liquid 10-20 mg NG Q4H:PRN pain
12. Quetiapine Fumarate 25 mg PO BID:PRN agitation
13. traZODONE 25 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Trauma s/p motorcycle crash:
- Open book pelvic fracture with active extravasation
- Posterior 1st, bilateral 2nd, Left 3rd rib fractures
- Segment VI liver laceration with active extravasation
- Subcapsular splenic laceration
- Right colic perivascular hematoma
- Atlanto-occipital joint widening
- L2-L3, T4-T5 spinous process fractures
- Right acromium fracture
- Acute Respiratory Distress Syndrome
- Sepsis
- Ventilator-associated pneumonia
- Acute blood loss anemia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital after a motorcycle crash. You
sustained multiple injuries from your accident. You required a
stay in the intensive care unit. You are now being discharged to
rehab to continue your recovery.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2141-8-15**] at 4:30 PM
With: Dr. [**Last Name (STitle) **] [**Name (STitle) **] in the ACUTE CARE CLINIC
Phone: [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROSURGERY
When: WEDNESDAY [**2141-8-16**] at 11:45 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2141-8-8**] at 8:00 AM
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
Department: ORTHOPEDICS
When: TUESDAY [**2141-8-8**] at 7:40 AM
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
Completed by:[**2141-7-28**]
|
[
"78552",
"0389",
"99592",
"2760",
"2851",
"4019",
"2720"
] |
Admission Date: [**2139-12-15**] Discharge Date: [**2139-12-21**]
Date of Birth: [**2080-2-7**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is 59 year old male
with known coronary artery disease. He reported new onset
angina with radiation to arms and upper back times two months
which was brought on by activity and usually relieved with
rest. He had a positive stress test on [**2139-12-7**], with
chest pain and ST segment depression. On [**2139-12-9**], he
underwent cardiac catheterization which revealed three vessel
disease. He was now referred to the Cardiac Surgery Service
for surgical intervention or bypass surgery. As well as the
chest pain, he also reported dyspnea on exertion, fatigue and
diaphoresis.
PAST MEDICAL HISTORY: Hypercholesterolemia.
PAST SURGICAL HISTORY: Tonsillectomy.
Minor back surgery for removal of tumor.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lipitor 10 mg p.o. daily.
2. Aspirin 325 mg p.o. daily.
SOCIAL HISTORY: He lives in [**Location 5289**] with his wife. [**Name (NI) **] is a
current tobacco smoker with a forty pack year history. He
works full time as a project manager, and he drinks a couple
beers a day.
FAMILY HISTORY: He has no family history of coronary artery
disease.
REVIEW OF SYMPTOMS: All review of systems are negative
except the ones that were mentioned in the history of
presenting illness.
PHYSICAL EXAMINATION: The patient is five foot ten inches,
180 pounds, pulse 64, sinus rhythm, blood pressure 150/90,
respiratory rate 21. The patient was generally lying flat in
bed in no acute distress. He is awake, alert and oriented
times three, responding appropriately to all questions and
commands. He had fine rales at the right lung base. His
heart rate was regular rate and rhythm, positive S1 and S2,
no clicks, rubs or murmurs or gallops. His abdomen was soft,
flat, nontender, nondistended with positive bowel sounds.
His extremities were warm and well perfused, nonedematous
without any varicosities. His pulses were bilateral radial
pulse two plus, bilateral dorsalis pedis pulses one plus and
bilateral posterior tibial pulses were two plus.
LABORATORY DATA: His preoperative chest x-ray showed no
acute cardiopulmonary process. Preoperative
electrocardiogram was 62 beats per minute, sinus rhythm. His
urinalysis was negative. His preoperative laboratories were
as follows: White blood cell count 6.7, hematocrit 37.6,
platelet count 202,000. Sodium 139, potassium 3.8, chloride
106, bicarbonate 24, blood urea nitrogen 10, creatinine 0.8,
glucose 92. Prothrombin time 12.9, partial thromboplastin
time 26.5, INR 1.0. ALT 16, AST 20, alkaline phosphatase 79,
total bilirubin 0.4, albumin 4.2. Urinalysis was negative.
Hemoglobin A1C was 5.8. His cardiac catheterization results
were as follows: He had a totally occluded left anterior
descending coronary artery after a proximal mild lesion of 30
percent and his left circumflex was 60 percent occluded.
Obtuse marginal one was 90 percent and his right coronary
artery was totally occluded and ejection fraction was 60
percent.
HO[**Last Name (STitle) **] COURSE: On [**2139-12-15**], the patient was brought into
the operating room and after being intubated and Foley
induced by anesthesia, he underwent coronary artery bypass
graft times three. Grafts were as follows: left internal
mammary artery to the left anterior descending coronary
artery, saphenous vein graft to obtuse marginal, saphenous
vein graft to diagonal. This procedure was performed by Dr.
[**Last Name (Prefixes) **]. The patient tolerated the procedure well. His
total cardiopulmonary bypass time was 97 minutes. His cross
clamp time was 65 minutes. Following the procedure, the
patient was transferred to the CSRU. He was receiving
Nitroglycerin drip 1 mcg/kg/minute and he was being titrated
on Propofol. His vital signs on transfer, he had a mean
arterial pressure of 63, CVP of 78 and heart rate of 81 beats
per minute and was being A paced. Later this day on
[**2139-12-15**], once the patient was in CSRU, he was successfully
extubated. On postoperative day number one, the patient was
hemodynamically stable with a blood pressure of 94/47, heart
rate 70, and he had an oxygen saturation of 99 percent on
three liters of nasal cannula. The plan today was to wean
and discontinue his Neo-Synephrine and Nitroglycerin which
was currently at 1.2 of Neo-Synephrine and 0.25 of
Nitroglycerin and to start Lasix. Due to poor target, to
start oral nitrates. Also, since apparently the patient was
a difficult intubation, it was thought that the patient would
need to have a swallowing evaluation which was performed on
postoperative day number two. On postoperative day number
two, the patient was hemodynamically stable and physical
examination was unremarkable. Swallowing evaluation
recommended soft liquids and then thin liquids, swallow with
head turned over right shoulder and with chin tucked to his
chest, alternate liquids and one sip to clear throat and if
the dysphagia was not resolved by Monday, the patient would
need a VV consult. On postoperative day number three, the
patient was transferred to a telemetry floor. The chest
tubes were discontinued. On postoperative day number four,
the patient was hemodynamically stable, no events overnight.
His physical examination was unremarkable. His pacing wires
were still intact. The plan was just to continue advanced
activity. The patient is out of bed with physical therapy,
occupational therapy and incentive spirometry. On
postoperative day number six, the patient appeared to be
doing well. There were no events overnight and he was
hemodynamically stable with pulse of 80, sinus rhythm, blood
pressure 136/74, respiratory rate 20. His epicardial pacing
wires were removed today and today is also the day that he
will be discharged. Physical examination on discharge date
of [**2139-12-21**], was as follows: He was neurologically alert
and oriented with no focal deficits. His lungs were clear
bilaterally. His heart rate was regular rate and rhythm.
His sternal incision was dry, no drainage, no erythema, and
it was stable. His abdomen was soft, nontender, nondistended
with positive bowel sounds. His extremities were warm and
nonedematous. His leg incision was clean and dry. There
were no chest tubes and no pacing wires were intact. He was
discharged to home with services in good condition.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass graft times three.
Hypercholesterolemia.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg one p.o. twice a day.
2. Ranitidine 150 mg one p.o. twice a day.
3. Aspirin 81 mg one p.o. daily.
4. Percocet 5/325 one to two tablets p.o. q4hours as needed
for pain.
5. Lipitor 10 mg p.o. daily.
6. Thiamine 100 mg p.o. daily.
7. Folic Acid 1 mg p.o. daily.
8. Lasix 20 mg p.o. daily for seven days.
9. Potassium Chloride 10 mEq two capsules p.o. q12hours.
10. Atenolol 25 mg p.o. daily.
11. Isosorbide Mononitrate 30 mg Sustained Release one
p.o. q24hours.
12. Nicotine Patch 14 mg per 24 hour patch, one patch
per 24 hours times seven days and then Nicotine 7 mg 24
hour patch, one patch 24 hours times two weeks.
FO[**Last Name (STitle) 996**]P: The patient was recommended to follow-up with Dr.
[**Last Name (Prefixes) **] in four weeks and follow-up with Dr. [**Last Name (STitle) **] in one
to two weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 40180**]
MEDQUIST36
D: [**2139-12-21**] 15:05:56
T: [**2139-12-21**] 20:28:12
Job#: [**Job Number 59572**]
|
[
"41401",
"2720"
] |
Admission Date: [**2198-6-28**] Discharge Date: [**2198-7-2**]
Date of Birth: [**2141-2-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**6-28**] Coronary Artery Bypass Graft x 5 (LIMA->LAD, SVGs ->OM1,
D1, D2, PDA)
History of Present Illness:
57 y/o male with recurrent syptoms of chest pain and dyspnea on
exertion post diag stenting in [**4-12**]. Again underwent cardiac
cath which revealed severe three vessel disease. Then referred
for surgical intervention.
Past Medical History:
Coronary Artery Disease s/p Diag stenting, s/p laser eye
surgery, partial herniated disc, s/p L knee hematoma,
hyperlipidemia, s/p R tear duct surgery
Social History:
Denies Tobacco or ETOH. Prosecutor for district Attorney.
Family History:
Mother died of MI at age 55.
Physical Exam:
VS: 55 158 130/74 5'7" 70.3kg
General: 57y/o male in NAD
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM -JVD
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused -edema, -varicosities, good pulses
throughout
Neuro: MAE, Non-focal, A&Ox3
Pertinent Results:
Echo [**6-28**]: PREBYPASS: Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is normal(LVEF>55%). There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. POSTBYPASS: Preserved biventicular
systolic function. Study is otherwise unchanged from prebypass.
CXR [**7-1**]:Single portable chest radiograph demonstrates interval
removal of mediastinal drains, left-sided chest tube, and
Swan-Ganz catheter when compared to [**2198-6-28**]. The lungs are
clear. No effusion. Cardiomediastinal contours are normal. The
patient is seen to be status post CABG. No pneumothorax.
[**2198-6-28**] 11:47AM BLOOD WBC-16.6*# RBC-3.09*# Hgb-8.9*#
Hct-26.1*# MCV-85 MCH-28.6 MCHC-33.9 RDW-13.9 Plt Ct-215
[**2198-6-29**] 01:28AM BLOOD WBC-9.8 RBC-3.39* Hgb-10.1* Hct-28.0*
MCV-83 MCH-29.9 MCHC-36.1* RDW-14.3 Plt Ct-269
[**2198-7-1**] 04:40AM BLOOD WBC-11.2* RBC-3.14* Hgb-9.5* Hct-26.6*
MCV-85 MCH-30.1 MCHC-35.6* RDW-14.5 Plt Ct-174
[**2198-6-28**] 12:45PM BLOOD PT-16.9* PTT-39.5* INR(PT)-1.6*
[**2198-6-30**] 03:14AM BLOOD PT-11.3 PTT-25.0 INR(PT)-0.9
[**2198-6-28**] 12:45PM BLOOD UreaN-13 Creat-0.6 Cl-109* HCO3-21*
[**2198-7-1**] 04:40AM BLOOD Glucose-109* UreaN-15 Creat-0.9 Na-136
K-4.3 Cl-99 HCO3-30 AnGap-11
[**2198-7-2**] 05:40AM BLOOD UreaN-14 Creat-0.7 K-4.3
Brief Hospital Course:
Admitted [**6-28**] and underwent cabg x5 with Dr. [**Last Name (STitle) **].
Transferred to the CSRU in stable condition on phenylephrine and
propofol drips. Extubated successfully and had a syncopal /vagal
episode on POD #1. His chest tube output remained high and he
received platelets and PRBCs. This improved, Swan removed, and
he was transferred to the floor on POD #2 to begin to increase
his activity level. Pacing wires removed on POD #3. He made
excellent progress with clear CXR on [**7-1**]. Cleared for discharge
to home with VNA on POD #4. Pt. to follow up per discharge
instructions.
Medications on Admission:
Atenolol 50mg qd, Aspirin 325mg qd, Plavix 75mg qd, Zocor 80mg
qd, Drixoril prn, Ciprofloxacin
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. 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*
6. Zocor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1
weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Southeastern MA VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
PMH: s/p Diag stenting, s/p laser eye surgery, partial herniated
disc, s/p L knee hematoma, hyperlipidemia, s/p R tear duct
surgery
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incisions, or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting or driving until follow up with surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) 12832**] 2 weeks
Dr. [**Last Name (STitle) 696**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
The following appoinments were already scheduled:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 10464**] Date/Time:[**2198-8-2**]
8:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 10464**] Date/Time:[**2198-11-22**]
11:40
Completed by:[**2198-7-13**]
|
[
"41401"
] |
Admission Date: [**2194-1-21**] Discharge Date: [**2194-2-5**]
Date of Birth: [**2115-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
78 year old white female who had post MI angina.
Major Surgical or Invasive Procedure:
CABGx3(LIMA-.LAD, SVG->OM1, Diag.) [**2194-1-30**]
[**Last Name (NamePattern4) 15255**] of Present Illness:
78 yr old female admitted to MW w/NQWMI last night and
transferred to [**Hospital1 18**] for eval by CT [**Doctor First Name **] for possible CABG. Pt
developed chest pressure, [**3-6**], while at rest on day of
admission to OSH. She states that it did not radiate and was
assoc with only a minimal amount of SOB, no nasuea, no
diaphoresis. She went to [**Hospital1 **] and the pain disappeared
after 3 hrs without any meds. On EKG, she was found to have ST
depressions inf/laterally and a CK 190, tropI 1.25. Pt started
on NTG at 11mcg/min and heparin gtt. BNP on admission of 340.
Cardiac cath @ MWMC today revealed: 40-50% LMCA, 80% LAD [**Last Name (un) 2435**].,
80% D1 [**Last Name (un) 2435**]., 80% [**First Name9 (NamePattern2) 8714**] [**Last Name (un) 2435**]., 40-50% RCA [**Last Name (un) 2435**]., and an LVEF of
50%. Transferred to [**Hospital1 18**] for CABG with Dr. [**Last Name (Prefixes) **]. She
is currently pain free.
.
ROS: productive cough x one week, no fevers/chills; no PND,
orthopnea or lower ext swelling, constipation (requires daily
digital disimpaction)
Past Medical History:
HTN
IBS
GERD
hx of tobacco use
Social History:
Lives alone, has 3 sons, one lives locally
Tobacco: smoked 1ppd x 20 yrs, quit 45 years ago
ETOH: none
Family History:
no CAD
no DM
Physical Exam:
temp 99.7, BP 164/62, HR 81, RR 20, O2 96% 4L
Gen: NAD, restless
HEENT: PERRL, EOMI, MMM, anicteric sclera
Neck: no bruits, JVP nl
CV: RRR, no g/m/r
Chest: crackles bilaterally at bases
Abd: soft, +BS, NTND
Groin: no bruit, thrill, no oozing
Ext: no edema, 2+ DP B
Neuro: CN 2-12 intact, pt is AO x 3 but vrey tangential and
restless
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2194-2-2**] 05:50AM 12.0* 3.85* 11.2* 34.1* 88 29.0 32.8 14.4
595*
BASIC COAGULATION (PT, PTT, PLT, INR) PT Plt Ct INR(PT)
[**2194-2-2**] 05:50AM 595*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2194-2-2**] 05:50AM 91 14 0.7 142 3.9 107 28 11
Brief Hospital Course:
The patient was admitted on [**2194-1-21**] and was in an agitated
state. She was pain free on IV NTG and heparin, and required
Haldol and Ativan for sedation. Psychiatry was consulted and
her agitation eventually resolved. She also had an infected
pilonidal cyst, which was cleared by general surgery, and had an
abdominal CT which showed a rectus sheath hematoma. She was
transfused 2 UPRBC and the hematoma stabilized once the heparin
was d/c'd. She was also evaluated by neurology who felt she has
a baseline dementia and cleared her for surgery as well.
Eventually she was cleared for surgery and on [**2194-1-30**] she had a
CABGx3 with LIMA->LAD, SVG->OM and Diag. She tolerated the
procedure well and was transferred to the CSRU in stable
condition on Epi and Propofol.
She was extubated on her post op night and was transferred to
the floor on POD#1. Her chest tubes were d/c'd on POD#2 and her
epicardial pacing wires were d/c'd on POD#3. She continued to
progress and had her pilonidal cyst debrided on POD#5. She was
discharged to rehab in stable condition on POD#6.
Medications on Admission:
lisinopril 20 daily
lopressor 50mg [**Hospital1 **]
asa 162 daily
Zantac 150 daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
11. Zantac 150 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 102084**] Rehab
Discharge Diagnosis:
Coronary artery disease
HTN
Infected pilonidal cyst
Rectus sheath hematoma
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 349**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 32255**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for [**2194-2-14**]
Make an appointment with Dr. [**Last Name (STitle) 70**] for 6 weeks.
Completed by:[**2194-2-5**]
|
[
"41071",
"4280",
"486",
"2851",
"41401",
"4019"
] |
Admission Date: [**2176-1-29**] Discharge Date: [**2176-2-7**]
Date of Birth: [**2116-5-13**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
Prostate Ca
Major Surgical or Invasive Procedure:
Radical prostatectomy
History of Present Illness:
Mr [**Known lastname **] is a 59-year-old gentleman with a
history of abnormal digital rectal exam. He had a prostate
needle biopsy approximately seven months ago which
demonstrated high grade PIN. A followup prostate biopsy
demonstrated a [**Doctor Last Name **] 3 plus 3 involving 40 percent of the
core on the right side. He presented to the hospital for a
radical retropubic prostatectomy with Dr. [**Last Name (STitle) 4229**].
Past Medical History:
HTN
Afib
hyperchol.
Social History:
He does not smoke. He works as a maintenance worker.
Family History:
Significant for stroke of father at the age of
92 and of mother who [**Name2 (NI) **] at the age of 53.
Pertinent Results:
[**2176-1-29**] 08:21AM HGB-12.2* calcHCT-37
[**2176-1-29**] 08:21AM GLUCOSE-105 NA+-140 K+-3.8 CL--103 TCO2-26
[**2176-1-29**] 01:15PM WBC-14.8*# RBC-3.37*# HGB-10.5*# HCT-30.9*#
MCV-92 MCH-31.2 MCHC-34.0 RDW-13.7
[**2176-1-29**] 01:15PM PLT COUNT-204
Brief Hospital Course:
Patient tolerated procedure well and was transferred to 12R. On
POD2, on [**2176-1-31**], he started becoming short of breath
and his oxygen sats dropped to low 90s with a temp of 102.1. He
had a chest x-ray that showed bilateral consolidations and he
was treated with antibiotics for pneumonia. On POD3, [**2-1**],
patient experienced O2 desaturation to mid-80s and he had a CTA
that showed bilateral PEs. He desaturated down to 72% on 3
liters and he was transferred to the ICU. Hematology was
consulted and recommendations were followed. He was started on
heparin IV. He was transfused 2 units of blood. He had lower
extremity Dopplers that showed no clot. On POD4, He was
hemodynamically stable and transferred back to floor. Warfarin
was initiated. On POD6, INR was 2.2, and Heparin was
discontinued. On POD7, INR was elevated and Warfarin was held.
On POD8, INR remained elevated and he was given a low dose of
Warfarin. On POD9, patient was deemed stable and suitable for
discharge. At discharge, he had 96% O2 sat on room air and lungs
sounded clear. His INR was 2.2. Hct was stable.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Please take first day on the day prior to
appointment with Dr. [**Last Name (STitle) 4229**].
Disp:*3 Tablet(s)* Refills:*0*
6. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for insomnia.
Disp:*30 Capsule(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Prostate Ca
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience symptoms including,
but not necessarily limited to: new and continuing nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Proceed to the ER/EW/ED if your wound becomes red, swollen,
warm, or produces pus.
Leave the steri strips on until they begin to peel, then you may
remove them. Staples and stitches will remain until your
follow-up
appointment.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Continue taking your home medications unless otherwise
contraindicated and follow up with PCP.
[**Name10 (NameIs) **] will go home with a leg bag for at least one week.
Start Levaquin on day prior to clinic appt with [**Doctor Last Name 4229**].
Continue anticoagulation for 6mo to 1 year. Thereafter
prophylactic anticoagulation when in high risk situation
(prolonged immobilization, plane ride, etc).
Followup Instructions:
Follow up in 1 weeks with Dr. [**Last Name (STitle) 4229**] for catheter removal. Please
restart taking Levoquin starting one day prior to this clinic
appointment.
See Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] tomorrow for 1st blood draw. Continue blood
draws per schedule listed on Page 1.
After completion of his anticoagulation treatment and after you
have been
off anticoagulation for a month, need to see a hematologist
in order to have his antithrombin III, protein C, and protein S
checked and perhaps a D-dimer.
Completed by:[**2176-2-7**]
|
[
"42731",
"2720",
"4019"
] |
Admission Date: [**2149-3-4**] Discharge Date: [**2149-3-8**]
Service:
Patient was admitted to Medicine, first to the Medical
Intensive Care Unit, and then to the [**Hospital1 **] team, and he
was then transferred to the floor.
HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old male
[**2149-2-28**] for lower gastrointestinal bleed with a
presenting complaint of bright red blood per rectum. At that
time his hematocrit fell from 36.4 to 30.8. The patient was
given 4 units of packed red blood cells and his hematocrit
was maintained around 30.
The patient had a colonoscopy on [**2149-3-3**], which
sigmoid colon, descending colon, transverse colon, and
ascending colon all nonbleeding. By report, an EGD was
negative for bleeding source, although it was not done on
that admission. The patient remained stable with no further
episodes of bright red blood per rectum and was discharged on
[**2149-3-3**].
On the evening of discharge, the patient had four bowel
movements with bright red blood per rectum and returned to
the Emergency Department. In the Emergency Department, the
patient had two peripheral IVs placed and 2 units of packed
red blood cells were given. Pretransfusion hematocrit was
29.2. His discharge hematocrit was 30.4. Patient's
posttransfusion hematocrit was 24.8 and the patient was
admitted to the Medical Intensive Care Unit after a tagged red
blood cell scan showed bleeding at the hepatic flexure. The
patient had angiography which showed the bleeding site to be
suggestive of diverticular dz, and the bleeding site was
therapeutically embolized. The bleeding
vessel was the branch of the middle colic artery. The
patient was admitted to the Medical Intensive Care Unit for
observation.
PAST MEDICAL HISTORY:
1. Diverticular bleed about 10 years ago.
2. Hypertension.
3. Gout.
4. Prostate cancer, no interventions, observation status, PSA
of 8.0. [**Doctor Last Name **] score of 7.
5. Appendectomy.
6. Hernia repair.
7. Glucose intolerance.
8. History of murmur.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Atenolol.
2. Accupril.
3. Allopurinol.
SOCIAL HISTORY: The patient has a 20 pack year smoking
history, quit 30 years ago. Lives with his wife. [**Name (NI) 1403**] in
the heating business. Had two sons, one of which is
decreased, still active and working. Drinks one drink of
alcohol a day.
FAMILY HISTORY: Mom with diabetes and coronary artery
disease.
PHYSICAL EXAMINATION: Vital signs on admission: Temperature
98.4, blood pressure 217/112, which went to systolic blood
pressures in the 90s after his bleed, heart rate 100,
respiratory rate 16, and 98% on room air. General: In no
acute distress, obese. HEENT: Pale conjunctivae.
Extraocular movements are intact. No jugular venous
distention, no LAD. Cardiovascular: Regular, rate, and
rhythm, S1, S2, 3/6 systolic murmur at the apex and base.
Chest was clear to auscultation bilaterally. Abdomen is
soft, nontender, and nondistended, bowel sounds are positive.
Extremities: No clubbing, cyanosis, or edema, cool to touch,
[**1-30**]+ pulses globally. Neurologic is alert and oriented times
three.
LABORATORIES ON ADMISSION: White count of 8.1, hematocrit of
29.2 which a repeat showed 24.8, platelets 185, 70%
neutrophils, 25% lymphocytes, 3% monocytes, 2% bands, 0.4%
eosinophils. PTT 28.2, INR of 1.1. Sodium 134, potassium
3.5, chloride 103, bicarb 22, BUN 16, creatinine 0.8, glucose
200, magnesium of 1.7, calcium of 8.4, phosphorus of 3.8,
protein of 5.6, albumin 3.6, globulin 7.0. ALT and AST 14
and 20, LDH 185, alkaline phosphatase 57, amylase 124, lipase
55, and total bilirubin 0.6.
ELECTROCARDIOGRAM: Showed normal sinus rhythm at 97 beats
per minute, normal axis, no Q waves or ischemic ST-T wave
changes.
ASSESSMENT: This is a 78-year-old male with a history of
hypertension, history of diverticular bleed with recent
admission for the same, readmitted one day after discharge
found to have a bleed at the hepatic flexure status post
angiography and thrombosis.
HOSPITAL COURSE BY SYSTEMS:
1. Gastrointestinal: The patient was admitted to the Medical
Intensive Care Unit for observation after he had a nuclear
red blood scan which showed the bleed at the hepatic flexure
and had therapeutic intervention with embolization of the
middle colic artery.
Patient's hematocrit bumped appropriately, and he was stable.
Patient again in the MICU had a fall in his hematocrit
went from 28.2 to 25.2. He again had a mesenteric angiogram,
however, no active bleeding was seen in the superior or
inferior mesenteric artery. He had two unit packed red blood
cells, and repeat hematocrit was 29.
Patient remained stable with no further episodes of bright
red blood per rectum. He received two more units of packed
red blood cells. His hematocrit stabilizing at around 35.
Patient was transferred to the Medical floor. The patient
remained stable on the Medical floor. On the day of
anticipated discharge, the patient had a bowel movement which
was again significant for bright red blood per rectum.
Patient's hematocrit remained stable, VS were OK and he was not
orthostatic, and he was watched
overnight. His hematocrit again was checked
on the day of discharge, and it remained stable at around 30, VS
continued to be stable without orthostasis, and he had no
further bleeding from the rectum. The impression was that he
may be clearing out old blood, and that as long as this
progressively decreases over the next wk, further small amts of
blood per rectum would not be worrisome.
2. Cardiovascular: The patient has a history of hypertension
currently on atenolol 50 mg po q day and Accupril at home,
however, patient was unclear of his dose. He was kept on
Captopril, and was told to switch to his Accupril dose when he
went home.
3. Rheumatoid: The patient has a history of gout. He has
not had a flare for quite some time and was anxious to
discontinue his Allopurinol. We suggested that he continue
his Allopurinol as that is probably why he is not having any
flares, but to address this issue as an outpt
4. Psych: The patient's family was extremely concerned that
patient had depression and anxiety with anxiety significantly
contributing to his elevated blood pressures. The patient
was treated with Ativan while he was hospitalized 0.5 to 1 mg
q day prn. He was given a prescription for this for a one
month supply, and was told to followup with his new primary
care physician in regards to medical therapy for his anxiety.
DISCHARGE STATUS: Stable.
DISCHARGE CONDITION: Home, ambulating, eating, urinating,
and having bowel movements without difficulty.
DISCHARGE DIAGNOSIS: Lower gastrointestinal bleed.
Blood loss anemia
Hemorrhage
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg po q day.
2. Atenolol 50 mg po q day.
3. Allopurinol 150 mg po q day.
4. Ativan 1 mg po q day prn.
5. Accupril, the patient is to resume his home dose.
FOLLOWUP: The patient should follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]. He should have his blood
pressure checked and his medications titrated accordingly.
The patient should also have his anxiety issues addressed for
possible pharmacologic intervention.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D.
Dictated By:[**Doctor Last Name 99470**]
MEDQUIST36
D: [**2149-3-8**] 14:49
T: [**2149-3-12**] 08:35
JOB#: [**Job Number **]
|
[
"2851",
"4019"
] |
Admission Date: [**2124-7-18**] Discharge Date: [**2124-8-2**]
Date of Birth: [**2067-1-6**] Sex: F
Service: PODIATRY
Allergies:
Tape / Provera / Antibiotic / Verapamil / Heparin Agents /
Codeine / Dicloxacillin
Attending:[**First Name3 (LF) 3821**]
Chief Complaint:
Bunion and hammertoe deformity R foot
Major Surgical or Invasive Procedure:
Bunionectomy and 2nd toe hammertoe repair R foot
History of Present Illness:
57 DM F known well to podiatry service seen routinely for care
of charcot foot L and for recurrent ulceration and infection of
R 2nd toe. Pt has been undergoing conservative care for 2nd toe
and given the extent of deformity of the toe with severe bunion,
it was decided to take Pt to OR for hammertoe and bunion
correction.
Past Medical History:
1. CHF (Diastolic pMIBI [**3-19**] Mild [**Last Name (LF) **], [**First Name3 (LF) **]=57%)
2. Aortic Valve Insufficiency
3. Bleeding diathesis with neg prior workup which has previously
responded to ddAVP. Pt is followed by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
of Heme/Onc
4. OSA on bipap at home
5. Insulin Dependent DM complicated by Charcot foot and
peripheral neuropathy.
6. PVD with multiple foot ulcers
7. Hashimoto's Thyroiditis
8. Asthma
9. Anemia
10. IBS
11. Hepatitis C
12. MRSA in past
13. Cataracts
14. Macular degeneration
15. Osteoarthritis
16. Bladder spasms
17. Stress urinary incontinence
18. Fibromyalgia
19. Anxiety
20. Major Depression
21. s/p tonsilletcomy and adenoidectomy
22. s/p c-section with significant post partum bleeding
23. s/p bladder suspension complicated by post op bleeding
24. s/p hernia repair
Social History:
Married. Lives with husband. Daughter is HCP.
Family History:
Non-contributory.
Physical Exam:
GEN: NAD, AAOx3
HEENT: nasal BIPAP, PERRLA, EOMI
CV: RRR, S1, S2
Chest: CTA with mild wheezes
Abd: NT, ND +BS
Ext: Severe R 2nd hammertoe and bunion deformity. Superficial
ulceration dorsal 2nd toe at PIPJ with mild surrounding redness.
No active drainage. Generalized 1+ b/l LE edema. All incisions
completely healed on L foot s/p Charcot recon. No other open
lesions. Pt w/ palpable DP and dopplerable PT R foot with
decreased protective sensation plantarly.
Pertinent Results:
[**2124-7-22**] 10:12 am SWAB Source: R 2nd toe:
_________________________________________________________
ENTEROCOCCUS SP.
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| | PSEUDOMONAS
AERUGINOSA
| | |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
PENICILLIN------------ 4 S =>0.5 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ <=1 S 2 S
ANAEROBIC CULTURE (Final [**2124-7-26**]): NO ANAEROBES ISOLATED.
[**Date range (1) 44486**] BLOOD CULTURE: No growth
[**2124-7-18**] Pathology Tissue: BONE FIRST METATARSAL,
A. Bone, 1st right metatarsal (A):
Bone with some reparative changes; cartilage with some
degenerative changes.
B. Skin, right 2nd toe (B):
Skin with ulceration, granulation tissue, fibrosis, chronic
inflammation, and fibrinopurulent exudate.
C. Bone, 2nd toe (C):
Bone with some reparative changes; no significant acute
inflammation noted.
Cartilage with degenerative changes
CHEST (PORTABLE AP) [**2124-7-19**]: A single upright portable film of
the chest on [**7-19**] at 2051 hours. Sternal sutures are in place
from previous surgery, the diaphragm is high bilaterally which
is presumably due to position and a poor inspiratory effort. The
heart is enlarged to the left thoracic margin, unchanged since
[**Month (only) 205**]. There now appears to be some increased density at the left
base consistent with atelectasis or infiltrate
UNILAT LOWER EXT VEINS [**2124-7-19**]: No evidence of deep venous
thrombosis in the left lower extremity
CHEST (PA & LAT) [**2124-7-22**]: Resolving left lower lobe opacity,
likely atelectasis
FOOT AP,LAT & OBL RIGHT [**2124-7-29**]: Post-op films following
amputation of the right second toe at the metatarsophalangeal
joint.
Brief Hospital Course:
[**7-18**]: Pt was admitted same day for correction of severe hammertoe
and bunion deformity of R foot. Pt tolerated the procedure well
without any complications (see op note for details). Pt w/
undiagnosed bleeding disorder and instructions were given from
Pt's Heme/Onc physician for perioperative medications/recs
including pre and post op DDAVP (desmopressin). Postoperatively,
R 2nd digit was noted to be mildly dusky but still warm with
adequate CRT with pin intact. Pt [**Name (NI) 20851**]
[**7-19**]: POD1; Low grade temps, VSS; R 2nd toe continued to be dusky
but warm, pin still in tact. Dsgs clean and dry. c/o L calf
pain. Venous ultrasound neg for DVT.
[**7-20**]: Temp spike o/n to 101.9 w/ c/o nausea and chills. EKG w/ no
changes and portable CXR w/atelectesis, LLL effusion. White
count bump to 12.9. Incisions still dry, sutures in tact to R
foot but 2nd toe remaining dusky so pin was pulled without
incident. IS was encourage and Pt was also pan cultured and
foley d/c'd. Cipro was added for broadened coverage. Pt
evaluated and cleared by PT for TDWB through heel.
[**7-21**]: Cont w/ low grade fevers, VSS. Continued bibasilar crackles
though improving. R 2nd toe cont to be warm but color worsening
with white count increasing to 14. Med consulted for fever who
rec switching to levo and flagyl for questionnable PNA. Also
believe toe is source. ? ECHO if fevers cont. Pt w/ h/o
neurogenic bladder s/o mult bladder suspensions but with urinary
incontinence since foley removed. Bladder scanned showing
>400ccs. Urology curbsided and believed cause likely [**12-17**]
overflow and recommended replace foley until day of discharge
and at that time trial void her and get post void residual. [**Month (only) 116**]
need foley on discharge if doesn't improved
[**7-22**]: (POD4) Pt still spiking fevers to 101.3 while VSS. To date
all Ucx, UA, Bcx were negative but toe worsening in color.
Sutures along dorsal 2nd toe were removed at bedside revealing
necrotic base; Wcx were taken. Lesion flushed and packed open.
White count improving.
[**7-23**]: Cont low grade temps but white count improving. Remaining
sutures prox to 2nd toe removed [**12-17**] incrased drainage and packed
w/ betadine; [**Last Name (un) **] consulted for irregular blood glucose
levels. Medicine unconvinced of any clear signs of PNA but would
cont to monitor for endocarditis/graft infection. Pt made NPO
after MN for possible OR debridment vs amputation next day.
[**7-24**]: OR for open 2nd toe amp. Pt tolerated procedure well (see
op note for details). Postoperatively, Pt doing well still with
low grade temps but white count completely resolved.
[**7-25**]: (POD 7,1) Afebrile o/n w/ VSS. Amp site clean, red and
granular with appropriate bleeding. Cont Abx and NWB RLE.
[**2130-7-27**]: Cont [**Month/Day/Year 20851**]; Amp site clean and granular. 2U PRBC infused
for low Hct with appropriate bump. Bedside wcx growing pseudo,
coag(-) staph and enterococcus. Cultures from sterile intraop
tissue growing coag (-) staph and enterococcus and GNR. Pt made
NPO for amp closure next day.
[**7-28**]: OR for R 2nd toe amp closure (see op note for details). Pt
tolerated procedure well with uncomplicated postop; [**Month/Year (2) 20851**].
[**2033-7-29**]: (POD12,6,2): Pt [**Name (NI) 20851**] over weekend with no events.
Incisions cont to look clean and dry with sutures in tact and no
active drainage for clinical signs of infection. Levo changed to
cipro for better gram(-) coverage.
[**2035-7-31**]: [**Month/Day/Year 20851**] with normal white count. Wcx growing entero (pan
sensitive), GNR, CNS ([**Last Name (un) 36**] to vanc). PT reconsulted for NWB RLE
who was cleared to go home w/ PT services. Incisions cont to be
clean and dry with redness and swelling improving. Found to
have preulcerative lesions along distal achilles tendon of RLE
[**12-17**] having leg elevated on pillows. No signs of infection; began
wet-to-dry dsgs and applied mulitpodus splint.
[**8-2**]: Cont to be [**Month/Year (2) 20851**] without white count. Pt was discharged
home w/ VNA and PT services on 3 weeks of Linezolid and Cipro to
follow up with Dr. [**Last Name (STitle) **] in 1 week.
Medications on Admission:
Alprazolam 0.5', Amitriptyline 150', ASA 81', Desmopressin 1
spray NU PRN, ditropan 10', furosemide 80', levothyroxine
125mcg', Lyrica 50mg, Metoprolol XL 100', Lyrica 50''',
Montelukast 10', Nexium 40', KCL 10', Simvastatin 20', Ultram
100 q4hr, Venlafaxine XR 150'
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. Ultram 50 mg Tablet Sig: 1-2 Tablets PO q6 hr as needed for
pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Amitriptyline 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Levoxyl 175 mcg Tablet Sig: One (1) Tablet PO daily ().
10. Lyrica 50 mg Capsule Sig: One (1) Capsule PO tid ().
11. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for breakthrough pain.
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
15. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO qd ().
16. Oxybutynin Chloride 10 mg Tab,Sust Rel Osmotic Push 24hr
Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO daily ().
17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
18. Vancomycin 1000 mg IV Q 12H
19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
20. HYDROmorphone (Dilaudid) 1 mg IV Q6H:PRN breakthrough
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] home health
Discharge Diagnosis:
Bunion and 2nd hammertoe deformity R foot
Discharge Condition:
Stable
Discharge Instructions:
Please resume all prehospital medications. You were prescribed
2 antibiotics and a pain medication, please take both as
directed.
You are to remain non-weightbearing on your right foot in
surgical shoe and crutches.
Please keep your dressing clean and dry at all times, also
keeping your foot elevated to prevent swelling. You will have
daily dsg changes performed by visiting nurses.
Please call your doctor to go to the ED for any increase in pain
not managed by pain medication. Any drainage through your
dressing, nauseas, vomiting, fevers greater than 101.5, chills,
nightsweats
Followup Instructions:
Please call [**Telephone/Fax (1) 543**] to schedule an appointment to see Dr.
[**Last Name (STitle) **] in one week.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**] DPM 48-125
Completed by:[**2124-8-2**]
|
[
"4280"
] |
Admission Date: [**2159-11-29**] Discharge Date: [**2159-12-11**]
Date of Birth: [**2096-10-2**] Sex: M
Service: SURGERY
Allergies:
Nickel
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
LLE ischemia
Major Surgical or Invasive Procedure:
[**2159-11-30**] CARDIAC PERFUSION PERSANTINE
[**2159-12-4**] Ultrasound imaging-guided vascular access, common iliac
contra third order, abdominal aortogram, extremity unilateral,
extremity native arthrosclerosis with rest
[**2159-12-6**] Left profunda femoral artery to posterior tibial artery
bypass graft with in situ saphenous vein, angioscopy, vein
inspection, valve lysis.
History of Present Illness:
53F with chronic low back and left hip pain s/p laminectomy in
[**2158-10-19**] c/b DVT, requiring anticoagulation and IVC filter. Pain
continued to be unrelieved and with additional multiple
interventions at the [**Location (un) **] Spine Center (bursa injections,
sacroiliac injections, physical therapy). Received an arthrogram
at OSH (5 days ago) for evaluation and since then complaining of
worsening L thigh pain and swelling.
Noticed swelling increasing to her knee. Still with severe pain
to LLE. She is still able to ambulate and denies any motor or
sensory loss. Continues to take her coumadin for DVT (INR
checked at 3.3). Denies any trauma. Minimal ambulation given
chronic back pain. All other ROS negative.
Past Medical History:
PMH: HTN, HL, CAD, DVT, PTSD, anxeity, brain/aortic aneurysm
(2.5
cm), DVT (R) on coumadin, h/o substance abuse in [**2148**], H.pylori
PSH: TAH, laminectomy w/ fusion for spinal stenosis, IVC filter,
s/p partial thyroidectomy ~6 years ago,
Social History:
Originally from [**Country 5976**], moved to the US when he was 16. Works as a
security officer at [**Location (un) 86**] Latin School. He has been married for
41 years, 3 biological children, 20 adopted children. Currently
smokes 3 cigarrettes/day, previously smoked 3 ppd x40 years.
drinks alcholol on rare social occasions. No illicits.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Cancer (unknown type) in both parents.
Physical Exam:
Physical Exam:
VITAL SIGNS - 97.2 66 140/63 18 100%
Gen: in bed, uncomfortable, irritated, mild distress with pain
Neck: supple
Lungs: CTA
Cardio: RRR
Abd: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding.
Abd
aorta not enlarged by palpation. No abdominal bruits.
Ext: Ecchymosis to left thigh with extension to knee. Tenderness
circumferentially with evidence of hematoma but overall soft
throughout. Normal motor/sensory.
Pulses fem [**Doctor Last Name **] DP PT
L p p p p
R p p p p
Pertinent Results:
[**2159-11-29**] 04:37PM BLOOD WBC-7.0 RBC-3.57* Hgb-9.8* Hct-30.6*
MCV-86 MCH-27.4 MCHC-31.9 RDW-16.3* Plt Ct-158
[**2159-12-6**] 06:45PM BLOOD Hgb-8.2* Hct-24.5* Plt Ct-131*
[**2159-12-10**] 08:20AM BLOOD WBC-6.5 RBC-3.46* Hgb-10.1* Hct-30.0*
MCV-87 MCH-29.3 MCHC-33.7 RDW-16.7* Plt Ct-108*
[**2159-11-29**] 04:37PM BLOOD PT-20.2* PTT-29.2 INR(PT)-1.9*
[**2159-12-6**] 06:45PM BLOOD PT-15.5* PTT-32.4 INR(PT)-1.4*
Stress test - No significant ST segment changes noted and no
anginal type
symptoms reported with Persantine. Appropriate hemodynamic
response.
Nuclear report filed separately.
PMIBI - No focal myocardial perfusion defect identified on
stress or rest images. Left ventricular ejection fraction 47%
Vein - The greater saphenous veins are patent bilaterally.
Please see
digitized image on PACS for formal sequential measurements. The
vessels
appear to be patent from the saphenofemoral junction through to
the level of the ankle.
Brief Hospital Course:
In brief, Mr. [**Known lastname **] is a 63-year-old male with thoracic and
aortic aneurysms was who is status post thoracic aneurysm
repair, had embolization from an ectatic popliteal artery to his
digital vessels. He was treated with anticoagulation and
stabilized over the course of several weeks. We also did not
want to perform an operation because he had a spinal cord
ischemia with hypotension during thoracic aneurysm repair and
was starting to recover. He was admitted to Dr.[**Name (NI) 1720**]
surgical service on [**2159-11-29**]. He was maintained on lovenox.
PMIBI/cardiac clearance was obtained prior to surgery. His
procedures were diagnostic angiogram on [**2159-12-3**] and L profunda
to posterior tibial artery bypass graft with in situ saphenous
vein, angioscopy, vein inspection, valve lysis on [**2159-12-6**]. No
complications to the procedure. He was kept on our pathway and
had an uncomplicated postoperative course. Physical therapy
cleared for home. Patient to be discharged home on [**2159-12-11**] with
[**Name (NI) 269**], PT and health aide. His following hospital course can be
summarized by the review of systems -
Neuro - Patient pain was well controlled with percocet. He had
no neurological issues during this hospitalization
Cardio - Followed closely by Atrius cardiology and consulted for
cardiac clearance. Chemical stress test on [**2159-11-30**] revealed no
focal myocardial perfusion defect with ventricular ejection
fraction of 47%. He was maintained on all his home medications
with adjustment per cardiology. His discharge dosing will be
Lopressor 50mg PO QID and Amlodipine 2.5 mg PO daily. He will
continue his statin and aspirin.
Pulm: No respiratory issues. He is discharged on room air and no
oxygen requirements.
GI: Maintained on H2B. Diet advanced as tolerated per pathway.
No issues.
GU: His home medication, Tolterodine, was resumed for overactive
bladder. No issues with hematuria or incontinence. Foley was
removed POD2 and urinated without difficulty.
Heme: He had been found to have a thrombosed popliteal artery
aneurysm which had showered emboli distally into his foot. He
had been on lovenox and a heparin gtt for systemic
anticoagulation prior to the surgery, but because he has now
undergone bypass of the popliteal aneurysm, there is no further
need for system anticoagulation. Accordingly, lovenox/heparin
gtt have not been resumed after surgery. This plan has been
formulated with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], attending vascular surgeon. He
will continue his aspirin.
ID: Given preoperative antibiotics and was not continued
postoperatively. Patient remained afebrile throughout this
hospital course.
Endo: Since his admission from rehab, he was maintained on a
sliding scale of insulin in addition to his metformin. Metformin
was held prior to angiogram procedure to prevent any
nephropathy. This was resumed on day of discharge with strict
blood sugar monitoring. He will follow up with his PCP regarding
any further antiglycemic agents. Home health aide will be
assigned to assist with blood glucose checks.
Dispo: Physical therapy continually working with patient.
Cleared to be discharged home.
Medications on Admission:
norvasc 2.5'; asa 81'; lipitor 10'; colace 100''; ferrous
sulfate 325'; folic acid '; reg insulin ss; metoprolol tartrate
25''; zantac 150''; senna'; flomax 0.4'; detrol 1''; comadin;
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
11. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Left lower extremity ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-21**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2159-12-25**] 1:00
PCP within one week
Completed by:[**2159-12-11**]
|
[
"496",
"4019",
"25000",
"2724",
"53081",
"V5861",
"V4582"
] |
Admission Date: [**2192-11-11**] Discharge Date: [**2192-11-14**]
Date of Birth: [**2130-5-14**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 62 year old male with
a history of hyperlipidemia who was well until the date of
admission when he noted the acute onset of chest pain at
11:30 AM while shoveling snow. The pain was described as a
tightness, radiation to the left arm and axilla. Nausea and
vomiting, diaphoresis, shortness of breath and dizziness were
all noted by the patient. He called emergency medical
services and emergency medical services gave nitroglycerin,
aspirin, morphine sulfate with resolution of the pain from 10
out of 10 to 1 out of 10. Taken to [**Hospital1 **] where
electrocardiogram was notable for 1 to [**Street Address(2) 1766**] elevations in
1, L, V1 and V3, T wave inversions in 3 and F. The patient
was started on heparin drip, enteral feed and still with 1
out of 10 pain. Transferred to [**Hospital6 2018**] Catheterization Laboratory. Found to have 100% left
anterior descending with faint collaterals, 60% right
coronary artery lesion. Cardiac index 2.1. The patient had
stent to left anterior descending with kissing balloon
following stent to open up the diagonals. Sent to CCU for
monitoring. Course was complicated by supraventricular
tachycardia, self-terminated. Chest painfree and no other
symptoms.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia; 2. Gastric ulcer in [**2181**].
ALLERGIES: No known drug allergies.
MEDICATIONS: Lipitor 10 q. day, on transfer from the outside
hospital medications were enteral feeds, heparin, aspirin and
nitroglycerin drip.
FAMILY HISTORY: Uncle died from a heart attack at the age of
48, sister with breast cancer died three months ago. No
history of any one on dialysis.
SOCIAL HISTORY: Married, lives with wife, history of
tobacco, quit 3 years ago. No smoking since and no alcohol.
years. The patient works as an emergency medical
services/fire fighter. Walks but not regularly active.
PHYSICAL EXAMINATION: Vital signs: Heart rate 75, blood
pressure 135/60, respirations 14, 95% on room air. General:
Lying in bed in no acute distress. Head, eyes, ears, nose
and throat: Jugulovenous pressure flat. Pupils equal, round
and reactive to light. Extraocular movements intact. No
carotid bruits. Cardiovascular: Regular rate and rhythm,
no murmurs, rubs or gallops. Lungs: Clear to auscultation
bilaterally. Abdomen: Soft, nontender, nondistended and
bowel sounds present. Extremities: No cyanosis, clubbing or
edema. Cool extremities. 2+ dorsalis pedis and posterior
tibial. Right red cheek. Neurological: Alert and oriented
times three. Cranial nerves II through XII grossly intact.
LABORATORY DATA: Outside hospital laboratory data: Sodium
137, potassium 2.9, chloride 100, bicarbonate 22, BUN 33,
creatinine 1.3, glucose 137, white blood cell count 10.7,
hematocrit 44.7, platelets 407, INR 0.9. Arterial blood
gases at [**Hospital6 256**], pH 7.5, pACO2
22, pAO2 92, sating 98% on 2 liters of nasal cannula.
Laboratory data at [**Hospital6 256**] 2:30
PM: White blood cell count 15.7, hematocrit 39.1, platelets
343, INR 1.5, PT 15, PTT 107. Sodium 143, potassium 3.9,
chloride 110, bicarbonate 19, BUN 23, creatinine 0.2, glucose
138. Electrocardiogram at outside hospital: Normal sinus
rhythm at 60, normal axis, interval. ST elevation in 1, V1
through V4. No Qs, T wave inversions in 3 and F. Cardiac
catheterization showed right atrial pressures of 13/11/9,
right ventricular pressures of 44/13. PA 44/17/29, pulmonary
capillary wedge 26/29/22, aortic 121/65/72, cardiac output
4.8, cardiac index 2.1. SVR 1050, PVR 117, proximal RCA 70%,
mid RCA 60%, mid LAD 100% within collaterals. EM jailed
apparent procedure requiring kissing balloon: Good outcome.
Cardiac catheterization complicated by supraventricular
tachycardia, self-terminated after procedure. Conclusion:
1. Left ventricular cavity small dilated, left ventricular
systolic function is moderately depressed, anterior
subsequent hypokinesis, akinesis present. 2. Aortic valve
leaflets were mildly thickened. 3. Mitral valve leaflets
were mildly thickened.
HOSPITAL COURSE:
1. Cardiovascular - Ischemia, the patient was directly taken
to the Cardiac Catheterization Laboratory from the Emergency
Department. In the Cardiac Catheterization Laboratory the
patient had Hepacoat stent to the left anterior descending
with post dilatation to 3.5 with kissing balloon placed in
the diagonal, 2.5 mm balloon. The patient also had an
episode of AIVR which was self-limiting after the procedure
was done. The patient was transferred t the CCU for further
monitoring on ................... for 18 hours and then
Plavix. Procedure done in the Cardiac Catheterization was
complicated by intermittent supraventricular tachycardia and
intermittent left bundle. Their recommendation was to
consider stent his right coronary artery in the near future.
The patient did well in the CCU and had an echocardiogram
done the following morning to evaluate cardiac ejection
fraction. Echocardiogram results were as stated above. The
patient was transferred to the floor the day after admission
to the CCU. The patient was started on beta blocker, ACE
inhibitors and statin. Beta blocker and ACE inhibitor were
titrated up as tolerated by blood pressure and heart rate.
The patient was subsequently discharged on the following
cardiac medication regimen: Aspirin 325 mg q. day, Plavix 75
mg q. day, Atorvastatin 20 mg p.o. q. day, Atenolol 50 mg
p.o. q. day, and Lisinopril 20 mg p.o. q. day.
Pump, the patient's subsequent injection fraction was noted
to be approximately 35%. Our goals while in the CCU were to
keep the patient even slightly negative. Prn Lasix was used
to obtain this goal with good results.
Rhythm, no further Telemetry events were noted in the CCU or
on the floors. He was in normal sinus rhythm throughout the
remainder of his stay.
It was the recommendation of the team that the patient follow
up with electrophysiology in the future for possible
consideration of implantable cardioverter defibrillator given
the patient's low ejection fraction. No anticoagulation was
administered on this admission. The patient is to have a
repeat echocardiogram in approximately four to six weeks for
reassessment of cardiac function. The patient is also to
have an outpatient stress in six weeks for further evaluation
of this 70% right coronary artery lesion.
2. Hyperlipidemia - The patient was placed on Atorvastatin.
3. Fluids, electrolytes and nutrition - The patient was
placed on a cardiac healthy diet low fiber/cholesterol.
Nutrition consult was obtained for further teaching.
4. Prophylaxis - Ambulation was recommended to patient.
Physical therapy was also consulted and the recommendation
was that the patient be discontinued home with outpatient
cardiac rehabilitation.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Anterior myocardial infarction, status post left anterior
descending stent.
2. Hyperlipidemia.
3. Ischemic cardiomyopathy.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg q. day.
2. Plavix 75 mg q. day.
3. Atorvastatin 20 mg q. day.
4. Atenolol 50 mg q. day.
5. Lisinopril 20 mg q. day.
FOLLOW UP PLANS:
1. The patient is to follow up with primary care physician,
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 53718**] to arrange follow up in one to two weeks,
he is to call [**Telephone/Fax (1) 2394**] to schedule an appointment.
2. The patient is to have an appointment with cardiologist,
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2192-11-16**], Friday.
3. The patient discussed with cardiologist regarding having
a repeat echocardiogram and stress test in four to six weeks.
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Last Name (NamePattern1) 9622**]
MEDQUIST36
D: [**2193-2-5**] 22:13
T: [**2193-2-6**] 06:42
JOB#: [**Job Number 53719**]
|
[
"41401",
"2720"
] |
Admission Date: [**2178-4-30**] Discharge Date: [**2178-5-26**]
Date of Birth: [**2120-6-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 38982**]
Chief Complaint:
Right parietal wound dehiscence. CSF
leak.
Perforated diverticulitis.
Major Surgical or Invasive Procedure:
Lumbar drain placement [**2178-4-30**]
Exploratory laparotomy [**2178-5-2**]
Abdominal washtou [**2178-5-2**]
Sigmoid colectomy and Hartmans pouch [**2178-5-2**]
Lumbar drain placement [**2178-5-5**]
CT-guided aspiration [**5-8**] for pelvic abscess
Reveision Right craniotomy [**5-10**]
revsion of bone flap [**5-10**]
Emergent intubation [**5-11**]
PICC line placement [**2178-5-15**]
History of Present Illness:
57yo right handed male with seizure history since [**2154**], s/p
craniotomies x 3 (most recently [**4-11**]) for oligodendroglioma. The
patient began having generalized tonic- clonic seizures in [**2154**],
which at the time were thought to be related to asthma
medications. At this time, his head CT was negative, and he was
treated with Dilantin and Phenobarbital. However, he continued
to
have left arm focal motor seizures and problems thinking. In
[**8-/2167**] he stopped his medication and had a generalized tonic-
clonic seizure in 12/94. He was diagnosed by biopsy with
oligodendroglioma, and gross total resection by Dr. [**Last Name (STitle) **] in
95
revealed a low-grade oligodendroglioma. He was followed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8026**], with serial MRI's. In [**2177-4-7**], he was
requiring more ativan to control his seizures, and was
increasingly disoriented and forgetful with headaches. He had a
repeat total resection in [**5-11**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] which
revealed anaplastic oligodendroglioma grade III. He had
radiation following the resection and was doing well on monthly
Temodar until [**2178-3-30**] when he had a marked change in behavior,
his balance was off, speech slurred, and he had difficulty using
the computer. A head MRI on [**2178-3-31**] revealed increasing tumor
infiltration with increased edema and mass effect. He underwent
a right craniotomy with resection and gliadel wafers on [**2178-4-8**]
at
[**Hospital1 18**] by Dr. [**First Name (STitle) **]. Came for neurosurgery follow up on [**4-27**], and
had
been having clear fluid leaking from his incision, as well as
frontal headache, imbalance, bumping into things with his left
leg and worsening tremors. He was admitted for Lumbar drain
placement
Past Medical History:
Right parietal oligodendroglioma, as above
status post craniotomy x3 ('[**68**], '[**77**], '[**78**])
hernia surgery x 3
right hand ganglion cyst removed
asthma
Social History:
Lives w wife, has home health assistance.
Employment: on short term disability, has boat which he enjoys
as
hobby
Physical Exam:
RRR
CTA
Abdomen soft Nontender and nondistended
Alert and oriented times 3
Speech fluent, comprehension intact
Pupils equal round and reactive to light, extraocular movements
intact
Face symmetric
Tongue midline
No pronator drift
Strength 5/5 throughout
Normal tone
2+ reflexes throughout
Toes downgoing bilaterally
No dysmetria
Pertinent Results:
Admission labs:
[**2178-4-30**]
WBC-6.3 RBC-4.17* Hgb-13.7* Hct-40.2 MCV-96 MCH-32.7* MCHC-34.0
RDW-13.6 Plt Ct-143*
PT-11.9 PTT-21.1* INR(PT)-0.9
Glucose-207* UreaN-17 Creat-0.9 Na-134 K-4.6 Cl-93* HCO3-35*
AnGap-11
Calcium-8.3* Phos-1.8*# Mg-2.1
Discharge labs:
[**2178-5-25**]
WBC-6.5 RBC-3.20* Hgb-10.5* Hct-30.7* MCV-96 MCH-32.8* MCHC-34.2
RDW-14.3 Plt Ct-227
PT-13.4 PTT-24.6 INR(PT)-1.1
Glucose-117* UreaN-12 Creat-0.6 Na-140 K-4.2 Cl-102 HCO3-32*
AnGap-10
Calcium-9.0 Phos-3.9 Mg-2.0
Pathology:
Sigmoid colon:
Diverticular disease of the colon:
1. Multiple diverticula.
2. Rupture of diverticulum with pericolic abscess.
CT head [**2178-5-18**]:
IMPRESSION:
1) Overall, a slight decrease in the mass effect and edema
associated with the postoperative changes.
2) Slight increase in epidural fluid collection adjacent to the
craniotomy site.
CT abdomen [**2178-5-25**]:
IMPRESSION: Small residual collection anterior to the rectum,
smaller than on the prior study, and without substantial fluid
components to allow drainage.
WOUND CULTURE (Final [**2178-5-12**]): (PELVIC ABSCESS)
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).
ENTEROCOCCUS SP.. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- <=0.25 S
GENTAMICIN------------ 2 S
IMIPENEM-------------- 8 I
LEVOFLOXACIN---------- 1 S
MEROPENEM------------- 4 S
PENICILLIN------------ 2 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ <=1 S
WOUND CULTURE (Final [**2178-5-12**]): (from OR revision craniotomy)
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**8-/2479**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
patient was admitted on [**2178-4-30**] after having drainage from his
incision for the last couple of days. He was seen in the brain
tumor clinic on [**4-27**] and stitches were placed in the
incision,however it continued to leak. He had a lumbar drain
placed. He c/o of abd pain and distension on [**5-1**] he had a kub
done which was negative. on [**5-2**] he continued to c/o of
epigastric pain had a chest x-ray done to due to decreased lung
sounds. The Chest x-ray showed free air. general surgery was
consulted and the patient was taken to the OR for exploratory
laproratomy. he was found to have a perforated sigmoid
diverticulum. He had a colostomy and partial colectomy. patient
recovered well from colocetomy. He was found to have an abd
abcess which was drained via CT guidance on [**5-8**]. On [**5-9**] his
lumbar drain pulled out. he had to have it replaced, however,
because his head incision began to leak again. On [**5-10**] he was
taken back to the OR for debridement of his head wound with
removal of the remaining gliadel waffers. He tolerated the
procedure well, postop however he had a grand mal seizure and
was intubated and sent to the ICU. ID was consulted for both the
abd abcess and possible meningitis given the large amount of wbc
in the csf cultures. Patient was placed on vancomycin 1gm IV q12
and zosyn. He was kept on antibiotics until [**5-24**]. Neurologically
he slowly woke up after the seizures and was extubated on [**5-10**].
He was transfered to the step down unit and had his lumbar drain
slowly weaned. The lumbar drain was d/ced on [**5-21**]. He had a head
Ct which remains stable and head wound remain dry.
Neurologically he is awake and alert and oriented x3 he is [**6-11**]
in all muscle group bilat. He follows commands, he is out of bed
ambulating with max assist. PT and OT are recommending rehab.
He will follow up with Dr [**Last Name (STitle) 5182**] the general surgeon in two
weeks and follow up in the brain tumor clinic in two weeks for
stitch removal. H ewas switched to oral CIpro for the pelvic
abcess and will continue it until he has his followup with
infectious disease in 2 weeks.
Medications on Admission:
Neurontin, Keppra, Lamictal, decadron, multivitamin, [**Doctor Last Name 1819**],
Calcium
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed.
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-8**]
Puffs Inhalation Q4H (every 4 hours) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
7. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
8. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks. Tablet(s)
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
14. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): 51-150 0 Units
151-200 2 Units
201-250 4 Units
251-300 6 Units
301-350 8 Units
351-400 10 Units
>400 [**Name8 (MD) **] MD
.
16. Hydralazine HCl 20 mg/mL Solution Sig: 0.5 syringe Injection
Q4HR () as needed for sbp>150. Disp:*qs syringe* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] [**Doctor Last Name **] hospital
Discharge Diagnosis:
Cerebrospinal fluid leak
Chronic steroid use
wound infection
Perforated sigmoid diverticulum
status post exploratory laparotomy
Status post sigmoid colectomy, hartmans pouch and washout
Post operative fever
fever
status post Reveision Right craniotomy and revsion of bone flap
change in mental status
Seizure
[**Doctor Last Name 555**] palsy with Left sided weakness
Respiratory failure requiring intubation
Methicillin resistant staph aureus infection of central nervous
system
Pelvic abscess
oligodendroglioma
Asthma
S/p craniotomy x 3
Hernia Surgery x 3
Discharge Condition:
Good
Discharge Instructions:
Call with any spiking fevers, leakage from your head wound,
increase in headaches, confusion, blurry vision severe neck
stiffness, redness, swelling, or discharge around your wound
site
Call your general surgeon if you experience increased abdominal
pain, vomiting, decreased or increased ostomy output.
Followup Instructions:
1. Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 54805**] or Dr. [**Last Name (STitle) 11382**] in infectious disese in 2
weeks. Call for an appointment [**Telephone/Fax (1) 11486**]
2. Dr [**Last Name (STitle) 5182**] in General surgery, 1 week, call his office for
an appointment. [**Telephone/Fax (1) 5189**]
3. Follow up in 1 week at brain tumor clinic. Call for an
appointment [**Telephone/Fax (1) 1844**]
|
[
"51881"
] |
Admission Date: [**2110-6-29**] Discharge Date: [**2110-7-6**]
Date of Birth: [**2038-3-23**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
1)Right femoral hernia repair.
History of Present Illness:
72y/o WF with h/o CAD s/p MI, HTN who presented c/o abdominal
pain, nausea, vomiting soon after a colonoscopy. The pain/N/V
continued for 3 days after procedure with several episodes of
nbnb vomiting. She described the pain as epigastric,
internittent, dull, nonradiating, w/o assoc. diaphoresis, SOB,
CP, dysuria.
Past Medical History:
CAD
HTN
MI
hyperlipidemia
GERD
IBS
Bells Palsy
Social History:
supportive family, lives alone, nonsmoker, nondrinker
Family History:
not available
Physical Exam:
vitals: Tm 98 BP 118/80 HR 80 RR 16 97% RA
General: A+O X 3, NAD
HEENT: PERRLA, EOMI, Oral MMM
CV: RRR, no m/r/g, no JVD, nl S1, S2
Pulm: CTABL
Ab: s/nd/nm/nhsm; minimally tender to palp diffusely about
surgical site which was c/d/i
Ext: 2+radial, DPP BL; [**Last Name (un) 17610**]
Rectal: guiac negative
Pertinent Results:
[**2110-7-6**] 05:30AM BLOOD WBC-14.1* Hct-35.5*
[**2110-7-6**] 12:26AM BLOOD Hct-30.4*
[**2110-7-5**] 06:00AM BLOOD WBC-9.7 RBC-3.16* Hgb-9.0* Hct-26.7*
MCV-84 MCH-28.4 MCHC-33.6 RDW-14.5 Plt Ct-405
[**2110-7-4**] 06:10AM BLOOD WBC-8.5 Hct-27.8*
[**2110-7-3**] 05:35AM BLOOD WBC-6.8 RBC-3.45* Hgb-9.5* Hct-29.0*
MCV-84 MCH-27.7 MCHC-33.0 RDW-14.2 Plt Ct-336
[**2110-7-2**] 03:30PM BLOOD WBC-7.7 RBC-3.66* Hgb-10.2* Hct-30.3*
MCV-83 MCH-27.8 MCHC-33.6 RDW-14.0 Plt Ct-328
[**2110-7-1**] 04:00AM BLOOD WBC-10.8 RBC-4.26 Hgb-12.0 Hct-34.2*
MCV-80* MCH-28.1 MCHC-35.0 RDW-14.1 Plt Ct-344
[**2110-6-30**] 01:15PM BLOOD Hct-28.5*
[**2110-6-30**] 06:35AM BLOOD WBC-12.7* RBC-4.35 Hgb-11.8*# Hct-35.5*
MCV-82 MCH-27.0 MCHC-33.2 RDW-13.4 Plt Ct-446*
[**2110-6-29**] 07:45AM BLOOD WBC-12.0*# RBC-5.54* Hgb-15.4 Hct-43.2
MCV-78* MCH-27.8 MCHC-35.6* RDW-13.6 Plt Ct-457*
[**2110-6-29**] 07:45AM BLOOD Neuts-81.0* Lymphs-12.5* Monos-6.2
Eos-0.1 Baso-0.2
[**2110-6-29**] 07:45AM BLOOD Microcy-1+
[**2110-7-5**] 06:00AM BLOOD Plt Ct-405
[**2110-7-4**] 06:10AM BLOOD PT-12.7 PTT-23.8 INR(PT)-1.1
[**2110-7-3**] 05:35AM BLOOD Plt Ct-336
[**2110-7-2**] 03:30PM BLOOD Plt Ct-328
[**2110-7-4**] 06:10AM BLOOD Fibrino-462*
[**2110-7-6**] 05:30AM BLOOD Glucose-102 UreaN-15 Creat-1.2* Na-133
K-4.3 Cl-99 HCO3-23 AnGap-15
[**2110-7-5**] 06:00AM BLOOD Glucose-83 UreaN-14 Creat-1.2* Na-138
K-4.6 Cl-103 HCO3-26 AnGap-14
[**2110-7-4**] 06:10AM BLOOD Glucose-84 UreaN-19 Creat-1.1 Na-137
K-3.7 Cl-101 HCO3-27 AnGap-13
[**2110-7-2**] 03:30PM BLOOD ALT-23 AST-29 AlkPhos-77 TotBili-0.4
[**2110-6-30**] 12:15AM BLOOD CK(CPK)-81
[**2110-6-29**] 07:45AM BLOOD ALT-14 AST-27 CK(CPK)-99 AlkPhos-142*
Amylase-115* TotBili-0.7
[**2110-6-29**] 07:45AM BLOOD Lipase-31
[**2110-7-6**] 05:30AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.5*
[**2110-7-5**] 06:00AM BLOOD Calcium-7.8* Phos-3.5 Mg-1.8
[**2110-7-6**] 05:30AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.5*
[**2110-7-4**] 06:10AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.6
[**2110-6-30**] 06:35AM BLOOD Osmolal-298
[**2110-6-29**] 10:29AM BLOOD pO2-33* pCO2-46* pH-7.45 calHCO3-33* Base
XS-6 Intubat-NOT INTUBA
Brief Hospital Course:
Pt was admitted to the hospital on [**6-29**] for iv hydration and r/o
MI. Pt developed hematemesis and was stabilized,transfered to
the MICU. An EGD was performed which was largely normal.
Surgery was consulted and the patient was found to have an
incarcerated femoral hernia which was manually reduced. The pt
was scheduled for surgical repair of the hernia. The surgery
was performed successfully and without complication. Pt was
transfered to the floors in good condition. Post op the pt was
anemic to HCt 26 and was transfued one unit of PRBC to which she
responed with pot transfusion Hct of 30. Pt also had some
trouble voiding post op, but eventually was able to void prior
to discharge. Bladder scan confirmed that pt's bladder function
had returned and that voiding was not just overflow from a
nonfunctioning bladder. Pt was discharged home in good
condition.
Medications on Admission:
tiazac, lisinopril, HCTZ, liptor, protonix
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
4. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day: Do
not take for systolic blood pressure less than 100 mmHg; do not
take for heart rate less than 60.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. incarcerated right femoral hernia
2. coronary artery disease
3. Hypertension
4. hyperlipidemia
5. Irritable bowel syndrome
Discharge Condition:
Good
Discharge Instructions:
1) [**Name8 (MD) **] MD if any worsening or concerning symptoms especially
persistent abdominal pain, nausea, vomiting, diarrhea, inability
to void/urinate (you should be urinating about every 6hrs)chest
pain, dizziness, difficulty breathing.
2)Follow up with Dr. [**Last Name (STitle) **] as indicated below.
3)Stay hydrated (drink at least 8oz water evry two hours).
Followup Instructions:
1)Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]([**Telephone/Fax (1) 6439**]next week.
Call his office on Tuesday to set an appointment
2) Follow up with Primary Care Physician
|
[
"5849",
"2851",
"4019",
"2720",
"412"
] |
Admission Date: [**2162-8-8**] Discharge Date: [**2162-8-12**]
Date of Birth: [**2103-3-15**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Epigastric Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 59 year old woman with history of HTN, DM, s/p renal
transplant in [**2150**], currently on cellcept and cyclosporine
presents with one week of nausea and vomiting.
One week prior to presentation she has acute onset of nausea,
vomiting and abd pain. She did not notice any blood in the
vomitus. Her pain was [**8-2**], epigastric and radiated to the back.
She has not had pain like this before. She denies drinking
alcohol. No recent spider bites. No change in her weight
recently. No personal or family history of cancer.
She was recently admitted at [**Hospital1 **] for dyspnea attributed to
pulmonary edema/fluid overload. ECHO [**6-1**] shows mild LVH and EF
55%. Prior to this she was admited for E. coli pyelonephritis
and was treated with Zosyn and ciprofloxacin.
She has history of ESRD s/p cadaveric renal transplant in [**2150**].
She has a baseline cre of 2.5 (near her baseline). She has been
mantained on immunosupression with prednisone, cellcept and
cyclosporin (all of these were started more than one year ago
without recent changes). She also takes EPO for anemia.
.
In the ED, initial vs were: 97.4 63 160/63 18 99. Patient was
placed NPO and given morphine for pain and ondasentron. RUQ US
showed a distened GB but without stones. No CBD dilatation. CXR
without acute changes. While in the ED her urine output was 150
cc over a period of 5 hrs. She received 1 lt NS. Prior to
transfer her vitals were 97.6 60 149/44 18 99RA.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of [**Year (4 digits) 1440**]. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias
Past Medical History:
1. Hypertension
2. Diabetes-45+ years, type I
3. Status post renal transplant in [**0-0-**] crt 1.3-1.6
4. Sciatica
5. Multinodular goiter
6. Cataract surgery.
7. Hyperlipidemia.
8. Depression.
9. History of vertigo.
10. History of nephrolithiasis.
11. s/p left eye vitreous hemorrhage
Social History:
The patient is divorced with two adult children. She lives
alone in a one family house with stairs. Her two daughters and
ex-husband see her regularly and lve near by. No tobacco, ETOH,
illicit drug use. From [**Location (un) 4708**].
Family History:
Father with CAD, died age 55yo
Physical Exam:
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, systolic murmur
left sternal border [**2-26**], rubs, gallops
Abdomen: diffusely ttp, more pronounced on epigastrium, no
rebound tenderness or guarding, no organomegaly, no [**Doctor Last Name 4862**] or
[**Last Name (un) 4863**] signs.
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
.
ADMISSION LABS:
[**2162-8-8**] 01:40PM BLOOD WBC-15.5* RBC-5.16 Hgb-12.4 Hct-41.3
MCV-80* MCH-24.0* MCHC-30.0* RDW-16.9* Plt Ct-272
[**2162-8-8**] 01:40PM BLOOD Neuts-83.3* Lymphs-12.0* Monos-3.5
Eos-1.0 Baso-0.1
[**2162-8-8**] 01:40PM BLOOD PT-12.2 PTT-27.1 INR(PT)-1.0
[**2162-8-8**] 01:40PM BLOOD Glucose-185* UreaN-113* Creat-2.5* Na-133
K-4.6 Cl-101 HCO3-17* AnGap-20
[**2162-8-8**] 01:40PM BLOOD ALT-8 AST-15 AlkPhos-163* TotBili-0.4
[**2162-8-8**] 09:15PM BLOOD LD(LDH)-828* TotBili-0.4
[**2162-8-8**] 10:57PM BLOOD LD(LDH)-260* TotBili-0.3
[**2162-8-8**] 01:40PM BLOOD Lipase-2812*
[**2162-8-8**] 10:57PM BLOOD Lipase-1451* GGT-10
[**2162-8-8**] 09:15PM BLOOD TotProt-5.6* Albumin-3.1* Globuln-2.5
Calcium-8.2* Phos-6.8* Mg-2.0
[**2162-8-8**] 10:57PM BLOOD TotProt-4.8* Albumin-2.8* Globuln-2.0
Calcium-7.8* Phos-6.0* Mg-1.7
[**2162-8-8**] 09:15PM BLOOD Cyclspr-63*
[**2162-8-8**] 10:57PM BLOOD Cyclspr-60*
[**2162-8-9**] 09:21PM BLOOD Type-ART Temp-36.7 pO2-35* pCO2-46*
pH-7.24* calTCO2-21 Base XS--8
[**2162-8-8**] 01:46PM BLOOD Lactate-1.7
[**2162-8-9**] 09:21PM BLOOD Glucose-134* Lactate-0.8 Na-132* K-4.7
Cl-103
[**2162-8-9**] 09:21PM BLOOD freeCa-1.21
.
MICROBIOLOGY:
MRSA SCREENING: NEG
BLOOD CULTURE ON [**8-8**] X 2: NO GROWTH
URINE CULTURE ON [**2162-8-8**]: NO GROWTH
URINE CULTURE ON [**2162-8-10**]:
[**2162-8-10**] 4:32 am URINE Source: Catheter.
**FINAL REPORT [**2162-8-12**]**
URINE CULTURE (Final [**2162-8-12**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
DISCHARGE LABS:
[**2162-8-12**] 04:55AM BLOOD WBC-8.8 RBC-3.94* Hgb-9.4* Hct-32.5*
MCV-83 MCH-23.9* MCHC-29.0* RDW-16.2* Plt Ct-198
[**2162-8-11**] 05:15AM BLOOD PT-13.1 PTT-32.5 INR(PT)-1.1
[**2162-8-12**] 04:55AM BLOOD Glucose-140* UreaN-89* Creat-2.2* Na-136
K-4.6 Cl-105 HCO3-20* AnGap-16
[**2162-8-10**] 05:40AM BLOOD ALT-7 AST-11 LD(LDH)-180 AlkPhos-142*
TotBili-0.3
[**2162-8-12**] 04:55AM BLOOD Lipase-276*
[**2162-8-12**] 04:55AM BLOOD Calcium-8.4 Phos-4.8* Mg-2.4
IMAGING:
CXRAY ON [**2162-8-8**]:
CHEST, AP AND LATERAL: There has been interval removal of a
right PICC. The
lung volumes are low, with accentuation of the cardiomediastinal
contours. The heart is stable in size. Atherosclerotic
calcifications of the aortic arch are noted. Aside from minimal
discoid atelectasis in the left lower lung, the lungs are clear
without consolidation or edema. There is no pleural effusion or
pneumothorax.
IMPRESSION: Low lung volumes and minimal left lower lung
atelectasis.
LIVER AND GALLBLADDER US ON [**2162-8-8**]:
FINDINGS: No focal hepatic lesion is identified. The portal vein
is patent
with hepatopetal flow. There is no evidence of gallstones,
gallbladder wall
thickening, or pericholecystic fluid. There is no intra- or
extra- hepatic
biliary ductal dilatation with the CBD measuring 6 mm. Limited
views of the
pancreatic head and body are unremarkable, without a focal
lesion. Limited
views of the right kidney reveal an atrophic native right
kidney.
IMPRESSION: No evidence of gallstones or acute cholecystitis.
ECHO [**6-1**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion
.
EKG ON [**2162-8-8**]:
Sinus bradycardia. Possible left atrial abnormality. Left
bundle-branch block.
Compared to the previous tracing of [**2162-6-8**] the heart rate is
slower.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 178 146 470/463 53 -23 122
Brief Hospital Course:
59 year old woman with history of HTN, DM, s/p renal transplant
in [**2150**], currently on cellcept and cyclosporine presents with
one week of nausea and vomiting, who was found to have an
elevated lipase, AP and leukocytosis consistent with
pancreatitis.
.
# Abdominal pain/Nausea and vomiting: Pt presented with one wk
of nausea/vomiting and was found to have elevated lipase (2812
at admission) and Alk Phos (160) with leukocytosis (WBC at 15).
She also complained of epigastric pain radiating to her back
level [**8-2**]. These findings were consistent with pancreatitis.
The etiologies of her acute pancreatitis was not clear. The
differential diagnosis included biliary causes including gall
stones, however this is less likely given that US of RUQ did not
show gall stones. This still not completely excluded given that
she could have passed the stone. This could also be due to gall
bladder sludge. Another common cause is alcohol which the
patient denies having any alcohol intake. She has a history of
hyperlipilipidemia but this is well controlled as of [**5-1**]
(total chol 158, HDL60, LDL 82, TG 80). She was on Immuno
suppressant meds, so opportunist infections that can cause
pancreatitis were also in the differential. These include
cytomegalovirus, varicella-zoster virus, herpes simplex virus,
and parasites (Toxoplasma, Cryptosporidium). This is however
less likely and pt had negative blood cultures. Medications can
also cause acute pancreatitis. Patient has been on tetracyclin
for recurrent UTIs and on meridia which are likely culprits. GI
was consulted and these meds were stopped. She was also started
on ursodiol 600 mg [**Hospital1 **] for gallbladder sludge. There was also
recommendation for MRCP if pt continued to be symptomatic. She
was initially treated with supportive therapy with NPO, IV
fluids and pain management. She was initially admitted to the
ICU for close observation of SIRS and sent to the floor once
stable. After stopping the tetracyclin and meridia her symptoms
started to improved and pt had her diet advanced as tolerated.
Her labs had also trended down with lipase quickly dropping to
246 and Alk phos to 140. Her epigastric and right upper quad
pain had subsided and pt was able to tolerate small-mod amounts
of solid food and appropriate amounts of fluids.
.
# CKI: Pt has a history of ESRD s/p cadaveric renal transplant
in [**2150**].
She has a baseline cre of 2.5 (near her baseline). Her creatine
trended down to the 2.2 by time of discharge. She has been
maintained on immunosuppression with prednisone, cellcept and
cyclosporin (all of these were started more than one year ago
without recent changes). She initially had low UO in the ED and
was given IV fluids which she responded to with appropriate UO.
Her Cyclosporin levels were WNL at low 60s. She also takes EPO
for anemia. She had prior admission for fluid overload which
seen to be stable during this hospitalization. She was continued
on her home meds.
.
# Recurrent UTIs: Pt had recurrent episodes of E.coli UTI for
which she was taking tetracyclin for it. Tetracyclin was stopped
since it was thought to be likely to be the cause of her
pancreatitis. Her Urine culture grew E.coli resistant to:
Ampicillin, cipro, gent, Bactrim, and zozyn. Pt was asymptomatic
so no antibiotics were started. She had recent cystoscopy for
evaluation of recurrent UTIs which showed apparently normal
bladder by and normal bladder emptying. Pt will have close
follow-up with ID to further decide antibiotic options for
prophylaxis therapy.
.
# DM1 - She was diagnosed more than 45 years ago. Her last
A1C=6.5% in [**Month (only) 116**] of 09. She was continued on her home Lantus and
Humalog insulin sliding scale. Her glucose in the evening have
been difficult to control and I attempted to get pt an
appointment with [**Last Name (un) **] post discharge. [**Hospital **] clinic will call
once they are able to arrange for appointment.
.
# HTN/diastolic CHF - Pt had recent admission for fluid
overload. She has been stable during this admission. Continued
her home dose of Losartan 100 mg Qday, Metoprolol 200 mg twice a
day and lasix 80mg [**Hospital1 **].
.
# Anemia: Pt on iron supplementation and on Epo injections
weekly her Hct remained stable in the low 30s%.
.
# Hyperlipidemia - Continued home simvastatin
.
# Constipation - continue on colace and lactulose
.
# Gout - Her home renally dosed allopurinol was continued.
.
# Code - full code
Medications on Admission:
ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet
- one to two Tablet(s) by mouth twice a day
ALBUTEROL - 90 mcg Aerosol - 2 puffs inh four times a day as
needed for shortness of [**Hospital1 1440**]
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth every other
day
CALCITRIOL - 0.25 mcg Capsule - one Capsule(s) by mouth daily
CYCLOSPORINE - 25 mg Capsule - 1 Capsule(s) by mouth twice a day
to be taken with 50mg tablet, for total 75mg twice daily
CYCLOSPORINE MODIFIED - 50 mg Capsule - 1 Capsule(s) by mouth
twice a day to be taken with 50mg tablet, for total 75mg twice
daily
EPOETIN ALFA [PROCRIT] - 20,000 unit/mL Solution - [**Numeric Identifier 389**] units
weekly
FLUTICASONE - 50 mcg/Actuation Spray, Suspension - one spray
each nostril qd
FUROSEMIDE - 40 mg Tablet - three Tablet(s) by mouth in the am,
two tablets at night
INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - 70 units 2-3
times a day
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 25-30 units
in
am 25 u in the evening
LACTULOSE - 10 gram/15 mL Solution - 30ml Solution(s) by mouth
every 8 hours as needed
LANCETS,THIN - - AS DIRECTED
LOSARTAN [COZAAR] - 100 mg Tablet - 1 Tablet(s) by mouth once a
day
METOPROLOL TARTRATE - 100 mg Tablet - Two Tablet(s) by mouth
twice a day
MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg Tablet - one Tablet(s)
by mouth twice a day
NIFEDIPINE - 60 mg Tablet Sustained Release - one Tablet(s) by
mouth daily
NYSTATIN - [**Numeric Identifier 4856**] U/G Cream - APPLY TO AFFECTED AREA TWICE A DAY
OXYCODONE-ACETAMINOPHEN [ROXICET] - 5 mg-325 mg Tablet - [**12-25**]
Tablet(s) by mouth q4-6 hrs as needed for as needed for pain
PREDNISONE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 1 Tablet(s) by
mouth three times a day
SIBUTRAMINE [MERIDIA] - 10 mg Capsule - 1 Capsule(s) by mouth
daily
SIMVASTATIN - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
SYRINGE 1ML (INSULIN) - 1 ML SYRINGE - USE AS DIRECTED
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - as
directed 3-4 times a day
CALCIUM CARBONATE - (OTC) - 500 mg Tablet, Chewable - 2
Tablet(s) by mouth three times per day with meals
CALCIUM CARBONATE [EXTRA-STRENGTH CHEW ANTACID] - 300 mg (750
mg)
Tablet, Chewable - 2 Tablet(s) by mouth three times a day with
meals
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
Iron) Tablet - 1 Tablet(s) by mouth per day
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO
Q12H (every 12 hours).
3. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of [**Month/Day (2) 1440**] or wheezing.
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Epogen 20,000 unit/mL Solution Sig: One (1) Injection once a
week.
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal once a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS). Tablet(s)
10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous twice a day.
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other
day.
13. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Simvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
16. Metoprolol Tartrate 100 mg Tablet Sig: Two (2) Tablet PO
twice a day.
17. Novolog 100 unit/mL Solution Sig: 1-10 units Subcutaneous
four times a day: per sliding scale.
18. Lactulose Oral
19. Calcium 500 500 mg (1,250 mg) Tablet, Chewable Sig: [**12-25**]
Tablet, Chewables PO once a day.
20. Ferrous Sulfate 325 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
21. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 7 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Abdominal pain
Pancreatitis
.
Secondary:
ESRD s/p renal transplant in 98
Hypertension
Hyperlipidemia
Diabetes
Discharge Condition:
Stable, tolerating po, renal function at baseline
Discharge Instructions:
You were admitted with abdominal pain and found to have acute
pancreatitis. This has been evaluated by the gastroenterologist
the underlying cause is not entirely clear, though it may have
been precipitated by the Tetracycline or Meridia. It is
important that you avoid these medications and you will need
follow up with ID with regards to alternative antibiotics for
prophylaxis of UTIs. It is also important that you maintain
adequate hydration while at home.
Please note the following changes to your medications:
- stop tetracycline
- avoid Meridia
- start Ursodiol
you can discuss whether this will need to be restarted)
If you develop any recurrent abdominal pain, nausea, vomiting,
inability to take oral fluids, decrease urine output or any
other general worsening of condition, please call your PCP or
come directly to the ER.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1-2L per day
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 724**] Tuesday [**8-31**] at 10 am transplant clinic
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2162-8-25**] 10:00
Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **], RNC Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2162-9-1**] 11:40 (Dr.[**Name (NI) 4864**] nurse)
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2162-9-15**] 9:15
It is important for you to call the [**Last Name (un) **] at [**Telephone/Fax (1) 4865**] as
they are trying to fit you in for a follow up in the next few
weeks
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
|
[
"2761",
"40391",
"V5867",
"4280",
"2724"
] |
Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-12**]
Date of Birth: [**2080-6-29**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
right upper extremity weakness
Major Surgical or Invasive Procedure:
[**2142-1-11**] Diagnostic cerebral angiogram
History of Present Illness:
61M with PMH significant for cardiac artery aneurysm and
aortic valve repair (on coumadin) presents to ED with c/o
intermittent RUE weakness and numbness for 3 days. Patient was
in
his usual state of health until 3 days ago when he noted that
his
right arm felt heavy while it was laying on his lap. He tried to
raise his right arm, but was unable to do so. This epsidoes
lasted approximately 10 minutes and resolved. He was
asymptomatic
2 days ago and throughout the day yesterday. Last night [**1-7**], he
noted the onset of symptoms again with weakness and numbness in
his arm. He went to sleep but when he awoke the symptoms were
still present. He called his cardiologist, who recommended that
he come to the ED for further eval. No HA. No visual changes. No
CP/SOB. No n/v/d. No gait instability or difficulty.
Past Medical History:
Aortic pseudoaneurysm
Aortic Stenosis
s/p Redo Sternotomy, pseudoaneurysm repair, AVR (mechanical)
- Congential aortic stenosis s/p Open valvulplasty [**2091**] and
Bentall [**2132**]
- Ascending aortic aneurysm
- Benign prostatic hypertrophy
- Erectile dysfunction
- Hypertension
- Aortic valvuloplasty [**2091**]
- Redo Sternotomy/Bentall/Prox.Arch repl. (homograft to
Gelweave)) [**2132**] (Dr. [**Last Name (STitle) 1290**]
- Vasectomy
Social History:
Lives with: Wife
Occupation: [**Name2 (NI) **] works for a federal agency that performs audits
and financial analyses of federal contractors.
Cigarettes: Smoked no [] yes [X] Hx: Quit [**2132**]
ETOH: < 1 drink/week [X]
Illicit drug use: None
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 1 GCS E: 4 V:5 M:6
O: T: 98.3 BP: 118/83 HR: 60 R 16 O2Sats 100%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength 4/5 Right Upper extremity otherwise [**4-14**]
throughout. slight Right pronator drift
Sensation: Intact to light touch
Reflexes: B T Br
Right 1+ 1+
Left 1+ 1+
Toes downgoing bilaterally
ON DISCHARGE:
Awake, alert, oriented x3, short term memory deficit, slow
speech, MAE, slight R pronator drift
Pertinent Results:
Atrial fibrillation with a rapid ventricular response. Right
axis deviation.
Prior anteroseptal myocardial infarction. Compared to the
previous tracing
of [**2141-10-11**] there has been some resolution of the anterolateral
ST-T wave
abnormalities consistent with an ischemic process. The
ventricular response has
increased. Otherwise, no diagnostic interim change.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 0 102 374/424 0 100 41
[**2142-1-8**] FINDINGS:
The arteries of anterior circulation including bilateral
intracranial internal carotid, anterior and middle cerebral
arteries appear normal.
The basilar artery, intracranial vertebral arteries, and
bilateral posterior cerebral arteries appear normal.
There is no evidence of focal flow limiting stenosis, occlusion,
or aneurysm.
Subarachnoid hemorrhage is noted in the left superior frontal
region which is unchanged since the prior study.
The visualized paranasal sinuses and mastoid air cells appear
normal.
IMPRESSION:
1. No evidence of stenosis, occlusion, or aneurysm in arteries
of head.
2. Subarachnoid hemorrhage in the left superior frontal region
which is
unchanged since the prior study.
MR head without and with contrast is advised to rule out other
causes of
subarachnoid hemorrhage like cortical vein thrombosis.
[**2142-1-8**]
FINDINGS: cxr
There is tortuosity of the aorta. There is no pleural effusion
and no
pneumothorax. The cardiomediastinal silhouette and hila are
normal. Patient is status post median sternotomy.
There is no evidence of pneumonia.
IMPRESSION:
No acute cardiothoracic process.
[**2142-1-11**] CEREBRAL ANGIOGRAM:
Negative
Brief Hospital Course:
Mr. [**Known lastname 3646**] was admitted to the surgical intensive care unit
Neurosurgery service for
serial neurological examinations and workup. The Neurology team
was called to evaluate and an EEG was performend revealling no
seizure activity. A CTA was negative for aneurysm. Coumadin was
held and daily labs were checked to trend patient's INR.
Patient was transferred to the floor on [**2142-1-9**] and underwent a
cerebral angiogram on [**2142-1-11**] after his INR was under 2.0. The
procedure was uneventful and did not demonstrate a cause for the
sah.
His post operative exam was stable. It was confirmed with his
cardiologist that his coumadin could be restarted. He was
evaluated by PT/OT and discharge planning was initiated.
He was cleared for discharge with outpatient OT.
Medications on Admission:
aspirin 81 mg daily, warfarin 2.5 mg daily, metoprolol tartrate
37.5 mg daily
and ranitidine
goal INR is 2.0-2.5 according to his wife.
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
Disp:*10 Tablet(s)* Refills:*0*
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 HS (at bedtime).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*1*
7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Discharge Instructions:
Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
*** Please continue Coumadin dosing and follow-up with your PCP
regarding dosing. INR goal is 2.0-2.5 ***
*** You do not need to take Aspirin per your cardiologist ***
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
?????? You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
?????? We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain
Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you
have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**]
[**Last Name (NamePattern1) 16368**].
Completed by:[**2142-1-12**]
|
[
"42731",
"4019",
"V4581",
"V5861"
] |
Admission Date: [**2170-5-2**] Discharge Date: [**2170-5-17**]
Date of Birth: [**2093-12-30**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: This is a 76-year-old gentleman
with a history of diabetes type 2 with last hemoglobin A1C in
[**7-/2169**] of 11 percent who was in his usual state of health
until the morning of admission when he noticed that his blood
glucoses were abnormally high in the 500 to 550 range and
that he felt nauseated. Patient vomited times two. The
emesis was non-bloody and non-bilious. He denied any chest
pain, shortness of breath, palpitations. No dyspnea on
exertion but states that he did have limited exercise
tolerance secondary to gait imbalance. Patient had stable
two-pillow orthopnea, no postnasal drip, positive lower
extremity edema in the past controlled with a "water pill."
Patient states that he has never had a stress test echo or
other cardiac workup. Patient's CAD risk factors include
diabetes type 2, hypertension, his age, gender, obesity,
sedentary lifestyle. The patient went to an outside hospital
secondary to his high blood sugars and nausea and vomiting.
At the outside hospital he continued to have dry heaves and
CK was 13.13, MB was pending, AST 174, ALT 174. The
patient's EKG at the outside hospital revealed an isolated Q
wave in Lead III and ST elevations in V1 through V3. He was
transferred to the [**Hospital3 **] for further management. CK at
the [**Hospital3 **] initially was 2200 with an MB of 200 and
troponin 6.1.
EKG was unchanged from prior at the outside hospital.
Cardiology was consulted and patient was started on Heparin
and renally dosed 2b3 inhibitor.
PAST MEDICAL HISTORY: Type 2 diabetes; most recent
hemoglobin A1C in [**7-/2169**] was 11. His diabetes is
complicated by peripheral neuropathy and question of
Parkinson's disease, history of lacunar infarct, history of
depression, history of left-sided Bell's palsy, status post
cholecystectomy, status post appendectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lantus 36 units q. h.s.
2. Regular insulin sliding scale.
3. Paxil.
4. [**Doctor First Name **].
5. Lasix.
6. Blood pressure medicines that are unknown at time of
admission.
SOCIAL HISTORY: Patient is married with children. He is a
former car salesman. No tobacco. Rare ETOH.
FAMILY HISTORY: Father drowned. Mother has diabetes
mellitus and sister has coronary artery disease.
LABORATORY DATA ON ADMISSION: White count 13.7, hematocrit
36.4, platelet count 196, neutrophils 92, 5 lymphs, 1.6
monos, 0.4 eos. Coags: 13.8 for PT, PTT 22.1, INR is 1.3,
CK 2289, MB 200, index 8.7, troponin 6.17. Lytes: 136 for
sodium, potassium 6.5, chloride 96, bicarbonate 30, BUN 51,
creatinine 2.2, glucose 150.
EKG: Sinus rhythm, 88, normal axis, normal intervals, [**Street Address(2) 28585**] elevation V1 through V3, 0.[**Street Address(2) 1755**] depressions V5 and V6,
Q waves in Lead III, evidence of left ventricular hypertrophy
and left atrial abnormally.
Chest x-ray is consistent with congestive heart failure.
PHYSICAL EXAMINATION: Patient's vitals are as follows:
Temperature is 98.2, blood pressure is 130/70, respiratory
rate is 12, patient is satting at 96 percent on 3 liters.
Generally, the patient is a well developed male in no acute
distress, alert and oriented times three. HEENT: Jugular
venous distention is 12 cm, no lymphadenopathy, otherwise
extraocular movements intact. Oropharynx is clear with moist
mucous membranes. Heart is regular rate and rhythm, a normal
S1, normal S2, and positive for S3, pulmonary bibasilar
crackles, right greater than left; no rales. Abdomen is
obese, soft, nontender, nondistended with no
hepatosplenomegaly. Extremities: No clubbing, cyanosis, or
edema.
HOSPITAL COURSE BY SYSTEM: Patient was taken to the
Catheterization Lab. He had a right heart coronary
angiography, rotablator, and drug-eluting stent of proximal
mid left anterior descending. Patient's cardiac output was
4.6, index 2.16. His pulmonary capillary wedge was 10, PA
pressure 27/12, mean was 19, and the results of the
catheterization were as follows: Left anterior descending 90
percent proximal long, 70 percent mid, diffuse disease
distally up to 80 percent first diagonal, 70 percent
proximal, 90 percent distal of the left circumflex, and 99
percent PDA bifurcating obtuse marginal 1 with 80 percent
upper branch and 70 percent lower branch, right coronary
artery 100 percent origin, probably nondominant.
Patient also had an intraprocedure echo performed which
revealed a depressed ejection fraction at approximately 20
percent with a relative preservation on inferolateral wall.
Post myocardial infarction patient was maintained on an intra-
aortic balloon pump. The patient had three TAXUS stents
placed to his left anterior descending. Post procedure
patient was brought to the Cardiac Care Unit. Patient's
hematocrit dropped to 32.9, had been 36.4. Though he was
hemodynamically stable he later developed respiratory
distress, was intubated, two pressors were started for
hypotension. Chest x-ray was performed which revealed no
congestive heart failure with patchy infiltrates. The
patient was started on Levophed as well as Dopamine. There
was concern that patient may have down stents. He was taken
to the Catheterization Lab for a re-look which revealed that
all stents were patent, and at that time he was placed on an
intra-aortic balloon pump. Patient returned to the CCU on
Levophed and Dopamine as well as a balloon pump.
His status overnight worsened and patient's hematocrit
dropped to 23.7. He received four units of packed red blood
cells, four units of fresh frozen plasma, one bag of
platelets, 10 units of vitamin K. Had a CT which was
positive for right-sided intrapleural hematoma as well as an
extra pleural hematoma. On further view of the CT films it
became evident that the patient had a cracked rib. On
discussing the case with the Cardiac Medicine team that
initially had the patient overnight, it became evident that
patient had a ventricular fibrillation arrest in the
Emergency Room and did received chest compressions for a
short period of time. In total, patient received a total of
12 units of packed red blood cells, 12 units of platelets,
four bags of fresh frozen plasma, and vitamin K.
Post myocardial infarction patient was weaned off of his
intra-aortic balloon pump. His cardiac status was stabilized
on Lopressor, Hydralazine, as well as Isordil. Captopril was
held off given the patient did have chronic renal
insufficiency. Patient's cardiac status remained stable
throughout his hospitalization. His blood pressures remained
mildly hypertensive to normotensive.
Pump: Patient was initially maintained on p.r.n. Lasix and
later changed to Natrecor along with p.r.n. Lasix boluses.
Patient's creatinine bumped to 3.6 on the Natrecor along with
p.r.n. boluses were discontinued. Patient also had a Swan
placed as line status and his numbers were as follows: RV
30, number 12 at 30 cm, pH 139/21 at 42 cm, pulmonary
capillary wedge 15 at 53, cardiac output 9.1, index 4.2, and
SVR 413. These findings were felt to be consistent with a
sepsis. Patient was placed on broad spectrum antibiotics
including Levofloxacin, Vancomycin, and Flagyl. His Natrecor
was stopped. The cortisol was checked, which was within
normal limits. Patient's cardiac output and index continue
to improve on antibiotics and by date of transfer his cardiac
output was 6.2, index 2.89, SVR 890. Patient was replaced on
Lasix GTT and diuresed well. His creatinine remained stable.
Rhythm: Throughout his hospitalization patient remained in
normal sinus rhythm but did have evidence of an
supraventricular tachycardia with three-beat run to the max.
Electrophysiology was consulted and felt that patient would
likely need an ICD once extubated and medically stable. The
patient's electrolytes were kept off.
Pulmonary: For patient's right-sided hemothorax patient had
chest tubes placed by Cardiothoracic Surgery. Patient
initially had aggressive output, but then output fell. A
video-assisted thoracic surgery was performed with drainage
of bloody fluid. Post VATS right-sided chest tubes were
placed. Patient had minimal drainage at these chest tubes
and in the setting of a mild decrease in hematocrit, a
noncontrast CT was obtained. Per the radiologist there was
evidence that there may be some new areas of oozing. The
case was discussed with Cardiothoracic Surgery who felt that
patient did not have evidence of active bleeding.
Patient's chest tubes were pulled. Patient's hematocrit
remained stable. Extubation, however, was very difficult.
The patient was very difficult to wean from AC mode of
ventilation. Changing him to pressure support was attempted. The
patient would become extremely tachypneic and would drop his
tidal volumes. Eventually a trach was placed on [**2170-5-16**].
Again, weaning from the ventilation was attempted, but
patient's rhythm consistently remained above 100 and he would
become tachycardiac as well as drop his tidal volumes on
attempt to try a spontaneous breathing trial. This failure
was felt secondary to fluid overload and due to persistence
of intrapulmonary infiltrate secondary to the hemothorax.
Renal failure: Patient's renal failure was improving on
Lasix at time of discharge from the Cardiac Care Unit. His
creatinine bumped to a high of 3.6 felt likely secondary to
overdiuresis as well as sepsis.
Diabetes: Patient was maintained on an insulin GTT. He had
very good glycemic control throughout his hospitalization.
Patient was initially maintained on tube feeds later changed
to Nepro with ProMod. He had a PEG placed on [**2170-5-17**].
Lines: Patient's lines at time of transfer to the Medical
Intensive Care Unit included a right art line, right-sided
Swan, and a left IJ. Patient is a Full Code. The
communication was with the family throughout his
hospitalization.
Infectious Diseases: Patient, in the setting of hypotension
and elevated cardiac output, as well as decreased SVR
and sepsis, blood cultures were sent off which, by time of
transfer, were no growth to date. Patient also had a urine sent
off which was no growth. A sputum culture was consistent with
oropharyngeal flora. Clostridium difficile was sent times one;
was to follow up to be performed still. Other sources of
infection were felt to include patient's hemothorax as well as
chest tube insertion sites as those areas had some mild purulent
discharge which was managed by wound care. The patient was
maintained on Levofloxacin, Vancomycin, and Flagyl and then later
changed to Levofloxacin and Vancomycin by time of transfer to the
Medical Intensive Care Unit.
Patient also had a stage 2 decubitus ulcer on his coccyx
which were managed with DuoDerm as well as air mattress.
MEDICATIONS ON TRANSFER TO MEDICAL INTENSIVE CARE UNIT:
[**Unit Number **]. Acetaminophen liquid 650 q. 4 to 6 hours.
2. Aspirin p.r.n. 325 one p.o. q.d.
3. Isosorbide dinitrate 40 mg one p.o. t.i.d.
4. Lansoprazole 30 mg one p.o. q.d.
5. Levofloxacin 250 mg one IV q. 48 hours.
6. Metoprolol 50 mg one p.o. t.i.d.
7. Atorvastatin 40 mg one p.o. q.d.
8. Calci-Mix 1334 one p.o. t.i.d. with tube feeds.
9. Plavix 750 mg one p.o. q.d.
10. Docusate 100 mg one p.o. b.i.d.
11. Fentanyl citrate IV.
12. Versed IV.
13. Furosemide GGT 10 mg per hour.
14. ______ 50 mg one p.o. q. 6 hours.
15. Insulin GTT.
16. Miconazole powder.
17. Paxil 20 mg one p.o. q.d.
18. Senna one p.o. b.i.d.
19. Vancomycin 1000 units one IV q. 24 hours.
The remainder of [**Hospital 228**] hospital course, as well as
patient's discharge status, will be dictated by patient's
acute team.
[**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD
[**MD Number(2) 15194**]
Dictated By:[**Last Name (NamePattern1) 18827**]
MEDQUIST36
D: [**2170-5-17**] 13:07:35
T: [**2170-5-17**] 14:45:42
Job#: [**Job Number **]
|
[
"41071",
"4280",
"5845"
] |
Admission Date: [**2124-6-5**] Discharge Date: [**2124-6-13**]
Date of Birth: [**2045-1-21**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Hayfever / Levaquin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Right leg swelling and pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 79M with a history of ESRD on HD (ANCA-related
GN) and DM with recent admission for fever without clear source
who presented to the ED with worsening right lower extremity
erythema and pain. The patient underwent biopsy a lesion on the
dorsum of his right foot in [**2124-4-11**], with residual ulcer
formation. Pathology revealed necrotizing vasculitis. The
patient reports significant increase in pain and erythema over
the dorsal surface of his foot over the last few days since
recent discharge. On the day of admission, he visited his
podiatrist, who debrided the ulcer. He denies fever, chills,
nausea, and vomiting.
Of note, the patient had a recent hospitalization from [**Date range (1) **]
after presenting with fever and weakness. He was noted to have a
mild leukocytosis on admission, but otherwise unremarkable
labwork and imaging studies, including a film of his right foot.
At the time, his right foot ulcer appeared clean and without
drainage, swelling or erythema. After 72 hours of negative blood
cultures, his antibiotics (vancomycin) were stopped. Podiatry
did not feel that the ulcer site was infected, and recommended
f/u with vascular.
Initial VS in the ED: 98.7 88 164/79 17 100% RA. On examination,
there was a small 0.5 x 0.5 cm ulcer with fibrinous exudate,
erythema and warmth over the entire shin, creeping up to just
below the patella. Patient was given IV vancomycin 1 g X 1. CXR
revealed interval increase in pulmonary edema and a stable
L-sided loculated effusion. He was taken to HD directly from the
emergency room.
On the floor, the patient reports mild shortness of breath. He
states his R foot is painful, but redness improved.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
- ANCA vasculitis
- ESRD on HD from ANCA-positive glomerulonephritis dx [**2112**], on
HD through left arm graft, MWF
- Gout
- Depression
- HTN
- Hyperlipidemia
- Glaucoma
- Diverticulosis
- h/o Septic thrombophlebitis
- h/o Cellulitis of the right upper extremity
- h/o Gastrointestinal bleed secondary to NSAID use
- h/o Diverticulitis
- s/p Left inguinal hernia repair
- LVH
- Mitral regurgitation
- Pulmonary HTN
- chronic anemia
- DM2
- asthma
- Wegener's granulomatosis
Social History:
Speaks fluent Spanish and is quite proficient in English.
Retired butcher. Lives with wife and oldest daughter. [**Name (NI) **] smoking
history. Denies any current alcohol use, or heavy use in the
past. No illicit drug use.
Family History:
Mother with diabetes, kidney disease, CAD. 3 brothers with heart
disease, one has had MI. Sister with diabetes. No family history
of cancer.
Physical Exam:
ADMISSION Physical Exam:
Vitals: T: 97.8 BP: 156/62 P: 80 R: 18 O2: 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM throughout,
no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: RLE erythematous from the foot to shin, tender, warm, right
foot with dressing in place. No improvement of erythema as
demarcated by pen on [**6-5**]. 2+ pitting edema to shin b/l
DISCHARGE Physical Exam:
Gen: Awake, alert, NAD
Heart: RRR, 3/6 systolic murmur
Lungs: CTAB
Abd: +BS, soft, NT/ND
Ext: WWP, no edema. did not see pt on admission, but redness,
swelling, warmth not present. ~1.5cm ulcer on right dorsal foot,
clean base, no surrounding erythema, no exudate.
Pertinent Results:
ADMITSSION LABS:
[**2124-6-5**] 11:35AM GLUCOSE-106* UREA N-89* CREAT-7.9*#
SODIUM-133 POTASSIUM-6.5* CHLORIDE-95* TOTAL CO2-20* ANION
GAP-25*
[**2124-6-5**] 11:35AM WBC-27.0*# RBC-3.42* HGB-9.9* HCT-32.1*
MCV-94 MCH-29.0 MCHC-30.9* RDW-20.0*
[**2124-6-5**] 11:35AM PLT SMR-NORMAL PLT COUNT-230
[**2124-6-5**] 11:35AM NEUTS-87* BANDS-7* LYMPHS-3* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2124-6-5**] 11:49AM LACTATE-1.6
DISCHARGE LABS:
[**2124-6-13**] 07:40AM BLOOD WBC-7.7 RBC-3.38* Hgb-10.0* Hct-31.2*
MCV-92 MCH-29.5 MCHC-32.0 RDW-19.1* Plt Ct-248
[**2124-6-13**] 07:40AM BLOOD Glucose-77 UreaN-36* Creat-4.7*# Na-130*
K-4.2 Cl-93* HCO3-26 AnGap-15
[**2124-6-5**] CHEST XRAY:
IMPRESSION: Pulmonary edema, bilateral effusions, large and
loculated on the left appearing stable, and small right effusion
appearing slightly diminished from prior.
[**2124-6-5**] R FOOT FILM
IMPRESSION:
1. Soft tissue swelling and dorsal ulceration along the mid
foot overlapping the cuneiforms. No definite radiographic
evidence for acute osteomyelitis.
2. Irregularity involving the base of the fifth proximal
phalanx which is stable since the prior study and may represent
a subacute fracture.
Brief Hospital Course:
The patient is a 79M with a history of ESRD on HD (ANCA-related
GN) and DM with recent admission for fever without clear source
who presented to the ED with worsening RLE cellulitis, improving
on IV Vanc and Ceftazidime.
Acute issues:
# RLE cellulitis and bacteremia: The patient's clinical findings
and leukocytosis to 27.0 with bandemia were most suggestive of a
soft tissue infection though there was no evidence of systemic
toxicity in the form of fevers. Blood cultures grew out
pan-sensitive Serratia while would culture from his right foot
ulcer grew out both Pseudomonas aeruginosa and Serratia. The
patient was treated with Vancomycin and Zosyn for his cellulitis
as well as Tylenol for pain; the patient's cellulitis improved
significantly with antibiotics and the patient was able to
ambulate with assistance. The patient's leukocytosis improved to
9.2 on [**6-9**]. The patient was transitioned to vancomycin and
ceftazidime to be administered at future hemodialysis sessions
(unable to receive PO Ciprofloxacin given his Levaquin allergy).
#Hematochezia: The patient had 8 episodes of BRBPR during this
hospitalization. Given the intermittent nature of these
episodes, they were may have been due to hemorrhoids although
the patient has a history of severe diverticulosis and AVMs. On
hospital day 3, the patient experienced further episodes of
BRBPR overnight without hypotension or tachycardia. The BRBPR
continued into the following day with an episode associated with
some dizziness and pre-syncope. NT lavage was attempted, but
unable to draw back fluid. He received 2L NS and 2 units pRBCs
and was transferred to the ICU for close monitoring. In the
ICU, his Hct remained stable at 30 after 2 units prbcs. He did
not have any further BRBPR and remained hemodynamically stable
throughout. Pt was then transferred to the floor where he passed
a large blood clot and received an additional 1 unit red cells.
He remained hemodynamically stable and his Hct was stable x
>36hrs prior to discharge. GI followed through his discharge.
# ESRD on HD: MWF HD schdule. Patient was significantly volume
overloaded at admission, but improved with HD. He was placed on
strict free water restriction after gaining 6.2 kg body weight
on [**6-9**] after his last HD session on [**6-7**]. The patient was
continued on his home Nephrocaps and Sevelamer.
# Dyspnea: Patient was initially dyspneic at admission due to
volume overload in the setting of his ESRD. CXR on [**6-6**] showed
significant improvement of his initial pulmonary edema as did
his clinical exam. Patient did not report any problems regarding
his breathing at discharge.
#. p-ANCA Vasculitis: The patient's vasculitis appeared to be
cutaneous involvement of Wegener's (small + medium necrotizing
vasculitis) per Derm note from 5/[**2123**]. The patient was
continued on his home Prednisone 30 mg daily.
#. HTN: The patient's hypertension improved on HD. He was
continued on his home Labetalol (on non-HD days), Nifedipine,
and Valsartan.
#. DM2: Patient's DM2 not an active issue. The patient was not
on insulin or oral agents at home, but his blood sugars were
monitored closely and maintained on an insulin sliding scale
given his infection and prednisone use. Per the patient's PCP,
[**Name10 (NameIs) **] patient was previously hyperglycemic in the setting of
infection and prednisone.
Chronic issues:
#. Asthma: Stable. The patient was continued on his home Advair
and Albuterol/Ipratropium.
#. Depression: Stable. The patient was continued on his home
Paroxetine.
Transitional issues:
# IV abx: needed for 14 day total course (started on Ceftaz and
Vanco [**6-9**])
# foot ulcer: to see Podiatry w/in 1 week of D/c
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
7. Hydrocodone-Acetaminophen (5mg-500mg [**12-13**] TAB PO Q8H:PRN pain
8. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
9. Labetalol 200 mg PO BID
10. Nephrocaps 1 CAP PO DAILY
11. NIFEdipine CR 30 mg PO DAILY
12. Omeprazole 40 mg PO BID
13. Paroxetine 20 mg PO DAILY
14. PredniSONE 30 mg PO DAILY
15. sevelamer CARBONATE 1600 mg PO TID W/MEALS
16. Simvastatin 20 mg PO DAILY
17. Valsartan 80 mg PO DAILY
18. Loratadine *NF* 10 mg Oral daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Serratia bacteremia
Polymicrobial cellulitis (Serratia marcescens and Pseudomonas
aeruginosa)
Discharge Condition:
Stable
|
[
"40391",
"2851",
"49390",
"311",
"4280"
] |
Admission Date: [**2146-5-26**] Discharge Date: [**2146-6-7**]
Date of Birth: * Sex: F
Service: Cardiothoracic Surgery Service.
DIAGNOSIS:
Massive hemoptysis from right middle lobe aneurysm, bronchial
artery aneurysm.
HISTORY OF PRESENT ILLNESS:
The patient is a 20-year-old normally healthy woman who
developed shoulder pain and took two ibuprofen. She went to
bed and awoke in the middle of the night coughing up massive
amounts of blood. She was taken to the emergency department
and was found to be again, coughing up massive amounts of
blood. She was emergently intubated and transported to the
Intensive Care Unit where she underwent a flexible
bronchoscopy and clearing of the airways by the Intensive
Care Service. She was then taken to the operating room later
that day by Dr. [**First Name (STitle) **] ___________________________ of Invasive
Pulmonology and underwent a rigid bronchoscopy. He found a
2 cm tracheal tear of the distal right trachea at the
tracheal bronchial angle. Additionally, flexible
bronchoscopy demonstrated a pulsatile mass in the right
middle lobe which upon evaluation opened up and began
bleeding massive amounts of blood. He evacuated the airways
of 600 cc of blood and placed a bronchial blocker down the
right main stem bronchus and inflated it. Dr. [**Last Name (STitle) 952**] of
Thoracic Surgery was then consulted. The bronchial blocker
balloon was deflated and there was no further bleeding. We
elected to temporize this situation by performing a medial
sternotomy and placement of a mediastinal drainage adjacent
to the tracheal tear and placing a double-lumen to isolate
the right lung from the ________________ circuit. The
following day she went to the invasive radiology angio suite
and had a aortogram which demonstrated a right middle lobe
bronchial artery aneurysm. This was successfully embolized
due to desaturations and in the radiology suite she was
placed on double lung ventilation and subsequently developed
massive mediastinal air and high fevers. High fevers,
hypotension and sepsis. She was therefore taken to the
emergency department by Dr. [**Last Name (STitle) 952**] to the operating room
where she underwent a small right thoracotomy with repair of
the tracheal tear. After several days of intubation in the
Intensive Care Unit she was finally extubated when her sepsis
cleared and was eventually discharged in good condition on
[**2146-6-7**].
PLAN:
The plan was to have her come back in one month's time to
undergo a flexible bronchoscopy and evaluation of the airway
to assess the right middle lobe bronchus in the area where
the aneurysm had been. Additionally we will obtain a CT scan
to rule out a parenchymal mass. I am dictating this it is
three months past the time of her discharge. We have
subsequently performed a three month bronchoscopy and CT scan
of the chest. There is no evidence on bronchoscopy or CT
scan of any residual mass or aneurysm within the right
frontal lobe. Thus we will perform one more CT scan and
bronchoscopy at the six month interval to confirm the absence
of any new masses.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-351
Dictated By:[**Last Name (NamePattern4) 9931**]
MEDQUIST36
D: [**2146-8-4**] 18:29
T: [**2146-8-8**] 07:22
JOB#: [**Job Number 48595**]
|
[
"51881",
"2762",
"5070"
] |
Admission Date: [**2193-5-15**] Discharge Date: [**2193-6-7**]
Date of Birth: [**2162-5-30**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 28789**]
Chief Complaint:
Transfer from outside hospital at 24+0 with severe
thrombocytopenia
Major Surgical or Invasive Procedure:
Classical cesarean section under general endotracheal anesthesia
Plasmaphoresis
Head MRI
History of Present Illness:
30yo G2P1 at 24w0d with history of cryptogenic strokes presents
as a transfer from [**Hospital1 **] ICU with severe thrombocytopenia.
Patient initially presented to her primary Ob/Gyn on [**2193-5-11**]
with epistaxis. Platelet count was found to be
13,000. She was admitted to the [**Hospital1 **] ICU and treated with
plasmaphoresis x 4 for possible diagnosis of TTP-HUS.
Patient was seen today by Dr. [**Last Name (STitle) **] ([**Doctor Last Name 13675**] Ob/Gyn), who
recommended transfer to [**Hospital1 18**] for further evaluation given blood
pressures noted to be as high as 160/97 (130-160/70-90s). She
was given Labetalol 100mg [**Hospital1 **] and started on a Magnesium sulfate
infusion.
Here, the patient reports a mild headache for two days. Denies a
history of chronic headaches. She denies visual changes or RUQ
pain. She denies a history of elevated blood pressures. She
reports active fetal movement. Denies contractions, vaginal
bleeding, or loss of fluid. She denies any complications with
this pregnancy up until this point.
Patient desires full intervention for this pregnancy. ROS:
Denies F/C. Denies nausea or vomiting. Denies CP/SOB. Denies
neurologic symptoms. Denies urinary or GI symptoms.
Past Medical History:
PRENATAL COURSE
*)[**Last Name (un) **]: [**2193-9-4**] by first tri U/S
*)Labs: O+/Ab-/RPRNR/RI/HBsAg-/HIV-
*)Testing: Quad screen low risk, GLT 83
U/S: Full fetal survey nl, S=D, anterior placenta
Issues:
1. Booking BP 110/70; highest BP recorded at a prenatal visit
during this pregnancy, 120/80
2. Hospitalized [**2193-4-2**] with TIA, started on 81mg ASA during this
pregnancy
ObHx:
[**2189**] 35weeks, LTCS for NRFHT after evaluation for decreased
fetal
movement, 4# infant
- PP course c/b thrombocytopenia, underwent plasmaphoresis,
remained in hospital x 1 month
PMH:
Anemia
[**2190**] left MCA stroke
- thrombophilia w/u negative
- TEE negative
[**2191**] left posterior parietal stroke
[**2192**] TIA
[**4-/2193**] TIA during pregnancy, started on ASA 81mg
PSH:
Cesarean section
Social History:
Lives with FOB/boyfriend is [**Name (NI) 1692**]. He is involved in his
pregnancy. Patient is [**Country 13622**]. She is not employed. Denies
tob/EtOH/drugs.
Family History:
Mother died of stroke at age 65yo. Father is a diabetic. Two
healthy sisters. Denies family history of hematologic or
thrombotic disease.
Physical Exam:
On admission:
VS: T 97.4 BP 147/81 HR 65 RR 21 O2Sat 99%
Rpt BPs
NAD, comfortable
Skin no rash, petechiae
RRR
CTAB
Abd soft, gravid, NT
Ext NTNE, pboots in place, DTRs 2+
Imaging:
Bedside U/S:
EFW 477g (22w0d), good fetal movement, DVP 3.9cm, anterior
placenta, FH 133bpm
Brief Hospital Course:
30y/o G2P1 transferred at 24+0 weeks gestation for further
workup of severe thrombocytopenia and suspected preeclampsia.
.
Ms [**Known lastname 83190**] was initially admitted to the ICU for close
hemodynamic monitoring. Her blood pressures were stable
(140s/80s) on arrival. Her platelet count was 76,000. Additional
preeclampsia labs were significant for an elevated creatinine
(0.9) and urine protein/creatinine ratio (0.9). She was
continued on magnesium sulfate for seizure prophylaxis. A 24
hour urine collection revealed 608mg of protein, concerning for
preeclampsia. Heme/onc was consulted and felt her clinical
presentation was most consistent with TTP and recommended
continuing high dose steroids and plasmapheresis with hem path
following. She received a course of betamethasone for fetal lung
maturity (complete on [**5-18**]), then was transitioned back to IV
Solumedrol. She responded to the steroids and plasmapheresis.
After 24 hours of ICU monitoring, she was transferred to the
antepartum floor. Her initial testing from the OSH revealed that
she may have congenital TTP as she had negative antibody
testing.
.
Her blood pressures were stable on Labetolol 100mg [**Hospital1 **]. The
magnesium sulfate was discontinued. Once her platelets were
stable (>150-200) for three days (following three days of
plasmapheresis), the plasmapheresis was held. She was
transitioned back to po prednisone and serial labs continued to
be closely monitored. Over the next 3-4days the Labetolol was
titrated up to 400mg tid at 24+4 weeks due to worsening
hypertension and nifedipine 30mg was started. At 25w0d, she was
also noted to have slightly elevated LFTs. She continued to be
managed expectantly with close maternal and fetal surveillance.
The night prior to delivery, she received an additional dose of
200mg of labetolol, increasing her to 600mg TID of labetolol and
she received a second dose of 30mg of nifedipine. On the day of
delivery, 25w2d, her LFTs were further increased to the 60-80s.
.
In regards to fetal surveillance, she underwent daily NSTs
starting at 25wks and daily biophysical profiles since admission
at 24 weeks. The NICU was consulted on admission. Her NSTs were
concerning for minimal variability, rare small accelerations,
and occasional quick variable decelerations. The biophysical
profiles were always reassuring ([**9-8**]) and the EFW was 477 grams
at 24wks. On [**5-23**] fetal dopplers revealed absent end diastolic
flow but not reversed and a BPP [**9-8**].
.
Her third plasmapheresis (prior to delivery) was performed on
[**5-18**] and her platelets remained quite stable until [**5-23**] when
they dropped to 141,000. The following day, [**5-24**], she reported
visual changes, including blurry vision and vision loss.
Neurology was consulted and did not feel that her neurological
exam was consistent with an acute stroke. An MRI was ordered,
however, was not performed immediately due to machine
maintenance and other more pressing clinical concerns. Her
platelets dropped to 35,000, confirming a relapse of her TTP.
She received 2 units of FFP and she underwent plasmapheresis
after a line was placed. During continuous fetal monitoring, the
fetal heartrate tracing continued to have minimal variability
with spontaneous decelerations. Ultrasound was repeated and
umbilical dopplers revealed reverse EDF and delivery was
recommended.
.
On [**5-24**] the patient had a NRFHT in the setting of acute TTP (
with severe visualk changes and platelets had been in the normal
range and then severe thrombocytopenia again) and severe
pre-eclampsia while she was being monitored on L&D. She
underwent a classical cesarean section at 25+2 weeks gestational
age urgently due to a fetal bradycardia shortly after her US
revealing reverse EDF. Please see operative note for full
details. Intraoperatively she received 2units of PRBCs, 3 units
of FFP, and 2 units of PLT.
.
Post-operatively she was taken to the [**Hospital Unit Name 153**] and remained
intubated until POD#1. On POD#1 she received one additional unit
of PRBCs for a low HCT of 22 from 26 post-operatively. She
plasmapheresed daily in the [**Hospital Unit Name 153**] and received high-dose steroid
(IV solumedrol 80 mg twice daily). Given the plasmapheresis and
intubation and sedation and concern for bleeding, she did not
receive magnesium. Her blood pressures were initially
controlled with labetalol standing as well as hydralazine prn.
These were converted to oral doses as soon as she was tolerating
po. She was followed by the neurology team. The patient
reported new visual symptoms involving right sided visual
deficits. She had repeat neuro-imaging which showed no new
findings of PRES or thrombosis although showed bilateral
retro-ocular fluid collections and partial right retinal
detachment. She was seen by ophtho in the [**Hospital Unit Name 153**], who felt these
accumulations were associated with her hypertension and required
no acute intervention. She will follow-up with them as an
out-patient. She did well and was transferred to the PP floor
on [**5-27**] in the early morning.
.
She continued to have daily pheresis per the transfusion team
until [**5-31**], at which time her platlets had been over 150K for 2
days. Her platlets continued to remain over 150K on daily labs
and she required no additional pheresis sessions. Her steroids
were tapered during the hospitalization and she was discharged
on prednisone 80 mg daily. While taking high-dose steroids she
required small doses of insulin to control her blood sugars.
She did not require any insulin on discharge. Anti-hypertensives
were titrated over the course of her hospitalization as she
graudally required less and less therapy. She was discharged
with labetalol 200 mg three times daily.
.
On [**5-27**] her wound was explored at the bedside due to a large
hematoma. The fascia was intact and there was no active
bleeding. She was started on wet to dry dressing changes for
healing by secondary intent.
.
She was discharged in stable condition on [**6-7**]. She will have
VNA to closely follow her platlets, blood pressures, and wound
healing.
Medications on Admission:
Meds at home:
Iron 325mg daily
ASA 81mg daily
PNV
Meds on transfer:
Methylprednisolone 125 mg IV BID (since [**2193-5-13**] PM)
Ranitidine 150 mg PO BID
Multivitamin daily
Ferrous sulfate 325 mg PO daily
Labetalol 100 mg PO BID
Calcium carbonate 1000 mg q4h PRN heartburn
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 4 days: Please take 60 mg starting Saturday [**6-8**] am to
Tuesday [**6-11**]. .
Disp:*12 Tablet(s)* Refills:*0*
2. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain: for dressing changes.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
thrombotic thrombocytopenic purpura
severe preeclampsia
25 week pregnancy
Discharge Condition:
stable
Discharge Instructions:
llame si tienes dolor de [**Last Name (un) 33762**] que no se quite con
medicamentos, or si [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] es pior, or si tienes dolor en
abdomen que no se quite con medicamentos. tambien llame si
tienes fiebre, or dolor en [**Location 83191**].
Followup Instructions:
Martes con Dr. [**Last Name (STitle) 83192**], [**Hospital Ward Name 23**] building TCC 8 at 2pm. El
numero telefono es [**Telephone/Fax (1) 8992**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12766**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2193-6-11**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2193-6-11**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 83193**], MD Phone:[**Telephone/Fax (1) 8992**]
Date/Time:[**2193-6-11**] 2:00
You need to see an opthalmologist (eye doctor) for your vision.
We are concerned that you may have a retinal detachment.
Please call on Monday for an appointment. Tell them you were in
the hospital and told you needed to be seen. You have several
options in [**Location (un) 47**]:
1. [**Location (un) 511**] Eye Center: [**Location (un) 83194**], [**Location (un) 47**] , [**Numeric Identifier 83195**]
Telephone: [**Telephone/Fax (1) 83196**]
2. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. at Retina Eye Care; [**Apartment Address(1) 83197**], [**Location (un) 1110**], [**Numeric Identifier 8057**]
Telephone: ([**Telephone/Fax (1) 83198**]
In [**Location (un) **], you can see Dr. [**Doctor Last Name 83199**], who you saw in the
hospital, her office number is [**Telephone/Fax (1) 83200**].
|
[
"2859"
] |
Service: Date: [**2123-11-22**]
Date of Birth: [**2069-5-9**] Sex: M
Surgeon: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
HISTORY OF THE PRESENT ILLNESS: This is a 54-year-old
gentleman, who was recently discharged on the 13th of
[**Month (only) **] to rehabilitation with multiple medical problems,
including coronary artery disease, status post [**Female First Name (un) 899**] in [**2115**],
congestive heart failure with EF of 20% to 30%, status post
pericardial stripping, prostatic mitral and tricuspid valve
placement in [**Month (only) 205**], [**2123**] for valve dysfunction and
constriction after radiation; ICD placement for nonsustained
VT and low ER inducible VT. The patient was admitted
recently with shortness of breath and pulmonary edema. He
had respiratory distress, which was felt to be multifactorial
and in part, due to MRSA pneumonia and CHF. Hospital course
then was complicated by episodic hypotension requiring
transient inotropic and pressor support. Hemodynamic
monitoring was not possible secondary to the prosthetic
tricuspid valve. Hemodynamics using showed physiology
consistent with sepsis. He improved with antibiotics, and
eventually he was diuresed and afterload reduced. The
etiology of the infection was thought to be pneumonia. He
was covered broadly. Cultures were negative except for
sputum with MRSA. Pleural effusion was tapped and it was
transudative with on evidence of infection. He has had a
chronically low hematocrit, which is multifactorial. There
was no evidence for DIC. He did have blood loss from the
left femoral artery puncture site and required transfusion,
bronchitic support, and blood loss anemia.
On the evening of the 19th, he was found to be hypotensive
with the blood pressures in the 70s and poor oxygenation.
His chest x-ray showed CHF versus ARDS. He developed a fever
to 101.2. He was started on Dopamine. He was sent to [**Hospital1 98139**] for further care. He notes
increased sputum production, but no dyspnea or chest pain.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post inferior myocardial
infarction [**2114**] complicated by left ventricular thrombus,
status post left circumflex stent in [**2123-4-1**].
2. Congestive heart failure.
3. Status post mitral valve and tricuspid valve prosthetic
replacement [**2123-8-10**].
4. AICD in [**2123-4-1**].
5. History of cerebrovascular accident with residual left
finger numbness.
6. History of Hodgkin lymphoma at the age of 27, status post
radiation and splenectomy.
7. Hypercholesterolemia.
8. History of cervical diskectomy.
9. Tracheostomy in [**2123-8-1**].
10. Gastrostomy tube placed in [**2123-8-1**].
11. MRSA diagnosed in [**Month (only) **], [**2123**], with witnessed
aspiration with p.o. medications and liquids.
12. Constrictive pericarditis.
13. Iron-deficiency anemia.
MEDICATIONS ON ADMISSION:
1. Ceftazidime started [**10-19**].
2. Epogen.
3. Amiodarone 400 p.o.q.d.
4. Aspirin 325 p.o.q.d.
5. Iron.
6. Lasix 20 mg p.o.q.d., 20 mg IV.
7. Spironolactone.
8. Levothyroxine 200 p.o.q.d.
9. Enoxaparin 40 subcutaneously b.i.d.
10. Kayexalate.
11. Ativan.
12. Morphine p.r.n.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: The patient's father died from colon cancer.
No history of coronary artery disease. The patient is
married. He used to self employed. He does not smoke or
drink alcohol. He currently lives at [**Hospital **] Rehabilitation
Center.
PHYSICAL EXAMINATION: The patient is resting comfortably in
bed in no acute distress. VITAL SIGNS: Blood pressure 76/43
left arm; 97/44 right arm. Pulse 80. Saturation 94% on 100
FIO2. HEENT: Pupils equal, round, and reactive to light and
accommodation. Extraocular muscles are intact; anicteric
sclerae. Hearing aids are in place. Moist mucous membranes.
Neck was supple without lymphadenopathy. LUNGS: Coarse
sounds throughout; no wheezes or rhonchi. CARDIOVASCULAR:
No jugular venous distention. Carotids normal with brisk
upstrokes, regular rate and rhythm. Mechanical S1 and normal
S2; no rub or gallop. ABDOMEN: Abdomen was soft,
nondistended, nontender, normoactive bowel sounds.
EXTREMITIES: Positive pitting of the lower extremities of
thigh, pitting edema in the arm, markedly improved from
previous hospitalization. There was a well healed scar of
the left arm, PIC in the right arm. Dressings to both heels
decubitus ulcers. Chest: Well healed scar, muscular
chest-wall defect dressed. Decubitus on sacrum mildly
erythematous without obvious drainage.
LABORATORY DATA: Laboratory revealed the hematocrit of 23.4;
platelets 453,000, white blood cell count of 9.8 with no
bands; sodium 134; potassium 5.2; chloride 99; bicarbonate
26; BUN 123; creatinine 1.5; glucose 116; calcium 7.5;
magnesium 3.4; phosphorus 5.6; albumin 2.5; INR 1.3; PTT 32;
arterial blood gas on 90% with FIO2 with 5-cm of PEEP
revealed the pO2 of 7.36, pCO2 of 49, pO2 of 56. Chest x-ray
showed diffuse alveolar filling with patchy interstitial
markings. The last echocardiogram revealed an EF of 25 to
35% with normal valve function; severe global left
ventricular hypokinesis; mild right ventricular dilation.
HOSPITAL COURSE: Mr. [**Known lastname **] was treated simultaneously
for infectious pneumonic process, as well as congestive heart
failure. For pneumonia he had initially received Vancomycin,
and the Zosyn. He was extensively evaluated by the Heart
Failure Team, Dr. [**Last Name (STitle) **] for management of his CHF and
possible candidacy for heart transplant. He was initially
tried on Milrinone, but failed secondary to hypertension.
Dopamine was tried with limited success in conjunction with
aggressive bolus Lasix regimen. Dopamine was discontinued
and we started using a combination of afterload reduction and
inotropic support. The patient did not successfully diurese
to this regimen. Sputum eventually showed polys with no
organisms, but grew out a fairly resistant Serratia and
Klebsiella and was started on Imipenem. However, he
developed a rash from the Imipenem and he was started on
Bactrim. The Bactrim was ultimately discontinued. He
remained on the Dopamine until [**11-19**]. He had been
intermittently tried on Dopamine, Dobutamine, and Lasix drip
with again limited success in terms of diuresis. Multiple
blood transfusions were given to support hematocrit greater
than 30. His renal function intermittently improved and
worsened based on the degree of diuresis. There was an
episode of acute renal failure during the week of [**11-10**], probably secondary to hypotension after failed attempt
to wean Dopamine in conjunction with oncotic support in the
form of packed red blood cells and Lasix. Renal function
returned closer to baseline of 2.
Multiple trials of trach-mask were attempted, however, the
patient did not have the cardiac function to support
spontaneous ventilation and eventually tired. He has been
intermittently using between 10 to 20-cm of pressure support
in conjunction with 5-cm to 10-cm of PEEP and an FIO2 ranging
between .4 and 1.
The Dopamine was eventually weaned to off on [**11-29**] and
21st with just Dobutamine and Lasix. The patient diuresed
fairly successfully 3-4 liters over a [**3-6**] day period.
Access had been a difficult issue secondary to extensive
bleeding in the femoral region in the past. A right
subclavian was attempted, but failed. Right internal jugular
complicated by arterial puncture and a PICC line had been
placed in the right arm, which is functioning at this point.
Over the week of [**11-12**] to [**11-19**], the patient was tried on
trach-mask trials. However, this in conjunction with changes
in the Ativan dosing produced hallucinations and delirium.
The patient was placed back on pressor support ventilation
and improved significantly in terms of his mental status.
ISSUE #1. Cardiovascular: The patient is status post
multiple inotropic trials to improve cardiac function and
diurese both left and right side fluid overload. He has been
intermittently tried on milrinone, Dopamine, and dobutamine.
The most successful of these regimens has been a combination
of dobutamine and Lasix. The patient did not tolerate
Milrinone secondary to hypotension. On Dopamine, he would
intermittently diurese, but not progressively. Maintaining
the patient 200 cc to 300 cc negative a day is a reasonable
goal on a moderate dose of Dobutamine at 6 mcg per k per
minute using a Lasix drip at 5 to 20 mg an hour.
In terms of his tricuspid and mitral valve replacement, the
patient was initially on Coumadin, which had been stopped,
however, his INR continued to take a long to drip down
secondary to poor nutrition. He had an INR of 4.2. There
was moderate bleeding from the trach-site. The patient was
reversed with FFP. The INR was brought down to 1.9, at which
time Heparin was started. As the patient improved, he
started on Coumadin with a target INR of [**4-4**].
The patient continues to be V-paced at 80.
ISSUE #2. Pulmonary: The patient has a history of
pneumonia, which in the past grew MRSA. During this
admission grew Klebsiella and Serratia sensitive to Imipenem
and Bactrim. The patient developed a rash to Imipenem and
was started on Bactrim. The patient developed a rash to
Imipenem. The patient was started on Bactrim. However, this
was stopped in the setting of acute renal failure for the
worry of possible interstitial nephritis. However, the
patient did not seem, from the respiratory standpoint, to
acquire antibiotics. Antibiotics were stopped on the 10th
and 12th of [**Month (only) 359**]. Chest CT was performed on the [**11-19**] to help characterize the degree and extent of
pulmonary disease. The CT was notable for consolidation and
interstitial disease, which was central sparing the periphery
consistent the primary pulmonary process. No significant CHF
was seen in the periphery. It is possible that the amount of
radiation received 20 years ago may have resulted in a
primary interstitial process to whatever cardiogenic process
is occurring. With aggressive diuresis in [**Month (only) 359**] on
Dobutamine and Lasix the oxygen requirements decreased to
FIO2 of .41. Ensuring a steady diuresis of 200-300 cc a day
should prevent further oxygen requirements. However, it is
unlikely secondary to the patient's poor cardiac function and
extent of interstitial disease that he will become vent
independent in the near future.
ISSUE #3: Renal. The patient had sensitive renal function.
Creatinine ranged from 1 to 3. He is clearly sensitive to
renal perfusion and systolic blood pressure and keeping the
hematocrit above 30 to maintain good oncotic pressure for
renal perfusion is necessary for good renal function. His
renal function was very sensitive to blood pressures below 70
to 80, causing acute renal failure with an ATN type picture.
However, with improved and aggressive diuresis off the
Dopamine, his renal function has improved to a baseline of
1.1.
A limit to his diuresis may be reached in terms of the BUN,
which has risen to the high 90s.
ISSUE #4: Endocrinological: From an endocrinological
standpoint he has a history of hypothyroidism; TSH has been
relatively high and consistent with hypothyroidism in the
setting of systemic illness. His Levothyroxine doses have
been progressively increased. He is now at 200 mcg a day and
will need a TSH checked in the near future.,
ISSUE #5: Gastrointestinal. The patient was received tube
feeds through his PEG, however, due to increased agitation
and abdominal distention in the absence of clear obstruction
or perforation, his tube feeds were stopped in favor or TPN.
As his fluid balance continues to improve, he should be able
to start enteral feeding.
ISSUE #6: Psychiatric. The patient was controlled primarily
with Remeron and Ativan for sleep at night. When the Ativan
was discontinued in conjunction with trach-mask trials, his
mental status acutely decompensated in the form of
hallucination and delirium. The mechanical ventilation was
restarted with progressive clearing of his mental status.
There was no evidence of CO2 narcosis. However, hypoxia is a
significant possibility for cause of mental status changes
during independent ventilation. The Remeron was
discontinued. The patient responds well to Haldol, as
needed.
ISSUE #7. Electrolytes were followed closely. Potassium was
repleted as needed, as well as magnesium. Nutrition was as
above. The patient has a right peripherally inserted central
catheter, which is functioning. The patient has been placed
on a proton pump inhibitor and had an elevated INR for much
of his hospitalization, but recently this has been reversed
as described, and the patient has been Heparinized.
This discharge summary will continued in a DC addendum.
The patient is currently a full code. Numerous family
discussions with his wife and himself were held.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 30528**]
MEDQUIST36
D: [**2123-11-22**] 14:47
T: [**2123-11-22**] 15:18
JOB#: [**Job Number 98140**]
|
[
"4280",
"5849",
"51881",
"0389"
] |
Admission Date: [**2188-6-3**] Discharge Date: [**2188-6-11**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Thoracentesis
History of Present Illness:
This is an 81 year old female resident of the [**Hospital1 10151**] Center for Aged who has a history of a LLL
nodule, R hilar fullness on CT in [**10-15**], and a transbronchial
biopsy with lavage that initially showed initially squamous CA,
but which was then reread as reactive only. At time patient also
had endobronchial lesions concerning for ? aspiration but normal
swallow eval. Pt declined intervention/aggressive care for
possible CA and returned to [**Hospital1 5595**].
Pt continued to have chronic cough, and over last 4 days had
increasing sputum production, increasing SOB, and progressive
hypoxia. She had been started on Levo/Azithro at [**Hospital1 5595**] and
steroids added on [**6-2**]. Pt was urgently transferred to [**Hospital1 **] on
[**6-3**] due to hypoxia/tacypnea (ABG 7.39/46/81 on
100%NRB)...patient and daughter both agreed to reverse code
status despite previous DNR/I. CXR notable for new large L
pleural effusion.
Intubated in ED, started on coverage for nosocomial PNA
(levo/vanc) and a-line placed. No septic physiology
Past Medical History:
PMHx:
1)As above,
2)Gastritis,
3)UGI bleed,
4)Anemia (Fe deficiency),
5)CAD s/p CABG,
6)HTN,
7)Hypercholesterol,
8)s/pCCY and appy
Social History:
Pt is a retired teacher from Siberia. She denies EtOh intake.
Physical Exam:
T 97.7 BP 140/90 HR 94 RR 20 O2 sats 95% %L O2
General: Pt sitting in chair in NAD
HEENT: PERRLA, EOMI, no JVD, no LAD
CVS: RRR, no M/R/G
Chest: L base with decreased air movement, bronchial breath
sounds, dullness to percussion 2/3 up from base orf L lung field
Abd: soft, nontender, nondistended, + bowel sounds
Ext: 1+ pitting edema, no cyanosis or clubbing, good pedal
pulses
Neuro: CN II-XII grossly intact, strength 5/5 bilat UE/LE
Pertinent Results:
[**2188-6-3**] 08:28PM TYPE-ART TEMP-36.7 PO2-91 PCO2-42 PH-7.40
TOTAL CO2-27 BASE XS-0
[**2188-6-3**] 01:58PM URINE HOURS-RANDOM
[**2188-6-3**] 01:58PM URINE GR HOLD-HOLD
[**2188-6-3**] 01:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2188-6-3**] 01:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2188-6-3**] 01:58PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2188-6-3**] 01:58PM URINE MUCOUS-OCC
[**2188-6-3**] 12:35PM TYPE-[**Last Name (un) **] PO2-81* PCO2-46* PH-7.39 TOTAL
CO2-29 BASE XS-1 COMMENTS-NOT SPECIF
[**2188-6-3**] 12:35PM LACTATE-1.8
[**2188-6-3**] 11:30AM GLUCOSE-131* UREA N-26* CREAT-1.2* SODIUM-140
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16
[**2188-6-3**] 11:30AM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-71
AMYLASE-35 TOT BILI-0.4
[**2188-6-3**] 11:30AM ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-4.4
MAGNESIUM-2.5
[**2188-6-3**] 11:30AM WBC-12.9*# RBC-4.52 HGB-12.3 HCT-38.5 MCV-85#
MCH-27.3# MCHC-32.1 RDW-15.9*
[**2188-6-3**] 11:30AM NEUTS-95* BANDS-0 LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2188-6-3**] 11:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2188-6-3**] 11:30AM PLT SMR-NORMAL PLT COUNT-335
[**2188-6-3**] 11:30AM PT-13.4* PTT-29.1 INR(PT)-1.2
[**2188-6-11**] 06:35AM BLOOD WBC-6.4 RBC-3.81* Hgb-10.5* Hct-32.6*
MCV-86 MCH-27.5 MCHC-32.1 RDW-15.9* Plt Ct-278
[**2188-6-10**] 06:30AM BLOOD WBC-6.4 RBC-3.81* Hgb-10.6* Hct-32.2*
MCV-85 MCH-27.7 MCHC-32.8 RDW-16.0* Plt Ct-243
[**2188-6-9**] 06:25AM BLOOD WBC-7.3 RBC-3.80* Hgb-10.2* Hct-32.5*
MCV-85 MCH-26.8* MCHC-31.3 RDW-15.7* Plt Ct-286
[**2188-6-8**] 03:47AM BLOOD WBC-8.4 RBC-3.99* Hgb-11.1* Hct-32.9*
MCV-82 MCH-27.7 MCHC-33.7 RDW-15.4 Plt Ct-267
[**2188-6-7**] 03:30AM BLOOD WBC-8.6 RBC-4.03* Hgb-11.0* Hct-34.3*
MCV-85 MCH-27.3 MCHC-32.1 RDW-15.5 Plt Ct-288
[**2188-6-6**] 04:04AM BLOOD WBC-7.0 RBC-3.75* Hgb-10.5* Hct-31.8*
MCV-85 MCH-27.9 MCHC-32.9 RDW-16.2* Plt Ct-244
[**2188-6-5**] 04:55AM BLOOD WBC-8.5 RBC-3.93* Hgb-10.5* Hct-33.3*
MCV-85 MCH-26.8* MCHC-31.6 RDW-16.0* Plt Ct-254
[**2188-6-4**] 06:00AM BLOOD WBC-7.4 RBC-3.77* Hgb-10.3* Hct-31.1*
MCV-83 MCH-27.4 MCHC-33.2 RDW-16.0* Plt Ct-238
[**2188-6-4**] 04:00AM BLOOD WBC-8.3 RBC-3.83* Hgb-10.4* Hct-32.9*
MCV-86 MCH-27.1 MCHC-31.5 RDW-15.9* Plt Ct-286
[**2188-6-3**] 11:30AM BLOOD WBC-12.9*# RBC-4.52 Hgb-12.3 Hct-38.5
MCV-85# MCH-27.3# MCHC-32.1 RDW-15.9* Plt Ct-335
[**2188-6-4**] 06:00AM BLOOD Neuts-86.7* Lymphs-8.4* Monos-4.6 Eos-0.2
Baso-0.1
[**2188-6-4**] 06:00AM BLOOD Hypochr-1+ Anisocy-1+ Microcy-1+
[**2188-6-11**] 06:35AM BLOOD Plt Ct-278
[**2188-6-10**] 06:30AM BLOOD Plt Ct-243
[**2188-6-9**] 06:25AM BLOOD Plt Ct-286
[**2188-6-6**] 04:04AM BLOOD PT-12.4 PTT-33.3 INR(PT)-1.0
[**2188-6-7**] 07:54AM BLOOD Type-ART Temp-36.2 Tidal V-380 O2-40
pO2-81* pCO2-57* pH-7.35 calHCO3-33* Base XS-3 Intubat-INTUBATED
[**2188-6-3**] 12:35PM BLOOD Type-[**Last Name (un) **] pO2-81* pCO2-46* pH-7.39
calHCO3-29 Base XS-1 Comment-NOT SPECIF
Brief Hospital Course:
1)Respiratory failure: Her respiratory failure was felt to be
due to large LLL lesion, pleural effusion and ? underlying PNA.
She was extubated on [**6-7**] to face tent, then weaned to 5L O2 NC
and improved. Her lung exam continued to be consistent with a
left sided effusion and she continued to have coarse breath
sounds and secretions supporting a possible underlying PNA. She
was started on levofloxacin 250 mg QD on [**6-4**] and is to continue
for a 14 day course (to end [**6-17**]). The pleural effusion was
tapped for diagnostic and therapeutic purposes. Cytology is
pending at time of dicharge. Repeat CXR shows evidence of
reacculmulation of fluid, but stable pulmonary status. She may
require repeat thoracentesis if she becomes symptomatic.
2)LLL lesion: She has a persistent LLL lesion with possible
post-obstructive pneumonia. Therapuetic/diagnostic
thoracentesis on [**6-4**] removed 2L serosanguinous fluid; fluid
cytology exudative by numbers, with lots of atypical cells
present. Definitive cytology pending, lymphoma vs. adenoCA. At
time of discharge, final cytology was pending; however, the
preliminary report was poorly differentiated, and more stains
were being done to determine type of CA. Mrs.[**Known lastname 10152**] failed to
accept the possibility of having cancer and did not wish to
pursue further therapeutic options. This may be a topic for
discussion with her PCP who likely has a more longstanding
relationship with her. At the very least, if the pleural
effusion continues to worsen, she may need a repeat
thoracentesis with a sclerosing [**Doctor Last Name 360**].
3)Anemia: HCT dropped initially in setting of hydration, it
climbed back to 32.6 and remained stable. It was 32.2 on the day
of discharge. Stool guaiac was negative.
4)CAD/HTN: Pt was normotensive on started on Norvasc 5 mg PO QD.
5)Hyperlipidemia: Pt was on zocor for lipid control.
Medications on Admission:
Meds on transfer: albuterol, norvasc, ASA, dulcolax, HCTZ,
Celexa, zoclor, imdur, detrol, prednisone, levo, azithro
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*2*
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 inhaler* Refills:*2*
3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
QD (once a day).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
Disp:*1 bottle* Refills:*2*
10. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) ampule
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
13. Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: 5000 (5000)
units Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
1) Lung cancer
2) Post-obstructive PNA
3) L pleural effusion
Discharge Condition:
Stable.
Discharge Instructions:
Please return to hospital if worsening shortness of breath, temp
> 101, or chest pain.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
Phone:[**Telephone/Fax (1) 5091**] Date/Time:[**2188-7-17**] 2:45
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
Date/Time:[**2188-7-17**] 3:00
|
[
"486",
"2859",
"4019",
"2720",
"V4581"
] |
Admission Date: [**2119-7-13**] Discharge Date: [**2119-7-22**]
Date of Birth: [**2055-4-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / Alpha 2
Adrenergic Agonist
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
New onset throat pain with shortness of breath
Major Surgical or Invasive Procedure:
[**2119-7-17**] Coronary artery bypass graft x 4 (left internal mammary
artery > left anterior descending, saphenous vein graft > obtuse
marginal 1, saphenous vein graft > obtuse marginal 2, saphenous
vein graft > posterior descending artery)
History of Present Illness:
64 year old male seen by PCP for routine [**Name9 (PRE) 16574**] and mentioned
that he was having throat pain for over a period of a week. He
evaluated by cardiology and given his cardiac risk factors he
was admitted to the hospital and
underwent cardiac catheterization which revealed significant CAD
with 60%
LM. He was therefore transferred to [**Hospital1 18**] for surgical
evaluation.
Past Medical History:
HTN
dyslipidemia
severe RA
anxiety disorder
chronic back pain
muscular dystrophy
COPD
glaucoma
bil cataracts
retinal detachment left eye with vision loss
BPH
R knee replacement x2
left knee replacement x1
left nephrectomy in his 20's 2nd to trauma
exp laprascopic abd surgery
ventral surgery
[**Last Name (un) **] inguinal surgery
vasectomy
bilateral rotator cuff repairs
Social History:
Lives with:wife
Occupation:Disabled
Tobacco:smokes 1ppd x 40 yrs
ETOH:none
Family History:
+ CAD
Physical Exam:
Pulse:70's Resp: [**11-22**] O2 sat: 98%
B/P Right:131/96 Left: 140/94
Height:6ft Weight:250lbs
General:
Skin: Dry [] 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
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right:trace Left:Trace
DP Right: Trace Left:Trace
PT [**Name (NI) 167**]: Trace Left:Trace
Radial Right: +2 Left:+2
Carotid Bruit Right: none Left:None
Pertinent Results:
[**2119-7-13**] 03:10PM BLOOD WBC-6.5 RBC-5.03 Hgb-15.5 Hct-44.2 MCV-88
MCH-30.8 MCHC-35.0 RDW-14.7 Plt Ct-243
[**2119-7-13**] 03:10PM BLOOD PT-11.5 PTT-22.9 INR(PT)-1.0
[**2119-7-13**] 03:10PM BLOOD Plt Ct-243
[**2119-7-13**] 03:10PM BLOOD Glucose-91 UreaN-17 Creat-1.4* Na-141
K-4.8 Cl-103 HCO3-30 AnGap-13
[**2119-7-13**] 03:10PM BLOOD ALT-33 AST-24 LD(LDH)-202 AlkPhos-72
Amylase-56 TotBili-0.3
[**2119-7-13**] 03:10PM BLOOD Albumin-4.7
[**2119-7-18**] 01:16AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.1
[**2119-7-13**] 03:10PM BLOOD %HbA1c-6.3* eAG-134*
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.5 cm <= 4.0 cm
Right Atrium - Four Chamber Length: 5.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Lateral Peak E': 0.11 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 4 < 15
Aorta - Sinus Level: *4.6 cm <= 3.6 cm
Aorta - Ascending: *4.3 cm <= 3.4 cm
Aorta - Arch: *3.4 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.2 cm
Mitral Valve - E Wave: 0.4 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 0.67
Mitral Valve - E Wave deceleration time: *260 ms 140-250 ms
TR Gradient (+ RA = PASP): <= 25 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnorality cannot be fully
excluded. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aorta at sinus level. Mildly dilated
ascending aorta. Mildly dilated aortic arch.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
MS. Trivial MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Physiologic TR. Normal PA systolic pressure.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality as the patient was difficult to
position. Suboptimal image quality - patient unable to
cooperate.
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
arch 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. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal.
Brief Hospital Course:
Transferred in from outside hospital for surgical evaluation.
Underwent preoperative work up and on [**7-17**] was brought to the
operating room for coronary artery bypass graft surgery. See
operative report for further details. He received cefazolin and
vancomycin for perioperative antibiotics and was transferred to
the intensive care unit for post operative management. That
evening he was weaned off sedation, awoke neurologically intact
and was extubated without complications. On post operative day
one he was started on betablockers and diuretics. Additionally
he was transferred to the floor. Chest tubes and epicardial
wires were removed per protocol. Physical therapy worked with
him on strength and mobility however his chronic back pain was a
limiting factor. He also had pulmonary congestion which was
treated with nebs, CPT and pulmonary hygiene. He was maintained
on on his home dose of vicodin and ativan. He continued to
progress and was ready for discharge to rehab at [**Hospital 100**] rehab on
post operative day #5.
Medications on Admission:
Ativan 2mg tid
crestor 10mg daily
lisinopril 10mg [**Hospital1 **]
hydrocodone tid
cyclobenzaprine 10mg tid
asprin 325mg daily
MVI daily
fish oil daily
[**Doctor First Name 130**] daily
Discharge Medications:
1. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
3. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for anxiety.
Disp:*45 Tablet(s)* Refills:*0*
10. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
11. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
12. Lasix 40 mg Tablet Sig: Two (2) Tablet PO three times a day
for 10 days. Tablet(s)
13. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 10
days.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours).
15. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb
Miscellaneous Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
dyslipidemia
Anxiety
Rheumatoid arthritis
chronic back pain
muscular dystrophy
Chronic obstructive pulmonary disease
Glaucoma
Bilateral cataracts
retinal detachment left eye with vision loss
Benign prostatic hypertrophy
Left nephrectomy
ventral hernia
inguinal hernia
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 Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**8-9**] at 1:15pm in the [**Hospital **] medical office
building [**Hospital Unit Name **] [**Telephone/Fax (1) 10651**]
Cardiologist: Dr [**Last Name (STitle) 4922**] on [**8-28**] at 9:45am
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 89437**] in [**5-16**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2119-7-22**]
|
[
"41401",
"4019",
"2724",
"496",
"3051"
] |
Admission Date: [**2126-3-25**] Discharge Date: [**2126-4-8**]
Date of Birth: [**2070-9-28**] Sex: M
Service: O-MED
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
male with recently diagnosed abdominal carcinomatosis. The
patient presented with abdominal pain and bloating and was
found to have a large omental mass. Biopsy revealed
adenocarcinoma. Histochemical stains are consistent with
hepatobiliary origin. Endoscopies were negative except for
an extrinsic mass present on the stomach.
The patient presents with increased abdominal pain and poor
oral intake as well as generalized weakness. On
presentation, the patient denied chest pain, shortness of
breath, and cough.
PAST MEDICAL HISTORY:
1. Benign prostatic hypertrophy.
2. Osteoarthritis.
3. Gastrointestinal adenocarcinoma (as noted in History of
Present Illness).
MEDICATIONS ON ADMISSION: Colace, Senna, Dulcolax, Tylenol,
oxycodone as needed, Ambien, and Protonix.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Mother had adrenal cancer. Father had
coronary artery disease.
SOCIAL HISTORY: The patient was employed as a salesman. He
denied the use of tobacco and drugs. He uses alcohol
occasionally. The patient is married with two children.
REVIEW OF SYSTEMS: Review of systems was significant for
progressive abdominal discomfort, decreased oral intake, and
weakness in the past nine weeks.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 96.9, heart rate was 121, blood
pressure was 122/86, respiratory rate was 22, and oxygen
saturation was 96% on room air. In general, the patient
looked acutely and chronically ill. Head, eyes, ears, nose,
and throat examination revealed the oropharynx was clear.
Sclerae were anicteric. Mucous membranes were moist.
Cardiovascular examination revealed tachycardic first heart
sound and second heart sound. No murmurs, rubs, or gallops.
Lungs revealed decreased breath sounds and dullness to
percussion in the left lung base. The abdomen was distended
and firm. Positive bowel sounds. Extremity examination
revealed no clubbing, cyanosis, or edema.
IMPRESSION: This was a 55-year-old gentleman with recently
diagnosed abdominal carcinomatosis admitted with increased
abdominal pain and poor oral intake. The patient was
admitted to the O-MED Service for further management.
HOSPITAL COURSE: The patient was admitted to the O-MED
Service. He was placed on a patient-controlled analgesia for
pain control. He was administered intravenous fluids and
oral diet as tolerated.
On the night of [**3-26**], the patient complained of increased
vomiting. He also complained of increased shortness of
breath and "difficulty catching his breath." On room air,
the patient's oxygen saturation was 80%. His saturation
increased to 87% on a nonrebreather. A chest x-ray disclosed
a left pleural effusion. The patient was bolused with
intravenous heparin due to concern for pulmonary embolism.
The patient expressed a desire to be full code, so he was
transferred to the Intensive Care Unit.
The patient became more comfortable being seated upright with
nebulizer treatments. An angiogram was done which disclosed
possible subsegmental pulmonary emboli of the upper lobes as
well as infiltrates consistent with aspiration pneumonia.
The patient was placed on Flagyl and Levaquin for treatment
of pneumonia. He was continued on heparin for treatment of
the pulmonary emboli.
While in the Intensive Care Unit, the patient was noted to
have increasing abdominal distention. On [**3-28**] the patient
underwent an abdominal ultrasound with paracentesis, and 5
liters of fluid were removed.
On [**3-29**], the patient was transferred back to the O-MED
Service. Due to persistent gastric secretions, an
nasogastric tube was placed for decompression. The patient
was noted to have a functional ileus. Octreotide was
initiated in an attempt to decrease the gastric secretions.
On [**4-7**], the patient's respiratory status declined further.
He was noted not have an increasing left-sided pleural
effusion. A thoracentesis was done with removal of 1.5
liters of fluid. A paracentesis was repeated with removal of
2.5 liters of fluid.
On the night of [**4-7**], the patient continued to decline.
The family decided to pursue comfort measures. Morphine was
administered to insure patient's comfort. The patient
expired at 6 p.m. on [**4-8**].
FINAL DISCHARGE DIAGNOSES:
1. Gastrointestinal adenocarcinoma; primary unknown (likely
hepatobiliary).
2. Aspiration pneumonia.
3. Pulmonary emboli.
4. Hypoxia.
5. Dehydration.
6. Ileus.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], M.D. [**MD Number(1) 8654**]
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2126-4-8**] 19:24
T: [**2126-4-13**] 05:00
JOB#: [**Job Number 110248**]
|
[
"5070",
"5119"
] |
Admission Date: [**2159-1-3**] Discharge Date: [**2159-1-12**]
Date of Birth: [**2101-10-1**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Transfer from OSH for GIB
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
57 y/o Vietnamese M with HCV cirrhosis with declining mental
status over 48 hours ? hepatic vs. uremic encephalopathy per
[**Hospital1 2177**]--Managing HRS, ESLD, ascites, iatrogenic hemothorax s/p
Chest tube removal on [**1-3**] and worsening encephalopathy. Pt
nonoliguric but rising BUN/Cr despite
albumin/octreotide/midodrine, may likely need HD in next few
days. No emergent dialysis needed. Per sister [**Name (NI) 382**] pt was dx
w/liver disease ~2.5 years ago and had been relatively healthy
prior to his dx. Unclear transmission of HCV as no h/o IVDU,
Tattoos or blood transfusions. At end of [**2158-10-22**] pt started
to notice increasing peripheral LE edema which progressed up to
his thighs and into his abdomen over the course of [**2-24**] weeks.
Pt/family also noticed slight icteric sclera but no obvious
jaundice. Pt was admitted to [**Hospital1 2177**] on [**12-2**] for BRBPR. At
that time pt mentating well, Denied any abdominal
pain/N/V/diarrhea. Normal appetite. No cough/SOB. During [**Hospital1 2177**]
admission pt w/worsening Liver function, renal function, and
declining mental status. Pt was treated w/flagyl-completed 14day
course and Cefapime due to finish on [**1-11**] for E. Coli SBP, s/p
R sided Chest tube for iatrogenic hemothorax from line
placement, HRS w/octreotide/midodrin/albumin, and completed 14d
course w/Vanco for Nosocomial PNA on [**1-1**].
Pt was transferred to [**Hospital1 18**] for Liver transplant W/U.
Past Medical History:
-HCV Cirrhosis
-Ascites
-HRS baseline Cr 0.8 [**2158-12-17**]
-LGIB
-Transverse & Ascending colitis
Social History:
-Pt lives w/sister and relatives in [**Name (NI) 3786**]. Not married, no
children.
-Currently unemployed x2 years, fomer occupation-driver
-No h/o ETOH use or IVDU. No current TOB use, quit 11years ago,
smoked for ~5-10years
.
Family History:
-Both parents in their 80s, healthy
Physical Exam:
VS: 96.6 135/74 85 14 95%RA
GEN: Encephalopathic, not interacting
HEENT: Icteric sclera, dry MM, PERRL
RESP: Crackles at bases b/l, no wheezing
CV: Reg Nml S1, S2, 2/6 SEM LLSB
ABD: Soft, distended, NT, +BS, +fluid wave, no rebound, no
guarding, small ~3cm skin breakdown x3 sites on abdomen (former
para sites--minimal oozing)
EXT: 3+Pitting edema of LE b/l up to lower shins, warm, 1+DP
pulses b/l
NEURO: arousable, not interactive, did not follow commands-could
not evaluate for asterixis
Pertinent Results:
MAGING-OSH
[**12-3**] ABD CT: Advanced cirrhosis, ascites, esophageal varices,
mild concentric wall thickening w/in Right, Transverse, and
ascending colon
[**12-4**] TTE: LVEF 75%, Mild LAE,
[**12-16**] LENIs: negative for DVTs
[**12-24**] CXR: incrased R sided PTX, new b/l pleural effusions.
.
Labs on admission:
INR 5.5, Albumin 4.1, Bili 37.6, AST 53, ALT 17
Na 139, K 4.4, Cl 101, bicarb 24, BUN 118, Cr 2.8
WBC 17.8, Hct 28.4, Plt 123
.
Peritoneal fluid 1100 WBC 71% PMN.
OSH peritoneal cx + VRE
OSH blood cx + VRE
.
Endoscopy: grade 1 varix with diffuse oozing in esophagus,
mouth, stomoch, no discrete site of bleeding.
.
Eccho: The left atrium is mildly dilated. There is mild
symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly
thickened but aortic stenosis is not present. The increased
transaortic
gradient is likely related to high stroke volume. Mild (1+)
aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
7 yo M w/HCV cirrhosis, ESLD-MELD 49, HRS, hepatic
encephalopathy vs. worsening uremia, p/w worsening mental status
who was transferred to [**Hospital1 18**] for consideration of liver
transplant.
.
#. Liver: Mr [**Known lastname **] [**Last Name (Titles) 1834**] evaluation and testing by transplant
hepatology, transplant surgery, infectious diseases for
conisderation of liver transplantation. He was ultimately felt
to be in too poor health to be considered for transplantation
with hepatorenal syndrome, advaced liver disease with severe
coagulopathy and encephalopathy and overwhelming infection. He
was found on transfer to have both VRE bacteremia and
periotonitis which would automatically make him ineligable for
transplant for at least 14 days until his infection had been
adequately treated. He received aggressive care including
rifaxamin and lactulose for encephalopathy, Enteral tube feeds
for nutrition, antibiotics for bacteremia/peritonitis,
midodrine, octreotide, albumin and dialysis for HRS, and many
blood products for bleeding. He unfortunately decompensated
with critical bleeding and overwhelming infection and the
decision was made by the transplant hepatologists and surgeons
that he was not a transplant candidate and his care was
redirected toward comfort. (see below)
.
# Infection: Mr [**Known lastname **] [**Last Name (Titles) 1834**] diagnostic paracentesis which
showed increased number of WBC (1100 with 71% PMN) and was found
to have grown out VRE in both peritoneal fluid and blood
cultures the day prior to transfer. He was started on meropenem
and linezolid whch was then chagned to meropenem and daptomycin
due to concern over worsening thrombocytopenia.
.
# ARF: Pt w/normal baseline Cr. 0.8 1 month ago who presented in
HRS. Mr [**Known lastname **] was treated with octreotide/midodrine/albumin at
maximal doses. Nephrology was consulted and felt that he needed
dialysis for uremia and volume overload as a bridge to
transplantation. H Rt femoral HD catheter was placed without
complications but unfortunately persistantly bled despite no
obvious defects in the catheter positioning or suturing. (see
below). He [**Known lastname 1834**] HD x 1 before the decision was made to
change the goals of care to comfort
.
# Coagulopathy/bleeding: Mr [**Known lastname **] had extremely advanced cirrhosis
with MELD of 49 and severe coagulopathy (INR 5.5 on admission).
He had significant bleeding complicatoins at [**Hospital1 2177**] (hemothorax,
LGIB). At [**Hospital1 18**] he was initially hemodynamically stable but
began persistantly oozing from around his HD catheter site.
THis was unable to be reversed with aggressive FFP,
cryoprecipitate, DDAVP, topical thrombin, amicar, and platelet
transfustion. He required near 12 units of blood over 1 day for
this problem. In addition he was found to have a massive GIB
with spurting of dark purple blood from his rectum. NG lavage
was performed which showed clots but no active bleeding. He was
intubated for airway protection, hepatology emergently perfomed
upper endoscopy in the middle of the night and found grade 1
varices with diffuse oozing but no discrete site of bleeding.
Transplant surgery was also involved. He was started on an
octreotide drip. He required 12 units of blood. The family was
called in and given his overall exremely advanced ESLD,
overwhelming infectin, and diffuse oozing it was felt that liver
transplantation would be inappropriate as would any invasive
procedures given his profuse bleeding. He was supported with
blood products overnight and another family meeting was held the
next day and it was decided to redirect his care toward comfort
measures. He continued to receive antibiotics and was
mechanically ventilated but blood products were withheld.
.
Over the course of multiple days, Mr. [**Known lastname 46293**] blood pressure and
heart rate began to decrease. He remained sedated and on the
ventilator. On [**2159-1-12**] at 1505, an asystolic rhythm was noted
on the monitor. An examination was preformed, noting no heart
sounds, no pulse, and non-reactive pupils. Mr. [**Known lastname **] was declared
deceased at 1510. His family was present. A death report was
made.
Medications on Admission:
.
Discharge Medications:
.
Discharge Disposition:
Expired
Discharge Diagnosis:
The pateint expired while in the hospital
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
|
[
"5849",
"2851",
"99592",
"51881"
] |
Admission Date: [**2144-10-7**] Discharge Date: [**2144-10-14**]
Date of Birth: [**2074-4-9**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
with a chief complaint of six weeks of weight loss and
jaundice. The weight loss occurred throughout the majority
of this Summer and is felt to be up to 25 pounds.
The patient has had no abdominal pain but became overtly
jaundiced in early [**Month (only) 216**]. This was accompanied by dark
urine during this time. An endoscopic retrograde
cholangiopancreatography procedure was performed, and a stent
was placed initially. However, the jaundice was not relived.
He went on to develop fevers and chills two weeks after this
procedure.
An endoscopic retrograde cholangiopancreatography was then
performed on [**2144-9-22**] which showed migration of the
stent which was replaced, and his jaundice subsequently
abated. A follow-up ultrasound and computerized axial
tomography scan and dedicated computed tomography angiogram
was performed. This demonstrated a complex large cystic mass
in the head of the pancreas; consistent with an intraductal
papillary mucinous tumor. It should also be noted that the
findings of Dr.[**Name (NI) 12202**] endoscopy also corroborate that
diagnosis with distinct mucin production through the
pancreatic duct orifice.
PAST MEDICAL HISTORY: Significant for hypertension and non-
insulin-dependent diabetes mellitus for the past three years.
PAST SURGICAL HISTORY: He has had no surgical history.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's vital
signs were within normal limits. He was a well-appearing
elderly gentleman in no apparent distress. Awake, alert and
oriented times three. The patient had residual scleral
icterus. There was no lymphadenopathy or masses or
thyromegaly in the neck. His cardiac examination revealed a
regular rate and rhythm. There were no murmurs, rubs, or
gallops. Pulmonary examination revealed the lungs were clear
to auscultation bilaterally. Abdominal examination revealed
the abdomen was nondistended with normal active bowel sounds.
The abdomen was soft and nontender with firm abdominal wall
musculature. There were no evidence of Courvoisier
gallbladder. The inguinal region showed no evidence of
hernias or masses. Rectal examination was deferred at this
time.
SUMMARY OF HOSPITAL COURSE: On [**2144-10-7**] the patient
was preoperatively prepared. He was consented by both the
Anesthesia and Surgical team and brought to the Operating
Room for laparotomy. The patient tolerated the procedure
well, and an open cholecystectomy was performed in addition
to a pylorus preserving Whipple procedure. The surgical
findings indicated right hepatic artery high off of the
superior mesenteric artery with masses and tumor adherence to
that area. The procedure was done under general anesthesia,
and the patient did not require any blood products.
The patient's condition was stable at the conclusion of the
operation, and he was brought to the Post Anesthesia Care
Unit. The plan at this point was to keep the patient
intubated until the next morning, and replete electrolytes as
needed, and to continue expectant management. An arterial
blood gas was performed at that time that was reassuring with
a pH of 7.37.
On postoperative day one, the patient was extubated that
morning and progressed well. On postoperative day two, the
patient's blood sugars were noted to be somewhat elevated
during this time. The [**Last Name (un) **] Diabetes Service was consulted,
and the sliding-scale insulin was adjusted accordingly.
Throughout this time, the standard Whipple protocol was
followed. On postoperative day three, the patient's
nasogastric tube was removed. The patient continued to be
followed by the [**Last Name (un) **] Diabetes Service staff. On
postoperative day four, the patient's Foley catheter was
removed. The patient was voiding independently and was out
of bed to the chair at this point. A peripheral intravenous
line and the central line was removed. The patient was
placed of sips of clears and tolerated this well. On
postoperative day five, the patient was started on Reglan 10
mg q.6h. and was started on Percocet. At the same time, the
patient's analgesia was discontinued. The patient was also
given Ambien as a sleep aid at night. [**Last Name (un) **] weighed in
again at this point and stated that the patient would likely
need insulin at home, but would wait to see how he progressed
on a full diet before making this decision.
DISCHARGE DISPOSITION: On postoperative day seven -
[**2144-10-14**] - the patient was stable. Vital signs were
within normal limits. Physical examination was within normal
limits. The patient was able to be discharged to home with
services for blood glucose draws and blood pressure checks on
a daily basis.
DISCHARGE INSTRUCTIONS: The patient to be discharged to home
with a visiting nurse aide for help with blood glucose draws
and blood pressure checks. The patient to call his medical
doctor if having any increase in abdominal pain, fevers,
chills, nausea, vomiting, redness or drainage about the
wound, or if there were any questions or concerns. The
patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one to
two weeks in his office and to follow up with the [**Hospital **]
Clinic the day after discharge, with an appointment already
set up for [**2144-10-15**].
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Reglan 10 mg by mouth four times per day.
2. Percocet 5/325 by mouth q.4-6h. as needed (for pain).
3. Metoprolol 25 mg by mouth twice per day.
4. Colace 100 mg by mouth twice per day.
5. Ambien 5 mg by mouth at hour of sleep as needed (for
sleep).
6. Tylenol 325 mg by mouth q.4-6h. as needed.
7. Insulin sliding scale as directed.
8. Lantus 4 units subcutaneously at that time.
9. Protonix 40 mg by mouth once per day.
DISCHARGE STATUS: Discharged to home.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2144-10-21**] 14:45:47
T: [**2144-10-21**] 15:13:03
Job#: [**Job Number 56267**]
|
[
"25000",
"4019"
] |
Admission Date: [**2188-4-16**] Discharge Date: [**2188-4-30**]
Date of Birth: [**2132-11-2**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Left parietal mass / mental status change
Major Surgical or Invasive Procedure:
[**2188-4-18**] Lung Biopsy
[**2188-4-26**] Left craniotomy for tumor resection
[**2188-4-28**] Re-do Left Craniotomy for resection of residual tumor
History of Present Illness:
55M with no significant past medical history who presents with
acute mental status change over the last few days. Family
reports
he has been more lethargic, unsteady gait, word finding
difficulty, appeared depressed and not himself. Family describes
him as a heavy drinker but he abruptly stopped 3 days ago.
Patient himself reports feeling more tired, unsteady, and having
difficulty finding words. He denies any visual issues or
nausea/vomiting. He denies any other symptoms.
Past Medical History:
None
Social History:
Tob: 1 ppd
EtOH: Patient denies ETOH abuse, states he has [**3-14**] glasses of
wine/night, no history of blackouts. Family reports "heavy
drinking"
Illicits: denies
Lives at home with mother. Divorced, 4 sons in
their 30s who live in the area. Not currently employed,
previously worked in printing. Endorses some chemical
exposures.
Family History:
NC
Physical Exam:
O: T: 98.4 BP: 143/82 HR: 74 R 14 O2Sats 99%
Gen: Awake, NAD, flat affect
Neuro:
Mental status: Awake and alert, flat affect, difficulty
following
complex commands/ following along with exam.
Orientation: Oriented to person only. Stated [**Month (only) **] was the month
but when asked about the year patient continued to repeat [**Month (only) **]
with different dates. With cues, pt reported year as [**2178**].
Recall: Able to recall current president, city where he lives,
and name pen.
Language: Expressive and receptive aphasia
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full on the left but patient
repeats the same answer with right visual field. On repeat exam-
L VF remains intact, but abnormal on R.
III, IV, VI: Extraocular movements appear restricted with
laterally on both eyes- ? deficit vs. cooperation
V, VII: Right [**Last Name (un) **]-labial flattening
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue deviates to the left
Motor: Normal bulk and tone bilaterally. Bilateral tremor to
BLE.
Strength full power [**6-14**] throughout. Slight R pronator drift.
Sensation: Intact to light touch
Coordination: Bil dysmetria R > L
Upon discharge:
Intact
Pertinent Results:
MRI Head [**4-16**]
IMPRESSION:
1. Diffusion restricted, peripherally enhancing mass, centered
in the choroid plexus of the left trigone and infiltrating the
subependyma and possibly the adjacent left brain parenchyma.
2. Thickening and increased enhancement along the left sided
choroid plexus towards the choroid fissure which harbours a
second more solid focus (7 mm) of enhancement.
3. Extensive vasogenic edema involving the left parietal and
temporal lobe
with significant mass effect, midline shift of about 15 mm and
subfalcine
herniation. In the presence of a recently diagnosed lung mass,
the finding
most likely respresents metastatic disease, while a primary
plexus tumor is not entirely excluded.
CT Torso [**2188-4-16**]
1. 2.6 x 1.4 cm lobulated mass in left upper lobe of lung
concerning for
malignancy. This could represent a primary lung cancer.
2. No other pulmonary nodules or evidence of metastatic disease
in the chest, abdomen, or pelvis. Borderline, but not
pathologically enlarged, mediastinal lymph nodes.
3. Borderline fatty infiltration of the liver.
4. Mild distal aortic ectasia and atherosclerotic calcification.
Since
future followup examinations are anticipated, attention can be
paid at
followup imaging.
5. 1.3-cm left adrenal mass with imaging findings consistent
with adenoma
[**2188-4-21**] CTA head
IMPRESSION: Edema and rim-enhancing lesion in the left
periatrial region. No abnormal vascular structures are
identified in the region or abnormal draining veins are seen.
Calcification of the choroid plexus is seen adjacent to the
enhancing mass, but no ependymal enhancement is appreciated on
the CTA examination. No evidence of occlusion, stenosis, or an
aneurysm noted on the CTA examination in the arteries of
anterior or posterior circulation.
[**2188-4-21**] fMRI
Successful functional MRI of the brain demonstrates the expected
activation motor areas. No significant activation areas are
noted adjacent to the lesion. There is displacement of the left
primary motor cortex anteriorly by the edema. The dominance of
the language apparently is located on the left opercular area.
[**2188-4-25**] MRI brain
Unchanged lesion in the left temporoparietal lobe adjacent to
the
left trigone, with likely intraventricular extension and
extensive surrounding vasogenic edema. The second lesion in the
left cerebellum is also unchanged.
[**2188-4-26**] CT head
Expected postoperative changes status post craniotomy for left
parietotemporal lesion. Postoperative pneumocephalus and small
amount of
hemorrhage within the postoperative bed. There is appearance of
residual
abnormal soft tissue in the left periatrial region and within
the left lateral ventricle.
[**2188-4-27**] MRI brain
1. Post-surgical changes in the left parietal region and in the
left parietal lobe. Mild decrease in the size of the previously
noted lesion with presence of blood products and gas in the
surgical bed.
Significant moderate to marked vasogenic edema, with effacement
of the atrium of the left lateral ventricle and rightward shift
of midline structures by approximately 9 mm, mildly increased
since the presurgical study. Other details as above. No new
lesions noted.
2. Increased signal in the right mastoid air cells from fluid or
mucosal
thickening.
[**4-28**] head CT: post surgical changes with pneumocephalus and
vasogenic edema. Scant amount of hemorrhage in the L lateral
ventricle and surrounding the forth ventricle.
[**4-29**] Chest Xray: As compared to the previous radiograph, the
lung parenchyma has increased transparency. There is no evidence
of pneumonia, but atelectases are seen at both lung bases.
[**2188-4-29**]: MRI with and without contrast postop:
IMPRESSION:
1. Post-surgical changes and blood products in the left parietal
lobe and the adjacent bone. Moderate surrounding edema with
effacement of the atrium of the left lateral ventricle.
2. decrease in size of left cerebellar enhancing lesion
measuring approximately 6.6 mm with mild surrounding edema.
3. Diffuse fluid and mucosal thickening in the right mastoid air
cells.
Brief Hospital Course:
Pt was admitted to the neurosurgery service for further workup
of his L parietal mass. A CT torso revealed a large lung mass
and an adrenal mass. He was placed on decadron 6mg q6. An MRI
head showed a single mass with extensive edema that is not
proportionate to the size of the lesion. Neuro-oncology was
consulted. A lung biopsy was scheduled and performed on [**4-18**].
Further planning was dependent on the biopsy results. Patient's
exam/ speech improved and the Decadron was tapered down. He was
transferred to the floor on [**4-19**]. He continued to remain stable.
His lung biopsy results showed Poorly differentiated carcinoma,
favor adenocarcinoma.
A functional MRI and CTA was performed on [**4-21**] for surgical
planning. He was taken to the OR o n [**2188-4-26**] with Dr. [**Last Name (STitle) **] for
craniotomy. He tolerated the procedure well and was trasnfereed
to the SICU. CT showed minimal hemorrhage. MRI was done on [**4-27**],
This showed residual tumor. Dr. [**Last Name (STitle) **] spoke with the patient
and it was agreed that patient was to return to OR for further
resection.
He was taken to the OR on [**4-28**] for a Left craniotomy for
resection of residual tumor. OR course was uncomplicated. Post
operatively patient was extubated and taken to the ICU for close
monitoring. Post op exam, patient was intact and incision was
clean with minimal staining. Head CT showed post surgical
changes with minimal pneumocephalus. A repeat MRI postop on [**4-29**]
demonstrated decreased tumor burden. He remained neurologically
stable and was transferred to the regular floor.
On [**4-30**] he was seen and evaluated by physical therapy and
occupational therapy who determined he was safe for DC home. He
was DCd home in stable condition and will follow up accordingly.
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 days.
6. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q8h () for 2
days.
7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q12h () for
2 days.
8. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q24h ().
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Left parietal mass
Cerebral edema
Visual deficit
Left upper lobe lung mass
Left Adrenal mass
Discharge Condition:
AOx3. Activity as tolerated. No lifting greater than 10 pounds.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Dressing may be removed on Day 2 after surgery.
?????? You have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-19**] days (from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2188-5-12**]
at 10:30a. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain.
- You will be contact[**Name (NI) **] by the Oncology team for follow up of
your Lung and adrenal mass with Dr. [**Last Name (STitle) 3274**]. If you do not hear
from them in one week, please call to confirm an appointment
date and time: [**0-0-**].
Completed by:[**2188-4-30**]
|
[
"3051"
] |
Admission Date: [**2120-12-27**] Discharge Date: [**2121-1-15**]
Date of Birth: [**2050-1-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
CHF exacerbation
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
This is a 70 yo gentleman with Type 1 DM, HTN, CAD s/p MI '[**19**],
CHF, and [**Hospital **] transferred from [**Hospital3 **] for unstable
angina and ? cath. He presented to [**Hospital3 3583**] on [**12-25**] c/o
5 days if increasing shortness of breath, fatigue, and abdominal
discomfort. Of note the patient's anginal equivalent is
abdominal discomfort. The patient reported stable leg swelling,
stable 2 pillow orthopnea, chronic night sweats, and difficult
to control sugars. He denies CP, cough, sick contacts, chills,
myalgia, med changes, diet changes. At the OSH he was found to
have a temp to 101 on [**12-25**] and started on ceftriaxone/doxy for
presumed pna. Also he was found to have inf-lat ST depressions.
He was started on IV nitro, IV lasix before transfer to [**Hospital1 18**].
While in the hospital the patient had flash pulm edema with
desat to the 70's in the setting of an SBP of 180. He had an
echo that showed EF 35-40% and severely depressed systolic
function and pulomary hypertension. A cardiac cath that showed
3VD (LCx 90% ostial stenosis, RCA 90% distal stenosis, LAD 90%
diffuse disease, with severe depression of systolic function).
Post-cath he was sent to CCU for further monitoring.
Past Medical History:
DM type 1 since age 24 - triopathy
CRI baseline 1.9
Glaucoma
Legally Blind
CAD s/p NSTEMI '[**19**] (cath at [**Hospital3 **])
CHF
PVD
Anemia of Chronic Disease
HTN
BPH
Hearing loss
MRSA Osteomyelitis - s/p R 5th toe amputation
DJD
Social History:
lives with wife in trailer park
no tob/etoh/drugs
former computer operator
Family History:
DMII
Physical Exam:
98.3/97.1 144/51 (101-144/40-50s) 60s 20s 96%RA
I/O=1188/1325
GEN: pleasant, NAD, comfortable appearing male appearing his
stated age, well-nourished
HEENT: PERLLA, EOMI, sclera anicteric, no conjuctival injection,
mucous membranes moist, no lymphadenopathy, neg JVD, no carotid
bruits
[**Last Name (un) **]: fine crackles at bases R>L
COR: RRR, S1 and S2 wnl, no murmurs/rubs/gallops
ABD: non-distended with positive bowel sounds, non-tender,no
guarding, no rebound or masses
BACK: neg CVA tenderness
EXT: no cyanosis, clubbing, edema
NEURO: Alert and oriented x3. vision only to finger count,
otherwise CNIII-XII are intact. 4/5 strength throughout.
Pertinent Results:
OSH
UA negative
CK peak 202 [**12-27**]
CK-MB peak 8.4 [**12-27**]
TropI peak 1.39 [**12-27**]
[**2120-12-27**] 07:34PM WBC-5.5 RBC-2.76* HGB-8.3* HCT-26.1* MCV-95
MCH-30.1 MCHC-31.9 RDW-13.6
[**2120-12-27**] 07:34PM NEUTS-81.5* LYMPHS-13.1* MONOS-4.3 EOS-0.8
BASOS-0.3
[**2120-12-27**] 07:34PM PLT COUNT-160
[**2120-12-27**] 07:34PM GLUCOSE-487* UREA N-65* CREAT-1.8* SODIUM-138
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-26 ANION GAP-17
[**2120-12-27**] 07:34PM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-119* TOT
BILI-0.5
[**2120-12-27**] 10:16PM CK(CPK)-128
[**2120-12-27**] 10:16PM CK-MB-7 cTropnT-0.36*
CXR - Given the presence of Kerley B lines and small effusions,
the increased interstitial markings could represent asymmetric
pattern of interstitial edema. However, differential diagnosis
includes other causes, such as infectious and neoplastic
etiologies. Question nodular opacities, left suprahilar region.
Left lower lobe collapse and/or consolidation
EKG - NSR at 86, nl axis, normal intervals, 1mm ST dep
II,III,aVF & 2mm st dep V4-6
Echocardiography - EF 35-40% w/ 2+ MR & 2+ TR
Cardiac catheterization - LAD 90% mid vessel stenosis, LCX long
90% ostial stenosis, RCA 90% distal stenosis.
[**2121-1-14**] 06:15AM BLOOD WBC-7.6 RBC-3.07* Hgb-9.3* Hct-28.8*
MCV-94 MCH-30.3 MCHC-32.3 RDW-15.2 Plt Ct-230
[**2121-1-5**] 06:05AM BLOOD Neuts-79.2* Lymphs-13.8* Monos-5.2
Eos-1.4 Baso-0.3
[**2121-1-14**] 06:15AM BLOOD Plt Ct-230
[**2121-1-13**] 06:05AM BLOOD Plt Ct-234
[**2121-1-10**] 06:30AM BLOOD PT-13.2 PTT-52.4* INR(PT)-1.1
[**2121-1-14**] 06:15AM BLOOD Glucose-51* UreaN-95* Creat-3.2* Na-132*
K-5.0 Cl-98 HCO3-23 AnGap-16
[**2120-12-30**] 07:10AM BLOOD Fibrino-688*
[**2120-12-30**] 07:10AM BLOOD Ret Aut-1.8
[**2121-1-4**] 05:37AM BLOOD CK(CPK)-175*
[**2121-1-3**] 06:26PM BLOOD CK(CPK)-224*
[**2121-1-4**] 05:37AM BLOOD CK-MB-13* MB Indx-7.4* cTropnT-0.71*
[**2121-1-3**] 06:26PM BLOOD CK-MB-15* MB Indx-6.7* cTropnT-0.75*
[**2120-12-31**] 06:05AM BLOOD CK-MB-16* MB Indx-7.6* cTropnT-0.53*
[**2121-1-14**] 06:15AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9
[**2121-1-13**] 06:05AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.0
[**2120-12-31**] 05:00PM BLOOD VitB12-1139*
[**2120-12-30**] 07:10AM BLOOD calTIBC-212* Ferritn-496* TRF-163*
[**2120-12-31**] 05:00PM BLOOD Triglyc-72 HDL-42 CHOL/HD-2.8 LDLcalc-60
Brief Hospital Course:
* CARDIOVASCULAR
Ischemia: As discussed above, the patient was transferred from
an outside hospital with NSTEMI (lateral ST depressions on EKG).
He was maximally medically managed in the cardiac intensive
care unit for his coronary artery disease, MI, and congestive
heart failure (diastolic dysfunction). He was maintained on
ASA, metoprolol, a nitro drip, statin, and heparin drip before
going to cardiac catheterization. In the cath lab, the
following were found: the LAD was diffusely diseased with a 90%
mid-vessel stenosis. There was subtotal occlusion of the first
diagonal branch. THe LCx had a long 90% ostial stenosis. The RCA
had a 90% distal stenosis. Limited hemodynamics demonstrated
severely elevated right atrial and right ventricular pressures.
There was anomalous anatomy of the IVC. It appeared not to empty
into the right atrium rather, it looped upwards and joined the
SVC before the SVC emptied into the right atrium. There was
difficulty with the Swan-Ganz catheter and as such, it is not
recommended to attempt Swan-Ganz catheter floatation in any
setting other than under fluoroscopy. After this significant
disease was identified, the patient was referred to cardiac
surgery for CABG. While receiving pre-operative evaluation for
this procedure, the patient remained chest pain free.
Pre-operative evaluation included MRA chest in light of cardiac
anatomy discussed above, venous ultrasound of the extremities,
and carotid studies. Troponins reached a peak of 0.75. The
patient was transfused as needed to maintained a Hct > 30.
Congestive heart failure: EF at OSH 1 year ago was 50%. The
cardiac intensive care unit evaluated the patient and believed
the patient to have diastolic dysfunction. Repeat ECHO showed
an EF of 35-40%. The left atrium was elongated. Left
ventricular wall thicknesses were normal. The left ventricular
cavity was moderately dilated. There was moderate regional left
ventricular systolic dysfunction. Overall left ventricular
systolic function was moderately depressed. Resting regional
wall motion abnormalities included inferior, inferolateral and
inferoseptal hypokinesis. The remaining left ventricular
segments contracted normally. Right ventricular chamber size and
free wall motion were normal. The aortic valve leaflets (3)
appeared structurally normal with good leaflet excursion and no
aortic regurgitation. No aortic regurgitation was seen. Moderate
(2+) mitral regurgitation was seen. Moderate [2+] tricuspid
regurgitation was seen. There was moderate pulmonary
hypertension. There was no pericardial effusion. With lasix 80
mg, the patient diuresed and there was improvement in his
pleural effusions as seen on chest xray. He was weaned off
oxygen and at discharge was able to saturate 96% oxygen on room
air.
Rhythym - NSR on tele
* HYPERTENSION: The patient's blood pressure was initially
difficult to control despite being on a nitro drip, beta
blocker, hydralazine, nitrate, and dilt. When amlodipine was
added, however, the patient's blood pressure responded well and
he was able to be weaned off the nitro drip as well as
decreasing his beta blocker and hydralazine dose.
* RENAL FAILURE: After cardiac catheterization, the patient
experienced dye nephropathy with an acute rise in his
creatinine. He was hemodialyzed with good effect. Afterward,
the patient's renal function was carefully monitored and he
received lasix prn to encourage renal output. He responded well
to several doses of lasix 80 mg and at discharge, was able to
produce around 800 cc's of urine in one day without lasix. The
renal service evaluated the patient and expects that renal
function will recover slowly and that he will not likely require
hemodialysis again. In light of the patient's renal failure,
cardiac surgery did not feel comfortable operating. Instead,
the patient is to follow up with them in three weeks after
checking creatinine again. Should values be closer to the
patient's normal range, cardiac surgery will be reconsidered.
* Type 1 Diabetes - The patient was maintained on a regular
insulin sliding scale.
* ID: The patient remained afebrile during his hospital course.
He was treated empirically with ceftriaxone/azithromycin to
complete a 7 day course in light of asymmetric right>left
pulmonary edema.
* Glaucoma - The patient was continued on timolol, lumigan, and
brimonidine ou
Medications on Admission:
lasix 40/20 po alt days
isordil 40mg tid
lopressor 50mg tid
cardiazem 360mg qday
cardura 6mg qhs
methazolamide 50mg [**Hospital1 **]
alphagan
lamigan
timolol
ASA 325mg qday
mvi
vit c
zinc
senna
NPH 20/10 + RISS
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic qHS
().
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic QHS
(once a day (at bedtime)).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed.
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
14. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: SEE
INSTRUCTIONS Subcutaneous qam: 20 units every morning. 10
units every night.
Disp:*1 bottle* Refills:*2*
16. Continue your regular insulin sliding scale.
Discharge Disposition:
Home With Service
Facility:
partners[**Name (NI) **]
Discharge Diagnosis:
3 vessel coronary artery disease, DM type 1, acute on chronic
renal failure, Glaucoma (Legally Blind), CHF, PVD, Anemia of
Chronic Disease, HTN, BPH, Hearing loss, MRSA positive,
degenerative joint disease.
Discharge Condition:
stable
Discharge Instructions:
* Please take all of your medications.
* Please seek medical attention should you experience any of the
following: shortness of breath, chest pain, palpitations, sudden
weakness, lightheadedness, dizziness, loss of consciousness,
fainting, nausea, vomiting, fever, chills
* Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
* Adhere to 2 gm sodium diet
* See your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 780**] within 1 week
* Please see your cardiothoracic surgeon within 3 weeks as
scheduled for you by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Make sure to have your
creatinine checked before your appointment
Followup Instructions:
* Please see your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 780**] within 1 week of discharge
from the hospital.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 7045**], MD Where: CARDIAC SURGERY LMOB 2A
Date/Time:[**2121-2-4**] 2:00
|
[
"41071",
"4240",
"5845",
"40391",
"4280",
"486",
"41401"
] |
Admission Date: [**2196-1-26**] Discharge Date: [**2196-1-31**]
Date of Birth: [**2129-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 1283**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
[**2196-1-26**] Coronary artery bypass graft times three (LIMA to LAD,
SVG to DIAG, SVG to OM)
History of Present Illness:
Mr. [**Known lastname **] is a 66 year old gentleman who recently underwent a
cardiac catheterization after complaining of angina for one
year. This catheterization revealed three vessel disease. He
therefore was referred to [**Hospital1 69**]
for surgical evaluation.
Past Medical History:
hypertension
hypercholesterolemia
BPH
melanoma
right knee arthritis
s/p ventral hernia repair times three
s/p tonsillectomy
Social History:
Mr. [**Known lastname **] is a retired real estate finance officer. He has
never smoked and drinks one glass of wine per day. He lives
with his wife.
Physical Exam:
At the time of discharge, Mr. [**Known lastname **] was found to be in no acute
distress. His lungs were decreased throughout. His heart was
of regular rate and rhythm. No drainage or erythema was noted
at the sternal incision site and his sternum was stable. His
abdomen was soft, non-tender, and non-distended. His
extremities were warm and 1+ edema was noted. His leg incision
was clean, dry, and intact.
Pertinent Results:
[**2196-1-28**] 06:30AM BLOOD WBC-11.7* RBC-3.37* Hgb-10.7* Hct-31.9*
MCV-95 MCH-31.9 MCHC-33.7 RDW-13.4 Plt Ct-160
[**2196-1-28**] 06:30AM BLOOD Plt Ct-160
[**2196-1-28**] 06:30AM BLOOD Glucose-110* UreaN-21* Creat-0.9 Na-137
K-4.2 Cl-103 HCO3-30 AnGap-8
Brief Hospital Course:
Mr. [**Known lastname **] was brought to the operating room on [**2196-1-26**] and
underwent a coronary artery bypass graft times three. The
procedure was performed by [**Known firstname **] [**Last Name (NamePattern1) **]. The patient
tolerated the procedure well and was transferred in critical but
stable condition to the surgical intensive care unit.
In the surgical intensive care unit, he progressed well. He was
extubated and his chest tubes were removed. He was weaned from
his pressors. By post-operative day two he was ready for
transfer to the step down floor.
On the step down floor, Mr. [**Known lastname **] was gently diuresed and his
blood pressure regimen was maximized. He was seen in
consultation by the physical therapy service. His epicardial
wires were removed. He was ready for discharge on post operative
day 5.
Medications on Admission:
lisinopril/HCTZ 20/25, zocor 20, aspirin 325, glucosamine,
viagra 50, MVI, atenolol 50
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Please see your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 69904**]
in [**1-12**] weeks.
Please see your cardiologist in [**1-12**] weeks.
Please see Dr. [**Known firstname **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 11763**] in [**4-15**] weeks.
Please call to make these appointments.
Completed by:[**2196-2-1**]
|
[
"41401",
"4019",
"2720"
] |
Admission Date: [**2187-12-7**] Discharge Date: [**2187-12-25**]
Date of Birth: [**2112-1-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Traumatic fall resulting in T11-T12 fracture.
Major Surgical or Invasive Procedure:
1. Reduction of T11-T12 fracture
2. Posterior instrumented fusion of T10-L3
3. Tracheostomy
4. Percutaneous endoscopic gastrostomy
5. Inferior vena caval filter
6. Tube thoracostomy
7. Continuous bladder irrigation
History of Present Illness:
HPI:
75 y.o. M presents from [**Hospital3 **] intubated, s/p fall from
standing on [**2187-12-6**] 9:00 pm. Fall was not witnessed, and
patient
refused to go to ED immediately post-fall. on [**2187-12-7**] at 3:45
am
he was transported via ambulance to [**Hospital3 **] due to
increase in pain, where he was intubated due to declining
respiratory status. He was transported to [**Hospital1 18**] ED, and trauma
services consulted us at 14:15 pm. Thoracic CT done here shows
severe kyphosis & ankylosing spondylitis with fracture through
T11-12 anterior and middle columns. as well as narrowing of
space
at T11-12 spinal processes.
Past Medical History:
1. Chronic obstructive pulmonary disease
2. Ankylosing spondylitis
3. Congestive heart failure
4. Insulin-dependent diabetes mellitus
5. Peripheral vascular disease
6. Hypercholesterolemia
7. Obstructive sleep apnea
Social History:
Has two drinks of whiskey daily, lives with his wife, non-[**Name2 (NI) 1818**]
x 4 years.
Family History:
nc
Physical Exam:
PHYSICAL EXAM:
O: T:96.7 BP:161 /92 HR:96 R: 14 O2Sats 100% intubated
Gen: Intubated, difficult to arouse, off Propofol x 25 minutes,
opens eyes to painful stimuli
HEENT: Pupils: 1mm - 0.5 bilaterally, bilateral corneal reflexes
present
Neck: C-collar
Extrem: Severe PVD, with cellulitis, poor perfusion over fingers
and toes, cyanotic fingers bilaterally
Neuro:
Intubated, off propofol x 25 min. does not follow commands,
opens
eyes to painful stimuli
Motor:
Withdraws bilateral upper and lower extremities to painful
stimuli.
Toes downgoing bilaterally
Reflexes: Br Pa Ac
Right 1 2 1
Left 1 2 1
Pertinent Results:
CT T spine
1) Severe kyphosis & ankylosing spondylitis with fracture
through
T11-12 anterior and middle columns. In inferoposterior corner
of
T11, T11-12 left facet joint and right T12 pars. There is
anterior splaying of the T11-12 disc space, with 2.3cm
separation
anteriorl; associated closing of space between
T11-12 spinal processes.
2) Atelectasis. Interstitial pulmonary edema, bilateral pleural
effusion consistent with CHF. Calcific pleural plaques, likely
related to old asbestos exposure.
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
9.5 4.61 15.1 45.2 98 32.8* 33.5 14.9 277
Neuts Bands Lymphs Monos Eos
86.4* 7.5* 5.4 0.4 0.3
pH 7.26 pCO2 89 pO2 34 HCO3 42 BaseXS 8
Na:147 K:4.9 Cl:95 TCO2:39 Glu:111 Lactate:1.4 freeCa:1.12
PT: 13.8 PTT: 28.3 INR: 1.2
Trop-T: 0.04
Brief Hospital Course:
Pt transferred to [**Hospital1 18**] from [**Hospital3 3583**]. Pt arrives
intubated. Pt with CT findings compatible with "bamboo spine"
likely secondary to ankylosing spondylitis with acute fracture
at T11-12. Syndesmophyte disruption along the anterior and
posterior longitudinal ligaments with T11 inferior endplate
fracture and fracture involving both inferior facet joints.
Acute lordotic angulation at T11-12 and marked widening of the
disc space also was noted. Follow up MRI revealed ankylosis of
the cervical and thoracic spine. Fracture through T11-12 disc
with disruption of the anterior and posterior longitudinal
ligaments. Mild trauma to the interspinous region without
definite evidence of disruption of the ligamentum flavum. No
intraspinal hematoma or extrinsic spinal cord compression. No
evidence of intrinsic spinal cord signal abnormalities. Pt also
noted to have large left-sided pleural effusion on CT of the
chest. Initially, fall was thought be related to a coronary
event.
Pt was seen by cardiology, but given pt's negative CE, EKG, and
echo, it was felt that the patient did not fit the profile of an
acute ischemic event as the precipitant of his fall.
Pt was brought to the OR with neurosurgery on [**2187-12-9**]. Pt had
Laminectomy T10-L2, Pedicle screw insertion, segmental, T10-L3,
Local autograft, Posterolateral arthrodesis T10-L3, and
fracture reduction, open, T10-L3.
In the immediate post op period, the patient was unable to be
weaned from his vent. Lasix was administered to decrease
pulmonary edema. Pt was noted to have thick secretions
requiring frequent suctioning. Repeat chest CT on [**12-13**]
demonstrated a large simple left pleural effusion with partial
loculation anteromedially, nodular pleural thickening in right
hemithorax, highly suspicious for malignant mesothelioma in the
setting of asbestos-related pleural plaques. Further evaluation
with PET/CT was requested when patient stabilized. In
addition, Pt had left chest tube placed with one liter of
effusion removed and sent for cytology. Cytology was negative
for malignant cells.
Urology was briefly consulted for hematuria in setting of
indwelling foley x ~7 days. They recommended urine cytology, CT
urogram, and follow up in [**3-23**] weeks.
On [**2187-12-21**], pt was brought to OR for trach/PEG/filter. He has
failed multiple attempts at extubation due to ventilatory
failure and CO2 retention. The patient is
expected to need long-term ventilatory support. The patient also
is not capable of eating and is not expected to be able to eat
normally with the tracheostomy in place for prolonged period. He
is also at high risk for venous thrombo-embolic
disease and has problems with heparinization due to hematuria.
He is therefore considered an appropriate candidate for IVC
filtration.
Patient deemed suitable for vented rehabilatation placement on
[**2187-12-24**].
Medications on Admission:
Medications prior to admission:
Byetta 10mg [**Hospital1 **]
Cozaar 50 mg [**Hospital1 **]
Furosemide 40 mg [**Hospital1 **]
Cilostazol 100 mg [**Hospital1 **]
Pravastatin 20 mg QD
Lantus 15 units QHS
? Diabetes medicine 4 mg QD
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) cc PO BID (2
times a day).
Disp:*600 cc* Refills:*2*
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*900 ML(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 6-10 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*10 aerosol* Refills:*0*
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
Disp:*2 tubes* Refills:*2*
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*10 aerosol* Refills:*2*
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Disp:*[**Numeric Identifier 31034**] units* Refills:*2*
10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
Disp:*150 ML(s)* Refills:*2*
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4H (every 4 hours) as needed for pain.
Disp:*150 ML(s)* Refills:*0*
12. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) ml
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*100 ml* Refills:*2*
15. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) cc PO TID
(3 times a day).
Disp:*450 cc* Refills:*2*
16. Morphine Sulfate 2 mg IV Q6H:PRN pain
17. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day.
Disp:*100 ml* Refills:*2*
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: 0-28
units Subcutaneous four times a day: FS 121-140, 2 units
FS 141-160, 4 units
FS 161-180, 6 units
FS 181-200, 8 units
FS 201-220, 10 units
FS 221-240, 12 units
FS 241-260, 14 units
FS 261-280, 16 units
FS 281-300, 18 units
FS 301-320, 20 units
FS 321-340, 22 units
FS 341-360, 24 units
FS 361-380, 26 units
FS 381-400, 28 units.
Disp:*1000 units* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Traumatic fall
2. Ankylosing spondylitis
3. Thoracic spine fracture, T11-T12
4. Chronic obstructive pulmonary disease
5. Congestive heart failure
6. Insulin-dependent diabetes mellitus
7. Obstructive sleep apnea
8. Simple left pleural effusion
9. Hematuria
Discharge Condition:
Good
Discharge Instructions:
1. Call office or go to ER if fever/chills, discharge or redness
from surgical wounds, chest pain, shortness of breath,
neurological deficits.
2. Follow up with Trauma Surgery and Neurosurgery as indicated.
3. Wean ventilatory support as tolerated. Trach care per
protocol. Tube feeds per protocol.
4. Physical therapy per protocol.
Followup Instructions:
Trauma Surgery, Dr. [**Last Name (STitle) **], 1-2 weeks, please call for
appointment.
Neurosurgery, Dr. [**Last Name (STitle) 548**], 1-2 weeks, please call for appointment.
Urology, Dr. [**Last Name (STitle) 770**], 1-2 weeks, please call for appointment.
|
[
"51881",
"5119",
"496",
"4280",
"2720",
"25000"
] |
Admission Date: [**2161-7-29**] Discharge Date: [**2161-8-13**]
Date of Birth: [**2087-2-5**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 79582**] is a 74-year-old man with a history of HTN, a
fib not anti-coagulated, alcoholism who presents with two
seizures. His wife says they had taken a drive up to [**Location (un) 28318**]
and
stopped for lunch in [**Location (un) **] on the way home. She says she thought
he was going to order a beer, but when he came back he had a
mixed drink. When she asked what it was, he said it was an
"encyclopedia." Shortly after that, his right arm extended and
became rigid, followed seconds after by a generalized rigidity
and then generalized shaking. She caught him, and an EMT and
fireman in the restaurant helped lower him to the floor. She
believes it lasted for 3-4 minutes. There was no cyanosis. He
seemed confused afterwards, but was back to his normal self when
the ambulance got to [**Hospital **] Hospital, about 10 minutes later.
At [**Hospital1 **], notes document an "expressive aphasia." He also had
an elevated blood pressure at 202/97 and received labetalol.
About an hour after his first seizure, his wife saw his right
hand start to shake, progressing to his whole arm, and within
seconds it had generalized again. It's documented as lasting 1
minute 20 seconds. He received 2 mg of Ativan and 1000 PE of
fos-phenytoin. He was transferred to [**Hospital1 18**].
On arrival, he was noted to "respond only to pain." He was
therefore intubated. He received 20 mg etomidate and 120 mg
succinylcholine at 4:30 pm, and placed on a propofol drip.
Although he cannot answer ROS questions, his wife says he had
not
complained of any headache, loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty; she denied that he had any
difficulties producing or comprehending speech. Denied focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, she also noted no recent fever or
chills. No night sweats or recent weight loss or gain. He does
cough frequently with his bronchitis. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
Stroke [**7-/2160**], presenting with left arm and leg weakness,
symptoms resolved now per wife.
HTN
Atrial fibrillation not on Coumadin due to alcoholism per wife
Chronic Bronchitis
Alcoholism
Inguinal hernia, not repaired
Social History:
Heavy alcohol use for a long time; now down to 4
drinks per day. Last drink at dinner on [**2161-7-28**].
Family History:
Mother died at 86 with CHF, DM. Father died of
ruptured abdominal aneurysm.
Physical Exam:
Vitals: T: afeb P: 67 R: 14 BP: 191/97 SaO2: 100% on AC 500x14,
FiO2 1.0
General: Intubated, sedated.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Regular.
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: Eyes closed, unresponsive, having received
etomidate and succ at 2 hours prior and having been on propofol
5
mins prior.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm and brisk. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: No doll's eyes.
V: Corneals intact.
VII: No facial droop, facial musculature symmetric.
VIII: Not tested.
IX, X: Gag with deep suctioning.
[**Doctor First Name 81**]: Not tested.
XII: Not tested.
-Motor: Flaccid throughout. Withdraws all four extremities
antigravity even having received paralytics and sedation
recently, perhaps right arm less vigorously.
-Sensory: Intact to pain in all 4.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 4 4 4 2 2
R 2 2 2 2 1
Plantar response was extensor bilaterally.
-Coordination & Gait: Not testable given clinical situation.
Brief Hospital Course:
This 74 yo M with hx AF, not anticoagulated, HTN, EtOH abuse,
presented with 2 secondarily GTC seizures (starting with R hand
focus) and found to have a L parietal hemorrhage, thought to be
c/w amyloid angiopathy. Pt intubated and sedated for airway
protection and treated in the ICU with Dilantin and later
switched to Keppra. Pt extubated 2 days after admission on
[**2161-7-31**], however, developed an aspiration PNA and was treated
with Zosyn. This improved over the course of days, but pt
developed some RLL collapse, and O2 sats have been in the 93-94%
range. Pt had a CT of the C/A/P to better characterize pulm path
and found incidentally to have 3.9 cm AAA and renal
calcifications, possibly contributing to stenosis. BP control
remained an issue and pt was put on Norvasc and a large dose of
metoprolol (100 mg Q6hrs) for both rate and pressure control. On
[**2161-8-10**], pt had an episode of temporary unresponsiveness with
head-tilting back, was shaken by family and pt returned to
baseline. However, tele correlate showed pt sustained a ~10 sec
sinus pause. Chem-10, trop, and CK sent and stat EKG done.
Cardio consult called who recommended transfer to cardiac floor
and EP consult. He was on cardiology service for 48 hours where
beta-blockers were held and thought to be the etiology of the
pause, although pt was noted to have at least one shorter pause
in the setting of having been off the beta-blockers. Discussion
with the cardiology team suggested that given the pt's other
risk factors that the risks outweighed the benefits for
pacemaker placement. He was discharged to rehab on [**2161-8-13**].
Medications on Admission:
Cartia XT 240 mg po daily
Metoprolol 75 mg po bid
Omeprazole 20 mg po daily
Combivent 2 puffs [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: 1-2 tabs PO Q6H
(every 6 hours) as needed for temp > 100.4, pain.
2. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day) as needed.
3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
4. Nicotine 14 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Citalopram 20 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection TID (3 times a day).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q4H (every 4 hours) as
needed.
12. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
13. Levetiracetam 1,000 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a
day.
14. Valsartan 80 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
left parietal intracerebral hemorrhage
Discharge Condition:
stable
Discharge Instructions:
You have had a left parietal brain hemorrhage, likely secondary
to amyloid angiopathy. This manifested itself as seizures. You
will need to continue on your anti-seizure meds and work to
maintain a good blood pressure. Please return to the ER if you
experience any sudden weakness, change in sensation, headache,
vertigo, double vision, change in speech, or have any seizures
manifested by altered consciousness, focal repetitive motor
movements, or generalized convulsions.
Followup Instructions:
Please call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **] [**Telephone/Fax (1) 41132**] to arrange
follow up for after dischargef rom rehab.
with Dr. [**Last Name (STitle) **] for neurological follow-up: [**Telephone/Fax (1) 2574**].
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2161-9-29**] 4:00
Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] [**Location (un) **].
You have a cardiology follow up appointment with [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],
JR. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2161-9-2**] 9:40
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2161-8-13**]
|
[
"5070",
"4019",
"42731"
] |
Admission Date: [**2203-6-26**] Discharge Date: [**2203-6-30**]
Date of Birth: [**2163-9-18**] Sex: M
Service: MEDICINE
Allergies:
Keflex / ORENCIA / Remicade
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Central venous catheter placement
History of Present Illness:
Mr. [**Known lastname 17385**] is a 39 yo M with complex medical history,
significant for psoriatic arthritis c/b steroid dependence.
Patient had been tapering his prednisone and his dose was
recently changed from 8mg/day to 7mg/day on [**2203-6-18**]. He reports
feeling more malaise, lethargy and somnolent, but his BP was
doing ok at home (pt checks it 3 times daily). On [**2203-6-25**],
patient noticed that his evening SBP was down to 100 (baseline
of 120-130). On rechecks, it ultimately came down to 50s/40s.
Patient reports 1 episode of vomiting and 3 falls during that
evening, last of which prompted him to call EMS. His falls were
thought to be from hypotension. He hit his head multiple times
on surrounding furniture during these falls as well.
.
He was brought to [**Hospital3 20284**] Center. BP was initially 70/33
at OSH where he received 6 L NS and was placed on levophed. Labs
significant for BUN 39, Cr 2.8, WBC 8.4, H/H 11.4/34.9, Plt 303
Bands 12% N 79% L 3% M 5% myelocyte 1%. He received vancomycin
1 g IV, zosyn 3.375 g IV, and hydrocortisone 100 mg before
transfer. Labs were significant at 4:35 [**2203-6-26**] for BNP 105,
CPK-MB 0.6, troponinI < 0.015, Lactic acid 2.9, phosphorous 5.9,
Cr 2.8, BUN 39. CXR with no acute cardiopulmonary process. At
this time, he was transferred to [**Hospital1 18**] for further management.
.
In the ED at [**Hospital1 18**], initial vs were: 96.4 72 109/61 18 100% 2L
NC, levo @ .11 mcg/kg/min. A RIJ central line was inserted, and
he was continued on levophed to SBP > 100. He was given
potassium chloride 40 mEQ IV. Initial ER labs are likely a
mistake, given repeat labs have normalized. WBC 8.3 with N 79.8,
L 11.6 with no bands, INR 1.2, Cr 1.6 (baseline ~ 1.2), CK-MB
3, cTropnT < 0.01, lactate 1.3. UA clean. Urine and blood
cultures pending.
.
When he was admitted to the ICU, he gave very detailed history
as above. He complained of an occipital headache that is similar
to his typical headaches. He was given compazine and dilaudid.
Past Medical History:
# Psoriatic arthritis c/b steroid dependence with exogenous
steroid-associated [**Location (un) **] syndrome, relative adrenal
insufficiency
# vitamin D deficiency
# abnormal thyroid function tests.
# Left gastrocnemius abscess and bacteremia growing MSSA ([**Month (only) 958**]
[**2201**]).
# History of MRSA infection status post eradication in [**2195**].
# Morbid obesity.
# Obstructive sleep apnea, autoset CPAP 14-18cmH20 with CFlex 2
# Irritable bowel syndrome.
# Hypertension.
# Diabetes mellitus type 2 on insulin
# Hyperlipidemia.
# Peripheral neuropathy.
# Nonalcoholic fatty liver disease secondary to previous
methotrexate treatment.
# Keratoconus status post bilateral corneal transplant ([**2186**],
[**2190**]).
# Status post four anal fistulotomies.
# Status post tonsillectomy x2 and adenoidectomy.
# Degenerative joint disease, status post L4/L5 discectomy.
# Patellofemoral syndrome, status post arthroscopic surgery for
both knees x3 each.
Social History:
Patient lives with his wife and children. He is currently on
disability, previously teacher for autistic children.
Tobacco: never
ETOH: occasional
Family History:
Mother: Ulcerative colitis, hypertension, hypercholesterolemia,
and bipolar disorder.
Father: Non smoking-induced COPD and hypertension.
Brother: Dermatologic psoriasis and ulcerative colitis.
Sister: Hypertension, hypercholesterolemia.
Paternal aunt: Crohn disease and sarcoidosis.
Physical Exam:
ON ADMISSION:
General Appearance: Overweight / Obese
Head, Ears, Nose, Throat: Normocephalic, buffalo hump
Cardiovascular: distant heart sounds
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present)
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Obese
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+
Skin: Warm, various small cysts/boils, non of which seem
particularly actively infected
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Tone: Normal, some midline
neck discomfort; limited neck ROM similar by patient report to
chronic state
.
ON DISCHARGE:
VITALS: Tm 98.4; Tc 98.4; BP 130/P; P 73; RR 18; O2 99% RA
GENERAL: Pleasant man, NAD. Cushingoid appearance, looks older
than his stated age
HEENT: NC/AT, OP clear, MMM. Thick neck with buffalo hump.
CV: Faint heart sounds but nl S1/S2, without m/r/g. +tender
gynecomastia
Lung: CTAB, no crackles or wheezes
ABDOMEN: Purple striae throughout abdomen, obese, nontender to
palpation. +BS
EXT: Both knees with well healed surgical scars, L leg with well
healed calf surgical scar. DP/PT pulses 2+ bilaterally. 1+
edema.
NEURO: Grossly intact. Conversant.
Pertinent Results:
ADMISSION LAB:
[**2203-6-26**] 11:19PM GLUCOSE-224* UREA N-21* CREAT-1.3* SODIUM-142
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-21* ANION GAP-15
[**2203-6-26**] 11:19PM CK(CPK)-278
[**2203-6-26**] 11:19PM CK-MB-3 cTropnT-<0.01
[**2203-6-26**] 11:19PM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-2.0
[**2203-6-26**] 11:19PM WBC-9.7 RBC-3.90* HGB-11.4* HCT-33.2* MCV-85
MCH-29.1 MCHC-34.3 RDW-15.5
[**2203-6-26**] 09:14PM LACTATE-1.4
[**2203-6-26**] 03:33PM CK-MB-3 cTropnT-<0.01
[**2203-6-26**] 03:33PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-2.0
[**2203-6-26**] 03:33PM HAPTOGLOB-296*
[**2203-6-26**] 03:33PM CORTISOL-8.8
[**2203-6-26**] 11:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
.
DISCHARGE LAB:
[**2203-6-30**] 08:25AM BLOOD WBC-7.5 RBC-3.90* Hgb-11.2* Hct-32.4*
MCV-83 MCH-28.7 MCHC-34.5 RDW-15.9* Plt Ct-254
[**2203-6-30**] 08:25AM BLOOD Glucose-125* UreaN-13 Creat-0.9 Na-142
K-3.7 Cl-108 HCO3-24 AnGap-14
[**2203-6-30**] 08:25AM BLOOD CK(CPK)-51
[**2203-6-28**] 03:18AM BLOOD ALT-14 AST-14 LD(LDH)-251* AlkPhos-38*
TotBili-0.2
[**2203-6-30**] 08:25AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.3
====================
IMAGING:
[**6-26**] CXR: The lungs are low in volume which results in crowding
of the bronchovascular structures. No [**Month/Day (4) **] pulmonary edema. The
cardiac silhouette is enlarged. The mediastinal silhouette
remains widened, compatible with mediastinal lipomatosis as
noted on prior CT. Hilar contours are unchanged. No focal
consolidation, pleural effusion or pneumothorax is present.
[**6-26**] CT-Cervical Spine: Slightly limited eval of lower cervical
spine due to pt size. No acute fx or malalignment. If concern
for ligamentous or cord injury, MRI should be obtained.
[**6-26**] NCHCT: No acute intracranial abnl.
======================
MICROBIOLOGY:
[**6-26**] BCx NGTD, UCx negative
[**6-26**] MRSA screen negative
[**6-29**] C diff toxin A &B negative
Brief Hospital Course:
Assessment and Plan:
39M with complex history including psoriatic arthritis on
chronic steroid therapy presents with hypotension requiring
pressors.
# Shock (adrenal insufficiency & hypovolemia): Patient
presented to [**Hospital **] Hospital with malaise and falls for the past
week. The day prior to presenation he took his BP meds
(CARVEDILOL - 12.5 mg and Torsemide 100 mg) despite SPBs in the
40s, and fell several times. He remained hypotensive in the 90s
systolic at the OSH despite fluid resucitation, stress-dose
steroids, and vasopressors. Concern was for hypovolemic shock in
the setting of fluid restriction and increased diuretic doses
versus septic shock given his immunosuppressed state versus
adrenal insufficiency given his chronic steroid usage. MI was
ruled out with serial enzymes. Cultures were negative at [**Hospital **]
Hospital, so antibiotics were stopped. Endocrine was consulted
who felt that adrenal insufficiency was likely contributing to
his hypotension but was not the primary cause. Vasopressors
were stopped in the MICU and his blood pressures were stable on
transfer. His blood pressure remained stable while his stress
steroid was tapered down and he was started on 10 mg of PO
prednisone daily. He will be discharged home with a rescue dose
of 4 mg IM dexamethasone.
# Syncope with trauma: The patient had several falls prior to
admission. He struck his head several times with enough force
to damage a wall and break a piece of furniture, which raised
concern for head or neck injury. Head and C-spine CT were
negative for acute injury. He had some pain at the trauma site
which were treated with tylenol.
# Chest pain: Symptoms correlated with hypotension and resolved
with normalization of blood pressure. Initial biomarkers at OSH
and BIMDC not suggestive of ACS. Troponin was <0.01 x2 at this
hospital. No complaint of chest pain at the time of discharge.
# Acute renal failure: Cr was 2.8 at OSH with trend to 1.2 with
volume resuscitation. This was likely pre-renal in etiology. By
the time of discharge, it had downtredned back to his baseline
Cr of 0.8.
# Steroid-induced fluid retention: Patient appears obese with
edema likely from underlying steroid-induced fluid retention. He
has been previously evaluated by cardiology with no apparent
cardiac, renal, or hepatic etiologies of fluid. His
spironolactone and torsemide were held in the setting of his
hypotension. His torsemide was started at 50 mg daily on [**6-30**]
given his increasing peripheral edema. Patient was instructed to
continue taking 50 mg torsemide daily for 3-4 days after
discharge while monitoring blood pressure. He was also
instructed to increase the dose to 100 mg torsemide daily
(torsemide) afterwards if peripheral edema worsened.
# Psoriatic arthritis: Azathioprine and ustekinumab were held
in the acute setting. Azathioprine was restarted on [**2203-6-28**] per
rheumatology recommendation.
# Diarrhea: pt developed diarrhea night of [**6-29**], characterized by
crampy abdominal pain relieved with defecation, typical of his
IBS flare. Stool sample was sent for c diff toxin and was
negative. Donnatal was ordered for symptom relief. Patient will
follow up with Dr. [**First Name (STitle) 2643**] for his IBS as outpatient.
# Hypertension: His carvedilol and diuretics were initially
held in the setting of hypotension. Carvedilol was restarted at
half dose after his blood pressure normalized given his
ventricular ectopy. He will follow up with his PCP and primary
cardiologist to adjust carvedilol dose as needed.
# DM2: was put on 70% home dose of lantus with an NPH sliding
scale while NPO. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained in order to
allow the patient to do carb counting like he does at home. His
lantus dose was changed to 20 unit in AM and 29 unit in PM. He
continued premeal carb counting with adequate control of his
blood glucose. He will go home with increased lantus dose and
continue carb counting at home.
# HL: Atorvastatin was initially held in the acute setting. It
was restarted in the ICU and continued on the floor. He will
continue the medication at home at full 80 mg daily dose, as he
has tolerated this dose in the past, does not have any
interacting medication and has normal ALT/AST and CK.
# Peripheral neuropathy: nortriptyline, pregabalin, tizanidine
were initially held in the acute setting. They were restarted
on [**2203-6-29**] at home dose, and he will continue those at home.
# Prolonged QTc: Etiology unknown as no overt QTc prolongating
drugs, but was seen on previous studies. Patient received
serial EKGs and [**Hospital1 **] lytes, both of which normalized. He was
monitored on tele which showed known ventricular ectopic beats
and prolonged QTc. Both of them remained stable. He will follow
up with Dr. [**Last Name (STitle) **] after discharge.
# OSA: continued on home CPAP
# Normocytic Anemia: OSH Hgb 11.4, Admission Hgb 6.4 (likely
due to drawing labs off a vein with fluids running in) with
repeat 11.7. [**Month (only) 116**] be marrow suppresion from azathioprine and
underlying chronic inflammation. His hemoglobin remained stable
between 10.1 and 11.7.
Medications on Admission:
-ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs po
four times a day
-ATORVASTATIN [LIPITOR] - 80 mg Tablet - 1 Tablet(s) by mouth
once a day
-AZATHIOPRINE - 50 mg Tablet - TWO(2) Tablet(s) by mouth in the
morning, THREE(3) at night
-CARVEDILOL - 12.5 mg Tablet - 1 (One) Tablet(s) by mouth twice
a day
-CLOBETASOL - 0.05 % Ointment - AAA body twice a day use for up
to 2 weeks only, then as needed
-ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 capsule
by mouth q month
-INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) -
Dosage uncertain
-INSULIN DETEMIR [LEVEMIR] - (Prescribed by Other Provider) - 20
qAM and 24 qHS
-LIDOCAINE [LIDODERM] - (Prescribed by Other Provider) - 5 %
(700 mg/patch) Adhesive Patch, Medicated - to ankle/knee 12
hours on and then 12 hours off prn
-NORTRIPTYLINE - (Prescribed by Other Provider) - 25 mg Capsule
- 1 Capsule(s) by mouth at bedtime
-PHENOBARB-HYOSCY-ATROPINE-SCOP - (Prescribed by Other Provider;
Dose adjustment - no new Rx) - 16.2 mg-0.1037 mg-0.0194
mg-0.0065 mg Tablet - 1 to 2 Tablet(s) by mouth four times a day
as needed
-PREDNISONE - 5 mg Tablet - 1 tablet by mouth daily in addition
to 1mg tabs taken separately
-PREDNISONE - 7 mg Tablet PO qd
-PREGABALIN [LYRICA] - 75 mg Capsule - 1 Capsule(s) [**Hospital1 **]
-SPIRONOLACTONE - 200 mg Tablet by mouth daily
-TIZANIDINE - 4 mg Tablet - 2 Tablet(s) by mouth at night, may
take 1 [**Hospital1 **] PRN for severe pain and spasm
-TORSEMIDE - 100 mg Tablet - 1 Tablet(s) by mouth once a day
-USTEKINUMAB [STELARA] - 90 mg/mL Syringe - 90 mg Sub-Q Weeks 0
- 4; then every 12 weeks
.
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet - one Tablet(s) by mouth once a
day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by
Other Provider) - 500 mg (1,250 mg)-400 unit Tablet, Chewable -
1 (One) Tablet(s) by mouth once a day
FERROUS SULFATE - (OTC) - 325 mg (65 mg Iron) Tablet - 1
Tablet(s) by mouth daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation four times a day.
2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. azathioprine 50 mg Tablet Sig: Three (3) Tablet PO in the
evening.
4. azathioprine 50 mg Tablet Sig: Two (2) Tablet PO in the
morning.
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
month.
6. insulin aspart Subcutaneous
7. insulin detemir 100 unit/mL Insulin Pen Sig: Twenty (20) unit
Subcutaneous in the morning.
8. insulin detemir 100 unit/mL Insulin Pen Sig: Twenty Nine (29)
unit Subcutaneous at bedtime.
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical on for 12 hours and off for 12 hours as
needed as needed for pain.
10. prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
11. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg Tablet
Sig: 1-2 Tablets PO up to 4 times a day as needed as needed for
diarrhea.
13. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
14. tizanidine 2 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)).
15. Stelara 90 mg/mL Syringe Sig: One (1) syringe Subcutaneous
every 12 wks.
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
17. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day.
18. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
19. clobetasol 0.05 % Ointment Sig: enough to cover affected
area Topical as needed.
20. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
21. torsemide 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
22. dexamethasone sodium phosphate 4 mg/mL Solution Sig: One (1)
mL Injection once as needed for for low blood pressure: Please
draw this up in with syringe and needle and inject it into your
thigh muscle.
Disp:*4 mg* Refills:*0*
23. syringe with needle (disp) 3 mL 25 x 1 Syringe Sig: One (1)
syringe Miscellaneous once.
Disp:*1 syringe* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypotension secondary to relative adrenal insufficiency
Secondary: Hypovolemia, irritable bowel syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 17385**], it was a pleasure to take care of you during
this hospitalization at [**Hospital1 **]. As you know, you
came into the hospital with low blood pressure and falls. You
were admitted into the ICU and received intravenous fluid,
stress dose (high dose) hydrocortisone and pressors for your low
blood pressure. Your blood pressure improved after these
medications and the pressor was stopped. You were then
transferred to the regular medicine floor. Your carvedilol and
torsemide were restarted at half dose after your blood pressure
returned to [**Location 213**]. Your stress dose hydrocortisone was tapered
off and you were transitioned to a higher dose of oral
prednisone. While these medications were changed, your blood
pressure remained normal.
.
You also had some diarrhea that you thought were similar to IBD
flares. Your stool was checked for toxin from c. diff and it was
negative.
.
After you go home, please continue to monitor your blood
pressure as you were doing. Also, please weigh yourself daily to
monitor for fluid retention.
.
These changes were made to your medications:
CHANGE prednisone to 10 mg by mouth daily
CHANGE detemir to 20 units in the morning and 29 units in the
evening
CHANGE carvedilol to 6.25 mg by mouth twice daily
CHANGE torsemide to 50 mg by mouth daily for 3-4 days. If you
notice increased swelling in your legs, you can increase
torsemide back to 100 mg by mouth daily.
STOP spironolactone
NEW: dexamethasone 4 mg rescue syringe. Please use this if your
blood pressure becomes too low.
.
Followup Instructions:
.
Department: RHEUMATOLOGY
When: FRIDAY [**2203-7-1**] at 9:30 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: PAIN MANAGEMENT CENTER
When: TUESDAY [**2203-7-5**] at 1:40 PM
With: [**Name6 (MD) 8673**] [**Last Name (NamePattern4) 8674**], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
.
Department: DIV OF GI AND ENDOCRINE
When: FRIDAY [**2203-7-15**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Name: [**Last Name (LF) 3240**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: INTERNAL MEDICINE
Address: [**Location (un) 35619**], [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 23661**]
Phone: [**Telephone/Fax (1) 35614**]
Appointment: Tuesday [**8-5**] at 9:45AM
.
Department: CARDIAC SERVICES
When: MONDAY [**2203-8-15**] at 8:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"5849",
"4019",
"V5867",
"2724"
] |
Admission Date: [**2152-11-30**] Discharge Date: [**2152-12-1**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old female discharged [**2152-11-28**] presenting to ED with
shortness of breath, chest congestion and hypoxia starting at
7:30 pm on [**2152-11-30**]. She was hospitalized from [**Date range (1) 97882**] for
altered mental status in the setting of a Proteus UTI and
hyponatremia. She was felt to be volume deplete and was volume
expanded. The discharge summary notes difficulty with fluid
balance from presumed age-associated aortic-sclerosis or CHF.
The patient developed anasarca, but not thought to be
intravascularly volume overloaded. The team uptitrated her
enalapril to improve afterload reduction in an attempt to
improve forward flow. The patient also required escalation of
antibiotics from ciprofloxacin to vancomycin/meropenem before
she clinically improved (mental status and leukocytosis). At
discharge, she was transitioned back to ciprofloxacin to
complete a 14 day course.
On the day of admission, she had acute onset shortness of breath
with desaturation to 83% on 2L NC, RR 40. She was given Lasix 40
mg po, Morphine 1 mg sq, and one duoneb. Following the neb, her
oxygenation improved to 90-91% on 4L NC, but proceeded to drop
to 70-80%. When EMS arrived she was satting 60% on 4L and they
placed her on a NRB with nasal trumpet airway.
Upon arrival in the ED, vitals were 100.2 102/70 80 26 92% NRB.
BP in ED 90-106/44-71. Her lowest O2 was 86% on NRB, but she
mostly was 100%. She was given 40 mg IV Lasix with 200+ cc UOP
at 1 hour and improvement in her tachypnea to a RR of 24. She
was given a dose of levofloxacin for presumed pneumonia. At
transfer, her vitals were 73 105/50 24 98% NRB.
Upon arrival to the [**Hospital Unit Name 153**], patient was in distress. HR in 140s,
SBP 80, RR 40, O2 86% NRB. ECG with atrial fibrillation,
spontaneously converted into NSR and BP improved to 90s.
Nephew/HCP contact, does not want aggressive/invasive measures,
but wants attempt at stabilization.
Past Medical History:
1. Hypertension.
2. Arthritis, gout
3. Hypothyroidism (Hashimoto's) and thyroid nodule.
4. Waldenstrom's globulinemia.
5. Anemia, with a work-up at [**Hospital6 **] Center that
revealed a negative colonoscopy, and the patient was started on
iron sulfate three times a day
6. Thrombocytopenia
7. s/p fall [**5-2**], subdural hematoma
8. s/p [**2153**], colles fracture
9. s/p cataract surgery
[**53**]. hip fxr s/p ORIF [**9-/2149**]
Social History:
Currently was staying at [**Hospital **] nursing home, nephew is HCP.
Family History:
NC
Physical Exam:
VS: 97.7 75 88/66 97% on 100% cool neb
Gen: comfortable, responds to name and answers questions
appropriately, difficult to understand, follows commands
HEENT: MM dry, PERRL
Neck: JVP not seen (pt at 90 deg angle and slouched to side)
Car: Regular, distant, difficult to hear due to very loud lung
sounds, III/VI SM c/w AS
Resp: Coarse ronchi bilaterally with insp and exp wheeze
throughout, decreased at bases bilaterally
Abd: s/nt/nd/nabs
Ext: 2+ pitting edema to knees, symmetric
Skin: bruising and skin tears on arms/legs
Neuro: unable to cooperate with exam, moves extremities,
responds to name, difficult to understand.
Pertinent Results:
[**2152-11-30**] 10:30PM GLUCOSE-143* UREA N-53* CREAT-1.3* SODIUM-142
POTASSIUM-5.4* CHLORIDE-111* TOTAL CO2-18* ANION GAP-18
[**2152-11-30**] 10:30PM CK(CPK)-40
[**2152-11-30**] 10:30PM CK-MB-NotDone cTropnT-0.05* proBNP-GREATER TH
[**2152-11-30**] 10:30PM WBC-22.3* RBC-5.13 HGB-15.1 HCT-46.4 MCV-90
MCH-29.3 MCHC-32.5 RDW-14.3
[**2152-11-30**] 10:30PM NEUTS-94* BANDS-0 LYMPHS-3* MONOS-0 EOS-1
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2152-11-30**] 10:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2152-11-30**] 10:30PM URINE RBC-[**10-19**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0-2
[**2152-11-30**] 10:43PM LACTATE-2.6*
Studies:
CXR: Findings compatible with moderate congestive heart failure
and bilateral pleural effusions, right greater than left.
Bibasilar opacities likely represent atelectasis; however,
developing infection or aspiration cannot be completely
excluded.
ECG:
-Initial: NSR at 77 bpm, LAD/LAFB, no ischemic changes
-[**Hospital Unit Name 153**] arrival: AF wtih RVR at 144 bmp, rate related ST cahnges
in I, aVL, V5/V6
Brief Hospital Course:
[**Age over 90 **] year old female with a history of HTN/Waldenstrom
macroglobulinemia presenting with respiratory distress and
hypoxia now deceased due to respiratory failure secondary to
congestive heart failure and volume overload.
The patient was admitted with hypoxia from a nursing home. She
had evidence of volume overload by CXR and a BNP > 70,000. She
had a recent hospital admission for a UTI and was volume
resusitated during the stay and was volume overload on
discharge. She has a history of heart failure so presentation
was consistent with an acute heart failure exacerbation. Given
her recent hospitalization requiring broad spectrum antibiotics
for response she was treated with vancomycin and meropenem
initially. She was DNR/DNI on admission and was placed on a
100% NR in the ED which was continued in the ICU.
The patient??????s respiratory status has continued to worsen over
the course of her admission. She was continued on the
nonrebreather at 100% as her family did not want more invasive
measures taken. As she continued to due poorly and did not
respond to lasix for gentle diuresis, further family discussion
in the afternoon resulted in the patient being changed to CMO.
Her antibiotics were stopped and a morphine drip was started for
comfort.
The patient was pronounced dead at 2120. Her nephew (health
care proxy), Mr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 97857**]), was called and
informed of her death at 2135. The ICU covering fellow, Dr.
[**Last Name (STitle) **], was called and informed of her death and the attending of
record, Dr. [**Last Name (STitle) **], was also informed. As she had been admitted
less then 24 hours ago the medical examiner??????s office was called
and they waived the autopsy. Mr [**Name13 (STitle) **] was asked if the family
wanted an autopsy which he declined. Her cause of death was
reported as respiratory failure secondary to congestive heart
failure and volume overload.
Medications on Admission:
Enalapril 5 mg in am 2.5 mg qhs
Ciprofloxacin 500 mg tab one tab daily (last dose due [**2152-12-9**])
MVI daily
Calcium carbonate 500 mg po three times dailyl
Vitamin D3 800 mg daily
Senna [**Hospital1 **]:prn
Colace 100 mg [**Hospital1 **]
Metoprolol 12.5 mg po bid
Acetaminophen prn
Levothyroxine 137 mcg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary -
Respiratory failure
Congestive heart failure
Secondary -
Hypothyroidism
Atrial fibrillation
Discharge Condition:
Expired
Followup Instructions:
None
Completed by:[**2152-12-1**]
|
[
"4280",
"51881",
"2762",
"5849",
"42731",
"2767",
"2449",
"4241",
"4019"
] |
Admission Date: [**2200-4-1**] Discharge Date: [**2200-4-3**]
Date of Birth: [**2125-7-25**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
Facial Swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 M h/o DM2, HTN, deaf presents to ED after awakening at 6:45AM
with left lower lip and cheek swelling. no cp/sob/difficulty
swallowing at that time, no urticara, pruritis. no recent
medications changes (on ace-i x 5y), trauma, insect bite, food
changes, detergent changes. similar type episode in [**12-28**] after
eating shrimp, though not as severe, and resolved within 1-2hrs.
per wife, swelling this am progressed over minutes, so brought
pt to ED. last took lisinopril at 10AM [**3-31**].
.
Upon arrival to ED 98.5 71 15/55 18 100%RA, pt given
solumedrol 125mg iv x 1, famotidine 20mg iv x1, benadryl 25mg iv
x1 at 0850AM, however swelling continued to progress, involving
right lower lip, left upper lip, and worsening of left cheek
swelling. again no cp, sob, stridor, though now admits to some
difficulty swallowing. Admitted to [**Hospital Unit Name 153**] for closer monitoring.
.
Past Medical History:
DM2
HTN
Hyperlipidemia
Anemia
Prostate Ca
Glaucoma
s/p R TKR revision [**3-18**]
Deafness [**2-22**] meningitis
Social History:
Denies tobacco, EtOH, recreational drugs
Family History:
Mother had MI, + DM2, no h/o blood clots
Physical Exam:
VS: 97.1 69 139/56 17 99%RA
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, no urticara, erythema,
swelling of bilateral lower lip, left upper lip, and ~3cm
diameter region of swelling on left cheek, no induration, OP
crowded, no enlargement of toungue, no LAD, No JVD. no facial
droop.
CV: regular, nl s1, s2, no r/g. 3/6 SEM.
PULM: few crackles at right base, no r/r/w.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL. Right knee incision c/d/i,
minimal edema, no blotting.
NEURO: alert & oriented x 3, CN II-XII grossly intact.
Pertinent Results:
[**2200-4-1**] 08:40AM BLOOD WBC-7.3 RBC-3.80* Hgb-10.8* Hct-33.2*
MCV-87 MCH-28.4 MCHC-32.5 RDW-14.2 Plt Ct-825*#
[**2200-4-1**] 08:40AM BLOOD Glucose-109* UreaN-22* Creat-1.3* Na-138
K-4.5 Cl-103 HCO3-27 AnGap-13
[**2200-4-2**] 04:29AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.1
[**2200-4-2**] 04:29AM BLOOD C1 INHIBITOR-PND
Brief Hospital Course:
74M admitted with left side facial swelling.
.
1. Facial swelling/angioedema: Patient admitted to [**Hospital Ward Name 332**] ICU
for monitoring. Ace inhibitor held-suspected offending [**Doctor Last Name 360**].
No shellfish etc. (Patient had similar episode in past with
shellfish) Treated with benadryl, famotidine. Patient received
tow doses of decadron as well. Patient had rpaid improvement in
his swelling and angioedema. Decadron discontinued given recent
right TKR and concern for septic joint. C1 and C4 complement
levels sent. ENT consulted-no evidence of airway compromise.
Discharged on 5 days of famotidine/benadryl. Allergy f/u with
Dr. [**Last Name (STitle) 2603**] scheduled for patient.
.
2 Acute renal failure - baseline 1.1, admit 1.3, likely
dehydration.
Resolved with IVF's.
.
3) Right TKR: 2 weeks post replacement. Followed by ortho
throughout. Staples removed. Ortho did not feel knee was
infected. PT evaluated patient. Lovenox x 10 more days then
[**Hospital1 **] apsirin as per ortho. F/u with Dr. [**Last Name (STitle) **] scheduled.
4)HTN - continued home amlodipine. Ace inhibitor discontinued.
Amlodipine titrated to 10mg from 5mg --bp generally well
controlled 120's to 130's on amlodipine alone.
5) hyperlipidemia - continued statin.
.
6)DM -
HISS while inpt, restarted metformin upon discharge.
.
#PPx
- lovenox 40 sc q24 given knee replacement.
- bowel regimen not necessary given recent loose bm's in setting
of colace.
.
.
#COMM: wife [**Name2 (NI) **], [**Telephone/Fax (1) 13417**], sign language interpreter
pager [**Numeric Identifier 13418**].
Medications on Admission:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY (Daily).
3. Amlodipine 5 mg PO DAILY (Daily).
4. Oxycodone 5 mg PO Q4H -> NOT TAKING
5. Lisinopril 40 PO DAILY
6. Enoxaparin 40 mg/0.4 mL Syringe Q24H
7. Metformin 500mg [**Hospital1 **]
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
7. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous Q 24H (Every 24 Hours) for 10 days.
Disp:*10 syringes* Refills:*0*
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO twice a day for
3 weeks: start after you have completed your enoxaparin(lovenox)
course, in 10 days.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Angioedema ([**2-22**] ACE inhibitor)
2. Allergy to ACE inhibitor
3. Acute Renal Failure
4. Hypertension
Secondary:
1. S/p total knee replacement
2. Hyperlipidemia
3. Anemia
4. Thrombocytosis
Discharge Condition:
Stable, swelling much improved.
Discharge Instructions:
If you develop recurrence of swelling after you stop the
benadryl and famotidine, you must call your doctor or go to the
emergency room immediately. If you start to develop any
breathing or swelling difficulty, go to the emergency room
immediately.
All medications as prescribed. The benadryl and famotidine are
for the lip swelling. Take these for the next five days. The
benadryl can make you sleepy and you should not drive or operate
machinery on this medication.
You should never take an ACE inhibitor again. This is a class
of medications which includes the lisinopril that you were on.
This type of medication can cause recurrence of the swelling and
if it happens again it could cause life threatening swelling
leading to inability to breath. You should also not eat
shellfish. You must see the allergist, he may make other
recommendations about limiting foods you can eat.
Take the lovenox for 10 more days, then start aspirin twice a
day.
Follow up as below. Se your primary care doctor [**First Name (Titles) **] [**4-23**].
You should see the allergist on [**5-7**].
You should follow up with Dr. [**Last Name (STitle) **] for your knee on [**5-16**].
Followup Instructions:
With your primary care doctor:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2200-4-23**] 2:30
With the podiatrist:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2200-5-9**] 3:50
For your knee
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2200-5-16**] 1:15
With the allergist:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 9316**] Date/Time:[**2200-5-7**]
9:00
|
[
"5849",
"2724",
"4019",
"25000"
] |
Admission Date: [**2160-6-9**] Discharge Date: [**2160-6-13**]
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 10682**]
Chief Complaint:
Anemia, Hct 18
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old male with a history of hemolytic anemia (autoimmune)
and recurrent GI bleeding without known source, status post
multiple EGDs and capsule endoscopy in the past, presenting from
[**Hospital 100**] Rehab with Hct 18 seen on routine labs. Patient reports
somewhat worsened fatigue over the last week or so, but
otherwise has been asymptomatic. He reports no diarrhea or
abdominal pain. There has been no report of hematemesis, melena
or hematochezia. He has experienced no dyspnea on exertion or
chest pain. Patient states that he would not like an EGD or
colonoscopy during this admission, but he will accept blood
transfusions. He has received numerous work-ups for his anemia
and GI bleeding in the past (EGD x4, [**Last Name (un) **] x2, capsule x3, CT
abd/pelvis, bleeding scan). Patient is typically transfused at
[**Hospital 100**] Rehab every two weeks. On past admission, more
conservative measures including transfusions and iron
supplementation were decided on. Patient has had no recent
changes in medications. Patient has an AVR with goal INR 2-2.5.
In the ED, initial vs were: 97.8 82 118/62 16 95% RA. Patient
was noted to have heme positive melena on exam. INR on
admission was 4.2. GI was consulted and recommended no NG
lavage and likely no colonoscopy since patient has had multiple
negative work-ups in the past. Patient's heme/onc doctor
recommended holding warfarin, but not to reverse INR, and admit
to the [**Hospital Unit Name 153**]. Patient was ordered for two units of blood in the
ED, but did not receive any while down there. Vitals in ED
prior to transfer are as follows: afebrile 82 109/53 16 99%RA.
On the floor, patient has no current complaints. He reports no
chest pain, shortness of breath, or abdominal pain. Patient
endorses left arm pain that is chronic. He has had no recent
falls.
Past Medical History:
# Anemia, multifactorial as below, baseline HCT 28
# Autoimmune hemolytic anemia (Coomb's +, warm autoantibody),
on prednisone 10mg Po daily
# Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped
due to hemolytic anemia
# Aortic mechanical valve, recently Coumadin resistant so
intermittently on Lovenox bridge, followed by Dr. [**Last Name (STitle) **]
# hx recent GI bleeds: colonoscopy [**1-10**]: noted normal colon
with melanotic stool in terminal ileum
# GERD: EGD [**12/2159**] Polyp in the area of the papilla; found on
the wall opposite the ampulla. Small hiatal hernia. Otherwise
normal EGD to third part of the duodenum.
# H/o presyncope
# CKD Cr 1.6-2.0 Stage III
# CAD s/p NSTEMI [**7-10**]
# Chronic CHF, likely diastolic, ([**9-9**] EF=50%)
# Hyperlipidemia
# Hypertension
# Depression vs adjustment disorder after death of brother
# Prostate cancer- s/p radiation
# Bladder/bowel incontinence
# Right lateral malleolus stage 1 pressure ulcer
# Dementia
Social History:
Never smoked, no EtOH or other drugs. Currently living at
[**Hospital 100**] Rehab. Uses wheelchair typically. Requires a
significant degree of assistance in all his ADLs and IADLs. Has
2 sons and 4 grandchildren.
Family History:
No bleeding diatheses. Father had stomach cancer. No other
cancers including colon.
Physical Exam:
At admission:
Vitals: T: 96.9 BP: 78 P: 109/59 R: 19 O2: 97%RA
General: Alert, oriented x 3, appropriate, no acute distress,
pleasant and cooperative
HEENT: Sclera anicteric, conjunctivae pale, MM dry, oropharynx
clear with no lesions noted
Neck: supple, JVP not elevated, no cervical or supraclavicular
LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate, mechanical heart sounds best heard at LUSB, no
rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, trace peripheral edema, no clubbing,
cyanosis or edema
Neuro: AAOx3, sensation intact in all extremities
Pertinent Results:
Admission labs:
[**2160-6-9**] 02:45PM BLOOD WBC-5.0 RBC-1.76*# Hgb-6.4*# Hct-18.4*#
MCV-105* MCH-36.5* MCHC-34.9 RDW-22.7* Plt Ct-166
[**2160-6-9**] 02:45PM BLOOD Neuts-80* Bands-0 Lymphs-16.0* Monos-4
Eos-0 Baso-0
[**2160-6-9**] 02:45PM BLOOD PT-40.5* PTT-30.9 INR(PT)-4.2*
[**2160-6-9**] 02:45PM BLOOD Ret Man-4.9*
[**2160-6-9**] 02:45PM BLOOD Glucose-179* UreaN-42* Creat-1.6* Na-140
K-4.6 Cl-109* HCO3-24 AnGap-12
[**2160-6-10**] 01:58AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.4
Discharge labs:
[**2160-6-13**] 10:15AM BLOOD WBC-4.9 RBC-2.54* Hgb-8.7* Hct-26.3*
MCV-104* MCH-34.1* MCHC-32.9 RDW-22.0* Plt Ct-115*
[**2160-6-13**] 01:13AM BLOOD PT-17.3* PTT-150* INR(PT)-1.5*
[**2160-6-12**] 06:35AM BLOOD Glucose-78 UreaN-24* Creat-1.3* Na-141
K-4.0 Cl-108 HCO3-28 AnGap-9
CHEST PORT. LINE PLACEMENT Study Date of [**2160-6-11**]
Left PICC tip is in the upper SVC. There are no other acute
interval changes from the prior study performed 6 hours earlier.
There are persistent low lung volume, cardiomegaly, and
bibasilar atelectasis. The sternal wires are aligned. The
patient is status post aortic valve replacement. Surgical clips
are noted in the right upper hemithorax. Right PICC has been
removed. There is no pneumothorax or large pleural effusions.
Brief Hospital Course:
[**Age over 90 **] year old male with a history of autoimmune hemolytic anemia,
AVR with goal INR of [**3-5**].5, and recurrent GI bleeding without
known source, status post multiple EGDs and capsule endoscopy in
the past, who presented from [**Hospital 100**] Rehab on [**2160-6-9**] with routine
Hct 18, asymptomatic, initially admitted to MICU.
# Chronic blood loss anemia/Hemolytic anemia: Patient had a
hematocrit of 18 on admission, baseline 28, likely
multifactorial, related to hemolysis (for which he is on
prednisone, low haptoglobin but nl LDH) and chronic bleed. He
was asymptomatic. Per patient, patient is intermittently
transfused at [**Hospital 100**] Rehab and the facility has a difficult time
finding matched blood. Melena was noted on admission in the ED.
No further episodes while hospitalized. Patient declined
colonoscopy, EGD, but accepted transfusions. He received 2 U
PRBC on [**6-9**] with appropriate increase, 1 U PRBC on [**6-11**], and 1 U
PRBCs on [**6-13**]. He was initially on IV PPI, changed to PO PPI
and started on carafate. He was continued on his home prednisone
and bactrim prophylaxis, vitamin B12, folic acid. His Coumadin
was initially held, and heparin gtt was started to complete
bridge back to therapeutic INR.
*****Patient should have HCT/HGB checked every 3-4 days. When
the HCT is <25, please call Dr.[**Name (NI) 3930**] clinic ([**Telephone/Fax (1) 3241**])
to arrange for outpatient blood transfusion. IF the patient is
symptomatic (chest pain, shortness of breath), then it is
reasonable to send patient to the Emergency Room.
# s/p Aortic mechanical valve: Patient is on coumadin with INR
goal 2-2.5. He was noted to have INR of 4.2 on admission. His
coumadin was initially held and restarted with heparin bridge
when his HCT stabilized.
# Hypertension: He was continued on his carvedilol.
# Hyperlipidemia: He was continued on his simvastatin.
# Chronic kidney disease, stage III: His Cr remained stable
throughout the hospitalization.
# Hypothyroidism: He was continued on levothyroxine.
Code: Patient would like DNR but may be intubated
HCP: [**Name (NI) **] [**Name (NI) 43131**] [**Name (NI) 66590**] ([**Telephone/Fax (1) 66592**] home, [**Telephone/Fax (1) 66591**] cell)
Medications on Admission:
Warfarin 2 mg PO daily
Carvedilol 3.125 mg PO BID
Bactrim SS 1 tab PO daily
Levothyroxine 75 mcg PO daily
Prednisone 10 mg PO daily
Omeprazole 40 mg PO BID
Simvastatin 40 g PO daily
Cyanocobalamin [**2149**] mcg PO daily
Folic acid 4 mg PO daily
Acetaminophen 325 mg PO Q6h PRN pain
Oxycodone 2.5 mg PO TID PRN pain
Senna 8.6 mg PO daily
Allergies:
Amoxicillin
Discharge Medications:
1. heparin (porcine) in NS 10,000 unit/1,000 mL Parenteral
Solution Intravenous
2. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
3. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. cyanocobalamin (vitamin B-12) 2,000 mcg Tablet Extended
Release Sig: One (1) Tablet Extended Release PO once a day.
10. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Chronic blood loss anemia
Hemolytic anemia
Aortic mechanical valve
Hypertension
Hyperlipidemia
Chronic kidney disease, stage III
Hypothyroidism
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 66590**],
It was a pleasure taking care of you. You were admitted for
anemia, likely from bleeding in the gastrointestinal tract like
before. You were given blood transfusions and your blood counts
improved. You declined further endoscopies as these have not
been revealing in the past. You were started on carafate to
protect the stomach. No other changes were made to your
medications.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2160-6-26**] at 11:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13863**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2160-6-26**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"41401",
"2724",
"40390",
"4280",
"2449",
"412",
"V5861"
] |
Admission Date: [**2185-6-13**] Discharge Date: [**2185-7-5**]
Date of Birth: [**2123-7-8**] Sex: M
Service: MEDICINE
Allergies:
Flagyl / Iodine; Iodine Containing / Keflex
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Bright red blood per ostomy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 61 year old male with past medical history
significant for rectal cancer s/p LAR with end colostomy
([**2174**])and XRT, CAD s/p CABG ([**2172**]), CHF (EF=25%) s/p placement
of PPM, HTN and DM who presents to ED with complaints of bloody
output from ostomy accompanied by dizziness. Patient reports the
first episode occurred about 10:00 this a.m. This was then
followed by an additional output around 10:30a.m. The patient
described the output as dark red and "jelly" like. In the
setting of this bloody output, the patient reports that he feels
tired and lightheaded. He denies however any associated chest
pain or shortness or breath. The patient reports that he takes
aspirin daily, which he has been doing for 10+ years, but
otherwise has not added any additional NSAIDs or anti-platelet
drugs to his daily regimen.
.
The patient reports that he has been eating and drinking well at
home without any associated nausea, vomiting, or abdominal pain
currently. However, the patient does reports dull abomdinal pain
for 1-2 days preceeding the current episode.
.
In the ED, the patient was evaluated and a gastric lavage was
negative for acute bleeding. The patient was additionally seen
and evaluated by surgery. Since his presentation to the ED to
his evaluation by surgery, the patient had decreased bloody
output and more normal appearing stool. The decision was made at
that time to admit the patient to medicine, assess the patient
again in the morning, and make possible plans for colonoscopy.
In the evening, around 8:00 pm, the patient again began to have
bloody output, with 425cc documented in the ED nursing chart. 50
minutes later there was an additional 225cc of maroon, partially
clotted bloody output. The patient reported that he still felt
lightheaded, but denied any chest pain or shortness of breath.
The patient was non-orthostatic at this time with a lying BP of
105/27 and HR of 62; sitting BP of 111/41 with a HR of 64; and a
standing BP of 114/23 with a HR of 65. Pt will be admitted to
medicine for further care.
Past Medical History:
1. DM
2. CHF, EF=25%
3. CAD s/p CABG, [**2174**]
4. Rectal Cancer, s/p LAR and XRT, [**2174**]
5. HTN
6. Back surgery [**2182**]
7. Anemia
8. Chronic draining sacral ulcer
Social History:
Social History:
Pt is a retired elctronic engineer. Remote smoking history.
Denies ETOH and drugs.
Family History:
Noncontributory
Physical Exam:
Physical Exam:
98.2 61 110/86 95% RA
Gen: Tired man resting on strecher. Reports that he is very
tired of answering questions.
HEENT- NC AT. Anicteric sclera. Mildly dry mucous membranes.
Cardiac- RRR. S1 S2. No m,r,g.
Pulm- CTAB. No wheezes, rales, rhonchi.
Abdomen- Soft. NT. ND. Positive bowel sounds. Small amount of
blood in the ostomy bag.
Extremities- 2+ pitting edema bilateral LE. No c/c. Pt with
chronic changes of venous stasis on the bilateral LE and ulcer
on the anterior right LE.
Pertinent Results:
[**2185-6-13**] CXR - No evidence of congestive heart failure
[**2185-6-15**] ECHO - The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe hypokinesis of the
inferior and lateral walls including the apex. The anterior wall
is not weel seen. Overall left ventricular systolic function is
moderately depressed. No masses or thrombi are seen in the left
ventricle. There is mild global right ventricular free wall
hypokinesis. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-5**]+) mitral regurgitation is seen.
There is no pericardial effusion.
[**2185-6-20**] LE Doppler (R) - No deep venous thrombosis within the
right common femoral, superficial femoral, deep femoral, or
popliteal veins
[**2185-6-21**] GI Bleeding Study - No evidence of active bleeding.
[**2185-6-21**] UGI SGL W/ SBFT - No reason for bleeding identified in
this study.
[**2185-6-27**] GI Bledding Study - No evidence of active bleeding
[**2185-6-28**] CXR - Interval development of congestive heart failure
with perihilar and basilar edema and new small right pleural
effusion.
[**2185-7-3**] CXR - The patient is status post sternotomy with
mediastinal clips. There is mild cardiomegaly. A left-sided dual
lead pacemaker is present, with lead tips over right atrium and
right ventricle. A third lead may also be present, not well
visualized here. There is minimal upper zone redistribution, but
no overt CHF. There is a small-to-moderate right effusion with
underlying collapse and/or consolidation. The left costophrenic
sulcus is clear. Aside from the right base, no focal infiltrate
is identified. There is mild diffuse parenchymal scarring.
Compared with [**2185-6-13**], the right pleural effusion is new.
Compared with [**2185-6-28**], there has been improvement in the CHF
findings and the left base has cleared.
[**2185-7-4**] CXR - There has been interval right thoracentesis with
near complete resolution of a previously noted right pleural
effusion. No pneumothorax is identified, and there is otherwise
no significant change since the recent chest radiograph of 1 day
earlier.
[**2185-7-4**] Pleural Fluid - NEGATIVE FOR MALIGNANT CELLS.
Cultures:
[**2185-7-4**] Pleural Fluid - GRAM STAIN (Final [**2185-7-4**]): 2+ ([**12-8**]
per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN. FLUID CULTURE (Final [**2185-7-7**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH
[**2185-6-16**] Wound Culture - WOUND CULTURE: CORYNEBACTERIUM SPECIES
(DIPHTHEROIDS). MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
GRAM NEGATIVE RODS. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE
GROWTH. (MRSA)
Labs:
[**2185-6-13**] 03:00PM BLOOD WBC-9.4 RBC-3.20* Hgb-8.6* Hct-27.0*
MCV-84 MCH-27.0 MCHC-32.0 RDW-16.1* Plt Ct-138*
[**2185-6-14**] Hct-25.6*
[**2185-6-14**] Hct-30.3*
[**2185-6-14**] Hct-29.4*
[**2185-6-14**] Hct-30.0*
[**2185-6-15**] Hct-30.0*
[**2185-6-15**] WBC-8.8 RBC-3.24* Hgb-9.2* Hct-27.0* MCV-83
[**2185-6-15**] Hct-30.1*
[**2185-6-16**] WBC-8.4 RBC-3.47* Hgb-9.7* Hct-29.6* MCV-85 Plt
Ct-148*
[**2185-6-17**] WBC-8.1 RBC-3.61* Hgb-9.8* Hct-31.0* MCV-86 Plt Ct-155
[**2185-6-18**] Hct-29.5*
[**2185-6-18**] WBC-9.1 RBC-3.65* Hgb-10.2* Hct-32.2* MCV-88 Plt Ct-150
[**2185-6-18**] WBC-10.2 RBC-3.66* Hgb-10.3* Hct-32.4* MCV-89 Plt
Ct-148*
[**2185-6-18**] Hct-31.9*
[**2185-6-18**] Hct-30.2*
[**2185-6-19**] WBC-9.1 RBC-3.38* Hgb-9.7* Hct-30.0* MCV-89 Plt
Ct-122*
[**2185-6-19**] Hct-34.4*
[**2185-6-20**] Hct-31.4*
[**2185-6-22**] WBC-10.1 RBC-3.16* Hgb-9.0* Hct-27.0* MCV-85 Plt
Ct-129*
[**2185-6-22**] Hct-30.3*
[**2185-6-23**] Hct-31.0*
[**2185-6-24**] WBC-7.4 RBC-3.18* Hgb-9.0* Hct-27.3* MCV-86 Plt
Ct-139*
[**2185-6-25**] WBC-9.0 RBC-3.60* Hgb-10.2* Hct-31.6* MCV-88 Plt
Ct-159
[**2185-6-26**] Hct-31.9*
[**2185-6-27**] WBC-8.0 RBC-3.61* Hgb-10.2* Hct-30.8* MCV-85 Plt
Ct-135*
[**2185-6-28**] Hct-34.5*
[**2185-6-29**] WBC-9.4 RBC-4.19* Hgb-11.8* Hct-36.9* MCV-88 Plt
Ct-150
[**2185-6-30**] WBC-6.7 RBC-3.49* Hgb-9.9* Hct-30.3* MCV-87 Plt
Ct-126*
[**2185-7-3**] WBC-6.2 RBC-3.42* Hgb-9.6* Hct-29.7* MCV-87 Plt
Ct-145*
[**2185-7-3**] Hct-31.7*
[**2185-7-4**] Hct-30.5*
[**2185-7-5**] WBC-7.2 RBC-3.57* Hgb-10.2* Hct-31.1* MCV-87 Plt
Ct-160
[**2185-6-13**] PT-13.9* PTT-27.3 INR(PT)-1.3
[**2185-7-5**] PT-14.0* PTT-29.2 INR(PT)-1.3
[**2185-6-13**] Glucose-151* UreaN-140* Creat-4.0*# Na-128* K-4.7
Cl-91* HCO3-22 AnGap-20
[**2185-7-5**] Glucose-71 UreaN-30* Creat-1.2 Na-135 K-5.0 Cl-101
HCO3-27 AnGap-12
[**2185-7-4**] proBNP-9539*
[**2185-7-4**] Calcium-8.9 Phos-4.3 Mg-1.9 Iron-28*
[**2185-7-4**] TIBC-248* Ferritn-253 TRF-191*
[**2185-6-26**] Triglyc-81 HDL-26 CHOL/HD-3.7 LDLcalc-55
[**2185-6-14**] Digoxin-2.2* (Admission)
[**2185-7-4**] Digoxin-0.9 (Discharge)
Brief Hospital Course:
1. GI Bleed - The patient was initially admitted to the floor
for active fluid resusitation and work-up. He was in and out of
the MICU for an episode of active bleeding and was then sent out
to the floor again on [**2185-6-16**]. On [**6-26**], the patient was noted
to have had a hematocrit drop from 31.6 to 27.5 and so was
transfused one unit of PRBC with an appropriate bump to 31.9.
The night float resident was called to the floor on the evening
of [**6-26**] due to a finding of 300 cc of BRB in the ostomy bag -
MICU evaluation was called - pt found to have bled a total of
550 cc by 1 am [**6-27**], although he remained hemodynamically
stable. A second unit of PRBC was transfused given the
witnessed blood loss (in the ostomy bag). On evaluation by the
MICU resident, he was initially found to have a pressure in the
140's, and a HR in the 80's, although he is on a beta blocker.
His pressure soon dropped to the 90's, and the unit of blood was
put in as quickly as possible (wide open). Additionally, he
complained of syptoms of dizziness and was transported to the
MICU expeditiously. During his hospital stay the patient
underwent upper and lower endoscopy, and both were essentially
unremarkable. Colonoscopy reveals some angiodysplasia and
laceration in ostomy. He subsequently underwent capsule
endoscopy which revealed multiple AVM's of the small bowel. So
far, however, no active bleeding detected by EGD, colonoscopy,
or tagged red blood cell scan. The patients Hct again
stabalized and he was transferred to the floor. His hct
remained stable after this point in time.
2. ARF - It was also noted on admission, that the patient had a
creatinine of 4.0. This was likely prerenal secondary to
hypovolemia in the setting of active GI bleeding. It slowed
trended down on the course of the patients hospitalization. He
was discharged with a creatinine of 1.2.
3. CHF - The patient has a history of CHF, but on admission had
denied any SOB and a CXR had shown no signs of fluid overload.
After the patients episode of active bleeding and time in the
MICU, the patient became fluid overloaded, secondary to
aggressive fluid resusitation and s/p 10 units of PRBC. The
patient began to experience increasing SOB. A subsequent CXR
showed: "Interval development of congestive heart failure with
perihilar and basilar edema and new small right pleural
effusion." The patient was placed on nasal canula and diuresed.
The patient was still having SOB so a subsequent CXR was
ordered. It showed a worsening pleural effusion. The pleural
effusion was tapped and the patient was continued on lasix. The
patient symptoms then began to improve.
The patients Hct remained stable, and his SOB resolved.
.
The patient was discharged home with serives on [**2185-7-5**].
Medications on Admission:
MVI
Arginine 500 mg PO BID
Vitamin C 500 mg PO BID
ASA 325 mg PO QD
Neurontin 300 mg PO TID
Iron 325 mg PO TID
Digoxin 0.125 mg PO QD
Folic acid 2 mg PO QD
Coreg 12.5 mg PO BID
Demadex 20-30 mg PO BID
Hydralazine 10 mg PO QID
Tolvaptan (Heart Failure Study at [**Hospital1 2025**])
Aranesp (injection preloaded)
Insulin - Lantus, 20 units QHS
Insulin - Nova, 7 units breakfast/lunch, 4 units snack, 9 units
dinner
Pain med preference: 30 units oxycontin, 2 percocets
.
Allergies:
1. Iodine
2. Cephalexin
3. Flagyl
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Coreg 12.5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Disp:*30 bottle* Refills:*2*
7. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 preloaded * Refills:*2*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*1 tube* Refills:*0*
10. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10)
milliliters PO BID (2 times a day).
Disp:*600 milliliters* Refills:*2*
11. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*30 Tablet Sustained Release 12HR(s)* Refills:*0*
12. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
15. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
Discharge Diagnosis:
Primary diagnosis:
GI bleed- Pt had bleeding into his ostomy.
Secondary diagnosis:
Acute renal failure
Type 2 diabetes mellitus
CAD
Hypertension
Anemia
Congestive heart failure
Discharge Condition:
Stable. Patients hct has been stable. His renal function has
improved. Vital signs are within normal limits.
Discharge Instructions:
1. Please keep all follow up appointments.
2. Please take all medications as prescribed.
3. Seek medical attention for fevers, chills, chest pain,
shortness of breath, abdominal pain, or any other concerning
symptoms.
4. Please monitor daily weights.
5. Return immediately if dizzy and lightheaded, and/or you
notice blood in your ostomy.
Followup Instructions:
1. Please follow up with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 24253**]. Call [**Telephone/Fax (1) 93432**].
2. Follow up with cardiologist Dr. [**First Name (STitle) **] in 2 weeks. We had
recommended to patient that he be started on a statin and beta
blocker but he refused on multiple occasions.
|
[
"5849",
"2851",
"5119",
"4019",
"V5867",
"V4581"
] |
Admission Date: [**2150-11-11**] Discharge Date: [**2150-11-21**]
Service: MEDICINE
Allergies:
Diltiazem / Demerol
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS: (per HPI) "84 year old
woman with known CAD (s/p BMS to RCA x 2 in '[**44**], DES to LAD
[**2-11**]), systolic HF (EF 45%), PVD (s/p bilateral LE bypass,) HTN,
RAS, PAF, who presented to an outside hospital w/ sudden onset
of SOB. Patient awoke in middle of night w/ difficulty
breathing. When EMS arrived, she was found to be hypoxic to 84%.
She was initially admitted to the ICU for CPAP, but with a
significant symptomatic improvement to lasix, she was able to
have oxygen titrated down to NC. She denies any ensuing CP prior
to the episode and had no palpitations. She denies any recent LE
swelling, premonitory SOB, or lightheadedness. Patient had a
recent hospitalization 2 weeks prior to presentation. At that
time she ruled out for MI, and was discharged following
adjustments to medication. Patient underwent a pharm neuclear
stress test, which was nondiagnostic on EKG, with failure to
show changes in baseline sinus bradycardia. There is no report
in the transfer records of elevated cardiac enzymes. Per report,
nuclear imaging showed nuclear mixed inferior defect. Patient
was transfered to [**Hospital1 18**] for cardiac catheterization."
.
Oon [**2150-11-11**], pt underwent a cardiac catheterization which showed
ISRS and she had 2 DES to the LAD placed. She did well post-cath
and received renal protection via bicarb and mucomyst. Her
volume status remained tenuous and she was aggressively
diuresed. However, her renal function also began to decline,
raising concern for overdiuresis. Her room air sats remained
low, though, so her outpatient lasix dose was resumed. Today,
she was given her AM dose of lasix, but her afternoon dose was
held because of her rising creatinine and her euvolemic status.
However, in the evening, the patient began to complain of
respiratory distress. Her SBP were found to be in the 160s-170s.
She was given: 60mg IV lasix (with minimal UOP), 4mg IV morphine
total, and nitroglycerin gtt at 1.4mcg/kg/min. Sats were 78% on
3-4L -> improved only to 90-92% on NRB. She was given an
additional dose of 120mg lasix IV with minimal UOP. An ABG
showed pH 7.18, pCO2 95, and pO2 94. Decision was made to
attempt BiPAP but that was unable to be performed on the floor.
The patient was minimally responsive and was using accessory
muscles of respiration. The decision was made to intubate her
for airway protection and control. She was intubated easily
(with etom/succ) and brought to the CCU for further management.
EKG performed on arrival to the SICU were concerning for ST
elevations in the precordial leads, but they resolved somewhat
with time so the decision was made to follow her enzymes and not
go to cath urgently. She remained on heparin IV overnight for
possible ACS as her troponins were elevated (but her CK was
flat).
Past Medical History:
-CAD -> multivessel s/p 2 complex angioplasties of RCA; [**2-6**] she
underwent PTCA/stenting of the mid/distal RCA; [**9-8**] LMCA had a
mild proximal stenosis, LAD had a 60% proximal stenosis at D1.
The remainder of the vessel had mild-moderate diffuse disease.
.
-The circumflex system was small with a 40% focal OM1 lesion.
The RCA had a 20% proximal stenosis. There were serial 90% and
80% focal in-stent restenotic lesions of the mid and distal
vessel. The PDA filled via collaterals from the left. Successful
PTCA of the RCA was performed using a 3.0x15 mm cutting balloon
proximally and a 2.5x15 mm cutting balloon distally. There was
20% residual stenosis in the mid-RCA and 10% distally with
normal flow and no apparent dissection.
.
-DES to LAD in [**2-11**]
--CHF - h/o recurrent admissions for CHF exacerbations; cath
[**2144**] showed elevated filling pressures but normal EF. Recent ETT
with anterior apical ischemia. LVEF 45-50%
.
--h/o pseudoaneurysm of brachial artery h/o difficult access due
to --
--DM
--HTN
--PVD s/p Aortobifemoral bypass
--hypercholesterolemia
--anemia (baseline Hct 31-34)
--PAF
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
.
Cardiac History: as above
.
Percutaneous coronary intervention, in [**2144**] anatomy as follows:
as above
.
Pacemaker/ICD: n/a
Social History:
Lives with daughter, non [**Name2 (NI) 1818**], no etoh.
Family History:
+ DM,
Physical Exam:
EXAM:
VS: T 97.3, BP 116/42, HR 62, RR 19, sats 100% on AC 450x18,
Fi02 100%, PEEP 5
I/O -1130 since arrival to unit
Gen: Elderly female, sedated and intubated.
HEENT: Sclera anicteric, NCAT. Pupils are small, minimially
reactive to light. ETT in place.
Neck: Supple, JVP ~9cm.
CV: NL S1 S2, RRR, II/VI systolic murmur at LUSB.
Lungs: Coarse, crackles anteriorly and at bases bilaterally. +
wheezes.
Abd: Soft, NTND. + BS throughout. No masses.
Ext: Unable to palpate femoral pulses, DP or PT bilaterally, but
are warm to touch w/o evidence of pitting edema. No c/c. Has
erythematous area on L second toe.
Pertinent Results:
.
ADMISSION LABS
.
[**2150-11-12**] 07:10AM BLOOD WBC-5.5 RBC-4.37# Hgb-12.1# Hct-37.3#
MCV-85 MCH-27.7 MCHC-32.4 RDW-16.8* Plt Ct-314
[**2150-11-11**] 11:00PM BLOOD Plt Ct-290
[**2150-11-12**] 07:10AM BLOOD Glucose-224* UreaN-32* Creat-1.3* Na-140
K-4.0 Cl-98 HCO3-30 AnGap-16
[**2150-11-11**] 11:00PM BLOOD CK(CPK)-22*
[**2150-11-12**] 07:10AM BLOOD Mg-2.5 Cholest-128
[**2150-11-18**] 08:19PM BLOOD %HbA1c-5.7
[**2150-11-12**] 07:10AM BLOOD Triglyc-122 HDL-41 CHOL/HD-3.1 LDLcalc-63
.
.
CARDIAC ENZYMES
[**2150-11-11**] 11:00PM BLOOD CK(CPK)-22*
[**2150-11-15**] 06:26AM BLOOD CK(CPK)-64
[**2150-11-15**] 12:21PM BLOOD CK(CPK)-251*
[**2150-11-15**] 08:58PM BLOOD CK(CPK)-351*
[**2150-11-16**] 10:48AM BLOOD CK(CPK)-563*
[**2150-11-17**] 11:16AM BLOOD CK(CPK)-337*
[**2150-11-18**] 12:10AM BLOOD CK(CPK)-162*
[**2150-11-19**] 03:00PM BLOOD CK(CPK)-48
.
[**2150-11-15**] 01:13AM BLOOD CK-MB-NotDone cTropnT-0.27*
[**2150-11-15**] 06:26AM BLOOD CK-MB-NotDone cTropnT-0.24*
[**2150-11-15**] 12:21PM BLOOD CK-MB-28* MB Indx-11.2* cTropnT-0.62*
[**2150-11-16**] 04:11AM BLOOD CK-MB-42* MB Indx-9.9* cTropnT-1.20*
[**2150-11-16**] 10:48AM BLOOD CK-MB-52* MB Indx-9.2* cTropnT-1.52*
[**2150-11-17**] 11:16AM BLOOD CK-MB-20* MB Indx-5.9 cTropnT-2.64*
[**2150-11-18**] 12:10AM BLOOD CK-MB-10 MB Indx-6.2* cTropnT-2.58*
[**2150-11-19**] 03:00PM BLOOD CK-MB-NotDone cTropnT-3.77*
.
.
LABS BEFORE DEATH
.
[**2150-11-20**] 05:00AM BLOOD WBC-7.1 RBC-3.40* Hgb-9.8* Hct-28.9*
MCV-85 MCH-28.8 MCHC-33.9 RDW-17.7* Plt Ct-388
[**2150-11-20**] 05:00AM BLOOD Neuts-90.2* Lymphs-7.0* Monos-2.3 Eos-0.4
Baso-0
[**2150-11-20**] 05:00AM BLOOD Plt Ct-388
[**2150-11-20**] 05:00AM BLOOD PT-13.8* PTT-32.0 INR(PT)-1.2*
[**2150-11-20**] 05:00PM BLOOD Glucose-132* UreaN-103* Creat-4.1* Na-133
K-3.6 Cl-90* HCO3-28 AnGap-19
[**2150-11-20**] 05:00PM BLOOD Calcium-8.8 Phos-5.4* Mg-2.9*
[**2150-11-20**] 05:00AM BLOOD Calcium-8.5 Phos-5.9* Mg-3.0*
[**2150-11-20**] 05:00AM BLOOD Osmolal-311*
[**2150-11-19**] 04:43PM BLOOD Osmolal-315*
[**2150-11-19**] 04:44PM URINE Hours-RANDOM UreaN-408 Creat-43 Na-34
[**2150-11-19**] 04:44PM URINE Osmolal-347
.
LAST ECG
Cardiology Report ECG Study Date of [**2150-11-21**] 2:01:08 AM
.
Sinus rhythm. Diffuse low voltage. Intraventricular conduction
delay.
Probable prior lateral myocardial infarction. Compared to the
prior
tracing of [**2150-11-20**] the rate has increased. Otherwise, no
diagnostic
interim change.
.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
.
LAST CXR
CHEST (PORTABLE AP) [**2150-11-20**] 7:45 AM
Reason: monitoring pulm edema and L pleural effusion
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with fluid overload, thoracentesis on [**11-18**],
ARF, stent thrombosis, s/p PCI.
REASON FOR THIS EXAMINATION:
monitoring pulm edema and L pleural effusion
REASON FOR EXAMINATION: Fluid overload and pleural effusion
monitoring.
.
Portable AP chest radiograph compared to [**2150-11-19**].
.
There is no significant change in bilateral perihilar haziness
suggesting pulmonary edema. In contrary, there is significant
increase in right pleural effusion. The left pleural effusion
remains unchanged. The bilateral atelectases are noted left more
than right with no significant interval change.
.
IMPRESSION: Interval increase in moderate-to-large right pleural
effusion. Unchanged mild-to-moderate pulmonary edema.
.
.
CARDIAC CATH [**2151-11-17**]
.
BRIEF HISTORY: Patient is a 84 year old woman with CAD, CRI,
DM, PVD
with stenting to LAD 5 days ago for in-stent restenosis in the
setting
of pulmonary edema which is her anginal equivalent. She had two
Taxus
stents 2.5x24 and 2.75x12 overlapping placed into the LAD. She
now
presents again with CHF and had to be briefly intubated. Her
troponin
rose and was thought to initially be demand but when CK rose to
500's
and echo showed anterior wall motion abnormality today, stent
thrombosis
in the LAD became a concern. EKG with LBBB which had been
present
intermittently in past. Patient was taken emergently to cath
lab to
exclude sub-acute stent thrombosis.
.
PTCA COMMENTS: Initial angiography revealed an occlusion of
the mid
LAD at the distal edge of the recently placed Taxus stent
consistent
with stent thrombosis. We planned to treat this lesion with
PTCA and
stenting. Heparin and integrelin were started in addition to
asa and
plavix. A 6F XBLAD guide provided good support for the
procedure. A PT
graphix wire crossed the lesion without difficulty. We Dottered
through
the lesion and re-established flow. A Voyager 2x15mm balloon
was
inflated at 8 atm and the lesion was stented with a 2.5x12 mm
Vision
stent at 18atm. The stent was post-dilated with a Highsail
2.75x8mm
balloon at 26atm. Final angiography revealed no
angiographically
apparent dissection and TIMI 2 flow. Patient left the cath lab
in stable
condition.
.
COMMENTS:
1. Selective coronary angiography of the left system
revealed occlusion of the recently stented LAD. The LMCA, LCX
and their
branches were unchanged from cath 5 days ago. The RCA was not
engaged.
2. Limited hemodynamics revealed systemic blood pressure of
125/49 with
HR of 56.
3. Successful treatment of mid LAD stent thrombosis with Vision
2.5x12mm stent. Final angiography revealed TIMI 2 flow.
.
FINAL DIAGNOSIS:
1. Single vessel CAD with stent thrombosis of the LAD
2. Successful recanalization of LAD and stenting with Vision
bare metal
stent.
.
ATTENDING PHYSICIAN: [**Last Name (LF) **],[**First Name3 (LF) **] M.
REFERRING PHYSICIAN: [**Last Name (LF) 38289**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 275**]
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] M.
[**Last Name (LF) 38290**],[**First Name3 (LF) **] M.
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] A.
.
.
CARDIAC ECHO [**2151-11-17**]
.
This study was compared to the prior study of [**2150-2-24**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
No LV mass/thrombus. Severely depressed LVEF. No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC [**Year (4 digits) **]: Mildly thickened aortic [**Year (4 digits) **] leaflets (3). No AS.
No AR.
MITRAL [**Year (4 digits) **]: Mildly thickened mitral [**Year (4 digits) **] leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
[**Year (4 digits) **] chordae. Calcified tips of papillary muscles. Moderate
(2+) MR.
[**First Name (Titles) 24998**] [**Last Name (Titles) **]: Mildly thickened [**Last Name (Titles) **] [**Last Name (Titles) **] leaflets. Mild
to moderate [[**12-9**]+] TR. Moderate PA systolic hypertension.
PULMONIC [**Month/Day (2) **]/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
.
Conclusions
The left atrium is mildly 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 normal. No masses or thrombi are
seen in the left ventricle. Overall left ventricular systolic
function is severely depressed (LVEF= 25%) with global
hypokinesis and regional akinesis of the mid to distal septum
and apex. There is no ventricular septal defect. Right
ventricular chamber size is normal. There is mild global right
ventricular free wall hypokinesis. The aortic [**Month/Day (2) **] leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral [**Month/Day (2) **] leaflets are
mildly thickened. There is no mitral [**Month/Day (2) **] prolapse. Moderate
(2+) mitral regurgitation is seen. The [**Month/Day (2) **] [**Month/Day (2) **] leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2150-2-24**],
the LVEF is now significantly depressed.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2150-11-16**] 16:06
.
.
CARDIAC CATH [**2151-11-12**]
.
BRIEF HISTORY:
84 year old female with a past medical history of CAD, diabetes,
hypertension, and hypercholesterolemia. Presented [**2150-11-8**] to an
outside
hospital with pulmonary edema which was thought to be her
anginal
equivalent. History of severe PVD (multiple bypass surgeries)
as well
as multiple coronary PCIs.
.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class IV, stable.
.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.65 m2
HEMOGLOBIN: 11.9 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 12/12/8
RIGHT VENTRICLE {s/ed} 53/12
PULMONARY ARTERY {s/d/m} 53/16/31
PULMONARY WEDGE {a/v/m} 18/18/16
LEFT VENTRICLE {s/ed} 138/16
AORTA {s/d/m} 138/40/60
.
PTCA COMMENTS: Initial angiography revealed a 90% mid LAD
ISR and
70% disease just distal to the prior stent. We planned to treat
this
lesion with ptca and stenting. Heparin was started
prophylactically for
the procedure. An xblad guiding catheter provided adequate
support for
the procedure. The lesion was crossed with a prowater wire with
minimal
difficulty. The lesion was dilated with a 2.0x15mm voyager
balloon at 10
atm and then at 12 atm. A 2.5x24mm taxus stent was ythen
deployed in the
distal stenosis at 6 atm., A 2.75x12mm taxus stent was then
deployed
overlapping the proximal edge of the just-placed stent and
within the
previously stented region at 18 atm. The stents were postdilated
with a
2.5x20mm nc [**Male First Name (un) **] balloon at 18 atm, 22 and then at 24 atm
sequentially. Final angiography revealed o% residual stenosis,
no
angiographically apparent dissection and timi 3 flow. The
patient left
the lab free of angina and in stable condition.
.
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated two vessel coronary artery disease. The LMCA had
moderate
diffuse disease, was moderately calcified, and had a distal
taper of
40%. The LAD had a 40% stenosis at its origin. The previously
placed
stent had 90% in-stent restenosis. There was distal LAD had a
90%
stenosis. The LCx was a nondominant vessel without critical
lesions.
There is a mid-segment 40% lesion unchanged from the previous
angiograpm. The RCA was the dominant vessel with a previously
placed
and widely patent stent. The previous 60% stenosis in now 40%.
There
is diffuse PLB disease that was unchanged from previous
angiography.
2. Resting hemodynamics demonstrated normal right sided filling
pressures. The RVEDP wa 12 mmHg. There was pulmonary arterial
hypertension with a pulmonary artery pressure of 53/16/31
(systolic/diastolic/mean in mmHg). LVEDP was 16 mmHg. There
were no
gradients across the [**Male First Name (un) **], pulmonary, mitral, or aortic
valves.
3. Successful PTCA and stenting of the mid LAD with
overlapping 2.5x24mm taxus and 2.75x12mm taxus both post dilated
to
2.5mm. Final angiography revealed o% resiudal stenosis, no
angiographically apparent dissection and timi 3 flow (see ptca
comments).
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
.
ATTENDING PHYSICIAN: [**Last Name (LF) **],[**First Name3 (LF) **] A.
REFERRING PHYSICIAN: [**Last Name (LF) **],[**First Name3 (LF) 1569**] W.
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] T.
[**Last Name (LF) **],[**First Name3 (LF) **] A.
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] A.
.
Brief Hospital Course:
Mrs. [**Known lastname 38291**] was an 84 y/o woman admitted for a CHF
exacerbation, anginal equivalent. She went to cardiac cath on
[**11-11**], was found to have 90% instent restenosis of her LAD and
90% stenosis just distal to the end of the stent. Two
overlapping Taxus stents were placed at this time. Patient
returned to the floor. She was noted to have a creatinine rise
at this time. She developed volume overload and went into flash
pulmonary edema on the floor. She was emergently intubated on
[**2151-11-15**]. She at this time had no urine output to 60mg IV lasix.
She then put out to 120mg IV lasix and diuril. Patient was noted
to have a new LBBB at this time. Pt was noted to have an enzyme
leak at this time, but her troponins were flat for the next day.
The following day [**11-15**] she was extubated. She at that time
developed shortness of breath and her enzymes trended up. She
was taken back to the cardiac cath lab where she was noted to
have an sub-acute thrombosus of at the distal margin of her
recently placed LAD taxus stent. PTCA was done and a bare metal
stent was placed. A repeat transthoracic echo was showed a LVEF
of 25%, with global hypokinesis, a change from patients [**2-11**]
echo.
.
At this time patient was noted to be in fluid overload. She had
a left sided pleural effusion and an increasing oxygen
requirement. On [**11-18**] a thoracentesis was done to help reduce
oxygen requirement.
.
Patient had received two dye loads in one week. She at this time
was making urine, but not putting out substantially to her
lasix. A lasix drip was started. At this time the patient
developed acute renal failure. Her Cr had climbed from 2.0 (1.3
on admit) to Cr 4.0. Patient was not responding well to diuril
or lasix. The renal service was consulted to evaluate for CVVH.
CVVH was considered and on the day prior to death, it was felt
that clinically the patient could wait another day before
starting dialysis.
.
Around this time metoprolol was stopped as patient was
considered to be in an acute systolic CHF exacerbation. She was
also started on Milrinone to help forward flow, in the hopes
that it would aide in kidney perfusion and lead to better
diuresis.
.
In the early morning of [**11-21**]. Patient reported sudden onset of
shortness of breath. An ECG was done which showed no change from
prior. Patients vitals were stable. She was slightly
tachycardic, but normotensive. Patients oxygen requirements had
not changed and on physical exam her lungs sounded clearer than
earlier in the day. She was given IV morphine, started on a
nitro drip and her milrinone was discontinued. Patients
shortness of breath was relieved by this regimen.
.
Starting 4 hours prior to this the patient stopped making urine.
She was not responding to lasix at this time. The patient's
vitals were at this time stable. Normal heart rate,
normotensive, normal RR, above 90% oxygen saturations. She was
breathing with out distress and denied any more sensation of
chest pain or dyspnea. The team felt that there was no need to
consult for urgent dialysis. Renal had evaluated the patient
only 7 hours prior and felt CVVH was not needed. Plans were in
place for renal to reevaluate for CVVH first thing in the
morning.
.
At 3AM, the housestaff was notified by nursing that the patient
had passed away. There was no change in vitals or further
complaints by patient prior to passing. Telemetry showed the
patient went from normal sinus rhythm straight into asystole.
The patient had been made DNR/DNI two days prior to this
episode, so no code was called.
.
The attending physician and next of [**Doctor First Name **] were notified. PCP was
later notified. Patient's daughter who was the healthcare proxy
was offered and refused an autopsy. The primary cause of death
was considered to be coronary artery disease. The immediate
cause was unknown as there was no post-mortem. It was
hypothesized that the cause of death was from a very sudden
etiology such as acute thrombosus of her LAD, pulmonary embolism
or another condition leading to a possible PEA cardiopulmonary
arrest. This is however only speculation. Pt was never witnessed
to be in PEA.
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8952**] MD
Medications on Admission:
lasix 60mg [**Hospital1 **]
amiodarone 200mg daily
atenolol 50mg daily
plavix 75mg daily
imdur 60mg daily
folate 1mg daily
simvastatin 40mg daily
hydralazine 25mg qid
iron sulfate 325 mg [**Hospital1 **]
calcium/vit D
alendronate 70mg q wed
ASA 325 mg daily
NPH insulin 21 Units qam 14u in hs and RISS
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Cardiopulmonary Arrest
Primary Cause of death was coronary artery disease, over years.
Discharge Condition:
Expired
Discharge Instructions:
No instructions. Pt expired.
Followup Instructions:
No follow up patient expired from unknown etiology. Post-mortem
analysis was refused by patient's next of [**Doctor First Name **].
|
[
"51881",
"5849",
"41071",
"5990",
"41401",
"4280",
"2720",
"V4582"
] |
Admission Date: [**2125-2-17**] Discharge Date: [**2125-2-23**]
Date of Birth: [**2063-5-20**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
RUQ pain, nausea, vomiting
Major Surgical or Invasive Procedure:
1. ERCP
2. esophagogastroduodenoscopy
3. colonoscopy
History of Present Illness:
Briefly, patient is a 61F with Hx Anemia, HTN who presented to
the ED with RUQ pain, nausea, and vomiting with background of
dyspnea, fatigue. RUQ U/S showed choledocholithiasis with
biliary obstruction and acute cholecystitis. Given 5L NS,
started on Levo/Flagyl. Hct 15. admitted to [**Hospital Unit Name 153**] for monitoring.
Transfused PRBCs for goal Hct > 25. Had ERCP on [**2125-2-18**] with
biliary stent placement; unable to do stone extraction or
sphincerotomy because of sedation issues. Evaluated by surgical
attending on [**2125-2-19**], patient looking great, recommended elective
CCY after heme work-up, colonoscopy, and repeat ERCP for
sphincterotomy.
.
On transfer to floor from [**Hospital Unit Name 153**], patient doing well. Without
abdominal pain, urinary complaints, difficulty breathing,
palpitations, nausea, or vomiting. Eager to return home.
Tolerating POs well, passing flatus. Denied hx of BRBPR, did
report occasional black stools after taking iron pills.
Past Medical History:
HTN
Anemia
Migraines
MVC with RLE fracture s/p surgery
Social History:
Remote rare tobacco use. No ETOH, no IVDA. Has 4 sons 1
daughter, housewife, lives with son
Family History:
No family history of gastrointestinal cancer
Physical Exam:
VS: T Afebrile HR 98 BP 106/52 RR 18 O2 97% RA
GEN: NAD, obese, comfortable
HEENT: MMM. OP clear. No erythema or exudate. EOMI.
Neck: JVP flat, supple
HEART: S1S@ RRR. No MRG
LUNGS: crackles [**1-19**] way up B/L, good air entry
ABD: obese, soft, NT/ND. +BS
EXT: 2+ DPS. RLE chronic swelling, surgical scar. Warm,
well-perfused.
Pertinent Results:
[**2125-2-17**] 10:01PM URINE HOURS-RANDOM TOT PROT-119
[**2125-2-17**] 07:45PM CK(CPK)-24*
[**2125-2-17**] 07:45PM CK-MB-2 cTropnT-<0.01
[**2125-2-17**] 07:45PM HAPTOGLOB-194
[**2125-2-17**] 07:45PM RET MAN-5.9*
[**2125-2-17**] 03:22PM HGB-6.2* calcHCT-19
[**2125-2-17**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-12* PH-5.0
LEUK-NEG
[**2125-2-17**] 02:22AM LACTATE-2.6*
[**2125-2-17**] 12:20AM LIPASE-22
[**2125-2-17**] 12:20AM PLT COUNT-350
[**2125-2-17**] 12:20AM PT-12.2 PTT-19.1* INR(PT)-1.1
.
([**2125-2-17**]) CXR Portable AP: Compared to the prior study, there
has been no significant change in the moderate cardiomegaly.
There is hazy bilateral pulmonary vasculature suggesting fluid
overload/CHF. Retrocardiac opacity suggestive of a hiatal hernia
is again seen. There is no focal infiltrate
.
([**2125-2-17**]) Gallbladder U/S: 1. Choledocholithiasis causing
biliary obstruction. 2. Cholelithiasis with gallbladder wall
edema and nonmobile stones at neck, likely representing acute
cholecystitis.
.
([**2125-2-17**]) ECG: Sinus tachycardia. Left bundle-branch block. No
previous tracing available for comparison.
.
([**2125-2-18**]) ERCP: IMPRESSION: Two filling defects within the
common bile duct, consistent with CBD stones, associated with
CBD and hepatic duct dilatation
.
([**2125-2-19**]) ECHO: 1. The left atrium is mildly dilated. 2. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is difficult to assess but is probably
somewhere between
normal to mildly depressed. No specific wall motion abnormality
could be
determined. 3. The aortic valve leaflets (3) are mildly
thickened. Trace aortic regurgitation is seen. 4. The mitral
valve leaflets are mildly thickened. Mild to moderatel ([**12-18**]+)
mitral regurgitation is seen, which was dificult to quantify. 5.
There is moderate pulmonary artery systolic hypertension.
.
([**2125-2-21**]) Colonoscopy: Polyp in the transverse colon Otherwise
normal colonoscopy to cecum
.
([**2125-2-21**]) EGD: Erythema and erosion in the antrum and stomach
body compatible with gastritis; Large hiatal hernia; A localized
erosion was noted within the hiatal hernia sac, possibly a
[**Location (un) 25056**] erosion.
Otherwise normal egd to second part of the duodenum
.
([**2125-2-21**]): UGI Series with SBFT: UPPER GI: There is a large
paraesophageal hernia which persisted throughout the
examination. Gastroesophageal reflux was observed during the
exam. The gastric mucosa is unremarkable although evaluation was
slightly limited due to limited patient mobility. No ulcers,
filling defects, or abnormalities and peristalsis were
identified. The duodenal bulb and duodenal sweep are
unremarkable. A plastic biliary stent is identified. SMALL BOWEL
EXAM: Contrast passed freely through the small bowel into the
colon within 90 minutes. The small bowel is normal in caliber,
contour, and mucosal pattern. No filling defects or strictures
are identified.
IMPRESSION:
1. Large paraesophageal hernia which persisted throughout the
examination.
2. Normal small bowel exam.
.
([**2125-2-22**]): P-MIBI: IMPRESSION: 1. Normal myocardial perfusion.
2. The ventricular ejection fraction is 47%.
Brief Hospital Course:
Patient is a 61 year-old female with HTN, Anemia who was
transferred from the [**Hospital Unit Name 153**] with cholangitis and anemia,
clinically doing well. The following issues were addressed
during her hospital stay:
.
# CHOLANGITIS
Patient underwent ERCP with successful placement of Cotton [**Doctor Last Name **]
biliary stent, and bile was seen draining into the duodenum. Due
to difficulties with sedation, sphincterotomy was not performed.
Patient to return for repeat ERCP in [**1-19**] weeks time for
sphincterotomy and stone extraction. Surgery team evaluated
patient post-ERCP for cholecystectomy; given overall good
clinical appearance, elective cholecystectomy was recommended
once acute issues resolved. Abdominal exam was subsequently
benign. Patient was started on 14 days Levofloxacin/Flagyl for
empiric gut flora coverage. For pre-operative risk assessment,
ECHO and p-MIBI were performed, revealing no significant
valvular abnormalities; EF was preserved, and resting/stress
myocardial perfusion was normal -- given these findings, patient
at low risk for perioperative cardiac events, and she was
already on a beta-blocker as part of her anti-hypertensive
regimen. Outpatient appointment with Dr. [**Last Name (STitle) **] was arranged.
.
# ANEMIA
Patient presented with Hct of 15 in setting of cholangitis and
guiaic positive stool. Iron studies consistent with iron
deficiency anemia. Hemolysis labs were negative. SPEP/UPEP
negative. EGD/Colonoscopy were performed to evaluate for source
of bleed. Colonoscopy showed small polyp which was resected,
otherwise normal. EGD showed findings consistent with gastritis,
as well has large hiatal hernia with localized erosion within
hernia sac ([**Location (un) 25056**] ulcer). Anemia was attributed to iron
deficiency anemia in setting of gastritis/erosions, and oral
iron/folate supplementation was initiated, as was PPI.
.
# HIATAL HERNIA
Hiatal hernia was seen on endoscopy, and UGI series with SBFT
was advised for further evaluation. UGI series with SBFT
confirmed that hernia was paraesophageal, necessitating surgical
intervention. Surgery team was contact[**Name (NI) **] and esophageal
manometry studies were recommended prior to intervention - these
were set-up as outpatient. We were hopeful that surgery could be
performed at same time as cholecystectomy; patient to follow-up
with Dr. [**Last Name (STitle) **].
.
# LBBB
On presentation, patient's EKG with LBBB, no old for comparison.
Patient was ruled out for ACS with negative serial enzymes.
Aspirin was held on admission in setting of Hct 15 and guiaic
positive stool. p-MIBI was normal.
.
# MIGRAINES
Not active currently, on Fioricet at home.
.
# HTN
Managed with Lisinopril and Metoprolol, added after bleeding
issues resolved
.
# PPx
SC Heparin
Medications on Admission:
lopressor
loratidine
butalbital
MVI
Fe
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Folic Acid 1 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 twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Capsule Sig: One
(1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for
migraines.
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Cholangitis.
2. Choledocholithiasis.
3. Blood Loss Anemia.
4. Diastolic Heart Failure.
5. Gastritis.
6. Paraesophageal Hernia.
6. Left Bundle Branch Block.
Discharge Condition:
stable, tolerating po, no abdominal pain
Discharge Instructions:
1. Please take all of your medications and keep all of your
appointments.
.
2. If you notice blood in your stool, experience dizziness or
weakness, or get worsening abdominal pain, please call your
primary care doctor or report to the emergency room.
Followup Instructions:
You have an appointment for an esophageal motility study to
measure your esophageal pressures as part of the work-up for the
hernia that was seen on the endoscopy here. This appointment is
on [**3-7**] at 11AM at 133 Gryzymsh, [**Hospital Ward Name 516**] of [**Hospital3 **].
Please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 63548**] if you need to change
the time.
.
You have an appointment with Dr. [**Last Name (STitle) 57300**] of surgery on [**3-26**] @ 2PM, [**Hospital Unit Name **], [**Hospital Unit Name 63549**]. It is VERY important that you make this appointment.
.
Your follow-up to your ERCP is scheduled on the [**Hospital Ward Name 516**] with
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2125-3-20**] 4:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2125-3-20**] 4:00
.
Test for consideration post-discharge: anti-Tissue
Transglutaminase Antibody, IgA
Completed by:[**2125-4-30**]
|
[
"4280",
"4019"
] |
Admission Date: [**2134-1-9**] Discharge Date: [**2134-1-10**]
Date of Birth: Sex: F
Service: ICU
HISTORY OF PRESENT ILLNESS: This is a 57 year old female
with a history of schizophrenia, atrial fibrillation, deep
vein thrombosis, on Coumadin, anemia with baseline hematocrit
of 32.0, and prior hospitalizations for upper
gastrointestinal bleed, most recently in [**2132-11-21**], and
then again in [**2133-2-21**].
She has refused workup in the past including
esophagogastroduodenoscopy and colonoscopy.
She was in her usual state of health until 9:00 p.m. on the
day prior to admission when she was noted by the nursing home
staff to have large dark tarry stool with heavy smell. Vital
signs were temperature 98.3, pulse 118, blood pressure
113/95, respiratory rate 22, oxygen saturation 92% in room
air. She was then transferred to the Emergency Department at
[**Hospital1 69**] where her vital signs
were heart rate 120, blood pressure 110/76. She was passing
copious large tarry loose stools. [**Name8 (MD) **] RN note, it was guaiac
positive. She refused nasogastric tube, fresh frozen plasma
and much of examination. She was given intravenous Protonix
and intravenous fluids with subsequent resolution of her
tachycardia and was transferred to the [**Hospital Ward Name 332**] Intensive Care
Unit for further monitoring. She currently complains of
diarrhea, but denies fever, chills, nausea, vomiting or
abdominal pain.
PAST MEDICAL HISTORY:
1. Schizophrenia/schizo-affective disorder.
2. Atrial fibrillation.
3. Hypertension.
4. Hypothyroidism.
5. Hyponatremia.
6. Cholelithiasis, reportedly refused surgery.
7. Wheelchair bound secondary to delusional belief of
paraplegia per the online [**Medical Record Number 29759**]. Baseline hematocrit 30.0 to 32.0.
9. Sacral decubitus, status post gluteal flap in [**2130-5-22**].
10. Chronic indwelling Foley secondary to urinary retention
and fecal and urinary incontinence.
11. History of Methicillin resistant Staphylococcus aureus
urinary tract infection and VRE in skin swabs.
12. History of upper gastrointestinal bleed with coffee
ground emesis without further workup.
ALLERGIES: She is allergic to Penicillin and Macrobid.
SOCIAL HISTORY: She is a resident of [**Hospital **] Nursing Home
for twelve years. Telephone [**Telephone/Fax (1) 29760**]. Her outpatient
psychiatrist is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 29761**] at [**Hospital1 **] Senior Care, 1 [**Telephone/Fax (1) 29762**]. Guardian is [**Name (NI) 1787**] [**Name (NI) 29763**], telephone [**Telephone/Fax (1) 29764**].
Distant tobacco, no alcohol and no illicit drugs. She is
DNR/DNI.
MEDICATIONS ON ADMISSION:
1. Lactulose 30 once daily.
2. Multivitamin.
3. Nifedipine 30 mg once daily.
4. Levoxyl 75 mcg once daily.
5. Docusate.
6. Niferex.
7. Tylenol.
8. Chocolate Chip Cookie once daily.
9. Remeron 15 mg q.h.s.
10. Acetaminophen p.r.n.
11. Milk of Magnesia.
12. Dulcolax and Fleets.
13. Ativan 0.5 mg q8hours p.r.n.
14. Coumadin 3 mg once daily.
15. Clozapine 50 mg q.a.m. and 200 mg q.p.m.
PHYSICAL EXAMINATION: Temperature is 97.9, blood pressure
140/104, heart rate 85 to 94, respiratory rate 14, oxygen
saturation 98% in room air. She was thin, in no acute
distress. Her sclera were anicteric. Mucous membranes were
dry. Neck was supple without lymphadenopathy. The heart was
tachycardic with normal S1 and S2. The lungs were clear.
The abdomen was soft, nontender, nondistended. Extremities
were without edema. Rectal - copious dark tarry stool, foul
smelling, guaiac negative by physician [**Name Initial (PRE) 29765**].
Neurologically, alert and oriented times three.
LABORATORY DATA: Her electrocardiogram showed sinus
tachycardia at 107 to 109 beats per minute, normal axis and
normal intervals, inferolateral downsloping ST depression in
leads II, III, aVF, V3 through V6 which has been present on a
previous electrocardiograms but not on others.
HOSPITAL COURSE: She was admitted to the [**Hospital Ward Name 332**] Intensive
Care Unit for following of her potential gastrointestinal
bleed.
Serial hematocrit was cycled and hematocrit was found to be
31.9, 32.3, 30.0 and 31.0. She had initially been
hemoconcentrated in the Emergency Department with a
presenting hematocrit of 40.0. She was seen by
gastroenterology consultation service who felt that her
hematocrit was stable at baseline, given her guaiac
positivity in the Emergency Department and age greater than
50, she needs follow-up colonoscopy and
esophagogastroduodenoscopy as an outpatient. The patient was
last with a stable hematocrit.
2. Anticoagulation - Coumadin was held during this
hospitalization and can be restarted on [**2134-1-11**].
3. Electrocardiographic changes - Initial cardiac enzymes
were checked and were negative and the electrocardiogram was
felt to be consistent with her old electrocardiograms and
further cardiac workup not pursued. The patient was in sinus
rhythm during this admission.
4. Mental health - Her current medications were continued.
5. Code - She remained DNR/DNI.
DISCHARGE DIAGNOSES:
1. Schizophrenia.
2. Atrial fibrillation.
3. Question melena.
4. Hypothyroidism.
MEDICATIONS ON DISCHARGE:
1. Pantoprazole 40 mg once daily.
2. Clozapine 50 mg q.a.m. and 200 mg q.p.m.
3. Mirtazapine 15 mg q.h.s.
4. Levothyroxine 75 mg once daily.
5. Digoxin 0.25 mg once daily.
6. Adalat DC 30 mg once daily.
7. Chocolate Chip Cookie once daily.
8. Multivitamin once daily.
9. Ativan 0.5 mg q8hours p.r.n.
10. P.r.n. Milk of Magnesia, Dulcolax and Fleets.
11. Lactulose should be held for now.
Dictated By:[**Last Name (NamePattern1) 2396**]
MEDQUIST36
D: [**2134-1-10**] 10:48
T: [**2134-1-10**] 15:02
JOB#: [**Job Number 29766**]
|
[
"42731",
"2859",
"4019",
"2449"
] |
Admission Date: [**2179-6-18**] Discharge Date: [**2179-6-27**]
Date of Birth: [**2179-6-18**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**First Name4 (NamePattern1) **] [**Known lastname 32145**] is a former 4.63
kilogram product of a 40 [**7-16**] week gestation pregnancy born to
a 30 year-old gravida I, para 0 woman. Prenatal maternal
history significant for [**Doctor Last Name 933**] disease treated with thyroid
replacement therapy. She also asymptomatic asthma not
positive, antibody negative, RPR nonreactive, rubella
immune, hepatitis B surface antigen negative, beta strep
negative. Estimated date of confinement was [**2179-6-18**] by
last menstrual period. Gestational age 40 6/7 weeks. She
had a benign antepartum history. There was 41 hours of
ruptured membranes prior to delivery with meconium stained
fluid, maternal fever to 101 degrees Fahrenheit. A cesarean
anesthesia. The infant was vigorous at delivery. Baby
received bulb suctioning and tactile stim only. Apgars 9 at one
minute and 9 at five minutes. She was admitted to the
newborn nursery. Her initial glucose by heel stick was 39
and normalized with feeding. She was noted to have a left
dislocated hip on initial examination. She breast fed well
according to nursing record and was stooling normally. Her
temperature was stable. On day of life number four she was
positioned in an infant swing, was noted to have a color
change and was admitted to the neonatal Intensive Care Unit
for admission. Upon admission to the Neonatal Intensive Care
Unit she was noted to have three further episodes of cyanosis
within one hour with desaturations of 60 to 70 percent and
periodic breathing.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit: Weight 4.18 kilograms, birth weight
4.63 kilograms, head circumference 37 cm. General:
nondysmorphic term female in no acute distress. Head, eyes,
ears, nose and throat: anterior fontanelle soft and flat,
normal facies, palate intact. Neck without masses, no nasal
flaring, positive red reflex bilaterally. Chest: no
grunting, no retraction, good bowel sounds bilaterally.
Cardiovascular: well perfused, regular rate and rhythm, S1,
S2 normal, no murmur. Abdomen soft, nontender, no
organomegaly, no masses. Bowel sounds active. Patent anus.
Genitourinary: normal female. Neurologic: active, alert,
responsive to stimuli, normal tone, moving all limbs
symmetrically, positive suck, root, grasp and [**Last Name (un) **] reflexes.
Skin pink without rashes. Musculoskeletal: dislocatable
left hip, normal spine, limbs, clavicles.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
Respiratory. Oxygen saturations were 98 percent
on room air. After six hours of the initiation of antibiotic
therapy the apnea and oxygen desaturations resolved. Since
day of life five she has remained on room air without any
episodes of desaturation or apnea.
Cardiovascular: Due to the unknown etiology of
the cyanotic episodes a screening cardiac evaluation was
done. An electrocardiogram and chest x-ray were both within
normal limits. She passed a hyperoxia test. She has
maintained normal heart rate and blood pressures during
admission, no murmurs have been noted during admission.
Fluids, electrolytes and nutrition. [**Doctor First Name **]
has breast fed well during admission. Weight at the time of
discharge is 4.7 kilograms.
Infectious disease. Due to the unknown etiology
of the cyanotic episode [**Doctor First Name **] was evaluated for sepsis.
The white blood cell count as 13,400 with a differential of
46% poly, 0% bands, platelets of 333,000. A blood culture
and lumbar puncture were obtained prior to the initiation of
the ampicillin and gentamicin. Cerebrospinal fluid
results showed 11,500 red blood cells and 7 white blood cells
per high power field. Protein 65, glucose 55. Gram stain
showed no organisms or polymorphonuclear cells. The blood
culture grew 16 hours gram positive cocci in pairs and
chains. This was later identified as a gamma strep. The
infectious disease team from [**Hospital3 28900**] was consulted
and they recommend at 10 to14 day course of ampicillin. The
gentamicin was continued for five days for synergism.
gentamicin levels were 0.6 trough and 12.2 peak.
Hematological. Hematocrit on day of life four
was 52.4 percent. She did not require any transfusion of
blood products.
Gastrointestinal. A serum bilirubin was obtained
on day of life number four and was a total of 11.5/0.4
direct.
Musculoskeletal. [**Doctor First Name **] was evaluated by
orthopedics surgical team from [**Hospital3 28900**]. She was
placed in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 41576**] harness for treatment of her left
developmental dysplasia. She is to follow up with the
orthopedic team from [**Hospital3 28900**] within seven to ten
days after being placed in the harness.
Sensory. Hearing screen was performed with
automated auditory brain stem responses. [**Doctor First Name **] passed in
both ears.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Transferred to [**Hospital3 **]
for continuing care. The primary pediatrician is Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], [**Location (un) 41577**], [**Location 9583**], [**Numeric Identifier 41578**], phone number [**Telephone/Fax (1) 41579**], fax number [**Telephone/Fax (1) 41580**].
Dr. [**Last Name (STitle) **] has seen [**Doctor First Name **] during her admission at the [**Hospital1 **].
CARE RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding ad lib breast feeding.
2. Medications: Ampicillin 475 mg intravenous q eight
hours for a total of 10 day course which was
initiated on [**2179-6-22**].
3. State Newborn Screen was sent on day of life number
three with no indication of abnormal results to date.
4. Hepatitis B vaccine administered.
5. Immunizations recommended:
Synagis RSV prophylaxis should be considered from
[**Month (only) 359**] through [**Month (only) 547**] for infants who meet the
following three criteria - first born at less than 32
weeks, second born between 32 and 35 weeks with plans
for day care during RSV season, with a smoker in the
household or with preschool siblings or third, with
chronic lung disease.
Influenza immunization should be considered annually
in the fall for preterm infants with chronic lung
disease once they reach six months of age. Before
this age the family and other caregivers should be
considered for immunization against influenza to
protect the infant.
FOLLOW UP APPOINTMENTS: Orthopedic surgery at [**Hospital3 41581**] within seven to ten days after placement in the
[**Last Name (un) 41576**] Harness.
DISCHARGE DIAGNOSES:
1. Term female.
2. Gamma streptococcus bacteremia.
3. Apnea.
4. Developmental dysplasia of the left hip.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 41582**]
MEDQUIST36
D: [**2179-6-27**] 07:35
T: [**2179-6-27**] 06:56
JOB#: [**Job Number 41583**]
|
[
"V053"
] |
Admission Date: [**2163-5-3**] Discharge Date: [**2163-5-4**]
Date of Birth: [**2105-10-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Lightheadedness.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 57F with DM2, hyperlipidemia, HTN who after getting
out of the shower, felt lightheaded, sat down, felt her heart
slow down. This feeling lasted for approximately 5 minutes and
resolved when she sat down. She then felt completely normal. She
denies any associated chest pain, shortness of breath,
palpitations, nausea, vomiting, seizure activity, bowel/bladder
incontinence. Patient was brought to the ED and was found to
have a HR of 40's, was given Atropine, transient Dopamine gtt,
and then placed on a Glucagon gtt.
Patient reports that she takes medication for HTN (listed as
lisinopril & norvasc) and thyroid disease, although reports
taking them diligently. She reports having these symptoms in the
past, but not as intense as this.
Of note, she reports that finger sticks usually run between
107-149, without episodes of symptomatic hypoglycemia.
She denies any PND or orthopnea.
Past Medical History:
1. Diabetes mellitus, type II
2. Dyslipidemia
3. Hypertension
4. Hypothyroidism
Social History:
Significant for the absence of current tobacco use. There is no
history of alcohol abuse. There is no family history of
premature coronary artery disease or sudden death.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - T:97.9 HR:66 BP:126/82 RR:17 O2sat:100% 3L NC
Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 3 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMIT LABS: [**2163-5-3**]
CBC:
WBC-14.0*# RBC-4.61 Hgb-11.9* Hct-36.4 MCV-79* MCH-25.9*
MCHC-32.7 RDW-16.0* Plt Ct-332
Neuts-48.0* Lymphs-44.2* Monos-4.9 Eos-1.2 Baso-1.8
COAGS:
PT-12.1 PTT-23.6 INR(PT)-1.0
CHEMISTRIES:
Glucose-163* UreaN-14 Creat-0.9 Na-134 K-4.5 Cl-100 HCO3-22
AnGap-17
Calcium-9.1 Mg-2.0
CARDIAC ENZYMES:
[**2163-5-3**] 11:55AM BLOOD CK(CPK)-58 cTropnT-<0.01
[**2163-5-3**] 05:00PM BLOOD CK(CPK)-46 cTropnT-<0.01
MISC:
%HbA1c-7.7*
HDL-49 CHOL/HD-3.0 LDLmeas-84
TSH-1.5
Free T4-1.2
Digoxin-<0.2*
TOX:
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
CXR ([**2163-5-4**]):
No active disease.
Brief Hospital Course:
1. Presyncope:
The etiology of this was unclear. The differential included
vaso-vagal syncope, sick-sinus syndrome with symptomatic
bradycardia. EP evaluated the patient and felt that the former
was more likely. Her EKG showed a rate in the 40s with a
possible junctional rhythm. She was given atropine, transient
dopamine gtt and was then placed on a glucagon gtt. She was
admitted and monitored in the CCU. She remained asymptomatic.
She was monitored on telemetry and an ECHO was obtained showing
a normal EF and Grade I (mild) LV diastolic dysfunction. In
addition, she was ruled out for MI.
At the time of discharge, the patient was feeling well and was
without any lightheadedness. Plan was for follow-up with a new
cardiogist (Dr. [**Last Name (STitle) 171**].
2. Hyperlipidemia:
Lipid panel showed and LDL of 84 with an HDL of 49. Her
atorvastatin was continued at her home dose.
3. Diabetes mellitus:
A1c checked and 7.7. She presented on metformin, which was held
during her stay with use of a HISS.
4. Hypothyroidism:
TSH and fT4 were within normal lipids; Levothyroxine 50 mcg was
continued.
5. Anemia:
Microcytic (MCV 78). Previously had a normal hct and MCV,
although has been intermittantly anemic in the past with one
period of low MCV in [**2156**]. Iron studies were obtained and
showed an iron and ferritin at the lower limits of normal (34
and 14 respectively) with a normal TIBC.
Medications on Admission:
Atenolol 100 qd
ACETAMINOPHEN 500MG tid
ATORVASTATIN 20MG qd
FLEXERIL 10 mg qhs prn
GLUCOPHAGE 1000MG [**Hospital1 **]
LEVOTHYROXINE SODIUM 50MCG qd
Citalopram 20 qd
PERCOCET 5-325 mg--[**1-25**] tablet(s) prn
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
9. Flexeril 10 mg Tablet Sig: One (1) Tablet PO QHS PRN.
10. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Vaso-vagal syncope
Secondary:
1. Diabetes mellitus, type II
2. Hyperlipidemia
3. Hypertension
4. Hypothyroidism
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted after feeling lightheaded. We have made
changes to your medication regimen, which will be outlined
below. If you experience any repeat of your symptoms, have
chest pains, shortness of breath or have any other
question/concerns, please be sure to call your primary care
doctor or go to an emergency room.
You should hear from your new cardiologist (Dr. [**Last Name (STitle) 171**]
regarding a new patient appointment.
In addition, you should be sure to follow-up with your primary
care physician.
You should obstain from driving for the ONE MONTH.
Please note the following medication changes
DOSE CHANGE:
1. ATENOLOL - This medication dose was decreased from 100mg
daily to 25mg daily.
STOPPED:
1. NORVASC (amlodipine) - This medication has been STOPPED.
STARTED:
1. HCTZ (hydrochlorothiazide) - This medication has been
STARTED. It should be taken once a day and is for blood
pressure control.
2. LISINOPRIL - This medication has been STARTED. It is also
for blood pressure control and is to be taken once a day.
3. ASPIRIN - You should take one baby [**Name (NI) 27471**] (81mg) daily.
This can be purchased over the counter.
Followup Instructions:
1. Dr. [**Last Name (STitle) 171**] (Cardiology) - You will be contact[**Name (NI) **] by Dr. [**Name (NI) 27472**] office to schedule a new patient appointment.
2. Dr. [**Last Name (STitle) 4569**] (Primary Care) - [**2163-5-10**] at 6:15pm
Phone:[**Telephone/Fax (1) 7538**]
3. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**] - [**2163-7-13**] 2:55
|
[
"42789",
"4019",
"25000",
"2449"
] |
Admission Date: [**2194-6-18**] Discharge Date: [**2194-6-20**]
Date of Birth: [**2194-6-18**] Sex: F
Service: NB
HISTORY: This infant was born at 35 weeks gestation and
admitted to the NICU for prematurity.
MATERNAL HISTORY: Mom is a 42-year-old, G 3, P 2 now 3 woman
with a past OB history notable for a 33 week male SVD born in
[**2189**], alive and well, a 33 week female SVD born in [**2191**], also
alive and well. Past medical history was notable for
ulcerative colitis treated with prednisone and DVT. She is on
heparin.
PRENATAL SCREENS: Blood type O+, DAT negative, HBsAg
negative, RPR nonreactive, Rubella immune, GBS unknown.
ANTENATAL HISTORY: The EDC was [**2194-7-23**]. Estimated
gestational age of 35 weeks at delivery. The pregnancy was
complicated by placenta previa and preterm labor which was
treated with nifedipine. A course of betamethasone was
completed on [**2194-6-5**]. Note this was an elective C-
section under epidural and spinal anesthesia. There was no
intrapartum fever or other clinical evidence of
chorioamnionitis. Intrapartum antibiotics were not
administered. Rupture of membranes occurred at delivery and
yielded clear amniotic fluid.
NEONATAL COURSE: The infant was vigorous at delivery. She
was dried, bulb suctioned and did well in room air. Apgars
were 9 and 9 at one and five minutes. On admission birth
weight was 2685 grams, which is 75th to 90th percentile.
Length of 47 cm, which is 50% to 75% percentile. Head
circumference of 34 cm, which is 75th to 90th percentile.
Physical exam shows anterior fontanelles soft and flat. HEENT
shows bilateral red reflexes. Nondysmorphic. Intact palate.
Neck and mouth normal. Normocephalic. No nasal flaring.
Chest: No retractions. Good breath sounds bilaterally. CVS:
Well perfused, pink. Normal rate and rhythm. Femoral pulses
normal. Normal S1, S2. Grade 2/6 systolic ejection murmur at
left sternal border, with radiation throughout chest. Abdomen
soft, nondistended. No organomegaly. No masses. Active bowel
sounds. Patent anus. A 3 vessel cord was noted at delivery.
GU: Normal female genitalia. CNS: Active, alert, responds to
stim, normal tone. Skin normal. Musculoskeletal: Normal
spine, limbs, hips and clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: The infant has remained in room air since birth.
She has not demonstrated any evidence for an immature
breathing pattern or apnea of prematurity.
Cardiovascular: The infant had a murmur noted on admission to
the NICU, however, the murmur was not present at the time of
transfer to the Newborn nursery. She has been
hemodynamically stable, with a normal blood pressure and
heart rate.
Fluids, electrolytes and nutrition: The infant was started on
enteral feedings on the newborn day and is ad lib p.o. feeding
breast milk or E20 with iron. The weight at 1 day of life was
down 165 grams to 2520 grams.
Hematology: No hematocrits or platelets have been measured.
Blood typing has not been necessary.
Infectious disease: There have been no issues concerning
infectious disease.
Neurology: The infant has maintained a normal neurologic exam
for gestation age.
Thermoregulation: The infant had some temperature instability
requiring a prolonged NICU stay beyond the initial 24 hours
after delivery. However, she has now demonstrated the ability
to maintain her temperature in an open crib.
Sensory: Audiology: A hearing screen was not performed yet and
is recommneded prior to discharge from the nursery.
Psychosocial: There are no active psychosocial issues at this
time. If there are any concerns, the [**Hospital1 18**] social worker can
be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to newborn nursery.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58818**], telephone
number [**Telephone/Fax (1) 48284**].
CARE RECOMMENDATIONS:
FEEDINGS: Ad lib p.o. feeding of breast milk of E20 with iron
or breast feeding.
MEDICATIONS: None.
IRON AND VITAMIN D SUPPLEMENTATION:
1. Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age.
2. All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 international units (may
be provided as multi vitamin preparation) daily until 12
months corrected age.
CAR SEAT POSITION SCREENING: Has not been performed to date
and is recommended prior to discharge to home.
STATE NEWBORN SCREEN: Has not been performed to date and is
recommended prior to discharge to home.
IMMUNIZATIONS RECEIVED: Has not yet receved any
immunizations.
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria.
a. Born less than 32 weeks gestation;
b. Both between 32 and 35 weeks gestation, with 2 of the
following: Either day care during RSV season, a smoker
in the household, neuromuscular disease, airway
abnormalities, or school age siblings;
c. Chromic lung disease;
d. Hemodynamically significant congenital heart defect.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age, and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
3. This infant has not received the Rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following discharge
from the hospital if they are clinically stable and at
least 6 weeks, but fewer than 12 weeks of age.
A follow-up appointment is recommended with the pediatrician
after discharge from the hospital.
DISCHARGE DIAGNOSES:
1. Late preterm infant.
2. Thermal instability.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 69916**]
MEDQUIST36
D: [**2194-6-20**] 01:00:18
T: [**2194-6-20**] 06:41:49
Job#: [**Job Number 73715**]
|
[
"V053"
] |
Admission Date: [**2165-1-15**] Discharge Date: [**2165-1-22**]
Date of Birth: [**2100-11-15**] Sex: M
Service: C-MED
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
male with a past medical history significant for end-stage
renal disease (on hemodialysis) who was admitted on [**1-15**] to the Surgical Transplant Service for arteriovenous
fistula revision and thrombectomy.
PAST MEDICAL HISTORY:
1. End-stage renal disease (on hemodialysis on Monday,
Wednesday, and Friday).
2. History of pancreatitis.
3. Status post cerebrovascular accident in [**2149**] with
residual left hemiparesis.
4. History of gout.
5. Multiple Escherichia coli bacteremia infections.
6. Diverticulosis.
7. Chronic obstructive pulmonary disease.
8. Hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Enalapril 20 mg p.o. q.d.
2. Labetalol 200 mg p.o. q.d.
3. Isosorbide dinitrate 20 mg p.o. t.i.d.
4. Clonidine TTS #3 patch every Thursday.
5. Sevelamer 800 mg p.o. t.i.d.
6. Nephrocaps one tablet p.o. q.d.
7. Lipitor 40 mg p.o. q.d.
SOCIAL HISTORY: The patient is an emigrant from [**Country 2045**]. The
patient is married and lives with his wife. The patient
speaks Haitian Creole as well as some English. The patient
denies a history of tobacco, alcohol, as well as illicit drug
use.
FAMILY HISTORY: Family history unknown.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on transfer from the Surgery Service to Cardiology Service
revealed temperature was 98.6, blood pressure was 140/70,
heart rate was 91, respiratory rate was 16, and oxygen
saturation was 98% on room air. In general, the patient was
a well-developed and well-nourished male complaining of chest
pain. In moderate distress. Head, eyes, ears, nose, and
throat examination revealed normocephalic and atraumatic.
Sclerae were anicteric. Pupils were equal, round, and
reactive to light and accommodation. The oropharynx was
clear. Mucous membranes were moist. The neck was supple.
No jugular venous distention or lymphadenopathy appreciated.
Cardiovascular examination revealed a regular rate and
rhythm. Normal first heart sound and second heart sound. A
systolic murmur at the right upper sternal border with no
third heart sound or fourth heart sound appreciated.
Pulmonary examination was clear to auscultation bilaterally
without wheezes, rhonchi, or rales. Abdominal examination
revealed soft and nondistended. Diffusely tender without
guarding or rebound. Normal active bowel sounds. Extremity
examination revealed no edema. Dorsalis pedis and posterior
tibialis pulses were 2+. Right arm arteriovenous fistula
dressing was clean, dry, and intact with a palpable thrill.
PERTINENT LABORATORY VALUES ON PRESENTATION: Admission
laboratories revealed complete blood count with a white blood
cell count of 5.2, hematocrit was 31.3, and platelets were
121. INR was 1.1. Chemistry-7 revealed sodium was 138,
potassium was 4.2, chloride was 99, bicarbonate was 19, blood
urea nitrogen was 76, creatinine was 3.3, and blood glucose
was 126. Calcium was 9.4, magnesium was 2.1, and phosphate
was 9.5. The patient had multiple sets of cardiac enzymes
with negative creatine kinase (peak of 90) and an evaluated
troponin I with a peak of 29. She also had a cholesterol
panel during her hospitalization with a total cholesterol of
118, triglycerides were 87, high-density lipoprotein was 34,
and low-density lipoprotein was 67. Hemoglobin A1c was 5.8.
RADIOLOGY/IMAGING: The patient's electrocardiogram on
hospital day two demonstrated a normal sinus rhythm at 68
with atrioventricular conduction delay. New T wave
inversions in leads I, aVL, V4 through V6. Q waves in leads
in III and aVF.
HOSPITAL COURSE: The patient underwent arteriovenous
fistula repair and thrombectomy on hospital day one without
complications.
However, on postoperative day one, the patient developed the
acute onset of substernal chest pain with diaphoresis,
nausea, and vomiting. An electrocardiogram demonstrated new
T wave inversions in the anterolateral leads, and the patient
was sent for emergent cardiac catheterization.
Cardiac catheterization revealed 3-vessel disease with 70%
proximal and 95% mid left anterior descending artery
stenosis, 70% proximal left circumflex stenosis, 80% second
obtuse marginal stenosis, and 75% proximal and 80% mid right
coronary artery stenosis. The patient underwent percutaneous
transluminal coronary angioplasty and stenting (times two) of
the left anterior descending artery with good results.
The patient had a stable post catheterization course until
[**1-17**]; when, during hemodialysis, the patient complained
of abdominal pain with nausea and vomiting. Hemodialysis was
discontinued early, and the patient was returned to the floor
where the nausea and vomiting continued, and the patient
complained of recurrent chest pain.
A repeat electrocardiogram demonstrated anteroinferior ST
elevations, and the patient went for emergent re-look
catheterization. Catheterization was without evidence of
acute thrombosis or change in anatomy, and no intervention
was required.
However, immediately status post catheterization, the patient
developed large hematemesis; initially coffee-grounds emesis
followed by bright red blood per rectum. The patient was
hemodynamically stable and without chest pain at the time and
was transferred to the Cardiothoracic Intensive Care Unit for
further management.
The patient's blood pressure medications were held, and the
patient was transfused one unit of packed red blood cells for
a hematocrit of 25.6 (down from 31 twelve hours prior). The
patient refused a nasogastric lavage and was started on
high-dose proton pump inhibitor without further episodes of
hematemesis. The patient continued to remain hemodynamically
stable without further episodes of chest pain.
An echocardiogram was performed which demonstrated mild left
and right atrial dilatation, symmetric left ventricular
hypertrophy, normal right and left ventricular size and
function, with an ejection fraction of 55%, moderate aortic
root dilatation, and 1+ aortic regurgitation, and trivial
tricuspid regurgitation.
The patient was transferred to the Cardiac Medicine floor
where he remained for 48 hours. The patient's hematocrit
remained stable with a discharge hematocrit of 33.4. There
was no further need for a transfusion. The patient remained
hemodynamically stable, and blood pressure medications were
restarted without complications.
The patient has a history of end-stage renal disease (on
hemodialysis three times per week). The patient was
continued on hemodialysis throughout the hospitalization via
a temporary port while the arteriovenous fistula matured.
The arteriovenous fistula remained dressed and without signs
of infection.
CONDITION AT DISCHARGE: Condition on discharge was good;
ambulating without difficulty, chest pain free, and without
further evidence of bleeding.
DISCHARGE DIAGNOSES:
1. Non-ST-elevation myocardial infarction.
2. Status post cardiac catheterization with percutaneous
transluminal coronary angioplasty and stenting of the left
anterior descending artery.
3. Upper gastrointestinal bleed (no intervention).
4. Status post arteriovenous fistula repair and
thrombectomy.
5. End-stage renal disease (on hemodialysis).
6. Cerebrovascular accident with residual left hemiparesis.
7. Chronic obstructive pulmonary disease.
8. Gout.
9. Diverticulosis.
10. Multiple Escherichia coli bacteremia infections.
MEDICATIONS ON DISCHARGE:
1. Plavix 75 mg p.o. q.d. (times three months).
2. Enalapril 20 mg p.o. q.d.
3. Labetalol 200 mg p.o. q.d.
4. Protonix 40 mg p.o. b.i.d.
5. Isosorbide dinitrate 20 mg p.o. t.i.d.
6. Sevelamer hydrochloride 800 mg p.o. t.i.d.
7. Nephrocaps one tablet p.o. q.d.
8. Sublingual nitroglycerin 0.3 mg tablet as needed (for
chest pain).
9. Clonidine patch TTS #3 every week.
DISCHARGE STATUS: The patient was discharged to home with
[**Hospital6 407**] services for medication teaching
and compliance reinforcement.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to continue hemodialysis as
per usual on the day status post discharge.
2. An appointment with Vascular/Transplant Surgery; follow
up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**1-31**] at 2 p.m. at [**Last Name (NamePattern1) 21589**].
3. The patient was scheduled with primary care physician
(Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**]) for an initial appointment on [**2-11**]
at 3:30 p.m. in the [**Last Name (un) 469**] Building, sixth floor, [**Hospital6 6613**] Clinic.
4. The patient was scheduled for an initial Gastroenterology
appointment with Dr. [**Last Name (STitle) **] on [**2-12**] at 1:20 in the [**Hospital 12053**] Clinic.
5. The patient was scheduled for an initial Cardiology
appointment with Dr. [**Last Name (STitle) **] on [**2-13**] at 9 a.m. at [**Last Name (NamePattern1) 21589**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2165-1-25**] 12:48
T: [**2165-1-29**] 07:53
JOB#: [**Job Number 32513**]
|
[
"40391",
"496",
"41401"
] |
Admission Date: [**2168-10-20**] Discharge Date: [**2168-11-2**]
Date of Birth: [**2085-1-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
S/P Pedestrian struck by truck c/o left hand pain and right leg
pain
Major Surgical or Invasive Procedure:
[**2168-10-21**]
1. Debridement and open reduction of left thumb.
2. Soft tissue and bone debridement, primary arthrodesis of
left ring finger.
3. Open reduction, plate and screw fixation of left distal
radius.
4. Bone graft using both a fibular strut and demineralized
bone morphogenic protein, left distal radius.
5. Application of long-arm splint.
[**2168-10-23**]
ORIF Right ankle
[**2168-10-26**]
1. Closed reduction left elbow dislocation.
2. Examination under anesthesia for assessment of
stability.
3. Placement of hinged external fixator from a multiplane.
[**2168-10-31**]
1. Debridement left long finger.
2. Full-thickness skin graft left long finger.
3. Arthrodesis distal interphalangeal joint left long
finger
History of Present Illness:
84 y.o. female who was a pedestrian struck and presented as a
trauma to the ED. She was walking and a pickup truck backed up,
striking her to the ground, and then dragged for several feet.
She was found to have left hand and wrist deformations as well
as
multiple abrasions.
Xrays were performed of her right ankle that revealed a distal
medial tibial fracture in close proximity to a laceration.
Past Medical History:
(1) HTN
(2) Hypercholesterolemia
Social History:
Tobacco none
ETOH none
Family History:
non contributory
Physical Exam:
Temp 98 HR 100 BP 123/87 RR22 O2 sat 99%
Sensorium: Awake (x) Awake impaired () Unconscious ()
Airway: Intubated () Not intubated (x)
Breathing: Stable (x) Unstable ()
Circulation: Stable (x) Unstable ()
HEENT NCAT conjunctiva pink aslera anicteris, PERRLA
Neck no tenderness or adenopathy
Chest clear
COR RRR
Abd large, soft non tender
Pelvis stable
Skin multiple abrasions
Musculoskeletal Exam
Neck Normal () Abnormal () Comments: c-collar in place
Spine Normal (x) Abnormal () Comments:
Clavicle
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Shoulder
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Arm
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Elbow
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Forearm
R Normal (x) Abnormal () Comments:
L Normal () Abnormal (x) Comments: radially angulated
eformity of left wrist along with exposed third digit, middle
phalanx, and likely comminuted fracture of 1st digit.
Wrist
R Normal (x) Abnormal () Comments:
L Normal () Abnormal (x) Comments: see above
Hand
R Normal (x) Abnormal () Comments:
L Normal () Abnormal (x) Comments: see above
Pelvis
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Hip
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Thigh
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Knee
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Leg
R Normal () Abnormal (x) Comments: Proximal fibular
tenderness; diffuse superficial abrasions.
L Normal (x) Abnormal () Comments:
Ankle
R Normal () Abnormal (x) Comments: tenderness along
medial mallelous, anteriorly. laceration overlying this area
which probes posteriorly about 1 cm to periosteum; does not
invade fracture site.
L Normal (x) Abnormal () Comments:
Foot
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Urethral Bleeding Yes () No (x)
Vaginal Bleeding Yes () No (x)
Rectal Tone Normal (x) Abnormal ()
Vascular:
Radial R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Ulnar R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Femoral R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Poplitea R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
DP R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
PT R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Quad R ([**4-4**]) L ()
Ant Tib R (not tested secondary to pain) L ()
[**Last Name (un) 938**] R (not tested secondary to pain) L ()
Peroneal R (not tested secondary to pain) L ()
GS R (not tested secondary to pain) L ()
Pertinent Results:
[**2168-10-20**] IR angio : 1. No evidence of active arterial
extravasation as described above.
2. Large round area of diminished/absent parenchymal enhancement
and
displacement of adjacent vessels within upper pole of the right
kidney is
consistent with known focal lesion, as was seen on the CT scan.
Given the
absence of any contrast enhancement, this likely represents a
markedly
hypovascular lesion such as a cyst.
[**2168-10-20**] CT Abd/pelvis :
1. Multiple bilateral anterior/lateral rib fractures, involving
ribs 5 to 11 on the left and 7 to 11 on the right. No evidence
of segmental fracture to suggest flail chest. No current
pneumothorax.
2. Right perinephric hematoma and hemorrhage into a probable
preexisting
upper pole right renal mass (renal cell carcinoma highly
suspect), with an
internal hyperdensity which washes out on delayed imaging,
suggestive of
pseudoaneurysm. Further evaluation by angiography is warranted.
3. Grade-II contained central hepatic laceration.
4. 1-cm preexisting splenic lesion such as hemangioma or cyst
versus Grade-I splenic laceration.
5. Left gluteal hematoma without active hemorrhage.
6. Comminuted left upper extremity fractures. Correlate with
dedicated
accompanying radiographs.
7. High grade stenosis of proximal left subclavian artery by
atheroma versus adherent thrombus. Thi sis pre-existent and not
related to trauma. Diffuse moderate-to-severe atherosclerotic
disease.
8. Multiple renal cysts
9. Calcified pleural plaque, consistent with prior asbestos
exposure.
[**2168-10-20**] Left hand : 1. Severely comminuted fracture of the
distal radius as detailed above. There is suggestion of
intra-articular extent and a small step-off on a select view.
2. Severe soft tissue injury associated with severely comminuted
bony
fractures and missing bone fragments at the third middle phalanx
and the first distal phalanx. This is highly consistent with
compound fracture. There is a comminuted intraarticular fracture
of the base of the second middle phalanx and to a much lesser
severity of the fourth middle phalanx. A nondisplaced transverse
fracture is suspected of the fifth middle phalanx.
3. Baseline arthritis of the first CMC and chondrocalcinosis
consistent with pseudogout
[**2168-10-20**] Right ankle :
Suggestion of a medial malleolar fracture, incompletely
evaluated
on this tibia, fibula protocol radiograph series. If indicated
and clinically feasible, consider standard 3 view assessment of
the ankle. Additionally, there is an oblique nondisplaced
fracture of the proximal fibula as noted on the accompanying
knee radiograph series.
[**2168-10-20**] Right knee :
1. Nondisplaced oblique fracture of the proximal right fibula.
2. Extensive tricompartmental osteoarthritis of both knees,
worse on the
left.
3. There is chondrocalcinosis consistent with underlying
pre-existing
pseudogout
Brief Hospital Course:
Mrs. [**Known lastname 87206**] was evaluated by the Trauma team in the
Emergency Room as well as the Orthopedic Service for her
multiple fractures. Her scans were reviewed and she had a right
perinephric hematoma with possible extravasation. Although she
was hemodynamically stable she was electively intubated in the
Emergency Room in preparation for angiography. There was no
extravasation in the renal area and 1 cyst was noted. Her
hematocrit was stable and she was subsequently transferred to
the Trauma ICU for further management.
She remained neurologically intact. Due to her multiple rib
fractures a thoracic epidural catheter was placed for pain
relief. She taken to the Operating Room on [**2168-10-21**] for ORIF of
the left hand and again on [**2168-10-23**] went to the Operating Room
for ORIF of the right ankle. On both occasions she did well and
was easily extubated after the procedure on [**2168-10-23**]. She
maintained stable hemodynamics and her hematocrit was stable in
the 24-25 range after receiving 2 units of packed red blood
cells perioperatively.
Following transfer to the Surgical floor she was tolerating a
regular diet and had adequate pain control after her epidural
catheter was removed. She had increased left elbow pain and exam
showed a failed closed reduction of her left elbow dislocation
therefore she returned to the Operating Room on [**2168-10-26**] for
reduction and the application of an external fixator. Again,
she tolerated the procedure well.
The Plastic Surgery Hand service took her to the Operating Room
on [**2168-10-31**] for a skin graft to the left long finger. The graft
was taken from the abdomen and she did well. Her left arm/hand
should remain splinted and elevated and she will need to be
avaluated by the hand surgeons next week.
She was evaluated by both the Physical Therapy and Occupational
Therapy services and due to her bilateral injuries, decreased
mobility and weight bearing restrictions, rehabilitation was
recommended with the hopes of getting her back to her baseline
prior to the accident.
Medications on Admission:
Lipitor 0 mg daily
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
3. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
S/P Pedestrian struk
1. Right renal hematoma
2. Right rib fractures [**7-10**] and left rib fractures [**5-10**]
3. Left distal radius fracture
4. Multiple left digital fractures
5. Left gluteal hematoma
6. Right medial malleolar fracture
7. Right proximal fibula fracture
8. Grade 2 liver laceration
9. Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* You were admitted to the hospital after your accident with
multiple fractures and internal bruising.
* You have undergone multiple operations to stabilize your
broken bones.
* Your injury caused left rib fractures 5 thru 11 and right rib
fractures [**7-10**] which can cause severe pain and subsequently
cause you to take shallow breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
* You must not bear weight on your right leg or left arm.
* You will need vigorous rehabilitation to keep your muscles
toned and occupational therapy for your upper extremities.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**2-3**] weeks.
Please follow up in the Hand Clinic on Tuesday, [**2168-11-8**]. You
must call ([**Telephone/Fax (1) 32269**] to make an appointment so they know you
are coming. The clinic is open from 8-12pm most Tuesdays and
you may show up at any time between those hours, despite your
formal appointment time. The clinic is located on the [**Hospital Ward Name 5074**], [**Hospital Ward Name 23**] Building, [**Location (un) **]. Please make sure that you
obtain a referral from your insurance company prior to your
clinic appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2168-11-2**]
|
[
"2851",
"4019",
"2720"
] |
Admission Date: [**2176-8-13**] Discharge Date: [**2176-8-17**]
Service: MEDICINE
Allergies:
Tylenol-Codeine #3 / Bactrim DS
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
ST Elevation MI
Major Surgical or Invasive Procedure:
Coronary Catheterization and angioplasty
History of Present Illness:
[**Age over 90 **]yoF with h/o bioprosthetic valve replacement unclear as to
which one at present time, HTN who was transferred from [**Hospital1 **] out of concern for and inferior STEMI.
.
She began having malaise/lethargy, anorexia, insomnia,
indigestionfor the past week. Last Tuesday, there was initial
concern for UTI after she went to her PCP's and reportedly had a
floridly positive UA, for which she was given a ten day course
of Ciprofloxacin started on [**2176-8-9**]. Earlier in the week she
started OTC prilosec for GERD sx as well as frequent belching.
.
Monday night while sitting in a chair she began having
pressure-like tightness radiating to L arm; she has never had
this pressure before and it was non-exertional. She thought it
was related to her GERD sx and tried to go to sleep. The
pressure never went away and the following day around noon the
CP became worse and it was associated with nausea / vomiting and
diaphoresis. Her daughter-in-law called her cardiologist about
the chest pressure and she was referred to [**Hospital1 **].
.
At [**Hospital1 **], EKG showed inferior STE and STD in V2-3, new compared
to 18 mos ago. She was noted to be hypertensive as well. Labs
there showed TropI 1.58 (normal 0-0.39), no CK's, Cr 1.5, and
WBC 17, Hct 37. She received 325 ASA, 600 mg PO Plavix, 5 mg IV
Metoprolol x2, bolus then gtt Heparin, 80 mg Atorvastatin. She
was transferred to [**Hospital1 18**] for further evaluation.
.
In the ED, initial VS: 150/76, p87 18. SBP's also noted to be
170. She was continued on Heparin gtt. Labs showed a
subtherapeutic PTT, WBC 18.3, Trop 0.35, and normal renal
function. EKG showed improvement, but not full resolution, of
the above noted ST segment deviations. Importantly, she was no
longer having any pressure; because of this and resolving EKG
changes, she was not taken to the cath, but admitted to CCU for
medical management and close observation.
.
Vitals before transfer: 91 151/77 23 97%RA
.
On arrival to the CCU she was denying CP, SOB, N/V, diaphoresis.
She was just tired and was requesting a sleeping pill to help
her relax.
On review of systems, she denies any prior history of stroke,
TIA, bleeding at the time of surgery. She denies recent fevers,
chills or rigors. She denies exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:
HTN
2. CARDIAC HISTORY:
- bioprosthetic valve replacement
- Pulmonary [**Name (NI) 91266**] unclear the time frame, family unaware of
this and pt cannot remember when it happened
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: States she had a prior
cath at [**Hospital1 756**] in [**2164**], no records available at this time
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- H/o breast ca s/p L radical mastectomy
- Hip fx s/p fall
- migraines
- arthritis
Social History:
Widow, lives alone, takes care of self. Has a chair that goes up
her stairs, cooks her own dinner.
- Tobacco history: denies
- ETOH: 1 drink / month
- Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
- Mother: pt states passed away of "old age" unknown etiology
- Father: pt states passed away of "old age" unknown etiology
Physical Exam:
ON ADMISSION:
VS: BP= 156/58 HR= 90s RR=20 O2 sat=96% 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.
NECK: Supple with JVP not elevated, trachea midline
CARDIAC: RRR, normal S1, S2. mechanical MR murmur appreciated
best at axilla No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
ON DISCHARGE
Pertinent Results:
ADMISSION LABS:
[**2176-8-13**] 11:47PM CK(CPK)-326*
[**2176-8-13**] 11:47PM CK-MB-60* MB INDX-18.4* cTropnT-0.57*
[**2176-8-13**] 11:47PM PT-12.9 PTT-42.1* INR(PT)-1.1
[**2176-8-13**] 07:40PM GLUCOSE-128* UREA N-19 CREAT-0.8 SODIUM-133
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17
[**2176-8-13**] 07:40PM CK(CPK)-258*
[**2176-8-13**] 07:40PM cTropnT-0.35*
[**2176-8-13**] 07:40PM TRIGLYCER-52 HDL CHOL-58 CHOL/HDL-2.9
LDL(CALC)-100
[**2176-8-13**] 07:40PM %HbA1c-5.9 eAG-123
[**2176-8-13**] 07:40PM WBC-18.3* RBC-4.80 HGB-14.6 HCT-41.8 MCV-87
MCH-30.5 MCHC-35.0 RDW-13.3
ADMISSION EKG:
Moderate baseline artifact. Normal sinus rhythm. ST segment
elevation
in leads II, III, aVF and V6. No previous tracing available for
comparison.
Consider acute inferolateral ischemia.
ADMISSION ECHO:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: Limited emergency study. Grossly preserved
biventricular systolic function.
CORONARY CATH:
[**Known lastname **],[**Known firstname **] [**Age over 90 91267**] F 91 [**2085-1-11**]
Cardiology Report Cardiac Cath Study Date of [**2176-8-14**]
*** Not Signed Out ***
BRIEF HISTORY: This [**Age over 90 **] year old female with history of
hypertension,
hyperlipidemia and bioprosthetic aortic valve replacement is
referred
for cardiac catheterization secondary to ruling in for a
myocardial
infarcation.
INDICATIONS FOR CATHETERIZATION:
1. MI
2. STEMI
PROCEDURE:
Percutaneous coronary revascularization was performed using
balloon
angioplasty.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.6 m2
HEMOGLOBIN: 14 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 8/7/4
RIGHT VENTRICLE {s/ed} 31/9
PULMONARY ARTERY {s/d/m} 31/10/19
PULMONARY WEDGE {a/v/m} 10/9/8
AORTA {s/d/m} 152/70/66
**CARDIAC OUTPUT
HEART RATE {beats/min} 84
RHYTHM NSR
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 50
CARD. OP/IND FICK {l/mn/m2} 4.0/2.5
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1240
PULMONARY VASC. RESISTANCE 220
**% SATURATION DATA (NL)
SVC LOW 72
PA MAIN 72
AO 98
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**PTCA RESULTS
PTCA COMMENTS: Initial angiography revealed a complete
occlusion in
the distal R-PL branch of the RCA which filled via right to
right
collaterals. We planned to treat this stenosis with PTCA.
Bivalirudin
was started prophylactically. A 5 French JR4 guiding catheter
provided
adequate support for the procedure. A PROWATER wire was used,
however
the wire was unable to cross the lesion despite multiple
attempts at
crossing. Just proximal to the complete occlusion there was a
[**Last Name (un) **] point
in the R-PL with a hazy appearance that suggested plaque rupture
(likely
cause of downstream embolization). We dilated this area with a a
1.5x15mm SPRINTER OTW balloon at 8 ATMs. Repeat angiography at
this
point showed minimal improvement in blood flow after the
complete
occlusion of the R-PL. Due to the small size of the R-PL and the
difficulty in corssing the lesion there was no further attempt
made at
intervention as the risks outweighed the benefits of opening up
this
small vessel which appeared to give blood supply to a small area
of
myocardium. Final angiography showed the complete occlusion was
still
present, but no angiographically apparent dissection was noted.
The
patient left the lab free on angina and in stable condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 41 minutes.
Arterial time = 28 minutes.
Fluoro time = 8.7 minutes.
IRP dose = 400 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 65 ml
Premedications:
Midazolam 0.25 mg IV
Fentanyl 12.5 mcg IV
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Other medication:
Bivalirudin 40 mg bolus via IV
Bivalirudin 96 mg/ hr via IV
Cardiac Cath Supplies Used:
- [**Doctor Last Name **], PROWATER 300CM
1.5MM [**Company **], SPRINTER 15MM
5FR CORDIS, JR 4 SH
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, LEFT HEART KIT
- MERIT, RIGHT HEART KIT
- [**Doctor Last Name **], PRIORITY PACK 20/30
5FR ARROW, BALLOON WEDGE PRESSURE CATHETER 110CM
COMMENTS:
1. Selective coronary asngiography demonstrated one vessel
disease. The
LMCA had no angiographically apparent disease. The LAD had no
angiographically apparent disease. The Cx had no
angiographically
apparent disease. The RCA had a complete occlusion in a distal
small
(1.5mm in diameter) R-PL. Prior to the complete occlusion there
is [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] point in the distal R-PL which appears to have a hazy area
consistent with plaque.
2. Limited resting hemodynamics revealed normal left and right
sided
filling pressures with an RVEDP of 9 mmHg and a mean PCWP of 8
mmHg. The
Pulmonary pressures were 31/10 mmHg with a mean of 19 mmHg. The
cardiac
index was preserved at 2.5 L/min/m2.
3. Unsuccessful attempt at crossing the distal R-PL. PTCA of the
[**Last Name (un) **]
point just proximal to the complete occlusion in the distal R-PL
where
there appeared to be a hazy area consistent with possible plaque
rupture. Final angiography revealed no apparent dissection and
TIMI III
flow up to the level of the complete occlusion.'
CXR:
Patient is status post median sternotomy with intact sternotomy
sutures. Both lungs are clear without lung consolidation.
Pleural effusion,
if any, is minimal on the left side. Heart size, mediastinal and
hilar
contours are normal. Mild atherosclerotic calcification seen in
the aortic
arch.
DISCHARGE LABS:
[**2176-8-15**] 04:12AM BLOOD WBC-10.1 RBC-3.94* Hgb-11.9* Hct-35.4*
MCV-90 MCH-30.3 MCHC-33.7 RDW-12.7 Plt Ct-440
[**2176-8-15**] 04:12AM BLOOD Glucose-106* UreaN-12 Creat-0.8 Na-137
K-4.4 Cl-106 HCO3-26 AnGap-9
[**2176-8-15**] 04:12AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.0
Brief Hospital Course:
ASSESSMENT AND PLAN
[**Age over 90 **]yoF with h/o bioprosthetic mitral valve replacement, HTN who
presented to [**Hospital3 4107**] found to have a inferior STEMI and
was transferred to [**Hospital1 18**] for further evaluation and medical
management.
.
# Inferior STEMI: Patient presented with symptoms of chest
pressure and abdominal discomfort which were felt to be anginal
equivalents. The time frame of symptoms was unclear as patient
was a poor historian, but likely occurred 24 hours prior to
admission. Right sided EKG and posterior EKG were performed and
no RV infarct was noted. She was started on atorvastatin 80mg,
Aspirin 325mg, Plavix 75mg, heparin gtt, metoprolol tartrate
12.5mg and Lisinopril 5 mg. Patient subsequently underwent
cardiac cath which showed wedge of 8 RA of 6, RV:32/5 PA:31/10
CI=2.5 CO=4, complete occlusion in the distal R-PL branch of the
RCA s/p balloon angioplasty with minimal improvement in flow.
ECHO prior to Cath showed a preserved EF and right ventricular
chamber size and free wall motion that were normal. A
bioprosthetic aortic valve prosthesis was present consistent
with her PMH. The mitral valve leaflets were mildly thickened.
Trivial mitral regurgitation was seen. There was no pericardial
effusion. She was discharged on aspirin 325mg, Plavix 75mg,
atorvastatin 80mg, metoprolol succinate 50mg and lisinopril 5mg.
.
# [**Name (NI) 12329**] Pt has chronic HTN. She continued on her home metoprolol
succinate 50mg and we stopped amlodipine and started Lisinopril
5 mg daily. Her blood pressures remained well controlled during
admission.
.
# Leukocytosis: patient had an elevated WBC at the time of
presentation, likely as stress response to her MI. Her
leukocytosis had resolved prior to discharge. Of note she was on
ceftriaxone on admission due to a diagnosed UTI as an out
patient. Her WBC trended down and she finished her 10 day course
of Ceftriaxone without incident.
.
# UTI: Patient was under treatment for a UTI at the time of
presentation and in the middle of a 10 day course of
ceftriaxone. Patient completed her course of antibiotics while
in patient. She remained a symptomatic throughout this admission
.
# H/o breast ca s/p L radical mastectomy: stable, no change in
treatment while inpatient.
.
#Hip fx s/p fall: stable no change in treatment while
inpatient.
.
# migraines: stable no change in treatment while inpatient.
.
# arthritis: table no change in treatment while inpatient.
.
TRANSITIONAL ISSUES:
Pt has a follow up appointment with her Cardiologist Dr. [**Last Name (STitle) 10543**]
on [**2176-8-19**].
Medications on Admission:
Metoprolol Succinate 50mg
Simvastatin 40mg
Aspirin 81mg
Calcium 600mg
Vitamin D3 1000U daily
Tylenol 650mg q4hr prn pain
Amlodipine 2.5 mg daily
Ciprofloxacin 500mg daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. calcium Oral
7. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Myocardial infarcation
Hypertension
Urinary tract 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:
Dear Mrs. [**Known lastname **],
.
It was a pleasure taking care of you. You were admitted to the
hospital because you had a heart attack. This means that one of
the arteries that supplies your heart with blood became
occluded. We treated you with medication to thin your blood and
performed a procedure call a cardiac catheterization. During
the procedure we dilated a small artery in your heart with a
balloon to allow the blood to flow to your heart effeciently.
We believe that the occlusion in your blood vessel has resolved.
We have made some changes to your medication regimen to
optimally protect your heart.
.
We made the following changes to your medications:
- INCREASED aspirin from 81mg to 325mg daily
- STARTED clopidogrel (Plavix) 75mg daily. **Do not stop taking
this medication unless instructed to by your cardiologist**
- STOPPED simvastatin and STARTED atorvastatin 80mg daily
- STOPPED amlodipine and STARTED lisinopril 5mg daily
- STOPPED ciprofloxacin since you finished the course of
antibiotics for your urinary tract infection
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appt: [**8-19**] at 11:15am
|
[
"5990",
"41401",
"4019",
"2724"
] |
Admission Date: [**2178-5-14**] Discharge Date: [**2178-5-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Aspiration
Major Surgical or Invasive Procedure:
Intubation
CVL placement
Arterial line placement
History of Present Illness:
[**Age over 90 **] y/o M with a PMH of afib who presents from home after a
fall. History is obtained from patient's wife as patient is
intubated. Per the patient's wife he was in his USOH today,
eating a meal when he got up from the table. He usually walks
with a walker, however he was not using it at the time. She
heard a thud and turned and found her husband on the floor. She
does not think that he lost consciousness. There was no
witnessed seizure activity. He was not complaining of chest
pain, SOB, palpitations, abdominal pain or nausea prior to the
fall. Per the patient's wife he has not been recently ill. EMS
was called and he was brought to [**Hospital1 **] [**Location (un) 620**]. At the OSH he was
found to have slowed speech and confusion. He complained of
right hip pain. A head CT was attempted and in the scanner the
patient had witnessed vomiting, aspiration and respiratory
arrest. He was intubated. CXR showed bilateral infiltrates and
he was given levo/flagyl and vanco. He also received morphine
2mg, etomodate, versed 1mg x3 and 3L IVF. Head CT was then
obtained and was reportedly negative. He was then transferred
here for further care.
.
In the emergency department, initial vitals: T 98.4 HR 63 BP
107/47 RR 28. He continued to be unresponsive despite no further
sedating medications. Due to concern for stroke he was evaluated
by neurology who felt that a primary neurologic event was less
likely and concern for hypoxic injury was raised. Hip films were
negative for fracture. He was placed in c-collar for narrowing
in his c-spine, however there was no fracture. He was given 1L
IVF and admitted to the MICU for further management.
.
Review of systems: unable to obtain, patient intubated and
sedated
Past Medical History:
A fib, not on anticoagulation due to prior ICH
h/o R occipital ICH in [**2174**]
Spinal stenosis
Sm. bowel obstruction s/p bowel resection
h/o R hip fracture s/p ORIF
Macular degeneration
Arthritis
Varicose veins
h/o kidney stones
Social History:
Lives with his wife in a retirement community. Retired engineer.
Smoked for 50 years, quit 20 years ago. Drinks one cocktail each
evening. Independent and active, however walks with a walker.
Family History:
NC
Physical Exam:
VITAL SIGNS: T 98.2 BP 102/72 HR 75 RR 30 O2 86% on vent FiO2
100%
GENERAL: Intubated, appears to be in mild distress
HEENT: Normocephalic, atraumatic. c-collar in place. Pupils
pinpoint, minimally reactive. No conjunctival pallor. No scleral
icterus. ETT in place.
CARDIAC: Iregularly irregular, normal rate. Normal S1, S2. No
murmurs, rubs or [**Last Name (un) 549**]. JVP unable to assess due to collar
LUNGS: course sounds throughout the anterolateral lung fields.
ABDOMEN: NABS. Soft, slightly distended, No HSM, well-healed
vertical abdominal scar
EXTREMITIES: No edema, superficial varicosities in b/l LE, 1+ DP
pulses, 2+ radial pulses
SKIN: No rashes
NEURO: Unresponsive, withdrawls to pain
Pertinent Results:
Micro:
Blood cx [**5-14**]: pending
.
ECG: a fib, rate 52, prolonged QT (526), normal axis,
.
STUDIES:
Head CT (OSH): per radiologist here no acute process
.
C-spine (OSH): cervical canal narrowing at C5/C6 and C6/C7, no
fracture
.
CXR [**5-14**]:
IMPRESSION: Extensive interstitial and alveolar opacities,
slightly improved from the study 3:14 p.m. today. It is unclear
to what degree the parenchymal findings are due to underlying
chronic disease; however, superimposed component of diffuse
edema is presumed in a somewhat ARDS-like pattern. Recommend
short interval followups for continued surveillance.
.
Pelvic xray [**5-14**]:
Pelvic alignment is grossly normal and there is no definite
evidence of fracture, however the sacrum is not well seen on
this study. There are three cannulated screws traversing the
intertrochanteric femur and femoral neck, likely fixing cervical
fracture that is not well seen on this study. There is callus
formation evident it appears along the superior aspect of the
femoral neck and greater trochanter. Oval radiopaque measuring 2
cm in the left lower abdomen is uncertain in position or
etiology. This could represent a lymphnode calcification or less
likely a collecting system calcification. This also could be
external to the patient. Loops of bowel are minimally distended
with gas, likely representing colon.
Brief Hospital Course:
[**Age over 90 **] y/o with PMH of a fib who presents with confusion after fall,
aspiration and respiratory arrest s/p intubation
.
#. Resp. failure: Had a witnessed aspiration at [**Location (un) 620**] followed
by respiratory arrest which is likely precipitant. No reason to
believe that it was cardiac in etiology. Intubated emergently at
OSH. Had bilateral infiltrates on CXR concerning for aspiration
pneumonitis/ARDS. On arrival to the ICU the patient became
progressively more hypoxic and difficult to oxygenate on the
ventilator. Off sedation he was quite uncomfortable with some
dysynchrony and he was quickly placed on propofol with some
improvement. He was placed on low tidal volume ventilation for
ARDS protocol, however his oxygenation continued to worsen. He
was tried on multiple ventilator settings including volume
control, pressure control and APRV without improvement. He was
continued on levo/flagyl for possible aspiration PNA. His
oxygentation would briefly improve when he was normotensive,
however his BP became more difficult to manage despite multiple
pressors. Given his quick, progressive decline and grave
prognosis the family was called in. After ongoing discussion
with the family about his evolving condition, they decided to
proceed with making him CMO. The patient's wife expressed that
he had clearly stated that he would not want to be kept alive
with heroic measures and if he had little chance of a meaningful
recovery to good functional status he would not want agressive
measures taken. At this point he was transitioned to CMO,
placed on morphine drip and life-saving measures were withdrawn.
The patient expired comfortably in the presence of his family.
.
# Hypotension: patient developed early sepsis/SIRS in setting of
aspiration event and severe pneumonitis. Lactate rose which
suggested infectious cause. No h/o cardiac problems. BP was
somewhat labile here. In setting of recent fall this brings up ?
of possible autonomic dysfunction. He was presssor dependent,
initially with levophed alone, however vasopressin was added for
more support. An emergent CVL and a-line was placed. His BP
cont. to trend down and he was switched to dopamine. His BP
responded well to this however it caused significant ectopy and
wide-complex beats and was therefore shut off. Dobutamine and
neo was eventually started, however his BP and oxygenation
continued to worsen. He was eventually made CMO as above and
expired in the ICU.
.
Medications on Admission:
Lipitor 10mg daily
Sertraline 25mg daily
Travatan 0.004% drops both eyes qhs
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Aspiration pneumonitis
ARDS
Hypotension
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"0389",
"5070",
"99592",
"42731"
] |
Admission Date: [**2188-10-14**] Discharge Date: [**2188-11-14**]
Date of Birth: [**2121-1-11**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67 F transferred to ICU from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with gallstone
pancreatitis complicated by acute renal failure and respiratory
failure requiring intubation. Patient was initially admitted on
[**10-9**] for abdominal pain w/ CT showing gallstones, dilated CBD
and pancreatic ducts, pancreatitis, probable common duct stone,
and small-mod ascites. Admitted and started on Zosyn. On
arrrival, labs were WBC 19K, AP 120, AST 223, ALT 142, Tbili
1.9, amylase 993, and lipase 2200. She was then transferred to
[**Hospital1 18**] for [**Hospital1 **] on [**10-9**]. During the procedure, the ampulla was
found to be edematous and boggy, preventing a sphincterotomy and
a 10F 7 cm plastic stent was placed; mild sludge was seen with
bile flow into the duodenum. After the procedure, patient
returned to [**Hospital3 26615**]. Labs after procedure: Tbili 3.1, AST
89, ALT 155, [**Doctor First Name **] 1120, Lip 1375, WBC 26k (60 segs, 34 bands).
Hypocalcemic to 6.4. On [**10-10**], patient was noted to be in
respiratory distress w/ CXR showing bilateral pleural effusions
L>R, but did not require intubation. On [**10-11**] labs continued to
trend down: Tbili 2.4, [**Doctor First Name **] 604, and Lip 492. Patient received
PICC for TPN but unclear if TPN administered. Urine output
continued to decrease and creatinine continued to increase:
BUN/Cr 54/2.1 on [**10-12**] and 69/3.0 on [**10-13**]. Urine output did not
respond to diuretics and diagnosed with ARF w/ possible ATN.
During stay, patient received a significant fluid volume:
admission weight was 79 kg and transfer note describes 40 kg
weight gain. The morning of [**10-14**] patient was in worse
respiratory distress with a pCO2 of 65 and was consequently
intubated. CXR showed slight increase in R-sided pleural
effusion. Patient was transferred in the afternoon due to need
to greater acuity of care and consideration of surgical options.
Past Medical History:
obesity, seasonal allergies
tonsillectomy, cesarean section, appendectomy
Social History:
no tobacco, rare EtOH
Family History:
neg for pancreatic or liver diseases
Physical Exam:
T 99.6 HR 100 BP 112/46 RR 14 SpO2 93% on 50% FIO2
gen: sedated, intubated, not arousable to voice
cardiac: tachycardic, no M/R/G
chest: scattered rhonchi
abd: distended, + BS, unable to assess tenderness
ext: pitting edema, anasarca
Pertinent Results:
ON ADMISSION:
CBC: WBC-20.8 Hgb-10.4 Hct-30.0 Plt Ct-197
Chem: Glucose-113 UreaN-99 Creat-4.5 Na-133 K-5.2 Cl-101 HCO3-20
AnGap-17
LFTs: ALT-21 AST-41 AlkPhos-103 Amylase-47 TotBili-1.6
Blood and Urine culture: NO GROWTH
CT Scan (Noncontrast):
1. Pancreatitis with significant fat stranding increased as
compared to the previous study, no focal fluid collection
2. Free fluid in the anterior perihepatic space, anterior to the
pancreas and in the pelvis.
3. Dilated small bowel loops likely related to ileus.
4. Cholelithiasis.
5. Bilateral basal collapse/consolidations with pleural
effusions.
6. Anasarca
DURING ADMISSION:
[**2188-10-20**] Hep B Panel: HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE\
[**2188-10-20**] C diff toxin: POSITIVE
[**2188-10-28**] Urine Culture: E coli >100,000 ORGANISMS/ML
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ON DISCHARGE:
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the TSICU on [**2188-10-14**] for treatment
of acute gallstone pancreatitis complicated by respiratory and
renal failure. She was transferred to the floor on [**2188-10-27**] and
recovered well during the remainder of her stay. Her hospital
course is described by system below.
Neuro: Patient's sedation was weaned in ICU, although patient's
mental status was slow to improve with minial responsiveness
until HD4 when she began to follow commands. After transfer to
floor, patient's mental status improved dramatically with
ability to follow commands and communicate appropriately. She
was oriented x3 for most of the time, but had episodes of
dilirium that gradually decreased in frequency. Her pain was
well controlled with IV dilaudid initially and later with
tylenol and po oxycodone.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. Patient was
hemodynamically stable throughout ultafiltration and dialysis.
Pulmonary: The patient's asthma was managed with albuterol
inhalers with Duonebs for persistent wheezing.
GI: Pancreatitis steadily resolved throughout hospitalization as
evidenced by decrease in amylase/lipase, improvement in pain,
and increased po tolerance. Patient was treated with tube feeds
through NG tube while in ICU and later with TPN on the floor
while abdominal pain resolved. NG tube was removed on [**2188-10-25**]
after patient began to pass flatus. She underwent a
speech/swallow study on [**2188-10-29**] after improvement in mental
status and was able to tolerate liquids and solids without
evidence of aspiration. She was started on clear liquids on [**10-30**]
which she tolerated well but was reverted back to sips because
of abdominal pain. Diet was kept at sips. Patient will
ultimately need a cholecystectomy, however given acute medical
issues currently, will reasses in [**1-30**] weeks and determine
optimal surgical time.
GU: Patient was transferred in acute renal failure, essentially
anuric and grossly fluid overload with anasarca. Lasix diuresis
was attempted, however patient did not respond. CVVH was started
on [**2188-10-16**] with 3L extracted daily. Intermittent HD was started
on [**2188-10-19**] for continued ultrafiltration and treatment of
hyperkalemia. Renal team was consulted throughout this period
and recommendations for treatment of likely ATN were followed
daily. By [**2188-10-29**], patient's Cr, K, and phos began to normalize
and patient started making urine. Her renal funtion improved
gradually,no longer requiring dialysis. Her foley was d/ced on
[**2188-11-12**].She was able to void witout any difficulty.
ID: On arrival, patient was afebrile with negative blood
cultures and no evidence of infected fluid collections on CT
scan. However, WBC count continued to rise daily and peaked at
36.2. Although patient was not having diarrhea, Cdiff was sent
and found to be positive. Patient was started on po vanc via NG
tube while in ICU with improvement in CBC. When NG tube was
dced, patient was switched to IV flagyl. After transfer to
floor, patient's WBC began to rise again although she remained
afebrile. U/A was positive and empiric cipro was started. Urine
culture grew [**First Name9 (NamePattern2) **] [**Last Name (un) 36**] to cipro and patient completed 3 day
course of treatment. IV flagyl was changed to po vanc on [**2188-10-28**]
after patient passed speech/swallow study.Her antibiotics were
discontinued on [**2188-10-12**].
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
On the day of discharge the patient was on TPN,sips, needed help
with ambulation,voiding spontaneously and the pain was well
controlled.
Medications on Admission:
claritin prn
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
4. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
8. insulin regular human 100 unit/mL Cartridge Sig: insulin
sliding scale Injection qid.
9. TPN
TPN via PICC
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
gallstone pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 [**5-5**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
Please call Dr[**Name (NI) 2829**] office at ([**Telephone/Fax (1) 2363**] to schedule an
appointment in [**1-30**] weeks
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2188-11-27**] 1:00
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2188-11-27**] 1:00
|
[
"51881",
"5845",
"5990",
"2760",
"2767",
"49390"
] |
Admission Date: [**2137-10-4**] Discharge Date: [**2137-10-15**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 80-year-old male with
history of congestive heart failure, coronary artery disease,
diabetes mellitus and pneumonia who was admitted to [**Hospital1 1444**] for dyspnea and found to have
a right pneumothorax. He had a chest tube placed during
hospital course. The patient has a history of multiple prior
admissions in the past few months for pneumonias. Chest tube
was placed during this hospital course. The chest tube was
discontinued shortly afterwards after discovery that it was
misplaced. The right lung was re-expanded. Pleural
effusions managed with diuresis.
A renal consult was obtained for an increasing BUN and
creatinine. It was thought that there was a prerenal picture
was developing. Renal ultrasound was recommended. Heart
Failure Service was consulted and recommended transfer to CCU
for aggressive diuresis, pressor support and Swan-Ganz
placement. During hospital course, the patient also had 2/4
bottles positive for MRSA, sputum positive for MRSA,
increased white blood cell count to 22. While on the floor
the patient was started on Levofloxacin and Vancomycin prior
to transfer to CCU.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft in [**2123**], four vessel disease, LIMA to LAD, SVG
to D2, SVG to circumflex and SVG to PDA.
2. Congestive heart failure.
3. Diabetes mellitus.
4. Chronic renal insufficiency.
5. CTCL.
6. Bilateral renal artery stenosis 60% on the left, 70% on
the right.
7. Osteoarthritis.
8. Gout.
9. Recent echocardiogram revealed LV ejection fraction of
less than 20%
ALLERGIES:
1. Penicillin.
2. Ambien which leads to confusion.
MEDICATIONS ON TRANSFER TO CCU:
1. Dopamine drip.
2. Metoprolol 25 mg p.o. b.i.d.
3. Levofloxacin 250 mg p.o. q. 48 hours.
4. Vancomycin 1 gram IV dosed by levels.
5. Regular insulin sliding scale.
6. Morphine p.r.n.
7. Zofran p.r.n.
8. Compazine.
PHYSICAL EXAMINATION: Vital signs with a temperature of 98.2
F, pulse 60, blood pressure 107/36, respirations 16. Pulse
oximetry 92%. In general elderly male who is lethargic.
Head, eyes, ears, nose and throat: Moist mucous membranes.
Cardiovascular: S1, S2, no murmurs, rubs, or gallops
appreciated. Pulmonary: Loud breath sounds, rhonchorus.
Abdomen is obese and soft. Extremities: Pitting edema
bilaterally.
INITIAL LABORATORY: White blood cell count of 19.2,
hematocrit of 29.6, platelets 252. INR 1.1. Fibrinogen 581.
INITIAL ASSESSMENT: This is an 80 year-old male admitted to
CCU for aggressive congestive heart failure management, MRSA
bacteremia.
HOSPITAL COURSE:
1. HEART FAILURE: Patient required pressor support with
Dopamine and eventually Norepinephrine as a bridge for
dialysis. After dialysis, the patient's heart function
eventually improved and he was able to be weaned off all
pressures. Patient had no chest pain or chest discomfort
during the entire hospital course. The patient was monitored
on telemetry during hospital course with no known
abnormalities or runs of ectopy. The patient was known to
have severe coronary artery disease and was kept on aspirin
and Lipitor throughout hospital course.
2. RENAL: Patient with increasing BUN and creatinine in the
setting of congestive heart failure thought to be a prerenal
condition. Acute renal failure on top of a chronic renal
failure. Patient's mental status and renal function improved
after a session of dialysis, however patient refused further
dialysis sessions as he thought it would be a new chronic
management that he would need.
3. PULMONARY: Patient with decreasing O2 saturations on
presentation. Patient is known to have coronary artery
disease and it was felt that his decreased pulmonary function
was secondary to congestive heart failure. Pulmonary
function did improve after dialysis and removal of fluid.
The patient also noted to have MRSA positive sputum and MRSA
positive blood cultures. The patient was kept on Vancomycin
therapy until the end of hospital course.
4. ENDOCRINE: Patient is a known diabetic who placed on
fingersticks q.i.d. with regular insulin sliding scale until
he changed his code status later in hospital course.
5. CODE STATUS: Patient and patient's family initially
wanted "everything done", however after a session of dialysis
and a clearing of mental status, the patient and patient's
family were extensively counseled in what lay probably in his
medical future in terms of his extremely grim prognosis given
his multiple medical conditions. Decision was made by the
patient to become DNR, DNI and to institute comfort measures
only. All non-necessary medications were discontinued. The
patient was kept only on comfort medications such as
Morphine, Scopolamine patch. Fingersticks were discontinued
and a palliative care nurse consultation was performed.
The patient requested not to be transferred out of the
hospital to a Hospice type setting, but rather requested to
remain in the hospital to pass away there. Overall, once
patient was transferred to CMO type care, the patient
lingered for approximately 30 hours before expiring.
CONDITION ON DISCHARGE: Expired.
DISCHARGE STATUS: Autopsy refused by family. Attending and
family made aware of patient's expiration.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Name8 (MD) 110497**]
MEDQUIST36
D: [**2137-11-5**] 14:00
T: [**2137-11-7**] 10:24
JOB#: [**Job Number 110498**]
|
[
"4280",
"5849",
"5119",
"25000"
] |
Admission Date: [**2200-6-30**] Discharge Date: [**2200-7-4**]
Date of Birth: [**2134-1-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Bactrim / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 yoF w/ a h/o Severe COPD, OSA, and diastolic heart failure
as well as HTN, DM II and alzhemiers dementia presents with
acute dyspnea. She is unable to provide a full history. She
does not know when her dyspnea started, she does not know if she
is orthopneic. She denies cough currently or with any of her
dyspneic episodes. She denies chest pain, lower extremity
edema, abd pain, constipation / diarrhea or other symptoms.
Good PO intake per patient.
She states that she lives at home by herself and that her friend
fills her pill box and helps her take her medications. She is
not sure if she uses her inhalers but she states that she uses
everything that her friend helps her take.
In the ED, 97.0 ax 110 150/100 40 95% continuous nebulizer. She
received Methylprednisone 125mg IV, levofloxacin 750mg IV and
magnesium 2gms with IV NS 500cc.
Past Medical History:
Obstructive Sleep Apnea (on BiPAP at night)
COPD (last spirometry [**2200-6-16**] FVC 0.82 (40%), FEV1 0.4 (28%),
FEV1/FVC 49 (70%)
Last intubation [**8-20**]. Multiple ICU admissions for BiPAP. On
[**3-17**].5 L by NC at home and BiPAP at night (14/10).)
diastolic HF (EF 75%)
DM2
HTN
GERD
Hyperlipidemia
Morbid Obesity (BMI 51)
Schizophrenia
Depression
Alzheimer's Dementia
s/p R ankle ORIF
Social History:
40 pack-year history of smoking, quit 10 years ago, no alcohol,
no drug use.
Family History:
non contributory
Physical Exam:
GEN: AOx 3.
HEENT: JVP unable to assess, upper airway sounds- wheezes
audible without stethescope, no stridor
CARD: SEM [**2-19**] @ USB w/o radiation
PULM: diffuse mild wheezes bilaterally, very poor air movement,
paradoxial breathing, prolonged expiratory phase
ABD: soft, obese, NT, ND, no masses or organomegaly
EXT: WWP, [**1-15**]+ non pitting pedal edema
Some baseline dementia
Pertinent Results:
[**2200-7-4**] 06:15AM BLOOD WBC-10.9 RBC-4.78 Hgb-11.0* Hct-36.1
MCV-76* MCH-23.0* MCHC-30.4* RDW-17.3* Plt Ct-313
[**2200-6-30**] 10:30PM BLOOD WBC-20.9* RBC-5.21 Hgb-11.8* Hct-41.1#
MCV-79* MCH-22.6* MCHC-28.6* RDW-17.0* Plt Ct-355
[**2200-7-1**] 06:22AM BLOOD Neuts-97.1* Lymphs-1.0* Monos-0* Eos-0
Baso-0 Myelos-2.0* NRBC-1*
[**2200-6-30**] 10:30PM BLOOD Neuts-90.9* Bands-0 Lymphs-5.4* Monos-2.5
Eos-1.0 Baso-0.2
[**2200-7-1**] 06:22AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-1+ Ellipto-2+
[**2200-6-30**] 10:30PM BLOOD PT-11.5 PTT-20.7* INR(PT)-1.0
[**2200-7-4**] 06:15AM BLOOD Glucose-78 Creat-0.6 Na-142 K-3.9 Cl-99
HCO3-36* AnGap-11
[**2200-6-30**] 10:30PM BLOOD Glucose-186* UreaN-15 Creat-0.8 Na-139
K-5.8* Cl-99 HCO3-30 AnGap-16
[**2200-6-30**] 10:30PM BLOOD CK(CPK)-86
[**2200-6-30**] 10:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-376*
[**2200-7-3**] 06:25AM BLOOD Mg-2.2
[**2200-7-2**] 05:55AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.5
[**2200-7-1**] 06:22AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.7*
[**2200-7-3**] 10:02AM BLOOD Type-ART pO2-59* pCO2-65* pH-7.41
calTCO2-43* Base XS-12
[**2200-6-30**] 10:34PM BLOOD Type-ART pO2-84* pCO2-79* pH-7.27*
calTCO2-38* Base XS-5
[**2200-6-30**] 10:27PM BLOOD Glucose-181* Lactate-1.0 Na-142 K-4.3
Cl-97*
[**2200-6-30**] 10:27PM BLOOD Hgb-12.2 calcHCT-37 O2 Sat-95
[**2200-7-1**] 02:57AM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]->1.030
[**2200-7-1**] 02:57AM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-5.5 Leuks-NEG
[**2200-7-1**] 02:57AM URINE RBC-[**3-19**]* WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2 RenalEp-0-2
[**2200-7-1**] 2:57 am URINE Site: CATHETER
**FINAL REPORT [**2200-7-2**]**
URINE CULTURE (Final [**2200-7-2**]): NO GROWTH.
[**Known lastname **],[**Known firstname 247**] M [**Medical Record Number 98820**] F 66 [**2134-1-20**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2200-6-30**]
10:01 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**2200-6-30**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 98821**]
Reason: please assess for pna
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with sob
REASON FOR THIS EXAMINATION:
please assess for pna
Final Report
SINGLE VIEW OF THE CHEST DATED [**2200-6-30**]
HISTORY: 66-year-old woman with shortness of breath; assess for
pneumonia.
FINDINGS: Single bedside AP examination labeled "erect" with
excessive
lordotic positioning, is compared with semi-upright study dated
[**2200-4-27**]. There
is more marked cardiomegaly with pulmonary vascular congestion
and blurring,
indicative of interstitial edema, as well as right greater than
left pleural
effusions. There is no overt alveolar edema or focal
consolidation. Airspace
opacity at the right lung base likely represents a combination
of atelectasis
and effusion; pneumonic consolidation at this site cannot be
excluded.
IMPRESSION: CHF with right effusion and right basilar
atelectasis,
significantly worse since [**2200-4-27**].
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
Approved: WED [**2200-7-2**] 9:39 PM
Imaging Lab
[**Known lastname **],[**Known firstname 247**] M [**Medical Record Number 98820**] F 66 [**2134-1-20**]
Cardiology Report ECG Study Date of [**2200-6-30**] 9:57:46 PM
Sinus tachycardia
Consider left atrial abnormality
Low precordial lead QRS voltages
Modest ST-T wave changes
These findings are nonspecific but clinical correlation is
suggested
Since previous tracing of [**2200-4-27**], no significant change
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
106 168 76 332/[**Telephone/Fax (2) 98822**]
Brief Hospital Course:
Ms [**Known lastname 35914**] was admitted to the ICU for respiratory distress and
treated for a severe COPD flare and acute on chronic diastolic
heart failure. She was treated with albuterol, atrovent, O2,
Bipap, steroids. She rapidly improved after the inital 24 hours.
Thereafter, advair and spiriva were restarted. Plan to complete
5 day course of levofloxacin. Patient is currently full code as
discussed with her friend and health care proxy is her friend
[**Name (NI) **] [**Name (NI) 1456**] ([**Telephone/Fax (1) 98823**].
Lasix dose was increased to 40 mg (20 mg is the home dose) wih
good diuresis and improvement.
She was transiently hypotensive in ER and responded to fluids.
Slowly home meds were reintroduced. At discharge the dose of
hydralazine is lower than the home dose with a normal BP. Her
home regimen is lisinopril 40mg daily, hydral 50mg tid and
norvasc 10mg daily.
Leukocytosis: trended downward with treatment of COPD. Abnormal
differential was noted. Please refer above. Defer to PCP to
recheck and follow up.
Schizophrenia/dementia: on resperidone, aricept. The dose of
fluoxetine is conflicting. Refer below. There is a discrepancy
between the dose of fluoxetine at home and that the pharmacy
told us. she was given 40 mg here til the dose was confirmed
with proxy. Discharge dose is 80 mg daily - which is the dose
she was discharged on last time from our hospital and what [**Doctor First Name **]
told us patient was on at home prior to this admission.
Medications on Admission:
Meds confirmed with health care proxy - [**Name (NI) **] [**Name (NI) 1456**]
([**Telephone/Fax (1) 98823**]:
Amlodipine 10 mg daily
Lisinopril 40 mg po daily
Lasix 20mg daily
Hydralazine 50mg po tid
Risperidone 2 mg po daily
Fluoxetine 40 mg tablet - 2 tabs daily (80mg/day)(confirmed with
proxy [**Name (NI) **])
Aricept 5 mg po qhs
Prilosec 20mg [**Hospital1 **]
Singulair 10 mg daily
Spiriva daily [**Hospital1 **]
Advair 250-50 [**Hospital1 **]
Albuterol nebs QID
Trazodone 50mg at bedtime
Prednisone 10 mg daily (has constantly been on prednisone since
[**2200-3-15**] due to various tapers). Last dose if 10 mg daily.
Home O2, 3lit / min (24 hours)
*** I called [**Company 4916**] pharmacy at [**Telephone/Fax (1) 98824**] to confirm the
fluoxetine dose. The dose they have is fluoxetine 40 mg tablets.
Take 2 tabs [**Hospital1 **]. This dose is different from the dose that [**Doctor First Name **]
tells us.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for shortness of breath or wheezing.
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
9. Donepezil 5 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 twice a day.
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
16. insulin
Insulin coverage for elevated sugars by sliding scale.
17. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): To be tapered depending on patient's clinical state. .
18. Levofloxacin 500 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily)
for 2 days: last day [**2200-7-6**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Acute on chronic respitatory failure
Chronic obstructive pulmonary disease exacerbation
Obstructive sleep apnea
Hypotension (history of hypertension)
Acute on chronic diastolic heart failure
Morbid obesity
Alzheimer's dementia
History of smoking
Discharge Condition:
stable
Discharge Instructions:
You were treated for a flare of the chronic obstructive lung
disease. You are being dischrged to pulmonary rehabilitation.
The steroids will need to be tapered based on your lung status
by the doctors at the rehab.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20111**]/DR. [**Last Name (STitle) 3172**] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2200-7-23**] 11:00
PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] [**Telephone/Fax (1) 693**] - follow up with your
primary care doctor once you have been discharged from the rehab
|
[
"4280",
"32723",
"4019",
"25000",
"53081",
"311"
] |
Admission Date: [**2104-9-24**] Discharge Date: [**2104-10-7**]
Service: MEDICINE
Allergies:
Penicillins / Celebrex / Plaquenil / Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**Hospital1 **]-ventricular pacemaker upgrade
Trans-esophageal Echocardiogram
Cardioversion
EGD (Esophago-gastro-duodenoscopy)
Colonoscopy
History of Present Illness:
83yo M with h/o HTN, DLP, CHF, A fib s/p permanent pacemaker
(4/'[**04**]), anterior MI s/p CABG ([**2084**]), AAA with multiple repairs,
CVA presents with shortness of breath.
.
Patient's cardiac history dates back to [**2084**] when he developed
chest pain and was found to have an anterior MI. He received a
CABG in [**2084**] and has been chest pain free since then.
.
Patient first experienced shortness of breath on exertion about
five years ago, when he was placed on Lasix with adequate
management of his symptoms until recently. Patient's EF as
reported by echo in [**2102**] and in [**2104-7-6**] was stable at 30-35%.
.
Patient's most recent symptoms became apparent beginning in
[**2104-5-6**] when he began to experience progressive episodes of
shortness of breath and fatigue. Symptoms began following a
stroke which occurred in [**2104-4-5**], which resulted in left arm
hemiparesis that resolved with physical therapy. Workup for the
stroke revealed that the patient was in atrial fibrillation, and
patient was placed on Coumadin. He began experiencing worsening
dyspnea on exertion and
had multiple medication adjustments of his HF regimen with
suboptimal response. As a result, an ICD was placed [**2104-6-5**] for
what was believed to be symptomatic a fib. Patient was also
subsequently cardioverted in [**2104-6-5**] for continued dyspnea on
exertion.
.
Patient reported worsening of dyspnea following placement of
ICD, with PND, orthopnea which was minimally relieved when
sitting up in a chair at night, inability to sleep due to
shortness of breath. Patient's activity tolerance also
decompensated from being able to walk and play golf without
shortness of breath in [**2104-5-6**] to his current state, where he
becomes dyspneic at rest. Patient also reports that he began to
experience hemoptysis of dark red sputum in the past two weeks.
He has noticed a bloated abdomen with nausea and feelings of
fullness for the past 4 months as well. Patient denies chest
pain, but reports that he experienced a mild tightness in his
chest with the episodes of dyspnea.
.
Patient was recently found by his cardiologist to have a low BP
in the upper 70's and upper 80's, and his Lisinopril was
discontinued and Lasix was stopped. Lasix was reinitiated and
stopped several times in an attempt to prevent hypotension while
treating symptoms of dyspnea.
.
Patient presented and was admitted to Upper [**Hospital 2748**] [**Hospital **]
Hospital [**9-21**] for continued worsening symptoms, and was believed
to be "profoundly azotemic." He was given IV fluids without any
improvement of dyspnea, and was re-initiated on Lasix briefly.
During his hospital stay at the OSH 2 days prior to presentation
at [**Hospital1 18**], per family, patient developed hypothermia of 90
degrees F. Family reports that patient was wrapped in multiple
blankets at the hospital, and his temperature increased to 92
degrees F.
.
CXR was obtained at OSH on [**9-23**] which showed cardiomegaly with
fine bibasilar markings. An echo obtained [**9-23**] at OSH showed
worsened MR (3+) with worsened EF ~15%. CT chest with IV
contrast was obtained at the OSH as well, which resulted in
elevation of patient's Cr from baseline of 0.9-1.5 to 3.4.
.
The plan at the OSH was to transfer the patient to [**Hospital **]
[**Hospital3 26522**] Center, but patient's family decided to seek
care at [**Hospital1 18**] and drove patient to [**Location (un) 86**]. On presentation, he
was mildly dyspneic on 3L O2 NC with sats in the low 90's.
However, patient reported that he felt his breathing was
improved. He has remained asymptomatic of chest pain since
admission, and had one episode of dyspnea and drops of sats into
80's following bedside TTE, which resolved following elevation
of the head of the bed and increase of oxygen to 4L. He is
currently breathing comfortably on 4L NC without use of
accessory muscles.
.
Past Medical History:
Cardiac Risk Factors:
- Hypertension
- Dyslipidemia
- s/p Prior anterior MI [**2084**]
.
Cardiac History: CABG ([**2084**]), anatomy as follows:
- LIMA to LAD, SVG to RCA
.
No PCI (most recent cardiac catheterization [**2084**])
.
ICD placed [**2104-6-5**] for symptoms attributed to atrial
fibrillation.
.
Other Past History:
- CHF, most recent Echo [**2104-9-23**] with EF ~15%, severe MR (Echo
[**2104-5-5**] and [**2104-7-14**] with EF 30%)
- Atrial fibrillation, diagnosed [**5-/2104**]
- CVA [**5-/2104**] with UE hemiparesis x1 week
- Abdominal Aortic Aneurysm [**2095**] with multiple endograft repairs
- [**Hospital1 **]-fem bypass several years prior
- Bilateral inguinal hernias
- h/o Rectal bleed [**2100**]
.
Social History:
Social history is significant for the absence of current tobacco
use, 120 pk-yr history of prior tobacco use (x60 years, quit
[**2084**]). There is no history of alcohol abuse.
.
Patient previously employed as mechanical contractor, plumber,
handyman repairing heating and air conditioning units.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had a heart condition of uncertain
nature, died at [**Age over 90 **]yo. Father had h/o lung cancer.
Physical Exam:
VS - T 98.0 P 78 BP 98/64 R 20 94% RA
Gen: Alert, interactive, WDWN male in mild respiratory distress.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Pale conjunctiva. No
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP ~14cm to earlobes. No carotid bruits.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, normal S1, S2. Grade I systolic murmer at RUSB, Grade II
systolic murmer at apex. No thrills, lifts. Occasional S4.
Chest: Mild pectus excavatum. Resp were minimally labored but
without accessory muscle use. Fine crackles to mid-lung on
right, fine crackles in lower lobes on left. Minimal
end-expiratory wheezes in upper lobes b/l.
Abd: Soft, NT, mildly distended. +BS. No HSM or tenderness. No
abdominial bruits.
Ext: No c/c/e. Cool LE's.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Non-suppurative, non-tender, non-erythematous scaly brown
lesions on mid-plantar surface of left foot.
Neuro exam: Alert, oriented. PERRL, EOMI, CNs symmetric and
intact. Strength 5/5 bilaterally in upper extremities, 4+/5
bilaterally in legs. Gait not assessed secondary to dyspnea.
Rapid alternating movements of fingers intact.
Pulses:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
.
Pertinent Results:
[**2104-9-24**] URINE HOURS-RANDOM UREA N-500 CREAT-94 SODIUM-LESS
THAN POTASSIUM-48 CHLORIDE-LESS THAN
[**2104-9-24**] 03:05PM GLUCOSE-132* UREA N-123* CREAT-4.1*
SODIUM-125* POTASSIUM-4.6 CHLORIDE-80* TOTAL CO2-27 ANION
GAP-23*
[**2104-9-24**] 03:05PM ALT(SGPT)-22 AST(SGOT)-22 LD(LDH)-282*
CK(CPK)-69 ALK PHOS-69 TOT BILI-0.8
[**2104-9-24**] 03:05PM CK-MB-6 cTropnT-0.14* proBNP-GREATER TH
[**2104-9-24**] 03:05PM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-6.2*
MAGNESIUM-3.5*
[**2104-9-24**] 03:05PM DIGOXIN-1.0
[**2104-9-24**] 03:05PM WBC-8.6 RBC-3.50* HGB-10.9* HCT-32.1* MCV-92
MCH-31.1 MCHC-33.9 RDW-15.9*
[**2104-9-24**] 03:05PM NEUTS-83.1* LYMPHS-11.1* MONOS-5.0 EOS-0.6
BASOS-0.2
[**2104-9-24**] 03:05PM PT-32.7* PTT-40.4* INR(PT)-3.4*
.
CXR on Admission [**2104-9-24**]: There is no comparison available.
[**Month/Day/Year **] enlargement of the cardiac silhouette, pacemaker in
situ. [**Month/Day/Year **] aortic tortuosity of the thoracic aorta. The lung
volumes are low and show bilateral blunting of costophrenic
sinus and increase in interstitial structures that have fibrotic
appearance. There are no signs of additional pneumonia and no
signs suggestive of overhydration. Clips of the bypass surgery,
abdominal aortic stent graft in situ.
.
Echocardiogram ([**2104-9-24**]): The left atrial volume is markedly
increased (>32ml/m2). Color-flow imaging of the interatrial
septum raises the suspicion of an atrial septal defect, but this
could not be confirmed on the basis of this study. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF = 15-20 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is dilated with severe global free wall hypokinesis. The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. [**Month/Day/Year **] to severe
(3+) mitral regurgitation is seen. [**Month/Day/Year **] [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. Severe pulmonic regurgitation is seen. There is no
pericardial effusion. IMPRESSION: Severe global biventricular
systolic dysfunction. The anterior wall and septum are akinetic.
The LV and RV are dilated. Severe mitral regurgitation, [**Month/Day/Year 1192**]
tricuspipd regurgitation. Possible atrial septal defect.
.
CHEST CT WITHOUT CONTRAST IMPRESSION ([**2104-9-29**]):
1. Findings consistent with pulmonary fibrosis, which can be due
to chronic hypersensitivity pneumonitis. Superimposed
ground-glass opacities can be seen in the setting of pulmonary
hemorrhage, which would be consistent with given history of
hemoptysis. Pulmonary infection cannot be excluded. The findings
are not typical for asbestosis. Amiodarone toxicity can present
with similar imaging findings and can be considered if patient
was treated with amiodarone. 2. Several noncalcified pulmonary
nodules, largest measuring 10 mm, three- month followup chest CT
is recommended. FDG-PET can be non-conclusive in the setting of
surrounding ground-glass opacities. 3. Dense atherosclerotic
coronary artery calcifications, status post bypass graft
procedure. 4. Basal bronchiectasis, which can be seen in the
setting of chronic aspiration. 5. No evidence of CHF.
.
CXR on discharge [**2104-10-5**]: Comparison with the previous study
done [**2104-10-2**]. Evidence for mild interstitial edema persists.
Heart appears enlarged as before. The patient is status post
median sternotomy. Mediastinal structures are unchanged. A
pacemaker remains in place.
Brief Hospital Course:
Patient is an 83 year old male with history of ischemic
cardiomyopathy with newly further depressed ejection fraction,
severe mitral regurgitation, atrial fibrillation status post
failed cardioversion in [**2104-6-5**], status-post ICD/pace-maker,
who was transferred to [**Hospital1 18**] for further management of dypsnea
and his cardiac problems.
Patient arrived on the floor and was very dyspneic with minimal
exertion. His laboratories were remarkable for creatinine of
4.1, sodium of 132, and INR of 3.4. He was also noted to have
mild hemoptysis.
Hospital course is as followed by system:
#) Congestive heart failure, history of ischemic cardiomyopathy:
Per report from patient's outside hospital, an echocardiogram
was completed prior to transfer that demonstrated a worsened
ejection fraction of 15%, with severe mitral regurgitation (as
compared to echocardiogram from [**2104-6-5**] where his EF was
approximately 30% and MR [**First Name (Titles) **] [**Last Name (Titles) 1192**]). On exam, he appeared
fluid overloaded with rales bilaterally and elevated JVP. A
chest x-ray was completed at admission as well as a bedside
echocardiogram, which confirmed the above findings. Patient was
started on a lasix drip after he failed to diuresis to lasix
boluses on night of admission; a goal urine output of 60cc/hr
was maintained. Hydralazine was added for afterload reduction as
well given his severe mitral regurgitation.
The next day, patient was transferred to the cardiac intensive
care unit for further monitoring and possible Swanz placment
given that he was still very dyspneic with minimal exertion (eg
moving in bed) and possible ionotropic support for diuresis. He
received Diuril in addition to his lasix drip, and continued to
have good diuresis. He was transferred back to the cardiology
floor the next day.
Given that the the patient's symptoms appeared to have worsened
around the time of his pacermaker placement, and he had failed
cardioversion, it was felt that he may have some benefit from a
[**Hospital1 **]-ventricular pacemaker. An electrophysiology (EP) consult was
obtained, and plans were made for placement of a biventricular
pacemaker to help his cardiac output, as he was being paced
approximately 90% of the time. It was also felt that a
tranesophageal echocardiogram (TEE), followed by cardioversion
if no clot was seen, would also be of benefit to give the
patient better cardiac output with "atrial kick."
Patient underwent an upgrade of his pacemaker to a
[**Hospital1 **]-ventricular pacemaker on [**2104-10-1**] and reported improvement in
his symptoms.
He underwent a TEE with subsequent cardioversion on [**2104-10-3**] and
again reported improvement in his symptoms.
He continued to diurese well on the lasix drip, which was
transitioned to intravenous lasix doses and then an oral regimen
(120mg PO daily). At time of discharge, his weight was down over
4 kilograms.
Because of some low blood pressures in hospital his Toprol XL
was restarted at half his dose (25mg [**2-6**] tab daily) His
hydralazine was restarted. An ace-inhibitor or [**Last Name (un) **] was not
started due to his renal function, which improved but continued
to be variable. His digoxin was stopped given his variable renal
function and decompensated failure at time of admission.
He has an ICD in place for primary prevention given his low
ejection fraction. He is on anticoagulation for that as well as
his atrial fibrillation and history of CVA.
If patient continues to have further symptoms from his mitral
regurgitation, mitral valve replacement might be a
consideration, however that was no pursued during this admission
given the improvement in his symptoms with medical therapy and
his multiple other co-morbidities.
#) Gastrointestinal bleed:
On [**2104-9-28**] the patient developed three episodes of bloody stools
which were maroon in color mixed with a significant quantity of
stool. He did not have any subsequent bowel movements or
hematochezia, and was asymptomatic apart from minimal dizziness
following the bowel movements. Given concern for acute
gastrointestinal bleeding from either an upper or lower source,
patient's anti-coagulation was held (he had been on a heparin
drip after his INR was <2.0); his diuresis and beta-blocker were
temporarily stopped. He was started on an intravenous proton
pump inhibitor and maintained on clears. The gastroenterology
team was consulted for further evaluation, and on [**2104-10-2**], the
patient underwent upper endoscopy and colonoscopy. Records were
obtained from the patient's prior colonoscopy, which was from
[**2099**], demonstrating no significant findings. There was some
erosion and friability of the gastric mucosa, however no
bleeding was located. Biopsies of the gastric mucosa and h.
pylori serologies were pending at time of discharge and should
be followed up. It was felt that it was safe to resume
anticoagulation. The prior bleeding was felt to likely be due to
gastritis or an ulcer, which had resolved. He should continue
twice daily proton pump inhibitor until follow up with his
primary care provider or [**Name Initial (PRE) **] gastroenterologist. He had no further
episodes of bleeding and his hematocrit remained stable.
#) Coronary artery disease: Patient has ischemic cardiomyopathy
as evidenced by echocardiogram, and is status post CABG for a
myocardial infarction in [**2084**]. During his stay, he had no
symptoms concerning for acute coronary syndrone. He was
continued on his aspirin once he had no evidence of bleeding, as
well as metoprolol and his statin.
#) Rhythm: Patient has a Pacemaker/ICD in place for history of
atrial fibrillation and for primary prevention given his low
ejection fraction. He had a few episodes of NSVT (less than 10
beats) at the time of his prep for his colonoscopy, with
accompanying electrolyte distrubances, which were felt to be the
cause. He had no further episodes once his electrolyte
abnormalities resolved.
Patient underwent upgrade of his biventricular pacemaker as well
as a TEE with cardioversion as described above. He was started
on an amiodarone load to prevent recurrance of atrial
fibrillation. He will ultimately take 200 mg daily for
maintenance.
His anticoagulation was continued for his history of atrial
fibrillation. His coumadin dose was lowered due to the fact that
he was started on amiodarone.
#) Acute on Chronic Renal Failure: Based on records accompanying
patient, his baseline creatinine appears to range between 0.9 -
1.4 until [**2104-6-5**], at which time it was in the mid 2's. At time
of transfer, his creatinine had risen to over 3, and upon
arrival it was over 4. It was felt that he likely had acute
tubular necrosis from the contrast given to the patient for a
CTA done prior to his transfer, coupled with his low flow state
due to his decompensated congestive heart failure. His
creatinine peaked at 4.4, and then stabalized in the 1.7 to 2.3
range.
#) Hemoptysis: Patient has been experiencing hemoptysis for 2
weeks prior to arrival, which has been dark about half a
spoonful of dark red blood mixed with sputum. It was felt that
was likely secondary to pulmonary edema and subsequent pulmonary
vascular dilation in the setting of supratherapeutic INR. A
pulmonary consult was obtained for further evaluation and
recommendations regarding anticoagulation. His hemoptysis
improved and resolved as his INR normalized. His outside
imaging, including the CTA of this chest was reviewed, and a
repeat CAT scan without contrast was obtained after diuresis to
rule out any signs of malignancy, given his long tobacco use
history and asbestosis exposure. No large lesions were seen,
however "several noncalcified pulmonary nodules, largest
measuring 10 mm" were reported. Patient should have a repeat
chest CT in three months to follow up. The radiology report
notes that a FDG-PET can be non-conclusive in the setting of
surrounding ground-glass opacities.
#) Interstitial Pulmonary Fibrosis: No acute issues. Patient was
weaned off of oxygen. Repeat CAT scan as noted in results.
#) Elevated INR: Patient's Coumadin was held beginning [**9-21**],
however his INR was still 3.4 at admission. He was given vitamin
K to further lower his INR in the event that he needed any
procedures. He was maintained on a heparin drip after his
gastrointestinal work-up and bridged back to coumadin. His INR
was 1.9 on the day of discharge.
#) Anemia: Patient has anemia, which may be due to combination
of renal insufficiency and heart failure. His work up for
gastrointestinal bleeding is as noted above. Iron studies were
obtained and revealed an iron of 26, TIBC of 286, ferritn 260,
and transferritin of 220. He should continue to follow up with
his primary provider for further management of his anemia. He
did not receive any blood transfusions, and his hematocrit
remained stable in the 28-32 range.
.
#) HTN: Patient's blood pressure has been in low 100's and high
90's since admission, likely due to his heart failure. He had no
problems with hypertension during his stay, and his blood
pressure actually remained on the low side, without symptoms.
.
#) Dyslipidemia: Continued home statin dose.
.
#) Possible Sleep Apnea: Consider assessment after patient's
acute cardiac issues have resolved.
.
#) Urinary tract infection: Patient was noted to have an urine
analysis consistent with infection. He had had a foley in place
to monitor diuresis and due to his severe dyspnea with any
exertion. The foley was removed and he completed a course of
treatment with vancomycin given his pencillin allergy.
.
#) Code: Full code.
.
#) Discharge: Patient was evaluated by physical therapy and felt
to be safe for discharge home without services. He had a very
supportive family that was involved in his care. He will follow
up closely with his local cardiologist for a device check and
cardiology appointment.
Medications on Admission:
- Toprol XL 25mg daily
- Lasix 80mg tid (recently discontinued)
- Lisinopril 5mg (discontinued 7/'[**04**])
- Metolazone 2.5mg 3x per week (M, W, F)
- ASA 81mg daily
- Coumadin 5mg daily (initiated 4/'[**04**], held since [**2104-9-21**])
- Simvastatin 10mg daily
- Protonix 20mg daily (initiated 1 month ago)
- PRN Nitroglycerin patch
- Tylenol prn arthritic pain
.
ALLERGIES: PCN (hives), Celebrex, Plaquenil (unknown reaction)
Discharge Disposition:
Home With Service
Facility:
Upper [**Hospital 2748**] Hospital Home Health Agency
Discharge Diagnosis:
Primary Diagnosis:
- Decompensated Heart Failure
Secondary Diagnosis:
- Chronic atrial fibrillation
- Acute renal failure
- Spontaneous GI bleed
- Severe mitral regurgitation
Discharge Condition:
Stable, ambulating without difficulty, cleared by physical
therapy for discharge. On room air.
Discharge Instructions:
You were admitted for further management of your heart failure,
respiratory distress, and atrial fibrillation. You were treated
with several medications. You underwent an upgrade of your
pacemaker as well as cardioversion after transesophageal
echocardiogram. You also underwent an upper endoscopy and
colonoscopy to ensure you had no active gastrointestinal
bleeding.
Please contact your primary care physician, [**Name10 (NameIs) 2085**], or go
to the emergency room if you experience any shortness of breath,
chest pain, headaches, dizziness, bleeding, or other concerning
symptoms.
A number of medication changes have been made, so please review
the changes closely.
You will need to have your coumadin level (INR) followed closely
(once a week until your amiodarone dose is stable) because of
the effect amiodarone has on coumadin levels. You will also need
to have pulmonary function tests completed and have an eye exam
when you return to your home town while on amiodarone.
Please weigh yourself every morning, and call your physician if
your weight increases more than 3 lbs. Please adhere to 2 gram
sodium diet, and limit your fluid intake to 1500 mL daily.
A follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] was scheduled on
[**10-14**] at 11:30am. Dr.[**Name (NI) 79032**] phone number is
[**Telephone/Fax (1) 79033**]. In addition to general cardiac follow-up, your
[**Hospital1 **]-ventricular pacemaker will be checked at this appointment. A
copy of your medical information from this hospital stay will be
faxed to Dr. [**Last Name (STitle) 9404**] at [**Telephone/Fax (1) 79034**]. You should have your INR
(coumadin level) checked regularly (weekly at first given
changes in your medications).
.
A follow-up appointment was also made with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79035**] for [**10-27**] at 3:45pm.
His phone number is [**Telephone/Fax (1) 79036**].
Followup Instructions:
A follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] was scheduled on
[**10-14**] at 11:30am. Dr.[**Name (NI) 79032**] phone number is
[**Telephone/Fax (1) 79033**]. In addition to general cardiac follow-up, your
[**Hospital1 **]-ventricular pacemaker will be checked at this appointment. A
copy of your medical information from this hospital stay will be
faxed to Dr. [**Last Name (STitle) 9404**] at [**Telephone/Fax (1) 79034**]. You should have your INR
(coumadin level) checked regularly (weekly at first given
changes in your medications).
.
A follow-up appointment was also made with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79035**] for [**10-27**] at 3:45pm.
His phone number is [**Telephone/Fax (1) 79036**].
|
[
"5849",
"5990",
"2761",
"4280",
"40390",
"5859",
"2859",
"4240"
] |
Admission Date: [**2145-6-15**] Discharge Date: [**2145-6-18**]
Date of Birth: [**2104-11-11**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 40-year-old
female with a history of C3-C4 spinal cord lesion leading to
quadriplegia, who was admitted initially for a history of
desaturation to 85%, oxygen saturation on room air, and with
increased somnolence. Also, of note, the patient has been
intubated five times during the past month.; Most recently,
the patient has been treated for MRSA in the sputum. The
most recent hospital admission prior to this admission was
between [**6-5**] and [**6-7**], during which time she was
intubated for respiratory distress and hypercarbic
respiratory failure. During that admission, the patient's
sputum was MRSA positive. She was treated with Vancomycin.
Previous admission had been between [**4-7**] to [**2145-4-12**] for
which she was intubated for approximately 36 hours for
hypercarbic respiratory failure. Previous to that she had
been admitted between [**2145-2-28**] to [**2145-3-10**] at the [**Hospital 882**]
Hospital for a right lower lobe pneumonia, which had required
intubation. The patient was noted to be MRSA positive at
that time. She was intubated for approximately seven days
and at that time she refused the placement of her
tracheostomy or PEG. During this admission, the patient, as
noted, has increased shortness of breath and decreased oxygen
saturations with saturations in the 80s. She was able to
speak in full sentences at this time, but she was noted to
have slightly labored breathing. Blood pressure was at her
baseline admission value of 90/60.
PAST MEDICAL HISTORY:
1. C3-C4 spinal cord lesion in [**2139**], status post motor
vehicle accident.
2. Gastroesophageal reflux disease.
3. Depression.
4. Chronic adrenal insufficiency from chronic steroid use.
5. History of anemia.
6. History of heel osteomyelitis.
7. History of decubitus ulcers.
8. History of multiple aspiration pneumonias requiring five
intubations during the last nine months.
ALLERGIES: The patient is allergic to PENICILLIN AND SULFA.
SOCIAL HISTORY: The patient has been a resident at the
[**Hospital 33091**] Rehabilitation Service. Her mother is involved in
her care. She has a history of smoking in the past.
PHYSICAL EXAMINATION: Examination revealed the following on
admission: The patient was a female in no acute distress,
who was alert and oriented times three. Temperature was
98.5, pulse 64, blood pressure 110/57, saturation 90% on room
air. HEENT: Notable for clear oropharynx with positive gag
reflex. NECK: Examination was supple. LUNGS: Lungs were
notable for diffuse and coarse rhonchi bilaterally.
CARDIOVASCULAR: Regular rate and rhythm with no murmurs,
rubs, or gallops. ABDOMEN: Benign. EXTREMITIES: 1+ edema.
The patient was alert and oriented times three. The patient
also had decubitus ulcers. The patient had an ischial wound,
stage 2, with granulation approximately 3 cm deep. The
patient also had an area on the posterior thoracic region of
her skin, which was approximately 4 cm x 4 cm with an eschar.
NEUROLOGICAL: Examination was notable for quadriplegia.
LABORATORY DATA: Laboratory data on admission revealed the
following: White count 9.3, hematocrit 26.3, platelet count
116,000, coagulations and BMP was within normal limits. The
bicarbonate was 26. The patient had a urinalysis, which was
notable for nitrate positive, large leukocyte Estrace
positive, as well as 3 to 5 white blood cells and many
bacteria. EKG: Sinus rhythm with no acute ST or T segment
changes. Chest x-ray: The patient had a persistent left
lower lobe opacity, which was similar to a previous chest
x-ray on [**2145-5-28**].
HOSPITAL COURSE: The patient, initially, was admitted to the
Intensive Care Unit for observation. During this time, the
patient was noted to have good oxygen saturations of 95%, 98%
on room air. The patient's blood pressure has been in the
range of the 90s to 110 systolic blood pressure, which is
near her baseline blood pressure.
The patient also completed her 14-day course of Vancomycin
during this admission. Regarding the patient's pulmonary
status during this admission she also had been given chest PT
to help with her secretions. Albuterol and Atrovent were
also continued.
INFECTIOUS DISEASE: The patient has been completing a course
of Vancomycin for MRSA in her sputum for 14 days, which had
been completed upon admission. The patient also was noted to
have UTI by urinalysis and she was started on a 7-day course
of Ciprofloxacin for the UTI. During the admission, the
patient spiked a fever to 101.2. The patient has been
afebrile for 36 hours and the patient's blood cultures and
urine cultures have no growth to date.
ENDOCRINE: The patient was admitted with a history of
chronic adrenal insufficiency and she was given stress dose
steroids of 100 mg hydrocortisone in the emergency room. The
patient continued on her pre-admission regimen of
Prednisone 5 mg PO q.d. afterwards.
GASTROINTESTINAL: The patient has history of reflux, so we
continued Protonix for that. The patient also was treated
with Reglan and Colace for promotility and stool softening.
DECUBITUS ULCERS: The patient was seen by the Plastic
Service during this admission and they noted that she had the
left ischial wound stage II with approximately 3 cm
granulation tissue, as well as the left posterior thoracic
area with some skin breakdown with approximately 4 cm x 4 cm.
They felt that at this time that these wounds did not need to
be debrided. They recommended b.i.d. wet-to-dry dressing
changes in the ischial wound. They recommended wet-to-dry
changes to the left back wound. They also noted an area of
early breakdown on the right ischemic, for which they
recommended DuoDerm dressing.
In addition, the patient, during this admission, was screened
for rehabilitation and currently the plan is to return to
Brick Farm and at that time the patient will have further
placement and screening from there.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: [**Hospital 33092**] Rehabilitation.
FINAL DIAGNOSIS:
1. Urinary tract infection.
2. History of pneumonia.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg PO q.4h. to 6h.p.r.n.
2. Prednisone 5 mg PO q.d.
3. Protonix 40 mg PO q.d.
4. Ditropan 5 mg PO b.i.d.
5. Iron 325 mg PO t.i.d.
6. Multivitamin one PO q.d.
7. Zoloft 50 mg PO q.d.
8. Estraderm patch.
9. Reglan 10 mg PO q.i.d.
10. Neurontin 900 mg PO b.i.d.
11. Baclofen 20 mg PO q.i.d.
12. Colace 100 mg PO b.i.d.
13. Klonopin 0.5 mg b.i.d.
14. Ciprofloxacin 500 mg PO b.i.d. times 5 days.
15. Albuterol and Atrovent nebulizers q.4h.p.r.n.
16. Albuterol inhaler MDI two to four puffs q.4h. to 6h.
p.r.n.
(DISCHARGE MEDICATIONS CONTINUED ON NEXT PAGE).
17. Atrovent two puffs q.i.d.
18. OxyContin extended 20 mg PO b.i.d.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Doctor Last Name 33093**]
MEDQUIST36
D: [**2145-6-18**] 11:29
T: [**2145-6-18**] 11:34
JOB#: [**Job Number 33094**]
|
[
"5990"
] |
Admission Date: [**2124-7-2**] Discharge Date: [**2124-7-5**]
Date of Birth: [**2074-6-20**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
New onset seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51 y/o male who was in his usual state of health this
morning did some yard work and was then taking a nap on his
couch
when his son observed him falling off the couch and having a
seizure. EMS was called, he was taken to [**Hospital **] hospital where
he had another tonic clonic seizure and was intubated for airway
protection.
Past Medical History:
HTN
Social History:
Drinks ETOH ( quantity unknown by ex-wife)
Family History:
Non contributory
Physical Exam:
T: BP:108 /81 HR:78 R 14 CMV O2Sats 100
Gen: Intubated
HEENT: NCNT
EOMs: intact
Neck: trauma collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft
Extrem: Warm and well-perfused.
Neuro: Off sedation for three min, patient moving all
extremities
purposefully and following simple commands.
Mental status:Alert, intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
Motor: full Strength throughout
Toes downgoing bilaterally
Pertinent Results:
[**2124-7-3**] 03:00AM BLOOD WBC-13.3* RBC-4.81 Hgb-15.5# Hct-41.2
MCV-86 MCH-32.2* MCHC-37.5* RDW-13.5 Plt Ct-218
[**2124-7-2**] 07:35PM BLOOD WBC-12.8* RBC-3.86* Hgb-12.4* Hct-33.2*
MCV-86 MCH-32.2* MCHC-37.4* RDW-13.3 Plt Ct-206
[**2124-7-2**] 07:35PM BLOOD Neuts-87.9* Lymphs-8.6* Monos-2.8 Eos-0.2
Baso-0.5
[**2124-7-3**] 03:00AM BLOOD Plt Ct-218
[**2124-7-3**] 03:00AM BLOOD Glucose-139* UreaN-14 Creat-1.5* Na-141
K-3.4 Cl-103 HCO3-25 AnGap-16
[**2124-7-2**] 07:35PM BLOOD CK(CPK)-112
[**2124-7-3**] 03:00AM BLOOD Albumin-4.2 Calcium-8.8 Phos-3.1 Mg-2.3
[**7-2**] CXR: IMPRESSION:
1. Endotracheal and nasogastric tubes in appropriate position.
2. Mild bibasilar atelectasis with possible mild aspiration.
[**7-2**] CTA Head: IMPRESSION: Low-attenuation right temporoparietal
lesions with coarse internal calcification are seen. The lesion
is better evaluated with the subsequent MRI brain. CT angiogram
of the head is unremarkable.
[**7-3**] MRI Head: IMPRESSION:
Right temporoparietal cortical mass with foci of parenchymal
susceptibility (correlates with calcifications seen on the CT
scan) likely oligodendroglioma.
Brief Hospital Course:
Mr [**Known lastname **] was admited to the NeuroICU for close neurological
monitoring. He was started on Dilantin for seizure prophylaxis.
An CTA of his brain was completed whihc showed a no evidence of
vascular malformation. no vessel occlusion or aneurysm. In
addition an MRI was completed which showed a right
temporoparietal lesion the finding are suggestive of a low-grade
mass lesion, such as an oligodendroglioma.
On [**7-4**] he was more alert, therefore he was cleared for
transfer to the floor. Neuro and Radiation Oncology consults
were requested. They recomended to start decadron for treatment
of surrounding edema and he began taking 2mg [**Hospital1 **] with famotidine
for GI prophylaxis. On the floor he remained seizure free and
remained neurologically intact. He will be DC'd on [**7-5**] to home.
He will follow up with the BTC on [**7-10**] to discuss further care
and treatment. He will continue to take his dilantin as
prescribed. His dilantin level was therapeutic prior to
discharge.
Medications on Admission:
HCTZ
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. 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*
6. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right temporoparietal lesion with calcification
Discharge Condition:
AOx3. Activity as tolerated. No driving.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your office visit.
Followup Instructions:
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**7-10**] at 2
P.M. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2124-7-5**]
|
[
"5180",
"4019"
] |
Admission Date: [**2181-1-11**] Discharge Date: [**2181-1-19**]
Date of Birth: [**2110-4-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
1. Ampullary carcinoma.
2. Reducible umbilical hernia.
Major Surgical or Invasive Procedure:
1. Pylorus preserving Whipple's pancreaticoduodenectomy.
2. Open cholecystectomy.
3. Umbilical hernia repair (separate procedure).
History of Present Illness:
This is a 70 year old male with a pyogenic liver abscesses in
the setting of cholangitis and an obstructed bile duct during
this summer. This is extremely debilitating to Mr. [**Known lastname 73946**], and
he still has not fully recovered to normal.
Prior to this event, however, he was very stout and hardy
healthy man. In the analysis of this problem, he was found to
have obstructing common bile duct stones, and he was referred
for an ERCP. Dr. [**Last Name (STitle) **] performed that and evacuated stones
from his bile duct, and at the same time however, recognized a
fungating mass indicative of a large adenoma at the base of his
bile duct.
Biopsies have been performed on multiple occasions and have
identified this as an ampullary adenoma. However, the most
recent biopsy suggests that there might be a tiny focus of
invasive malignancy at the mucosal level.
He has a threatening mass at the base of his bile duct, which is
clearly an adenoma of the ampulla.
Past Medical History:
1. PAF (only one episode several years ago). s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**]
filter and on coumadin.
2. BPH
3. chronic left hydronephrosis (has urologist)
4. h/o DVT/PE s/p MVC in [**2177**]
5. partial hip replacement in [**2172**] as well as treatment for his
trauma including a pneumothorax, broken ribs and a concussion.
Social History:
lives with wife, retired, former smoker
Physical Exam:
AVSS
Gen: NAD
HEENT: anicteric, PERRLA.
CV: RRR, no M/R/G
Pulm: CTA bilat.
Abd: significant umbilical hernia, which is easily reducible but
quite large.
Soft and nontender. There is a drain in the gallbladder, right
upper quadrant, with normal appearing bile.
Ext: peripheral edema in the lower extremities but this waxes
and wanes according to him based on whether he is upright or
not.
Pertinent Results:
[**2181-1-15**] 05:16AM BLOOD WBC-12.6* RBC-2.78* Hgb-8.0* Hct-24.8*
MCV-89 MCH-28.7 MCHC-32.1 RDW-16.2* Plt Ct-238
[**2181-1-16**] 05:15AM BLOOD Hct-30.2*
[**2181-1-14**] 01:59AM BLOOD Glucose-109* UreaN-20 Creat-0.8 Na-135
K-4.5 Cl-103 HCO3-25 AnGap-12
[**2181-1-15**] 05:16AM BLOOD Glucose-128* UreaN-19 Creat-0.7 Na-139
K-4.0 Cl-104 HCO3-28 AnGap-11
[**2181-1-14**] 01:19PM BLOOD Albumin-2.7*
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2181-1-13**] 11:35 AM
IMPRESSION:
1. No pulmonary embolism. No dissection.
2. Right lower lobe and posterior right upper lobe pneumonia
which could be secondary to aspiration.
3. Small bilateral pleural effusions without abnormal
enhancement.
4. Ascites seen in the left upper quadrant in this patient with
recent abdominal surgery. This is incompletely evaluated on this
study.
.
CHEST (PORTABLE AP) [**2181-1-13**] 6:47 AM
IMPRESSION: Postoperative findings include intraperitoneal free
air, and bibasilar atelectasis, right greater than left. Small
right effusion. No discrete pneumothorax.
.
Cardiology Report ECG Study Date of [**2181-1-13**] 7:53:02 AM
Intervals Axes
Rate PR QRS QT/QTc P QRS T
109 132 88 304/389 43 12 22
.
Brief Hospital Course:
Mr. [**Known lastname 73946**] was went to the PACU extubated following his
operation; for details please see operative note. The patient
recovered in the PACU, and was then sent to the floor for
recovery.
Neuro: The patient had a PCA for pain control. When
appropriate, he was transitioned to PO medications
CV: The patient was put on perioperative metoprolol.
Pulm: IS was encourage, and the patient was mobilized (OOB to
chair, ambulating) when appropriate. On the morning of [**1-13**],
the patient had an acute drop in his oxygen saturation, which
did not immediately improve with a change of oxygenation from
nasal cannula to face tent. An ABG at that time showed poor
oxygenation. The patient received nebulized treatments, labs
were drawn, and an x-ray was performed as well as a CT to rule
out pulmonary embolus. Though there was no pulmonary embolus,
the patient had developed a RUL/RLL pneumonia for which he was
put on levofloxacin. The patient had chest PT, was put on
aspiration precautions, with the head of his bed elevated > 30
degrees. His sputum was also cultured, and the patient was
closely monitored. His respiratory status improved, and the
patient was able to be transitioned back to nasal cannula
oxygen.
GI: The patient was made NPO with a NGT. Per the Whipple
pathway, the NGT was removed on POD 3. His diet was advanced per
the pathway. He was tolerating a regular diet on POD [**8-6**]. He
reported +BM prior to discharge.
His JP amylase was 38 and the drain was removed the next day.
His staples were removed and steri strips applied.
GU: The patient's urinary output was closely monitored; he was
bolused when appropriate. He was diagnosed with a UTI for which
he received levoquin.
Heme: The patient's hematocrit was routinely monitored, and he
received a blood transfusion when appropriate. He received 2
units of PRBC on POD 4 and his HCT rose from 24.8 to 30.2.
Endo: The patient was put on a sliding scale of insulin
ID: Sputum cultures were obtained, however were inadequate. The
patient was put on levoquin for his RUL/RLL pneumonia as well as
his UTI.
Proph: The patient received DVT and GI prophylaxis throughout
his stay.
On discharge, the patient was doing well. He was afebrile with
vital signs stable, ambulating, tolerating diet, and voiding
appropriately.
Medications on Admission:
Flomax, Proscar, MVI
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. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*56 Tablet(s)* Refills:*1*
5. Levofloxacin 500 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily)
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO TID (3 times
a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*24 Tablet(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Diversified VNA and hospice
Discharge Diagnosis:
Ampullary adenoma
Discharge Condition:
Good
tolerating a diet
pain well controlled
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 vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* No heavy lifting >10lbs for 4-6 weeks.
* It is OK to shower and wash, no tub baths or swimming
* Please drink plenty of fluids and maintain your hydration. Eat
several small, frequent meals throughout the day.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2181-2-9**] 9:00
You have been put on a medication to control your blood pressure
called Metoprolol. Please continue to take this medication.
You should follow up with your PCP [**Last Name (NamePattern4) **] [**2-1**] weeks for a blood
pressure check and any medication changes.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2181-2-20**] 11:20
Completed by:[**2181-1-19**]
|
[
"5070",
"5990",
"42731",
"4019",
"V5861"
] |
Admission Date: [**2146-1-9**] Discharge Date: [**2146-1-15**]
Date of Birth: [**2106-11-9**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Status-post crush injury by car
Major Surgical or Invasive Procedure:
Epidural catheter placement
History of Present Illness:
Mr. [**Known lastname **] is a 39 year-old male transferred from [**Hospital3 **]
w/chest injuries. He was working under a car and apparently the
[**Doctor Last Name **] malfunctioned and the car came down on him. He was
transferred to [**Hospital1 18**] for further management of his injuries. His
GCS was 15 upon arrival to the ED. He noted mostly pain in his
sides, right worse than left, with increased pain with
inspiration.
He was initially evaluated in the trauma bay, CXR showing
multiple right-sided rib fractures, a small apical pneumothorax
and subcutaneous emphysema.
Past Medical History:
Thalassemia minor
Social History:
Works as a mechanic, 1 pack-per-day smoking, drinks socially
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
HR: 71 BP: 128/79 Resp: 20 O(2)Sat: 100 Normal
Constitutional: uncomofortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation. crepitance anterior chest
wall on R. Normal chest rise, no evidence of flail.
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, mild upper abd ttp.
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent. normal strength and sensation all 4
ext.
Psych: Normal mood, Normal mentation
Upon discharge:
VS: AVSS O2 saturations 94-96%RA
General: in no acute distress,no increased work of breathing
HEENT:mucus membranes moist, no perioral cyanosis, nares clear,
trachea at midline
CV:regular rate, rhythm. no murmurs, rubs, gallops
Chest:resolving crepitance to right anterior chest.
Pulm:Bilateral breath sounds, clear.
Abd:soft, nontender, nondistended
MSK:warm, well perfused.
Pertinent Results:
[**2146-1-9**] 09:00PM GLUCOSE-122* UREA N-14 CREAT-0.7 SODIUM-138
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14
[**2146-1-9**] 09:00PM CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-1.9
[**2146-1-9**] 09:00PM WBC-19.2* RBC-4.85 HGB-10.5* HCT-32.8*
MCV-68* MCH-21.8* MCHC-32.2 RDW-16.2*
[**2146-1-9**] 09:00PM PLT COUNT-257
[**2146-1-11**] 06:03AM BLOOD WBC-10.9 RBC-4.43* Hgb-9.5* Hct-30.9*
MCV-70* MCH-21.5* MCHC-30.9* RDW-16.0* Plt Ct-187
[**2146-1-14**] 05:09AM BLOOD WBC-5.6 RBC-4.00* Hgb-8.8* Hct-27.4*
MCV-69* MCH-21.9* MCHC-32.0 RDW-16.3* Plt Ct-213
[**2146-1-13**] 05:12AM BLOOD WBC-5.9 RBC-3.77* Hgb-8.5* Hct-26.0*
MCV-69* MCH-22.6* MCHC-32.7 RDW-16.1* Plt Ct-194
[**2146-1-9**] 06:30PM BLOOD PT-12.7* PTT-25.3 INR(PT)-1.2*
[**2146-1-10**] 04:00AM BLOOD Glucose-137* UreaN-13 Creat-0.7 Na-137
K-4.1 Cl-105 HCO3-26 AnGap-10
IMAGING:
[**1-9**] OSH CT torso: chest: no effusion. small right pneumothorax
and air over the right chest wall, with fractures of the right
1st and 2nd ribs anteriorly (small contusion adjacent to first
rib fracture), right 1st posteriorly, and nondisplaced fracture
or posterior right ribs 4, 5, 7, 8, 9. left 3 and 4
posterolateral fractures, nondisplaced. No left pneumothorax or
contusion. bibasilar atelectasis. vertebral bodies and sternum
unremarkable. no evidence of aortic or other mediastinal injury.
no solid organ injury. no free fluid or air. no pelvic or lumbar
fractures.
[**1-9**] OSH CT head and c-spine: head: no intra-cranial hemorrhage
or other acute process; no fractures. C-spine: no fracture or
malalignment. Rib fractures as noted on concurrent torso.
[**1-10**]: CXR: Minimal opacification in the right apical region
could reflect
post-traumatic bleeding. Several displaced rib fractures are
seen on the
left. No evidence of acute vascular congestion or pneumonia.
[**1-14**]: CXR: A small right pneumothorax is less conspicuous than
before. Right subcutaneous emphysema has improved. Bilateral
pleural effusions larger on the right side are unchanged. Right
upper lobe atelectasis is stable. Right lower lobe opacity has
increased due to increasing atelectasis. The left lung is
grossly clear besides the small pleural effusion with minimal
adjacent atelectasis
Brief Hospital Course:
He was admitted to the Acute Care Surgery team and transferred
to the Trauma ICU for close monitoring of his respiratory status
and pain management for his multiple rib fractures. Dilaudid PCA
was started with minimal effect. On HD 2 the Acute Pain Service
was consulted, and an epidural catheter was placed for better
pain control. After placement of the epidural he was transferred
to the regular nursing unit.
His epidural remained in place for 2 days, during this time
Toradol and Neurontin were added. The Toradol was stopped after
24 hours for concern over his low hematocrits; serial
hematocrits were followed and remained low but stable. On HD 5
the epidural was removed and he was noted with increased pain
requiring several adjustments in his oral regimen including
adding IV Toradol back to his regimen and switching from
Oxycodone to Dilaudid. He continued to have moderate pain,
particularly with deep inspirationr or hiccups, of new onset;
Chronic Pain service was consulted a this point to continue his
current regimen with motrin and tylenol in addition to lidoderm
patch.
He was noted with bilateral subcutaneous emphysema; serial chest
xrays were followed which showed resolving bilateral effusions
and small anterior pneumothorax. He was started on nebulizers
and instructed on use of incentive spirometer.
He was evaluated by Physical therapy and cleared for home once
medically stable.
Upon discharge, he was afebrile, maintaining O2sats between
94-95% on room-air, was ambulating and tolerating a regular
diet.
Medications on Admission:
Denies
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
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. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
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. hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
9. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One
(1) Topical once a day for 3 weeks: apply to posterior right
ribs 12 hours on, then 12 hours off.
Disp:*21 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Crush Injury
Rib fractures:
-Right [**12-14**] anteriorly
-Right 1, [**3-21**] posteriorly
-Left [**2-13**] posterolateral
Small right pneumothorax
Small right pulmonary contusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a crsh injury where you
sustained multiple rib fractures on both sides. You were
monitored closley in the hopsital and evalauted by the Pain
Specialisits who placed a special catheter into your back called
an epidural in order to deliver medications in a manner that
would help control your rib pain. After this catheter was
removed you were given oral pain medications and you will be
discharged to home on these.
* Pain from rib fractures can cause you to take shallow breaths.
It is important that you use your incentive spirometer to take
[**7-22**] deep breaths every hour that you are awake. Coughing and
deep breathing should be done at the end of your incentive
spirometer excersises.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: MONDAY [**2146-2-7**] at 2:00 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
**You will need a chest x-ray prior to this appointment. Please
go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.
Completed by:[**2146-1-15**]
|
[
"3051"
] |
Admission Date: [**2198-3-14**] Discharge Date: [**2198-3-17**]
Date of Birth: [**2115-5-26**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Fatigue x 2 weeks
Major Surgical or Invasive Procedure:
Permanent pacemaker placement
History of Present Illness:
82 year old female with hx of bipolar disorder on lithium, HTN,
achalasia, and hypothyroidism presents with fatigue x 2 weeks.
She denies CP/SOB, no fever. She was noted to have bradycardia
during outpatient PT eval and was sent to her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
for further evaluation. He then sent her to the [**Hospital1 **] [**Location (un) 620**] ED.
Rates ranged from 30s to 50s. She has had similar presentations
in the past, in the setting of lithium toxicity.
.
In the ED, initial vitals were: 97.4, 50, 128/56, 97% on 2L NC.
She was noted once again to have HRs in the 30s, with SBPs in
90s. She was given 1L IVF, 0.5mg atropine with resulting vitals
on transfer of: HR 63, BP 125/69, RR 19, O2 sat 100% 3L.
.
Of note, she was last hospitalized at [**Hospital1 18**] in [**2197-3-25**] with
weakness, bradycardia, and tremors attributed to lithium
toxicity in the setting of acute kidney injury, with episodes of
bradycardia to the 30s. She was put on peripheral dopamine
briefly for hypotension and her bradycardia was generally not
responsive to atropine. She is now followed by Neurology as an
outpatient for carpal tunnel syndrome, neuropathic pain in the
feet (on Lyrica, followed by Pain service), lumbar
radiculopathy, and gait unsteadiness (working with PT).
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Achalasia
Bipolar disorder, on chronic lithium
Hypothyroidism ([**12-27**] Li toxicity)
Gait disorder
Carpal tunnel syndrome
Frequent UTIs and urinary incontinence
s/p cataract removal in left eye
rotator cuff tear
GERD
Social History:
Lives alone. Independent in ADLs.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission:
VS: T=97.4, BP=119/44, HR=58, RR=20, O2 sat=97%
GENERAL: elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT, PERRL, EOMI, sclera anicteric. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Mild sinus
tenderness. No xanthalesma.
NECK: Supple with no JVD, no carotid bruits, no LAD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1/S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Moderate kyphosis. Resp were unlabored, no accessory
muscle use. Crackles to right middle and lower lung fields, with
mildly decreased BSs at the right base. No wheezes or rhonchi.
ABDOMEN: Soft, NT/ND. No HSM or tenderness.
EXTREMITIES: No c/c. Mild edema over LE bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
NEURO: CN II-XII intact, 5/5 strength in UEs and LEs, intact
sensation to light touch, reflexes and cerebellar testing not
assessed. Mild resting tremor.
On discharge: no changes to exam.
Pertinent Results:
Labs on admission:
[**2198-3-15**] 04:55AM BLOOD WBC-7.4 RBC-3.59* Hgb-11.1* Hct-34.3*
MCV-95 MCH-30.9 MCHC-32.4 RDW-14.0 Plt Ct-341
[**2198-3-15**] 04:55AM BLOOD PT-12.8 PTT-23.7 INR(PT)-1.1
[**2198-3-15**] 04:55AM BLOOD Glucose-94 UreaN-27* Creat-0.8 Na-141
K-4.6 Cl-114* HCO3-22 AnGap-10
[**2198-3-15**] 04:55AM BLOOD ALT-14 AST-18 LD(LDH)-126 CK(CPK)-31
AlkPhos-44 TotBili-0.3
[**2198-3-15**] 04:55AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.7 Mg-2.1
[**2198-3-16**] 05:24AM BLOOD VitB12-336
[**2198-3-15**] 04:55AM BLOOD CK-MB-2 cTropnT-<0.01
[**2198-3-15**] 04:55AM BLOOD TSH-0.21*
[**2198-3-15**] 04:55AM BLOOD Free T4-1.4
Lithium
[**2198-3-15**] 04:55AM BLOOD Lithium-1.2
[**2198-3-16**] 05:24AM BLOOD Lithium-0.8
MICROBIOLOGY:
OTHER STUDIES:
EKGs:
#1 on admission: Sinus bradycardia with A-V conduction delay.
Otherwise, normal tracing. Since the previous tracing of [**2197-4-13**]
low T wave amplitude has improved.
#2: Sinus rhythm with possible S-A nodal block (question type
II). Clinical correlation is suggested. Since the previous
tracing of same date the rhythm as outlined has replaced sinus
bradycardia.
#3: Sinus bradycardia with slight A-V conduction delay.
Otherwise normal tracing. Since the previous tracing of [**2198-3-14**]
possible S-A nodal block is now absent.
IMAGING:
TTE: The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Right ventricular chamber size and free wall
motion are normal. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
left ventricular inflow pattern suggests impaired relaxation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
CXR: One view. Comparison with the previous study of [**2197-4-14**].
The lungs remain clear except for streaky density at the lung
bases consistent with
subsegmental atelectasis. The heart and mediastinal structures
are unchanged. The bony thorax is grossly intact. A bipolar
transvenous pacemaker has been inserted on the left with intact
electrodes terminating in the regions of the right atrium and
right ventricular apex.
IMPRESSION: Bibasilar subsegmental atelectasis. Transvenous
pacemaker in
place.
Brief Hospital Course:
82 year old female with hx of bipolar disorder on lithium, HTN,
and hypothyroidism, presents with recurrent episode of
symptomatic bradycardia secondary to lithium toxicity, here for
consideration of pacemaker placement.
.
ACTIVE ISSUES
.
# RHYTHM / Bradycardia [**12-27**] lithium toxicity: She was initially
bradycardic down to 30s along with hypotension down to SBPs of
90s, somewhat responsive to atropine (though noted to have very
little effect in the past). Cardiology described her rhythm as
junctional with ?sinus exit block or atrial escape. Lithium
levels were checked and she was only slightly supratherapeutic
and her PM dose was held prior to repeating a level the
following morning. Her normal home dosing was then restarted.
Her valsartan was held, given her hypotension at the OSH. Given
her need for long-term mood stabilization for bipolar disorder
and recurrent episodes of symptomatic bradycardia, it was felt
that a pacemaker was the most logical next step for her. Also,
chronic lithium therapy can affect sinus node function in the
long-term. Atropine was kept at the bedside prior to her
pacemaker placement. TTE on the morning following admission was
normal. The Electrophysiology team placed a permanent pacemaker
([**Company 1543**] Adapta L ADDRL1, SN: NWE231413H) and she was
discharged on cephalexin for 3 days after 1 dose of IV
vancomycin in house. She will be discharged with close
Electrophysiology follow-up.
.
# Hypothyroidism: Her TSH was recently just below the normal
range at 0.24, indicating relative hyperthyroidism from likely
over-replacement. fT4 was normal at 1.4. Her dose was initially
lowered to 50mcg prior to fT4, but restarted back at 75mcg.
While on lithium and levothyroxine, routine TSH testing should
continue as an outpatient.
.
INACTIVE ISSUES
.
# CORONARIES: There was no evidence of ischemia causing her
bradycardia, without ST changes on EKG. Initial Trop <0.01 and
cardiac enzyme trend was unremarkable. TTE did not show any wall
motion abnormalities.
.
# Achalasia: No recent difficulties with eating. She sees
gastroenterology as an outpatient, but previous motility studies
have been unremarkable.
# Bipolar disorder: On lithium chronically, with episodes of
lithium toxicity in the past, already manifested by thyroid
disease. No recent symptoms, well controlled with mood
stabilizers.
.
# Carpal tunnel syndrome - Previously with wrist splint, now
choosing to undergo surgery for release. Scheduled in about 1
month.
.
TRANSITIONAL ISSUES
.
#. Follow-up: She will follow-up closely with the
Electrophysiology Department as an outpatient.
.
#. Communication: [**Name (NI) 803**] [**Name (NI) 1124**] (HCP, daughter - [**Telephone/Fax (1) 71234**])
Medications on Admission:
Aspirin 81 mg a day
Citracal 950mg [**Hospital1 **]
Claritin 10mg daily PRN allergy symptoms
Detrol 2mg PRN incontinence
Diovan 80mg [**Hospital1 **]
Levothyroxine 75 mcg daily
Lithium 300mg qAM, 150mg qPM
Lorazepam 0.5mg daily PRN anxiety
Lyrica 50 mg TID
Omeprazole 20mg daily
Zonalon cream 5% q6h PRN pain/itching
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Citracal Regular Oral
3. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
4. Detrol 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for incontinence.
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
7. lithium carbonate 150 mg Capsule Sig: One (1) Capsule PO QPM
(once a day (in the evening)).
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
9. Lyrica 50 mg Capsule Sig: One (1) Capsule PO three times a
day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Zonalon 5 % Cream Sig: One (1) application Topical q6h () as
needed for itching.
12. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 3 days: start date:[**2198-3-18**]
end date:[**2198-3-20**].
Disp:*9 Capsule(s)* Refills:*0*
13. tramadol 50 mg Tablet Sig: 0.5 to 1 Tablet PO every six (6)
hours as needed for pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
14. Outpatient [**Month/Day/Year **] Work
Please have your primary care doctor check your lithium level in
the week after your discharge.
15. valsartan 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: bradycardia (sinus exit 2:1 block in setting of chronic
lithium usage), fatigue
Secondary: bipolar disorder, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 15131**],
You were admitted to the hospital for slow heart rate that is
likely secondary to chronic lithium usage. Since you will need
to remain on lithium, a pacemaker was placed to keep your heart
rate at a good rate. Given that you are fatigued, please visit
your primary care doctor for further evaluation.
You will also need to get your lithium level checked within a
week of discharge. Please have this done at your primary care
doctor's office.
Post-pacemaker placement instructions:
* Avoid any efforts with left arm. Avoid lifting heavy objects.
Avoid raising arm above the level of the shoulder for AT LEAST
ONE MONTH.
* You can wear the shoulder sling for comfort
* Do not drive for at least 4 weeks after the procedure
* Given that you have a pacemaker, you cannot be in magnetic
fields. You cannot have MRI. You cannot go through the regular
security at airports.
* Do not place cell phone in direct contact with pacemaker.
* Please report back to the hospital if you have fever or notice
pus or swelling coming from the pacemaker pocket.
* The steri-stripes under the dressing MUST remain in place. The
dressing can be removed if needed or it becomes bothersome.
* You MUST cover up the wound when taking a shower. DO NOT a
BATH.
Medication changes:
START keflex (an antibiotic) to prevent infection after
pacemaker placement for 3 days. Last dose is on [**2198-3-20**].
START tramadol for pain after your procedure. This medication
may make you constipated, so it is important to take
anti-constipation medicatons such as senna and colace if you are
not able to have consistent bowel movements.
Followup Instructions:
Since it is the weekend, we were unable to schedule all your
appointments. Please follow-up with your primary care doctor
within a week of discharge to check your lithiuim level and your
psychiatrist within 2-3 weeks of discharge
Department: CARDIAC SERVICES
When: THURSDAY [**2198-3-22**] at 1:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2198-8-9**] at 10:30 AM
With: [**Name6 (MD) 161**] [**Name8 (MD) 6476**], MD [**Telephone/Fax (1) 2998**]
Building: None [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
|
[
"4019",
"53081"
] |
Admission Date: [**2136-5-11**] Discharge Date: [**2136-5-15**]
Date of Birth: [**2054-6-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
angina for one day, in back, and anteriorly as well as abd. pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
81 yo male presented to OSH with abd. pain radiating to his
back. Also had a fever with temp of 103. He described pain as
intermittent,pulsating, and gripping with associated SOB. CT
scan at OSH suggestive of intramural hematoma of aorta.
Transferred here for further management.
Past Medical History:
Abd. aortic aneurysm
HTN
? bronchitis
PSH: none
Social History:
widowed, lives with son
quit smoking 3 years ago ( unclear as to amount)
no ETOH
Physical Exam:
T 97.2 HR 78 SR with freq. PVCs 106/53 RR 18 3L NC sat
100%
awake, uncomfortable, poor historian, but oriented
neuro grossly non-focal
RRR, no rub or murmur
BS clear with scattered wheezes
+ BS, initially firm to palpation associated with pain. but
subsequently soft and NT
extrems warm, knees mottled
fem 1+ bil., popl. NP, 1+ bil/ DP/PT, 2+ bil. radials
Pertinent Results:
[**2136-5-10**] 11:45PM BLOOD WBC-20.0* RBC-3.13* Hgb-10.0* Hct-28.8*
MCV-92 MCH-31.8 MCHC-34.7 RDW-14.2 Plt Ct-118*
[**2136-5-12**] 04:42AM BLOOD WBC-16.4* RBC-2.68* Hgb-8.6* Hct-24.0*
MCV-90 MCH-32.2* MCHC-35.9* RDW-14.4 Plt Ct-92*
[**2136-5-10**] 11:45PM BLOOD Neuts-62 Bands-25* Lymphs-3* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2136-5-10**] 11:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2136-5-12**] 04:42AM BLOOD Plt Ct-92*
[**2136-5-10**] 11:45PM BLOOD Glucose-138* UreaN-31* Creat-2.6* Na-139
K-3.5 Cl-103 HCO3-22 AnGap-18
[**2136-5-12**] 04:42AM BLOOD Glucose-153* UreaN-39* Creat-2.4* Na-136
K-3.4 Cl-100 HCO3-27 AnGap-12
[**2136-5-11**] 08:04AM BLOOD ALT-11 AST-24 LD(LDH)-238 AlkPhos-44
Amylase-23 TotBili-0.7
[**2136-5-11**] 08:04AM BLOOD Lipase-8
[**2136-5-10**] 11:45PM BLOOD CK-MB-5 cTropnT-0.02*
[**2136-5-11**] 08:04AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.6
[**2136-5-14**] 05:25AM BLOOD Vanco-12.7
[**2136-5-10**] 11:51PM BLOOD Lactate-2.8*
RADIOLOGY Final Report
ESOPHAGUS [**2136-5-11**] 9:27 AM
ESOPHAGUS
Reason: R/O esophageal perforation, use thin barium
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with
REASON FOR THIS EXAMINATION:
R/O esophageal perforation, use thin barium
HISTORY: 81-year-old male with probable infected aortic
hematoma. Evaluate for esophageal perforation.
Comparison is made to prior CT examination dated earlier on same
day.
ESOPHAGRAM.
Multiple thin sips of Optiray contrast was administered followed
by thin barium. No abnormal extravasation of contrast is noted
outside of the esophageal lumen, which displayed normal primary
peristaltic contractions and diffuse tertiary contractions. No
evidence of hiatal hernia or reflux is noted on this limited
exam. Contrast and thin barium was noted to pass freely through
the esophagus into the stomach.
IMPRESSION:
No evidence of esophageal perforation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: FRI [**2136-5-11**] 2:14 PM
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2136-5-11**] 12:49 AM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
Reason: please characterize aorta
Field of view: 36 Contrast: VISAPAQUE
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with known AAA and ? thoracic hematoma
REASON FOR THIS EXAMINATION:
please characterize aorta
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 81-year-old with known AAA and chest pain radiating
to the back, evaluate for dissection.
COMPARISONS: None.
TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis
with and without 90 cc of nonionic Visipaque contrast. Please
note that despite the patient's elevated creatinine of 2.6, the
ED and the covering vascular surgery team thought that the study
with emergent enough to rule out a type A dissection for which
contrast was warranted. The risks and benefits were discussed
with the patient prior to the study.
CT VASCULAR: On the non-contrast images, there is an extensive
type B aortic intramural hematoma, extending from the takeoff of
the left subclavian artery, to just proximal to the celiac axis.
There is a tiny linear area of non- enhancement involving the
arch distal to the takeoff of the left subclavian, which could
represent a very early dissection flap. There is a large
penetrating ulcer involving the proxiaml descending thoracic
aorta. Additionally, there is a large amount of air within the
aortic wall at this level and also at several other locations in
the abdominal aorta. Specifically, there is prominent air
involving the posterior aortic wall just inferior to the renal
artery takeoff. another focus involving the anterior aortic wall
just inferior to this. Finally, there is air seen within the
proximal right common iliac artery. Note is made of stenosis at
the celiac artery origin. The SMA and [**Female First Name (un) 899**] are widely patent.
CTA CHEST WITH IV CONTRAST: There are small bilateral pleural
effusions and atelectasis. The heart, pericardium, and great
vessels are unremarkable. There is no evidence of hematoma
within the mediastinum nor pericardium. There is trace coronary
artery calcification. This nongated study does not provide
optimal evaluation of the coronary arteries. The pulmonary
arteries enhance normally.
CT ABDOMEN WITH IV CONTRAST: Hypodense lesion in segment III of
the liver anteriorly, likely a cyst or hemangioma but not fully
characterized. Small hyperenhancing lesion in segment VII. There
is left-sided intrahepatic biliary ductal dilatation and mild
prominence of the extrahepatic common duct. The native kidneys
are minimally atrophic. The spleen, pancreas, adrenal glands,
stomach, and proximal bowel are unremarkable.
CT PELVIS WITH IV CONTRAST: No acute abnormalities are seen in
the pelvis. There are bilateral fat-containing inguinal hernias.
Evaluation of the osseous structures demonstrates only diffuse
degenerative changes.
MULTIPLANAR REFORMATS: Coronal and sagittal reformatted images
confirm the above findings. There is diffuse atherosclerotic
disease throughout the abdominal aorta. There is a large
infrarenal aortic aneurysm, measuring up to 5 cm in sagittal AP
dimension.
IMPRESSION:
1) Extensive type B aortic intramural hematoma, extending from
the origin of the left subclavian artery to the upper abdominal
aorta. No definite aortic dissection, however, there is a tiny
linear hypodensity involving the mid aortic arch medially, which
may be the very beginning of an aortic dissection flap.
2) Multiple foci of air within the aortic wall, highly
suspicious for multifocal mycotic aneurysms, the most prominent
in the proximal descending aorta adjacent to the large
pseudoaneurysm/penetrating ulcer, likely the origin of the
patient's intramural hematoma.
3) No colonic lesion or evidence of diverticulitis to account
for the aortic wall air, though colonoscopy may be considered
after the patient is stabilized.
4) 5-cm infrarenal aortic abdominal aneurysm.
5) Moderate left-sided intrahepatic biliary ductal dilatation.
6) Hyperenhancing segment VII and hypodense segment III hepatic
lesions, not fully characterized on this study, the former could
be further assessed by MRI.
Findings were discussed immediately after the study with the
covering cardiothoracic surgery fellow, Dr. [**Last Name (STitle) 71624**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21884**]
Approved: FRI [**2136-5-11**] 3:57 PM
Brief Hospital Course:
Admitted to CSRU from ER on [**5-11**] early AM and re-scanned
urgently. Results showed the infrerenal AAA as well as a Type B
intramural hematoma. Also noted were multiple foci of intramural
air consistent with a possible mycotic process, and a
penetrating ulcer of the thoracic aorta ( please see above
results of study). ID consult requested and pt. started on
triple antibiotic therapy with blood cultures and RPR sent.
Thoracic and vascular surgery also consulted as well as Dr.
[**Last Name (STitle) 914**] from CT surgery. Not a candidate for open repair of TAA
per vascular, but endo stent-grafting would be considered if
aorta further dilates of symptoms worsened. General surgery also
evaluated patient, with no change in plan for abx therapy and BP
control. Gram positive rods grew from blood cultures with
diagnosis of clostridium aortitis. Barium swallow did not reveal
any fistula.
High-risk surgery was discussed with the pt. and his family.
They refused surgery and opted for medical therapy. The pt. also
declined possible intubation and requested he not be
resuscitated. Pt. requested comfort measures only. PICC line
placed for continued abx therapy. Transferred to the floor on
[**5-12**]. Fentanyl patch and morphine continued for pain/palliative
care. BS coarse throughout on [**5-14**] with increasing somnolence.
Throughout the night, he became more hypotensive and
unresponsive to fluid therapy.
He did not appear to be in distress. At 5AM, he had cessation of
pulse, heart sounds and respirations. He was pronounced expired
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Medications on Admission:
HCTZ
lisinopril
(doses unknown)
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Mycotic Thoracoabdominal Aneurysm
HTN
Discharge Condition:
expired
Completed by:[**2136-5-15**]
|
[
"5859",
"40390"
] |
Admission Date: [**2115-5-15**] Discharge Date: [**2115-5-26**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Rectosigmoid colon cancer
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy
2. Low anterior resection
3. Hartmann's end colostomy
4. Feeding transgastric jejunostomy
5. Splenic flexure takedown
History of Present Illness:
[**Known firstname **] is an 88-year-old female with a history of lower abdominal
pain, heme positive stool who initially did not want evaluation
and workup but then conceded to a sigmoidoscopy. Sigmoidoscopy
demonstrated a large rectosigmoid mass that was biopsied and
showed high-grade dysplasia with likely adenocarcinoma. CT scan
showed a large mass in the pelvis. She was seen in the hospital
and as an outpatient and offered low anterior resection with
possible
colostomy. Risks and benefits of the procedure were discussed.
Consent was reviewed and signed.
Past Medical History:
MONOCLONAL GAMMOPATHY
DEMENTIA
HYPERTENSION
? of ANGINA, STABLE- PERSANTINE THALLIUM NEGATIVE [**4-18**]
OSTEOARTHRITIS
BACK PAIN- S/P LUMBAR DISC [**Doctor First Name 147**].
S/P ARTHROPLASTY KNEE, TOTAL REPLACEMENT, BILAT
HEADACHE
ESOPHAGITIS, REFLUX
OSTEOPOROSIS
? of GOUT- LEFT GREAT TOE
ATOPIC DERMATITIS
S/P INGUINAL HERNIA REPAIR, BILAT
S/P TOTAL HYSTERECTOMY [**2075**]
S/P REMOVE GALLBLADDER
S/P REMOVAL OF APPENDIX
? of POLYMYALGIA RHEUMATICA
SHOULDER PAIN, RIGHT, CHRONIC
RESTLESS LEG SYNDROME
.
MEDS:
ATENOLOL TAB 100MG one tab po qd \
FOSAMAX TABS 70 MG 1 tab po qweek
PROTONIX 40 MG Daily
MULTIVITAMIN one po qd
CALCIUM CARB CHW 500MG 2-3 per day
METROCREAM 0.75 % CREAM apply qd
DOXEPIN HCL 50 MG CAPS 1 cap po qhs
TRAMADOL HCL 50 MG 2 tabs po qd 4- 6 hours prn--not using
FUROSEMIDE TAB 20MG po qam
LISINOPRIL 5 MG TABS po qhs
REQUIP 2 MG TABS po 1 hour before bedtime
.
NKDA
Social History:
Married. Two sons who live in the area. Currently at [**Location (un) 8220**] NH. Pt is a holocaust survivor.
Family History:
unknown
Physical Exam:
AVSS
Gen: nad
CV: RRR
Chest: CTAb
Abd: S/ND, appropriately tender, surgical incision intact with
no signs of infection, stoma pink
Ext: WWP, non-tender
Pertinent Results:
[**2115-5-15**] 05:34PM BLOOD WBC-5.8 RBC-3.42* Hgb-10.5* Hct-30.9*
MCV-90 MCH-30.7 MCHC-34.0 RDW-15.5 Plt Ct-314#
[**2115-5-16**] 01:29AM BLOOD WBC-8.2 RBC-3.34* Hgb-10.4* Hct-29.9*
MCV-90 MCH-31.2 MCHC-34.9 RDW-15.9* Plt Ct-330
[**2115-5-17**] 04:50AM BLOOD WBC-8.7 RBC-3.17* Hgb-9.9* Hct-28.6*
MCV-90 MCH-31.2 MCHC-34.5 RDW-16.0* Plt Ct-312
[**2115-5-18**] 05:20AM BLOOD WBC-6.6 RBC-3.17* Hgb-10.2* Hct-28.8*
MCV-91 MCH-32.0 MCHC-35.3* RDW-15.8* Plt Ct-334
[**2115-5-19**] 06:00AM BLOOD WBC-4.9 RBC-3.13* Hgb-9.7* Hct-29.0*
MCV-93 MCH-30.9 MCHC-33.3 RDW-16.0* Plt Ct-305
[**2115-5-15**] 05:34PM BLOOD Glucose-146* UreaN-13 Creat-0.8 Na-140
K-3.9 Cl-108 HCO3-25 AnGap-11
[**2115-5-16**] 01:29AM BLOOD Glucose-124* UreaN-15 Creat-1.0 Na-139
K-4.1 Cl-107 HCO3-24 AnGap-12
[**2115-5-17**] 04:50AM BLOOD Glucose-102 UreaN-17 Creat-1.0 Na-139
K-3.9 Cl-106 HCO3-25 AnGap-12
[**2115-5-18**] 05:20AM BLOOD Glucose-133* UreaN-14 Creat-0.9 Na-139
K-3.2* Cl-104 HCO3-26 AnGap-12
[**2115-5-19**] 06:00AM BLOOD Glucose-123* UreaN-13 Creat-0.7 Na-141
K-4.2 Cl-104 HCO3-29 AnGap-12
[**2115-5-20**] 05:25AM BLOOD Glucose-120* UreaN-15 Creat-0.7 Na-141
K-3.9 Cl-104 HCO3-29 AnGap-12
[**2115-5-19**] 06:00AM BLOOD ALT-7 AST-20 AlkPhos-71 TotBili-0.4
[**2115-5-20**] 05:25AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8
Brief Hospital Course:
88F with pre-operative diagnosis of rectosigmoid cancer admitted
for scheduled, elective sigmoid colectomy.
Informed consent was obtained.
Pt tolerated the procedure well but was kept intubated and
admitted to the ICU overnight for anesthesia concerns and the pt
being slow to wake after general anesthesia. Pt did well
overnight in the ICU with no issues.
On POD1 she was extubated with no complications. Her NGT was
also removed. She was transferred to the floor.
Her bowel functions slowly returned to function and her diet was
advanced from sips to clears to regular diet as well as her
tubefeeds via the j-tube were advanced which she was tolerating
well. She had several episodes of emesis but a f/u KUB showed
the G-J tube to be in place. The G-tube balloon was reduced by
10cc for the possibility that that could be causing some mild
obstruction. She had had no episodes of vomiting for greater
than 24hrs on the day of discharge.
The geriatric service was consulted and assisted us with her
care in terms of medications and sleep aids. Of note, she
continued to be somewhat sleepy during her post-operative
course. The geriatric service felt that this might be due to
her haldol, trazodone and/or remeron but they had no definite
explanation. Haldol and trazodone were held and her remeron was
reduced then also d/c'ed. Once all of these medications were
discontinued, she was much more alert and oriented equivalent to
her baseline.
Physical and occupational therapy evaluated the patient and
deemed her in need of rehab placement.
Of note, her stool was sent for c.diff which came back positive.
Although she was afebrile and she did not have a white count,
she was started on flagyl given the positive cultures for a
course of 14 days.
On the day of discharge she was afebrile, VSS, incision CD&I,
and tolerating feeds and regular diet.
Medications on Admission:
Lopressor 150', Mirtazapine 15', Prilosec 20', Trazadone 75', Ca
500''', Vit D, Colace 100', Fe, MVI
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO every 4-6 hours as needed for pain.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
10. Lactobacillus Acidophilus Capsule Sig: One (1) Capsule
PO twice a day for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Rectosigmoid colon cancer
Discharge Condition:
stable
Discharge Instructions:
Call or come back in if you experience fevers, chills, [**Hospital6 **],
vomiting, increasing redness, increased swelling, bleeding or
purulent discharge from your incision, increasing pain, or any
other concerns.
You should only take pain medications as needed. Take stool
softeners to prevent constipation.
.
It is okay to shower but do not soak your wound. Do not immerse
your wound in water for at least 4 weeks postoperatively. Do not
lift greater than [**10-2**] lbs for 4 weeks.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) 2819**] in [**6-27**] days. Please call his office to
verify your appointment: ([**Telephone/Fax (1) 6347**]
|
[
"4019"
] |
Admission Date: [**2125-1-19**] Discharge Date: [**2125-1-21**]
Service: MEDICINE
Allergies:
Codeine / Adhesive
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
Blood transfusion.
History of Present Illness:
81 yo woman with hx of CAD, Afib, CKD here after few weeks of
progressive fatigue and anemia over which time she noted dark
black stools which she attributed to her iron supplementation,
she has been off iron for a few weeks and was started on IV iron
and eopgen shots per her nephrologist as anemia thought to be
secondary to her renal insufficiency. They were unable to
transfuse her with a Hct of 23 b/c of difficult anitbody match
and very trying other methods to support her anemia. She has
had chronic anemia initially was on B12 shots, but increasing
difficulty recently. She was transfused many yrs ago and also
after her right BKA.
.
She was seen at [**Hospital3 7569**] and noted to have an INR 10.1
and Hct 14.9, was given 2uFFP, Vitamin K and sent over because
of difficult to transfuse anemia and Gi evaluation.
.
NGL here was clear with 400cc per ED and stool was dark brown
with guiaic positive.
.
Currently getting 1uPRBC and 2u FFP and overall still feels
tired but has her chronic arthritis pain. She denies any CP,
SOB or palpitations. She admits to DOE at 10-15 feet, some
nausea, but no vomiting, no abd pain or other complaints.
Past Medical History:
Paroxysmal Atrial fibrillation on coumadin
CAD
CHF normal EF, diastolic dysfunction
Anemia-- chronic of unknonw etiology
Rheumatic fever at age 7, no known valvular disease
Diabetic diet controlled, very sensitive to insulin
Right elbow surgery.
Right hip total joint arthroplasty with sciatic injury and
neuropathy s/p stasis ulcers and gangrene resulted in right
right BKA
Bilateral mastectomy for breast cancer; the first 23years ago,
the second 15 years ago.
Status post cataract surgery in both eyes.
Bladder cancer, status post surgery with recurrent bladder
polyps, has placed local chemo [**Doctor Last Name 360**] placed by her chemo
Status post foot surgery in [**2117**]
Hypertension times 35 years
Diabetes mellitus, diet controlled times three to four years
Gout
Chronic renal insufficiency with a baseline of mid 2's
Hx of DVT
Social History:
She is a retired office worker. Lives with her husband, son and
daughter in law [**Name (NI) 2048**] [**Name (NI) 30075**] her HCP [**Telephone/Fax (1) 30076**]. She does not
smoke, nor does she drink.
Family History:
Her mother died at 68 of a heart attack. Her father died at 57
of stomach cancer.
Physical Exam:
VS: T 98.0 BP 133/45 P 64 R18 Sat 99%Ra and 100%2L
GEN aao, nad
HEENT PERRL, MMM, +pallor conjunctiva, neck supple with minimal
JVD
CHEST CTAB no wheezes, crackles.
CV RRR no murmurs, distant heart sounds.
ABD soft, Nt/ND, +BS, guaiac +, brown stool.
EXT right BKA, left LE with trace LE edema, 1+Dp pulses
NEURO a&ox3, cn ii-xii intact; motor, sensory, coordination, and
language grossly intact.
Pertinent Results:
[**2125-1-20**] 11:33PM BLOOD WBC-18.8*# RBC-3.28*# Hgb-10.4*#
Hct-28.0*# MCV-85 MCH-31.7 MCHC-37.2* RDW-20.7* Plt Ct-328
[**2125-1-19**] 07:00AM BLOOD WBC-10.8 RBC-1.37*# Hgb-3.9*# Hct-13.1*#
MCV-95# MCH-28.2 MCHC-29.6* RDW-23.6* Plt Ct-418
[**2125-1-19**] 07:00AM BLOOD Neuts-81.4* Lymphs-12.5* Monos-3.3
Eos-2.3 Baso-0.5
[**2125-1-19**] 07:00AM BLOOD PT-18.8* PTT-39.9* INR(PT)-2.5
[**2125-1-19**] 07:00AM BLOOD Plt Ct-418
[**2125-1-19**] 07:00AM BLOOD Ret Aut-7.5*
[**2125-1-19**] 07:00AM BLOOD Glucose-124* UreaN-70* Creat-2.7* Na-143
K-4.3 Cl-108 HCO3-22 AnGap-17
[**2125-1-20**] 11:33PM BLOOD Glucose-122* UreaN-66* Creat-2.6* Na-140
K-4.0 Cl-105 HCO3-23 AnGap-16
[**2125-1-19**] 07:00AM BLOOD ALT-11 AST-12 LD(LDH)-164 CK(CPK)-46
AlkPhos-62 Amylase-78 TotBili-0.1
[**2125-1-19**] 07:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2125-1-20**] 11:33PM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8
[**2125-1-19**] 07:00AM BLOOD calTIBC-265 VitB12-385 Folate-7.6
Hapto-230* Ferritn-220* TRF-204
[**2125-1-19**] 07:00AM BLOOD TSH-4.1
[**2125-1-19**] 09:48PM BLOOD Free T4-1.1
.
ECG: Sinus rhythm. First degree atrio-ventricular conduction
delay. Left bundle-branch block with secondary repolarization
abnormalities.
Brief Hospital Course:
A/P: 81 yo woman with CAD, Afib, CHF, CKD admitted with
worsening anemia in setting of supratherapeutic INR. Was seen at
OSH but had difficult antibodies for RBC transfusion,
transferred to [**Hospital1 18**] for further management.
.
Anemia: Likely acute blood loss superimprosed on chronic
underproduction from chronic kidney dx or even possibly from her
history of local chemotherapy for bladder cancer treatment. Hct
increased from 13 on admission to 28 with 4 units pRBCs.
Patient had melanotic stools x1, otherwise was asymptomatic.
Was diuresed with IV lasix with transfusions, and her BB/CCB
were held on admission, so as not to mask reflex tachycardia in
the setting of acute blood loss. At the time of discharge, she
was hemodynamically stable and her home doses of BB and CCB were
restarted.
.
GI bleed: Pt. was transfused to support anemia, and
anticoagulation was reversed with Vit. K and FFP. Pt. will have
a colonoscopy/EGD as outpatient to be arranged this week.
Aspirin and coumadin will be held until after GI studies are
completed. Pt. has h/o labile INR and was supratherapeutic (INR
2.5) on admission, so will have to be cautious when
anticoagulation is restarted. Encouraged Pt. to have frequent
INR checks.
Medications on Admission:
atenolol 50 mg p.o. [**Hospital1 **]
glucosamine
chondroitin
allopurinol 100mg qd
coumadin 2.5 M-F/1.25 S/S
lasix 40mg qd
norvasc 10mg qd
prevacid 30mg qd
tapazole 5mg qd
oscal
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Glucosamine / Chondroitin
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Anemia, GI Bleed
Discharge Condition:
Fair, stable.
Discharge Instructions:
Continue to monitor your symptoms. Return to the emergency room
immediately for bloody or black stools, chest pains, shortness
of breath, increased lightheadedness, or any other symptom which
concerns you.
.
For today ([**1-21**]) only, if you are feeling short of breath,
please take an extra lasix (furosemide) pill.
.
Please arrange for colonoscopy as soon as possible.
.
Please arrange to see a PCP after your colonoscopy so that your
coumadin can be restarted. Do not take coumadin or aspirin
until this appointment.
.
Please continue to take all your other meds as you have been
doing.
Followup Instructions:
Follow up with gastroenterology on Tuesday for a colonoscopy as
scheduled.
.
PCP: [**Name10 (NameIs) 30077**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 16827**]
Completed by:[**2125-1-21**]
|
[
"2851",
"42731",
"5859",
"4280",
"4019",
"25000",
"V5861"
] |
Admission Date: [**2182-12-3**] Discharge Date: [**2182-12-5**]
Date of Birth: [**2145-8-29**] Sex: M
Service:
CAUSE OF DEATH: Cerebral hypoperfusion.
HISTORY OF PRESENT ILLNESS: Patient is a 37-year-old male
with morbid obesity, a BMI of approximately 50 with a weight
of 350 pounds, who presents for laparoscopic adjustable
gastric band. His comorbidities included obstructive-sleep
apnea, hypertension, reflux, dyslipidemia, and backache, and
depression.
HOSPITAL COURSE: Patient was admitted on the morning of
[**2182-12-3**] prior to the operation. He underwent an
uncomplicated intubation, an uncomplicated laparoscopic
adjustable gastric band. Extubation was notable for
agitation and eventual tube removal followed by a respiratory
arrest requiring reintubation.
After the airway was established, the patient had cardiac
arrest, which was treated with multiple medications and CPR.
CPR was administered for over one hour. In the meantime, a
transesophageal echo-probe was placed and there was found to
be no evidence of an acute saddle embolus. Dr. [**Last Name (STitle) **] of
Cardiac Surgery was contact[**Name (NI) **] for possible placement on
cardiopulmonary bypass. This was achieved via the groin
without difficulty with subsequent hemodynamic improvement.
The patient was kept on cardiopulmonary bypass for several
hours at which point, he was removed given his significant
improvement. He was transferred to the ICU on multiple
pressors for hemodynamic monitoring.
He was noted to have a tense distended abdomen in the ICU
with an abdominal compartment pressure in the 30s, therefore,
an exploratory laparotomy and silo evacuation of abdominal
fluid and placement of a silo were performed on the evening
of [**2182-12-3**] with immediate resolution of respiratory
compromise. The patient was then managed on multiple
pressors. Started on CVVH for mobilization of fluid with
hopes of improvement. He had to be paralyzed and sedated
given his poor respiratory parameters. Therefore, neurologic
exam was impossible.
On [**2182-12-4**], the patient's hemodynamic parameters
relatively stabilized despite multiple pressors. His lactic
acid dropped down to the 6-7 range. Base access decreased
and his oxygenation started to improve slightly. An
intracranial bolt was placed given the lack of ability to
follow a neurologic examination. The opening ICP pressure
was 100. Therefore, the patient was started on mannitol and
maximally supported.
On the morning of [**2182-12-5**], nuclear medicine brain flow
study was performed, which was found to be negative for blood
flow. Upon transfer back to the Intensive Care Unit, the
patient hemodynamically decompensated requiring multiple
boluses of Epinephrine, bicarb, and calcium. The situation
was discussed with the family in detail, and the patient
ultimately expired from cerebral hypoperfusion and cardiac
arrest.
He was pronounced at 3:21 p.m. with his family at the
bedside. ME office was consulted and refused the case, and
the family is requesting an autopsy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 23652**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2182-12-5**] 16:34
T: [**2182-12-6**] 07:44
JOB#: [**Job Number 31179**]
|
[
"9971",
"5849"
] |
Admission Date: [**2150-6-9**] Discharge Date: [**2150-6-10**]
Date of Birth: [**2092-4-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Atrial Fibrilliation /SOB
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation procedure
History of Present Illness:
57M with multiple cardiac risk factors (prev MI, CABG, FH of
IHD, Hyperlipidemia, HTN) presents post elective PVI with
significant HTN onweaning sedation admitted to r/o intracranial
event.
.
Patient is a 57 year old male with a history of CAD s/p
CABG in [**2139**], PCI of SVG-PDA in [**2148**], atrial fibrillation
(diagnosed in [**2-4**]) on coumadin who had progressive increase of
shortness of breath and was found to have congestive heart
failure with an EF of 20% with severely decreased left
ventricular systolic function. This was thought to be due to
tachycardia induced cardiomyopathy as his EF was normal until
now. He underwent successfull PVI today with conversion to NRS.
After the procedure while they were weaning off sedation, with
propofol, but he was not responding appropriately and was found
to have SBP in the 200's mmHg (BP 90-100's during procedure).
This was thought to have caused flash pulmonary edema, he was
given lasix 20 mg IV x2, hydralazine 5 mg IV, started on a nitro
gtt and propofol was re-started. He quickly responded with SBP
lowering to 80-90 but it was decided to maintain him intubated
and sedated until an acute intracranial process was ruled out.
.
On admission to CCU he was intubated, sedated with SBP in the
80's. Post-procedure CT-head revealed no intracranial pathology.
Sedation was weaned and he was safely extubated at 00:30.
Normalneurological exam.
Past Medical History:
1. CARDIAC RISK
FACTORS:(-)Diabetes,(+)Dyslipidemia,(+)Hypertension
MI age 32. Angina since 2x/month on exertion, short-lived.
2. CARDIAC HISTORY:
-CABGx3: in [**2139**] with LIMA to LAD, SVG to OM, SVG to PDA
-PERCUTANEOUS CORONARY INTERVENTIONS: PCI [**2148**] of SVG-PDA
[**2149-3-20**]
3. OTHER PAST MEDICAL HISTORY:
Atrial fibrillation since [**2150-1-26**] - paroxysmal prior but did
not seek medical attention
Non-ischemic cardiomyopathy
Hypothyroidism 2o to XRT
Hypertension
Hyperlipidemia
? COPD no formal dx made
Depression/anxiety
Hodgkin's disease age 31 received XRT to chest and ?? no
chemo??. On thyroxine post XRT as irradiation of thyroid.
Obesity
Social History:
Lives with wife [**Name (NI) **] [**Name (NI) 33729**].Semi-retired parking garage
staff at [**Location (un) 6692**] Airport.
ETOH: socially 28-30 units/week
-Tobacco history: Ex-smoker quit 5 months ago. Prev 30/day since
teenage.
-Illicit drugs: Denies.
Family History:
Father - MI ?? PE.
Mother died from a ruptured cerebral aneurysm ? SAH.
Sister - MI age 64.
Physical Exam:
VS: T=98.8 BP=116/78 HR=77 RR=16 O2 sat=98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 3cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, HS I+II +0. Systolic flow murmur. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. BS normal.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
NEURO: GCS 15/15. UL and LL exam normal. CN II-XII normal - no
fundoscopy performed.
Pertinent Results:
Admssion Labs
[**2150-6-9**] 10:45AM PT-30.9* INR(PT)-3.1*
[**2150-6-9**] 10:45AM PLT COUNT-399
[**2150-6-9**] 10:45AM WBC-9.3 RBC-4.50* HGB-14.2 HCT-41.9 MCV-93
MCH-31.6 MCHC-33.9 RDW-15.8*
[**2150-6-9**] 10:45AM estGFR-Using this
[**2150-6-9**] 10:45AM GLUCOSE-119* UREA N-18 CREAT-1.0 SODIUM-142
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-25 ANION GAP-19
[**2150-6-9**] 08:17PM PT-34.0* PTT-31.0 INR(PT)-3.5*
[**2150-6-9**] 08:17PM PLT COUNT-371
[**2150-6-9**] 08:17PM WBC-11.0 RBC-4.20* HGB-13.5* HCT-39.1* MCV-93
MCH-32.1* MCHC-34.5 RDW-15.9*
[**2150-6-9**] 08:17PM CALCIUM-8.0* PHOSPHATE-3.8 MAGNESIUM-1.8
[**2150-6-9**] 08:17PM CK-MB-6 cTropnT-0.92*
[**2150-6-9**] 08:17PM GLUCOSE-150* UREA N-18 CREAT-1.2 SODIUM-141
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-21* ANION GAP-17
[**2150-6-9**] 08:36PM HGB-13.5* calcHCT-41 O2 SAT-96
[**2150-6-9**] 08:36PM LACTATE-2.6*
[**2150-6-9**] 08:36PM TYPE-ART PO2-96 PCO2-36 PH-7.38 TOTAL CO2-22
BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED
.
Discharge Labs
.
[**2150-6-10**] 03:57AM BLOOD WBC-9.6 RBC-4.12* Hgb-13.6* Hct-38.5*
MCV-93 MCH-33.0* MCHC-35.4* RDW-16.0* Plt Ct-396
[**2150-6-10**] 03:57AM BLOOD Plt Ct-396
[**2150-6-10**] 03:57AM BLOOD Glucose-141* UreaN-21* Creat-1.2 Na-141
K-4.7 Cl-107 HCO3-23 AnGap-16
[**2150-6-9**] 08:17PM BLOOD CK-MB-6 cTropnT-0.92*
[**2150-6-10**] 03:57AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.7
[**2150-6-9**] 08:36PM BLOOD Lactate-2.6*
[**2150-6-9**] 08:36PM BLOOD Hgb-13.5* calcHCT-41 O2 Sat-96
.
Reports
.
CT Head [**6-9**]:
There is no acute intracranial hemorrhage, edema, or mass
effect.
There is preservation of normal [**Doctor Last Name 352**]-white matter
differentiation. The
ventricles and sulci are normal in size and configuration. There
is mild
mucosal thickening of the maxillary and sphenoid sinuses, and
opacification of
multiple ethmoid air cells, which could be related to the
endotrachial
intubation.
IMPRESSION: No evidence of an acute intracranial abnormality.
Brief Hospital Course:
57 yo male with CAD s/p CABG and PCI, AF, possible tachycardia
induced cardiomyopathy, who underwent successful pulmonary vein
isolation but was unable to be extubated after procedure due to
episode of significant hypertension and flash pulmonary edema on
weaning sedation. Successfully extubated and appears well.
.
# Atrial Fibrillation: Pt with symptomatic AF since [**2150-1-26**].
Initiated on Coumadin at that time. INR today 3.1 on [**6-9**]. The
PVI successful - converted to SR. INR was 3.2 [**6-10**] and he was
continued on warfarin.
.
#Hypertension while lightening sedation and pulmonary edema. He
was safely extubated with no neurological deficits. His CT-head
was normal. We repeated his chest X ray as well and monitored
his hemodynamics. His urinary catheter was removed and he was
given bolus 40mg IV Lasix to encourage urination. The lasix was
continued p.o as outpatient.
.
# Dyslipidemia:
- Continued Simvastatin 80mg daily
.
# Cardiomyopathy/ Chronic HF: Prev MI, recently found to have an
EF
20% on echocardiogram with severely decreased left ventricular
systolic function. Pt reports SOB with minimal activity.
We Continued Metoprolol 50mg daily, Lisinopril 10mg daily,
Furosemide 40mg daily
.
FEN:
- Low Na diet, daily weights, monitor I+O's. IV KCL sliding
scale was carried out.
.
ACCESS: PIV's
.
PROPHYLAXIS:
-DVT ppx with TEDs. There was no need for sc heparin as INR
3.5.
- Discharged home on [**6-10**].
.
CODE: FULL
Medications on Admission:
Furosemide 40 mg daily
Levothyroxine 137 mcg daily
Lisinopril 10 mg daily
Metoprolol Succinate 50 mg daily
Pantoprazole 40 mg daily
Paroxetine 40 mg QHS
Potassium Chloride 20 mEq daily
Simvastatin 80 mg daily
Warfarin 5 mg
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Paroxetine Mesylate 40 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Fibrillation
CAD
Cardiomyopathy
Dyslipidemia
Hypothyroid
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a pulmonary vein isolation procedure for your atrial
fibrillation.
You should continue all your current medications you were taking
before coming to the hospital.
Your INR on [**6-9**] was 3.1. You repeat INr on [**6-10**] is 3.2. You
should continue your Coumadin at 5mg/daily. You will need to
have your INR checked once/ week for the next one month.
.
Please get your INR checked [**6-11**] at C Labs and have the results
faxed over to your primary cardiologist.
.
Followup Instructions:
Cardiology Appointment: [**Last Name (LF) 2974**], [**7-3**] at 3:15pm
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Location: Cardiovascular Consulting of [**Hospital3 **] View Map
Address: [**Location (un) 33730**], [**Location (un) 9101**], [**Numeric Identifier 33731**]
Phone: [**Telephone/Fax (1) 33732**]
.
Provider :[**Last Name (NamePattern4) **]. [**Last Name (STitle) 33733**]
Date: [**2150-6-18**]:15AM
Location:[**Location (un) 33730**], [**Location (un) 9101**], [**Numeric Identifier 33731**]
.
PCP [**Name Initial (PRE) **]: Wednesday, [**6-17**] at 11am
Name:ZOUHDI [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 33734**],MD
Location: APEX HEALTH
Address: 923 ROUTE 6A, BLDG 7, [**Location (un) 19655**],[**Numeric Identifier 19656**]
Phone: [**Telephone/Fax (1) 33735**]
|
[
"42731",
"4280",
"4019",
"2724",
"2449",
"V4581"
] |
Admission Date: [**2199-6-6**] Discharge Date: [**2199-7-11**]
Date of Birth: [**2123-5-11**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain
Sepsis
Major Surgical or Invasive Procedure:
Percutaneous Tracheostomy
Chest tube placement
History of Present Illness:
This is a 76 year old female s/p sigmoid resection & colostomy
[**2199-6-5**] at [**Location (un) **] for ischemic colitis following syncope at
home. She was determined to have ischemic colitis via fever, CT
scan and WBC 36k and a surgical resection of sigmoid colon with
colostomy was performed. A volvulus was noted at surgery.
Post-operative ressusitated was required with 7-8 L of IV
fluids, but now with development of hypotension. She was
transferred on Levophed & Dopamine via L subclavian line and had
oliguria of <20 cc/hr. She was transfered to [**Hospital1 18**] intubated, on
pressors, with ARF to the MICU on [**2199-6-6**].
Past Medical History:
Hypercholesterolemia, NIDDM, HTN, H/O pancreatitis, GERD, CCY,
tonsillectomy
Social History:
Former smoker, non-drinker; married
Physical Exam:
VS: Temp 100, HR 103, BP 99/49, RR 18, 100% on Vent.
Gen: Intubated, sedated
CV: RRR
Resp: Decreased breath sounds right apex; fair breath sounds
right base; left WNL
Abd: Colostomy bag in place. BS x 4, nondistended, mildly
tender.
Ext: + Pulses bilat.
Pertinent Results:
CHEST (PORTABLE AP) [**2199-6-7**] 11:12 PM
CHEST (PORTABLE AP)
Reason: ? chf ? worsening PTX ? effusion
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with septic shock now extubation, h/o R PTX w/
chest tube, desatting
REASON FOR THIS EXAMINATION:
? chf ? worsening PTX ? effusion
INDICATION: Septic shock, chest tube placement.
COMPARISONS: [**2199-6-7**].
SINGLE VIEW CHEST, AP: The right-sided chest tube is still
malpositioned with a side port lying within the chest wall.
There is persistent chest wall emphysema. There is a small
right-sided pneumothorax, which has increased in size when
compared to the previous exam. There has been interval removal
of the left subclavian CVL. The right subclavian CVL tip
terminates within the SVC. The NG tube terminates within the
stomach. There are persistent bilateral pleural effusions with
worsening bibasilar atelectasis.
IMPRESSION: Persistent malpositioning of right-sided chest tube
with side port placed within the chest wall. Interval increase
in small right-sided pneumothorax
CHEST (PORTABLE AP) [**2199-6-10**] 3:52 AM
CHEST (PORTABLE AP)
Reason: Eval pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with septic shock, reintubated, and R chest
tube for line PTX. significant crepitus.
REASON FOR THIS EXAMINATION:
Eval pneumothorax
INDICATION: Septic shock, right chest tube for pneumothorax.
COMPARISON: [**2199-6-9**].
FINDINGS: The chin overlies the right apex which limits
evaluation for a small pneumothorax that was present on
yesterday's exam. Subcutaneous emphysema is worsening, and the
side port of the right chest tube still lies within the
extrapleural space. ET tube is unchanged in position. NG tube is
located in the stomach. There is a new small right pleural
effusion. Diffuse aveolar opacities in the left lung and mixed
aveolar-interstitial pattern in the right lung are relatively
unchanged.
IMPRESSION:
1. Chest tube side port external to pleural space.
2. New right pleural effusion, and unchanged bibasilar opacities
Cardiology Report ECHO Study Date of [**2199-6-10**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. /sepsis.
Height: (in) 67
Weight (lb): 180
BSA (m2): 1.94 m2
BP (mm Hg): 109/45
HR (bpm): 44
Status: Inpatient
Date/Time: [**2199-6-10**] at 10:30
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W022-0:30
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.6 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.5 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 1.8 cm
Left Ventricle - Fractional Shortening: 0.49 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 65% to 70% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aorta - Arch: 2.7 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 1.11
Mitral Valve - E Wave Deceleration Time: 302 msec
TR Gradient (+ RA = PASP): <= 25 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 0.9 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Normal regional LV systolic function. No
resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta. Normal
aortic arch diameter. No 2D or Doppler evidence of distal arch
coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild (1+) MR.
Prolonged (>250ms) transmitral E-wave decel time.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. No PS.
PERICARDIUM: There is an anterior space which most likely
represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded.
Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with
normal cavity size and systolic function (LVEF>55%). Regional
left ventricular
wall motion is normal. 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. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery
systolic pressure is normal. There is an anterior space which
most likely
represents a fat pad.
CHEST (PORTABLE AP) [**2199-6-13**] 9:56 AM
CHEST (PORTABLE AP)
Reason: ? recurrent ptx
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with septic shock, reintubated, and R chest
tube for ptx, now on water seal. please do at noon
REASON FOR THIS EXAMINATION:
? recurrent ptx
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: Septic shock, re-intubated, and placement of
right-sided chest tube for pneumothorax. Evaluate for recurrent
pneumothorax.
FINDINGS: AP single view of the chest obtained with the patient
in supine position is analyzed in direct comparison with a
similar previous study of [**2199-6-11**]. The patient remains
intubated, the ETT terminating in the trachea some 3 cm above
the level of the carina. An NG tube reaches far below the
diaphragm. Right-sided chest tube remains in place, seen to
terminate in the apical portion of the pleura. No pneumothorax
is identified. The previously described subcutaneous chest wall
emphysema has regressed, minor traces remaining. No new
infiltrates are seen, however, some cloudy central parenchymal
densities are consistent with the pulmonary edema which
apparently has regressed further.
IMPRESSION: Further improvement of emphysema, regressing
pulmonary edema signs, unchanged instrument positions.
CT ABDOMEN W/CONTRAST [**2199-6-14**] 1:49 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: Please give PO contrast, R/O abscess
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman ischemic colitis
REASON FOR THIS EXAMINATION:
Please give PO contrast, R/O abscess
CONTRAINDICATIONS for IV CONTRAST: None.
CT ABDOMEN AND PELVIS
HISTORY: 76-year-old woman with ischemic colitis, rule out
abscess.
TECHNIQUE: Multidetector CT through the abdomen and pelvis with
oral and IV contrast. Coronal and sagittal reformations are
provided.
There are no prior cross-sectional studies available for
comparison.
ABDOMEN CT:
A large portion of the chest was scanned. There is a small right
pneumothorax. There are bilateral mild pleural effusions with
atelectasis of the adjacent lungs. There is a right chest tube
in place. Endotracheal tube with tip at the level of the carina.
NG tube with tip in the stomach.
Two ill-defined hypoenhancing subcentimeter foci are seen in the
right lobe of the liver too small to be characterized. There is
mild central intrahepatic duct dilatation. CBD measures up to 8
mm with air-fluid level in its more distal aspect. The spleen,
pancreas and adrenal glands are unremarkable. Multiple cortical
and exophytic cystic lesions are seen in both kidneys. There is
no hydronephrosis.
Trace of perihepatic fluid is seen.
There is [**Last Name (un) 12376**] wall thickening in the splenic flexure with
stranding and trace of free fluid in the adjacent soft tissues.
There are no drainable fluid collections. Ostomy is seen in the
left lower quadrant.
There is no pneumoperitoneum. There is no lymphadenopathy.
The aorta is atheromatous but normal in caliber.
PELVIC CT: The bladder has a Foley catheter in its lumen.
Surgical clips are seen apparently in the distal sigmoid colon.
The small bowel loops are unremarkable.
Enlarged uterus with an intramural fundal fibroid measuring 44
mm. Trace of free fluid is seen within the pelvis. There are no
pathologically enlarged lymph nodes.
BONE WINDOWS: There are no concerning bone lesions. Degenerative
changes are seen in the lower lumbar spine.
CT reconstructions confirm the findings in the axial images.
IMPRESSION:
1. [**Last Name (un) **] wall thickening in the splenic flexure, likely
ischemic or inflammatory in origin.
2. Bilateral pleural effusions.
3. Small right pneumothorax.
4. Small quantity of ascites.
5. Multicystic kidneys.
6. Fibroid uterus.
UNILAT UP EXT VEINS US RIGHT [**2199-6-16**] 11:03 AM
UNILAT UP EXT VEINS US RIGHT
Reason: RIGHT ARM COOL, PLEASE ASSESS FOR DVT
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with hypotension
REASON FOR THIS EXAMINATION:
Right arm cool, please assess AV patency
INDICATION: Hypotension, right arm cool.
FINDINGS: The exam is significantly limited due to air within
the subcutaneous tissues of the arms secondary to pneumothorax.
For this reason, the internal jugular, subclavian, axillary, and
basilic veins could not be visualized. The brachial veins were
visualized and there was normal flow, compressibility, and
augmentation without evidence for intraluminal thrombus. The
brachial artery in distal arm was patent.
IMPRESSION: Limited exam, but patent brachial arteries and
brachial veins.
CHEST (PORTABLE AP) [**2199-6-18**] 5:42 AM
CHEST (PORTABLE AP)
Reason: pneumothorax, f/u
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with septic shock, reintubated, and R chest
tube for ptx
REASON FOR THIS EXAMINATION:
pneumothorax, f/u
AP CHEST 5:50 A.M. [**6-18**].
HISTORY: Septic shock, reintubated. Pneumothorax.
IMPRESSION: AP chest compared to [**6-15**] and 22:
On [**6-17**], severe subcutaneous emphysema worsened. There has
been no subsequent change and a moderate right pneumothorax has
been stable throughout, while the course of the right pleural
tube suggests it may be fissural. There is no left pneumothorax.
Pneumomediastinum is stable. Moderate pulmonary edema and
bibasilar consolidation, most likely edema and atelectasis are
unchanged. Moderate cardiac enlargement is stable. Tip of the
left subclavian line projects over the junction of the
brachiocephalic veins and the nasogastric tube ends in the upper
stomach.
CHEST (PORTABLE AP) [**2199-6-21**] 11:02 AM
CHEST (PORTABLE AP)
Reason: chest tubes placed to water seal- plaese eval for PTX
-obtai
[**Hospital 93**] MEDICAL CONDITION:
s/p chest tube x 2 for pneumothorax, and chemical pleurodesis
[**6-19**]
REASON FOR THIS EXAMINATION:
chest tubes placed to water seal- plaese eval for PTX -obtain
cxr at 11am. tx
AP CHEST, 11:15 A.M., [**6-21**]
HISTORY: Chest tube for pneumothorax and chemical pleurodesis.
Chest tube to water seal.
IMPRESSION: AP chest compared to chest films since [**6-9**], most
recently [**6-20**].
Allowing for differences in radiographic technique, there has
been no change. A moderate volume of right pleural thickening or
loculated effusion, moderate left pleural effusion, severe left
lower lobe atelectasis, mild pulmonary edema, and moderate
enlargement of the cardiac silhouette are all unchanged. There
is less mediastinal vascular engorgement. Two right pleural
tubes, a left subclavian venous line, and a nasogastric tube are
in standard placements respectively.
CHEST (PORTABLE AP) [**2199-6-26**] 3:42 PM
CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN
Reason: Re-eval pulmonary edema/infiltrates
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman s/p PTX, bilateral chest tubes removed, out of
ICU with labored breathing, please evaluate for pulmonary
process
REASON FOR THIS EXAMINATION:
Re-eval pulmonary edema/infiltrates
INDICATION: Status post pneumothorax, bilateral chest tubes
removed, labored breathing.
COMPARISON: [**2199-6-24**].
FINDINGS: There has been significant interval increase in
alveolar and interstitial opacities involving the right
hemithorax. There has been increased right- sided pleural
effusion. Left lower lobe opacity and effusion appears
unchanged. There is no pneumothorax.
IMPRESSION: Increased right effusion and diffuse right lung
opacity / consolidation, possibly related to aspiration given
the rapid development. This would less likely represent
asymmetric edema.
Cardiology Report ECG Study Date of [**2199-6-26**] 8:45:20 AM
Sinus rhythm with occasional atrial premature beats. Compared to
the previous
tracing of [**2199-6-24**] atrial premature beats are new. Modest
anterolateral
ST-T wave changes persist.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 132 86 378/427.71 34 34 55
CT ABD W&W/O C [**2199-6-27**] 1:06 PM
CT CHEST W/CONTRAST; CT ABD W&W/O C
Reason: eval consolid
Field of view: 44 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with colonic ischemia
REASON FOR THIS EXAMINATION:
eval consolid
CONTRAINDICATIONS for IV CONTRAST: None.
76-year-old female with colonic ischemia and pulmonary
consolidations.
COMPARISON: CT abdomen and pelvis, [**2199-6-14**] and chest
radiograph, [**2199-6-27**].
TECHNIQUE: MDCT continuously acquired axial images of the
abdomen were obtained without IV contrast followed by images of
the chest, abdomen, and pelvis after the administration of 145
mL of Optiray IV contrast as well as oral contrast. Three-minute
delayed images through the kidneys were also performed.
CT OF THE CHEST WITH IV CONTRAST: There is an endotracheal tube
terminating approximately 2 cm above the carina. A left
subclavian central catheter terminates in the distal SVC. A
nasogastric tube terminates in the stomach. There are extensive
mural calcifications of the nondilated thoracic aorta. A
pericardial effusion is moderate in size. There are a few small
coronary artery calcifications. The great vessels of the chest
opacify well. There is no pathologic mediastinal, axillary or
hilar lymphadenopathy. The airways are patent to the
subsegmental level bilaterally. There is moderate diffuse
background emphysema. There is extensive ground-glass opacity
throughout the right lung with areas of more dense consolidation
at the right apex and at the base of the right lower lobe. There
are less severe patchy areas of ground- glass opacity throughout
the left lung as well as more dense consolidation at the base of
the left lower lobe. Moderate layering bilateral pleural
effusions cause associated compressive atelectasis of the
posterior lower lobes. There is no pneumothorax.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: Compared to [**6-14**], [**2199**], there is a new 6.4 x 3.7 cm high-density collection
adjacent to the anterior hepatic dome. Also noted is a 5 x 2.8
cm collection of fluid between the posterior hepatic dome and
the diaphragm which demonstrates a fluid-fluid level. These
findings likely represent hematoma, possibly secondary to chest
tube placement. Otherwise, the liver is unremarkable. A small
amount of subcutaneous emphysema of the right anterior abdominal
wall is also likely due to prior chest tube placement. The
patient is status post cholecystectomy. The adrenal glands,
pancreas, and stomach are unremarkable. Again demonstrated are
multiple bilateral renal cysts. Incidental note is made of a
small duodenal diverticulum. The patient is status post partial
colectomy and there is a colostomy in the left lower quadrant.
Previously identified wall thickening of the splenic flexure is
not appreciated on today's study. There is no inflammatory
stranding adjacent to the colon and no intraabdominal fluid
collection or abscess. There is no free intraabdominal air or
mesenteric or retroperitoneal lymphadenopathy. There are
extensive abdominal aortic calcifications.
CT OF THE PELVIS WITH IV CONTRAST: Again demonstrated is a
fibroid uterus. The rectum and Hartmann pouch are unremarkable.
There is trace free pelvic fluid within physiologic range. There
is no pelvic lymphadenopathy. There is a Foley catheter within
the urinary bladder.
BONE WINDOWS: No suspicious lytic or blastic osseous lesions are
identified.
IMPRESSION:
1. Asymmetric right-sided pulmonary edema and multifocal
pneumonia superimposed on moderate background emphysema. ARDS
cannot be excluded.
2. Moderate bilateral layering pleural effusions.
3. Small high-density collections anterior and posterior to the
hepatic dome, probably represent hematoma secondary to chest
tube placement.
4. Multicystic kidneys.
5. Fibroid uterus.
CHEST (PORTABLE AP) [**2199-7-2**] 9:56 PM
CHEST (PORTABLE AP)
Reason: Please assess for pneumo, etc
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman s/p tracheostomy w/ low pO2
REASON FOR THIS EXAMINATION:
Please assess for pneumo, etc
HISTORY: Tracheostomy with low oxygen saturation.
COMPARISON: [**2199-6-28**].
UPRIGHT AP VIEW OF THE CHEST: Tracheostomy tube has been placed
in the interval with tip lying 4 cm from the carina. Nasogastric
tube is seen looped within the stomach with the tip in the
fundus of the stomach, directed cephalad. Subclavian central
venous catheter remains in standard position within the SVC. The
heart demonstrates mild to moderate enlargement, not
significantly changed. Diffuse air space opacity within the
right lung and left upper lobe are worse in the interval, and
may reflect worsening asymmetric pulmonary edema, multifocal
pneumonia, or aspiration. Additionally, there is continued
consolidation within the left lower lobe with small bilateral
pleural effusions. No pneumothorax is present.
IMPRESSION:
1) Worsening right lung and left upper lobe opacities, which may
represent worsening asymmetric pulmonary edema, multifocal
pneumonia, or aspiration.
2) Persistent left lower lobe consolidation which could
represent atelectasis or pneumonia with small bilateral pleural
effusions.
3) Tracheostomy tube in satisfactory position.
CT HEAD W/O CONTRAST [**2199-7-5**] 11:02 AM
CT HEAD W/O CONTRAST
Reason: please assess for evidence of CVA, etc
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with MS changes
REASON FOR THIS EXAMINATION:
please assess for evidence of CVA, etc
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Mental status changes, assess for CVA.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT scan.
FINDINGS: There is no evidence of acute intracranial hemorrhage,
shift of normally midline structures, or hydrocephalus. There is
no evidence of acute major vascular territorial infarct.
Moderately severe confluent areas of hypoattenuation are seen
within the periventricular white matter of both cerebral
hemispheres consistent with chronic microvascular ischemia. Also
seen are multiple hypodense foci consistent with lacunes in the
caudate nuclei and basal ganglia bilaterally as well as within
the right cerebellum. Visualized paranasal sinuses appear
unremarkable.
IMPRESSION: No evidence of acute intracranial hemorrhage or
major vascular territorial infarct. Moderately severe
microvascular ischemic changes as well as multiple old lacunes,
consistent with longstanding hypertension. MRI with
diffusion-weighted images is more sensitive in the evaluation
for acute ischemia/infarct.
CHEST (PORTABLE AP) [**2199-7-6**] 11:04 AM
CHEST (PORTABLE AP)
Reason: Please assess for consolidation,etc
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman s/p tracheostomy w/ inability to wean vent
REASON FOR THIS EXAMINATION:
Please assess for consolidation,etc
STUDY: AP chest, [**2199-7-6**].
HISTORY: 76-year-old woman status post tracheostomy with
inability to wean off ventilator.
FINDINGS: Comparison is made to previous study from [**2199-7-2**].
Tracheostomy and nasogastric tube are again seen. There is a
left-sided central venous catheter with the distal tip abutting
the lateral wall of the SVC. The heart size is markedly
enlarged, but unchanged. There is again seen persistent
bilateral pleural effusions with pulmonary edema, which is not
significantly changed. There are more focal airspace opacities
within the right lung as compared to the left, however, which
may be secondary to multifocal pneumonia versus asymmetric
pulmonary edema. There is a left retrocardiac opacity.
IMPRESSION: No significant interval change. Persistent airspace
opacities and pulmonary edema with cardiomegaly and a left
retrocardiac opacity.
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**2199-6-6**] and received 2U of
FFP to reverse INR 1.8 of uncertain etiology. BUN/creat
reportedly stable @ 44/2.2. She was transferred intubated, AC
0.4 with 5 PEEP, last ABG @OSH= 7.36/37/106. CXR with ?LLL
infiltrate. Cipro/Flagyl, and Gent were started.
#Sepsis/Hypoperfusion- Most obvious source is abdominal, s/p
surgery, possible enteric gram neg bactermeia. Patient finally
stabilized the night of admission, pressors were weaned off.
The blood outpt from ostomy was concerning for ? ischemic
colitis. Antibiotics were continued Vanc/Zosyn/Flagyl
empirically for C. diff coverage. She received boluses for low
UOP. Fluconazole was started per ID recommendations. She is
currently on no antibiotics as she has been afebrile with a
stable WBC.
#Intubated- She was weaned and extubated on [**2199-6-7**] and her pO2
dropped and she required reintubation [**2199-6-8**]. No evidence for
resp failure. A CXR revealed a LLL infiltrate. A right chest
tube was placed on [**2199-6-6**]. A new chest tube placed [**6-18**] due to
a large pneumothorax. She was being followed by the Thoracic
service for management of her chest tube. She was again
extubated in [**2199-6-16**], POD 11, then became tachypneic, and
required reintubation. She was transferred to the floor and
continued to have difficulty breathing with a respiratory rate
in the 30's and pO2 43*1, pCO2 44, pH 7.34*, cal HCO325. She was
readmitted to SICU [**6-25**] for resp distress likely secondary to
pulmonary edema. She was reintubated. Multiple attempts were
made to extubate. She had a tracheostomy placed [**2199-7-2**].
#Elevated LFTs- LFTs were increasing from admission. Likely due
to shock liver, since no h/o viral inf, high risk behavior,
heavy etoh use. Her LFT's trended down during her hospital stay
to ALT 32, AST 16, Alk Phos 128*, Amylase 98, and Total Bili
0.8.
#Coagulopathy- Likely shocked liver/sepsis. The LFTs resolved
with resolution of sepsis.
#CV- Cardiology was consulted on [**2199-6-12**]. She was found to have
tachy-brady syndrome that was determined to be benign and no
intervention (pacemaker) needed. The patient had A.fib/flutter
on [**4-21**] and was started on Heparin and Coumadin. She
spontaneously converted on [**2199-6-21**]. She had other bouts of A.fib
and was started on an Amiodarone drip. She continues now on PO
Amiodorone.
#Demand ischemia- Patient had elevated CEs and ST depression in
inferolateral distribution @ OSH. CK and MB's were trending down
and Troponin were trending up likely due to renal falure
#DM- Insulin drip initially for close control given sepsis. She
was then switched to sliding scale and fixed dose.
#CRI- Per OSH, this is at baseline. It is likely secondary to DM
and HTN. She was repleted with IV fluids which will help any
contribution from sepsis.
#Ostomy
She was followed by the Ostomy nurse and had routine pouch
changes. On [**2199-7-9**], HD 33, there was bleeding from the
mucocutaneou junction or the peristomal skin. There has been
increasing amounts of blood in the pouch and her HCT has
dropped. A GI consult was obtained. A NG lavage on [**2199-7-9**]
returned no blood and no coffee ground output, just greenish
fluid. The patient has been anticoagulated with an elevated INR.
The INR was brought down to a therapeutic range, 2 units of
PRBCs for a HCT of 24 were transfused. No other intervention was
needed at this time.
#Pertinent Microbiology results are as follows: BCx ([**6-6**]): neg;
UCx ([**6-7**]): neg; Cath Tip ([**6-7**]): neg; Sputum ([**6-7**]): neg; C.
diff (5/15,17): neg; BCx ([**6-10**]): neg; sputum Cx ([**6-27**]): GNR
sparse growth w/OP flora; sputum Cx ([**6-26**]): enterobacter; MRSA
([**7-1**]): neg x2; VRE ([**7-1**]): neg; Sputum Cx ([**6-27**]): GS GNR, GPC in
pairs and clusters,
#Pertinent Radiology: [**7-6**] CXR: persist diff B mod-sized pl
effs. [**7-5**] head CT: no bleed/infart; many old HTN-related
infarcts. [**7-2**] CXR: worsening R lung and LUL opacities,
persistent LLL. [**6-28**] TTE: EF 70%, sm to mod pericard eff. [**6-28**]
CXR: CHF in setting of emphysema, prob pulm edema w/opacity @
base. [**6-27**] CT Chest/Abd/Pelvis: R pulm edema, R multifoc
PNA,?ARDS/interstitial process, b/l pl eff, ?ant/post hepatic
dome hematoma. [**6-26**]-CXR: worsening R effusion ? aspiration,
[**6-26**]-CXR CHF, [**6-20**]: CXR No PTX, stable LLL consol. [**6-19**] CXR: PTX
gone,sm R pleural eff inc, mild pulm edema. [**6-17**] CXR: new R PTX,
[**6-16**]: RUE u/s brachial a&v patent, unable to see axilla
(emphysema). [**6-14**] CT: splenic bowel wall thickening, sm B effs.
CXR [**6-13**]: LSC line OK. [**6-11**]: improved R eff, [**6-10**]: CXR Chest
tube side port external to pleural space. New small right
pleural effusion, and unchanged Bbas opacities. [**6-9**]
Echo-EF65-70%,1+MR,no WMA; [**6-7**] CXR: L effusion/ decreased R PTX
#Access- R Subclav placed on admission. A-line placed.
#Nutrition- She was NPO with an NGT. Then started on TPN. She
received a PEG tube and tube feedings were started and she was
at her goal tube feedings.
#PPX: IV famotididne, Sub Q heparin, pneumoboots.
[**Name (NI) **] [**Name (NI) 4906**] [**Name (NI) **]; son and daughter
[**Name (NI) **] MICU: [**Telephone/Fax (3) 67140**] main #
Full Code
Medications on Admission:
Meds on admission to OSH: ASA, glucophage 500 [**Hospital1 **], metformin 500
tid, HCTZ 12.5 QD, lipitor 80mg QD, lisinopril 10mg, omeprazole
20mg [**Hospital1 **], prilosec 40mg QD, vit E
Meds on transfer:
Gent 400mg this AM (84); cipro 400 Q12; flagyl 500 tid (last
2PM) protonix 40 QD; HC03 last PM
Discharge Medications:
1. Fludrocortisone 0.1 mg Tablet Sig: [**1-28**] Tablet PO DAILY
(Daily).
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-28**]
Drops Ophthalmic PRN (as needed).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheeze.
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
13. Hydralazine 20 mg/mL Solution Sig: [**1-28**] Injection Q6H PRN ()
as needed for sbp>160.
14. Acetazolamide Sodium 500 mg Recon Soln Sig: [**1-28**] Recon Soln
Injection Q12H (every 12 hours).
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
Subcutaneous twice a day: Fixed NPH dose breakfast and dinner.
Sliding Scale Regular q6H. See Sliding Scale.
16. Warfarin 3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Pantoprazole 40 mg Recon Soln Sig: One (1) Intravenous
Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Ischemic Colitits
Sepsis
Acute Renal Failure
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
No lifting greater than 10 lbs for 4 weeks
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] 2 weeks after discharge from
rehab. Call ([**Telephone/Fax (1) 9058**] to schedule an appointment
Completed by:[**2199-7-11**]
|
[
"0389",
"78552",
"4280",
"40391",
"42731",
"5849",
"51881",
"486",
"2859"
] |
Admission Date: [**2112-5-20**] Discharge Date: [**2112-5-20**]
Date of Birth: [**2089-3-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
EtOH intoxication, status post fall
Major Surgical or Invasive Procedure:
Endotracheal intubation, extubation.
History of Present Illness:
22M BIBA found down at the bottom of four stairs by friend. The
[**Name2 (NI) 9168**] report is not available on transfer to the MICU and the
patient's name or further history is unknown.
.
In the ED, VS: T: 98.2 BP: 154/89 HR: 106 RR: 20 O2: 100%RA.
- The patient was somnulent, unable to manage secretions and was
intubated.
- Trauma series negative for fracture.
- Serum EtOH 452, urine toxicology negative.
Past Medical History:
Unknown.
Social History:
Unknown.
Family History:
Unknown.
Physical Exam:
VS: T: 96.5 BP: 124/80 HR: 113 RR: 21 O2: 100%RA.
GEN: Intubated, agitated
HEENT: Superficial forehead laceration, PERRLA, EOMI, no
conjuctival injection, anicteric, ETT in place
CV: Tachycardic, RR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: Soft, NT, ND, + BS, no HSM
EXT: Warm, dry, +2 distal pulses BL
NEURO: Agitated, does not follow commands, moving all
extremities well
Pertinent Results:
Admission labs:
[**Age over 90 **]|107|15
----------<96
3.5|20|1.0
estGFR: >75 (click for details)
Ca: 10.0 Mg: 2.5 P: 2.7
ALT: 34 AP: 69 Tbili: 0.4
AST: 44 [**Doctor First Name **]: 34
Serum EtOH 452
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
TRAUMA PATIENT.
15.2
8.9>--<328
42.5
PT: 10.8 PTT: 21.5 INR: 0.9
Fibrinogen: 270
CT HEAD W/O CONTRAST Study Date of [**2112-5-20**]
IMPRESSION: No intracranial hemorrhage or fracture.
.
CT C-SPINE W/O CONTRAST Study Date of [**2112-5-20**]
IMPRESSION: No evidence of acute fracture or dislocation.
Straightening of the cervical lordosis is presumably related to
the collar.
.
CHEST (PORTABLE AP) Study Date of [**2112-5-20**]
(not official read) ETT 5.9 cm from carina. Lungs clear.
Brief Hospital Course:
A/P: 22M with unknown PMH p/w EtOH intoxication and inability to
manage secretions who was intubated for airway protection while
intoxicated.
1 Respiratory failure: In the setting of EtOH intoxication and
inability to manage secretions. He was easily extubated the
morning of admit when etoh cleared. He had no further difficulty
with respiration.
2 Alcohol intoxication: He reports recent heavy alcohol use
after his father died of cancer about a year ago. He has not had
an admission for this in the past and notes some episodes of
tremulousness in the past but denies history of alcohol
withdrawl, hospitalization for withdrawl, or seizures from
withdrawl. He has been coping poorly and has not seen a
therapist for this. He is very remorseful and seems genuinely
concerned by the severe consequence of his drinking. He met with
[**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**] who offered him information about AA in the area
and she will attempt to set up an appointment for him to meet
with a counselor on Monday [**2112-5-23**] and contact him with that
information. While in house he was given thiamin, B12 and folate
repletion. He was discharged on a thiamin and ativan 1mg po q6
for 5 days if he feels anxious, tremulous, diaphoretic or
tachycardic. He was instructed not to take this if he drinks or
does not feel these symptoms. He was instructed to return to the
ED if this medication did not relieve his symptoms or if he
found himself needing it more frequently than every 6 hours as
this might be a sign of life threatening alcohol withdrawl.
3 Anion gap metabolic acidosis: AG 18 on arrival. EtOH
intoxication. Lactate 4.0; may be due to alcohol and and patient
in addition likely dehydrated. No abdominal pain or signs of
muscle necrosis. This improved to AG of 13 on discharge.
4 Status post fall: In the setting of EtOH intoxication. No
fracture on CT head/neck. Superficial forehead laceration. His
cervical spine was cleared after extubation and despite multiple
eccymosis, he did not have focal areas of pain.
5 Prophylaxis: Heparin SC for DVT prophylaxis, bowel regimen.
Medications on Admission:
None.
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours
for 20 doses.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol intoxication.
Discharge Condition:
Eating, ambulating, stable.
Discharge Instructions:
Please avoid drinking alcohol to excess. Please take ativan if
you feel tremulous, anxious or sweaty. If you are needing this
more than every 6-8 hours you should come to the Emergency room
immediately, as you are at risk for withdrawl and seizures.
Followup Instructions:
Please follow up with outpatient alcohol abuse services.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"51881",
"2762"
] |
Admission Date: [**2110-4-5**] Discharge Date: [**2110-4-13**]
Date of Birth: [**2029-7-12**] Sex: M
Service: MEDICINE
Allergies:
Inderal
Attending:[**First Name3 (LF) 1642**]
Chief Complaint:
Increased lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefy, patient is an 80 yo male with Hx of IDDM, CAD s/p CABG,
PAF s/p pacer [**9-13**], CVA, initially transferred from [**Last Name (un) 883**] on
[**4-5**] with diagnosis of intracranial bleed secondary to
supratherapeutic INR and fall. On arrival to our E.D. the
patient was febrile, and initially treated with vanco,levoflox,
and flagyl empirically. He was also given 2 units of PRBCs for
Hct 23 of unclear etiology.
.
The patient was seen by Neurology and neurosurgery. The patient
was loaded on dilantin but felt not to be a surgical candidate
by NS. Patient was admitted to the MICU with complicated course
including MSSA bacteremia, ?GNR bacteremia, NSTEMI, meningitis,
multifocal PNA, and hydrocephalus.
.
The patient continued to have worsening mental status and had
repeat CT head w/o progression of bleed, stable hydrocephalus.
In the MICU the patient was treated with dexamethasone,
ampicillin, vanco, ceftriaxone, and acyclovir with some clinical
improvement. The patient never required pressors. He had a TTE
and TEE which showed 2+ MR and 1+AR but no vegetations. The
patient has been followed by neurology who would like a second
LP to be performed given negative cxs 1st time. However, given
hydrocephalus, an LP is thought to be currently high risk and
contraindicated. Neurosurgery was again consulted and reported
that the patient is not a candidate for other procedures to
assist diagnosis. Neurology continues to follow the patient
closely. On admission to the floor the patient is currently on a
medical regimen of Meropenem and Oxacillin which should provide
adequate coverage of the patient's known pathogens as well as
empiric coverage for meningitis.
Past Medical History:
ongoing urinary bleeding w/ ?mass- pending evaluation
CVA [**9-13**] on asa, aggrenox
CAD w/ CABG [**19**] yrs ago
PAF w/ extended pauses, s/p pacer [**9-13**], on coumadin
IDDM (on insulin x 40 yrs) w/ retinopathy, neuropathy
hyperlipidemia
LUE tremor
spinal stenosis w/ L5 radiculopathy
urticaric pigmentosa
admit for syncope to [**Hospital1 **] [**Date range (1) 32478**]
Social History:
Patient is a [**Hospital **] rehab resident x 4 years. he is a retired
dentist. His daughter lives in the [**Name (NI) 86**] area, sons in [**Name (NI) 108**],
no smoking or Etoh history.
Family History:
two children with type II DM.
Physical Exam:
Vitals: Temp 97.8, Pulse 81, BP 149/43, RR 21, 96% on 3L
Gen: elderly male, lying in bed, minimally responsive to pain,
gross hematuria in foley bag
HEENT: anicteric, pupils small, symmetrical, slow but reactive,
MM dry.
Neck: supple, no JVD
Resp: CTA bilateral but poor exam due to patient somnolence.
CV: RRR nl s1, s2, no murmers
Abd: soft, ND, NT, positive BS
Extr: no c/c/e, 1+ pulses
Neuro: minimally responsive, moving all extremities, PERRL.
.
On transfer from ICU:
PE: T 98.6 BP____126/68___ HR-82 _____RR 35
O2 Sat - 94% 3L
.
Gen: Patient is an elderly male, sleeping, minimally responsive.
Patient flinches to sternal rub but demonstrates no directed
movements.
HEENT: NG in place. Patient with 2mm pupils, minimally reactive
bilaterally. OP: MM dry
Neck: Supple, No LAD, No JVD
Chest: Healed sternotomy scar. Rapid shallow breathing,
tachypnic with rate 35-40. Diffuse rhonchi bilaterally without
wheezes or crackles
CV: Difficult to appreciate over breath sounds
Abd: Soft, obese, mildly hypoactive BS
EXTRM: multipodous boots and and pneumoboots in place. Patient
with 2+ edema over hands and feet
Neuro - patient obtunded, responsive only to pain. Patient does
not follow commands. Pupils reactive minimally bilaterally,
patient groans intermittently with some spontaneous movements.
Pertinent Results:
Admission Labs:
.
[**2110-4-5**] 06:45PM PT-17.9* PTT-30.7 INR(PT)-1.7*
[**2110-4-5**] 06:45PM PLT COUNT-398#
[**2110-4-5**] 06:45PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL
[**2110-4-5**] 06:45PM NEUTS-92* BANDS-0 LYMPHS-3* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2110-4-5**] 06:45PM WBC-18.8* RBC-2.31*# HGB-8.1*# HCT-23.6*#
MCV-102* MCH-35.2* MCHC-34.5 RDW-14.5
[**2110-4-5**] 06:45PM CALCIUM-8.7 PHOSPHATE-2.7 MAGNESIUM-2.1
[**2110-4-5**] 06:45PM CK-MB-5 cTropnT-0.08*
[**2110-4-5**] 06:45PM CK(CPK)-157
[**2110-4-5**] 06:45PM GLUCOSE-120* UREA N-26* CREAT-0.9 SODIUM-145
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-26 ANION GAP-15
[**2110-4-5**] 06:55PM LACTATE-1.8
Pertinent Labs/Studies:
.
Microbiology:
.
Blood cultures:
[**2110-4-5**]: 3/4 bottles - MRSA
[**2110-4-7**]: NG
[**2110-4-8**]: NG
[**2110-4-9**]: NG
[**2109-4-10**]: NG
.
Urine Cultures:
[**2110-4-7**]: NG
.
CSF Cultures:
[**2110-4-6**]: 1+ PMN on gram stain, cx without growth
.
Stool
[**2110-4-11**] - Stool negative for C. Diff
.
.
Imaging:
[**2109-4-5**]: Portable Chest - IMPRESSION: Interval development of
mild congestive heart failure. Small bilateral pleural
effusions.
.
[**2110-4-5**]: CT Head - There is hydrocephalus, new since [**2110-3-19**]. In
addition to the small amount of subarachnoid blood noted above,
there is a significant amount of material dependent in both
latral ventricles. This material is largely isodense to brain,
but slightly hyperdense along the margins. It may represent
evolving intraventricular hemorrhage, or pus. Consulation with
neurosurgery may be helpful. Imaging could contribute to
distinguishing blood from pus with MR.
.
[**2110-4-6**]: CT A/P
1. Bilateral lung base air space opacities, likely aspiration
versus
aspiration pneumonia.
2. Bilateral small pleural effusions, left bigger than right.
3. No fluid collection to explain hematocrit drop.
4. Bladder wall lesion similar in appearance to previous study.
5. Low-density renal lesions similar in appearance to previous
study.
6. Sigmoid diverticulosis.
Preliminary findings were relayed to the ED dashboard at 1:30
a.m., [**2110-4-6**].
.
[**2110-4-6**]: Repeat CT Head - Hydrocephalus and intraventricular
material-
blood vs pus- are unchanged.
.
[**2110-4-6**]: Portable chest/line placement - There is a left-sided
pacemaker, which is unchanged. Median sternotomy wires
are seen. There has been interval placement of a right
subclavian central line, which distal tip is not completely well
seen. The tip is seen at least to the level of the cavoatrial
junction and may be within the right atrium. This could be
pulled back slightly and reimaged for more optimal assessment.
No pneumothoraces are seen. There is again seen prominence of
the pulmonary vascular markings consistent with pulmonary edema.
Small bilateral pleural effusions are identified. These are
unchanged.
.
[**2110-4-7**]: Echocardiogram -
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy with normal cavity size and systolic
function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are moderately thickened. No masses or vegetations are seen on
the aortic valve. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. A mass or
vegetation on the mitral valve is not seen but cannot be fully
excluded. Mild to moderate ([**2-10**]+) 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 estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No valvular vegetation
seen. If
clinically indicated, a TEE would better exclude a small
valvular vegetation. Compared to the prior study report dated
[**2108-9-18**], the degree of mitral regurgitation seen has probably
increased.
.
[**2110-4-9**]: CT Head - No change compared to [**2110-4-7**]. Hypodense
material layering posteriorly within the ventricles is thought
to represent layering blood, as it would be unusual to have this
quantity of pus located only within the ventricles.
.
[**2110-4-9**]: CT CHest - 1. Multifocal pneumonia in the right lung
and inferior lingula.
2. Moderate left and tiny right pleural effusion.
3. Bibasilar atelectasis.
4. Aortic valvular calcification, hemodynamic significance
unknown.
.
[**2110-4-11**]: CT Head - No significant interval change in appearance
of left ambient cistern hemorrhage or intraventricular layering
material. Findings were discussed with Dr. [**First Name (STitle) 4223**] by
telephone at time of image acquisition.
Discharge Labs: None
Brief Hospital Course:
80 y.o. with history of CVA, AF on coumadin presented from
[**Hospital 100**] rehab nursing home with lethargy and found to have MSSA
sepsis, meningitis, pneumonia and intracranial hemorrhage in the
setting of supratherapeutic INR.
.
#. Sepsis/menigitis/PNA: On admission to the MICU, the patient
was empirically started on vancomycin, ampicillin, ceftriaxone,
acyclovir, and steroids (empirically for Strep meniningitis)
given his meningismus, fever, leukocytosis, and CXR c/w PNA. An
LP was performed on [**4-6**], but yielded only a small amount of
CSF. CSF analysis was consistent with bacterial meningitis
however. Subsequently, blood cultures (3/4 bottles)came back
positive came back for MSSA, and oxacillin was added tothe
patient's regimen on [**4-6**]. A TTE and TEE were performed without
evidence for endocarditis. The infectious disease team was
consulted for further management of the patient's MSSA sepsis
and meningitis. On [**4-8**], the MICU team was made aware that
cultures from [**Hospital 882**] hospital, prior to transfer, were growing
GNR in [**2-12**] bottles as well as staph aureus in [**4-12**]. Given this,
the ID team recommended discontinuing ceftriaxone and ampicillin
and starting ceftazidime and Flagyl in addition to oxacillin and
acyclovir. These GNR were evntually identified as E.Coli,
resistant to beta-lactam, for which ID recommended discontinuing
ceftaz and flagyl and starting meropenem. On transfer to the
floor from the MICU the patient was on meropenem, oxacillin, and
acylovir. A repeat LP was considered given unknown organism
causing meningitis, but given his hydrocephalus and blood in
ventricles, the risk of herniation was thought to be too high,
so repeat LP was not performed. During the course of his
admission the patient was additionally noted to have increased
stool output for which Flagyl was started empirically for likely
C. Diff colitis. Despite optimal medical therapy with
broadspectrum antibiotics and supportive care the patient's
mental status (see below) continued to decline. On transfer the
patient was somnolent but responsive to painful stimuli whereas
over the course of a few days he became nearly obtunded. In the
setting of his mental status depression, the patient
additionally suffered intermittent aspiratione events with
worsening respiratory distress, rising white count and again,
further worsening of his mental status. Given the extent of his
infection, sepsis, and many medical comorbidities the patient's
prognosis was thought to be very poor. After discussion with the
patient's family the decision was made to make the patient CMO.
Antibiotics were eventually discontinued and the patient was
made comfortable with morphine titrated to a level of 20-30 bpm.
The patient was noted to have significant improvement in his
respiratory distress with the inroduction of morphine and looked
appropriately comfrortable. The patient expired within 24 hours
of discontinuing antibiotics.
.
#. Respiratory distress: On transfer from the MICU to the floor,
the patient was known to be tachypneic and alkalotic, thought
likely to be secondary to underlying sepsis as well as increased
intracrnaial pressure from ICH and meningitis. The patient was
tachypnic with resp rates ranging from 35 to 50 with diffuse
rhoncherous breath sounds. A trigger was called nearly
immediately for these vital signs upon transfer to the floor
although the patient was with stable O2 sat of 93% on 3L as he
was on transfer. The nightfloat intern was called again for
worsening tachypena within 24 hours which prompted a repeat CT
head. Repeat CT head revealed stable hydrocephalus and ICH
without interval change. As above the patient was treated for
pneumonia and additionally suffered aspiratione vents worsening
his clinical status.
.
#. Intracranial hemorrhage - On admission to the MICU the
patient's INR was reversed with FFP and Vit K and coumadin was
held. The patient was evaluated by neurology and neurosurgery.
It was the impression of neurosurgery initially that there was
minimal evidence of head bleed and likely [**Last Name (un) **] finfinds
represented artifact from choroid plexus flow. Upon evluation,
neurosurgery assessed the patient to not be a surgical candidate
and signed off. Repeat CTs of the head were performed throughout
the patient's hopital course which showed stable blood/pus in
the ventricles as well as hydrocephalus. Dilantin was started in
the MICU for seizure prophylxis. Supportive care was given
including holding anticoagulation, maintaining a SBP < 140, and
continuing dilantin for seizure ppx.
.
#. Mental status - As previous, in the presence of a likely
intraventricular bleed as well as meningitis and sepsis the
patient on transfer from the MICU to the floor was somnolent. He
would not follow commands and withdrew only from painful
stimuli. Over the course of his stay, despite maximal supportive
therapy with broad spectrum antibiotics and management as above
the patients mental status continued to decline. He eventually
became obtunded and minimally reactive to any stimul. Given the
patient's declining clinical course, the extent of his infection
and his many medical comorbidities the patient was thought to
have a very poor prognosis. After discussion with the patient's
family the decision was made to make the patient CMO.
.
#. NSTEMI - On admission to the MICU the patient had positive
cardiac enzymes without ECG changes consistent with an NSTEMI in
the setting of sepsis. The patient was medically managed with a
BB, ASA, Statin and ACE.
.
#. Atrial fib - On admission the patient was known to have a
PPM. Patient was maintained on metoprolol without amiodarone,
without RVR during his hospital course.
.
#. Hematuria/bladder mass - The patient was admitted with a
known likely bladder mass and hematuria. He was admitted with
continuous bladder irrigation which was continued throughout his
hopsital course. Given the extent of his illness and ultimate
decision to transition the patient to CMO, aggressive workup of
this mass was not undertaken.
.
#. HTN - Patient was maintained on IV metoprolol and Hydralazine
until feeding tube placed, at which time the patient was
switched to PO BB and ACEI with SBP geenrally ranging from
120-160.
.
#. DM - Patient was initially on an insulin gtt, then switched
to lantus and qid FS.
Medications on Admission:
Simvastatin 5 mg PO DAILY
Flomax 0.5 mg daily
Amiodarone HCl 200 mg PO DAILY
Aspirin 81 mg PO DAILY
Aggrenox [**Hospital1 **]
Coumadin 2mg PO daily until [**4-2**]
Humalin 10 units qPM, 36 units qAC
Roxicodone 2.5mg [**Hospital1 **]
Dulcolax 10mg PRN
Colace
Senna
Lisinopril 2.5 mg daily
.
Medications on Transfer:
Heparin 5000 UNIT SC TID
Insulin SC
Meropenem 1000 mg IV Q8H
Metoprolol 25 mg PO BID
Acyclovir 600 mg IV Q8H
Morphine Sulfate 1 mg IV Q4H:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Oxacillin 2 gm IV Q4H known MSSA bacteremia
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Pantoprazole 40 mg IV Q24H
Aspirin 300 mg PR DAILY
Phenytoin 100 mg IV Q8H
Atorvastatin 80 mg PO DAILY
Captopril 25 mg PO TID
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Sepsis
Bacterial Meningitis
Pneumonia
Intracranial Hemorrhage
Discharge Condition:
Deceased
|
[
"41071",
"42731",
"4280",
"2760",
"4019",
"V5867",
"V4581",
"99592"
] |
Admission Date: [**2194-9-28**] Discharge Date: [**2194-10-1**]
Date of Birth: [**2152-1-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP [**2194-9-28**] with placement of 2 biliary stents
History of Present Illness:
This is a 42 year old male with PMH of cholecystectomy,
autoimmune pancreatitis, ERCP x 3 for recurrent cholangitis who
is transferring from [**Hospital3 417**] Medical Center for abdominal
pain and vomiting. Patient states that begining on friday he has
generalized epigastric pain that was increasing in severity and
described as sharp and worse in the RUQ. He has had this same
pain several times in the past for which he was diagnosed with
cholangitis and recurrent stones even post cholecystectomy. He
also endorses non-bloody, non-billious vomiting x1 day and his
ROS is (+) for constipation and hematochezia one time, two days
ago. He denies f/c/CP/SOB/diarrhea.
.
Patient labs from transfer sig for: WBC:9.9 w/ 12%bands, No gap,
TB:2.4,DB:1.3, AST:916, ALT735, AP:190,Lipase23
.
In the ED the patients vitals were 99.6, 116, 149/95, 18 sating
98% on RA. He was given dilaudid and zofran for symptom
management as well as started on ampicillin-sulbactam. A RUQ
ultrasound was performed and showed mild intra and extra hepatic
duct dilation with a CBD of 11 mm (7 mm on MRCP from [**2194-3-29**]).
The patient was given IV fluids and transferred to the [**Hospital Unit Name 153**] for
further management. He was never on pressors nor intubated.
.
On arrival to the MICU, patient's VS 102.3, 131, 132/88, 100% 2L
patient appeared fatigued and was in no distress.
.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies shortness of breath, cough, or wheezing. Denies chest
pain, chest pressure, palpitations. Denies dysuria, frequency,
or urgency. Denies arthralgias or myalgias. Denies rashes or
skin changes.
Past Medical History:
# Hypertension
# GERD
# s/p CCY ([**1-/2192**])
# s/p ERCP x3 ([**2-4**], [**5-6**], [**4-6**])
# Autoimmune Pancreatitis, dx by serology and improved on
steroids. Dx in [**2192**], has not used steroids since early in [**2193**]
# OSA with intermittent CPAP use (not currently using)
# [**3-/2193**]: CBD stricture and cholangitis. s/p ERCP, where pt was
found to have a 15 mm long stricture at distal CBD with mild
post obstuctive ductal dilatation.
Social History:
Pt works at a nursing home and lives with his wife. [**Name (NI) **] denies
smoking, ETOH or illicits. Born in [**Country 37027**], moved to US in [**2181**].
Family History:
Denies family hx of autoimmune disease, no cancers. Family
healthy, no reported medical issues
Physical Exam:
ADMISSION EXAM:
VS: 102.3, 131, 132/88, 100% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
ADMISSION LABS:
[**2194-9-28**] 06:30AM BLOOD WBC-13.5*# RBC-5.20 Hgb-14.1 Hct-43.5
MCV-84 MCH-27.2 MCHC-32.5 RDW-13.8 Plt Ct-186
[**2194-9-28**] 06:30AM BLOOD Neuts-94.8* Lymphs-2.1* Monos-2.6 Eos-0.2
Baso-0.3
[**2194-9-28**] 06:30AM BLOOD Glucose-123* UreaN-9 Creat-0.9 Na-138
K-3.9 Cl-101 HCO3-29 AnGap-12
[**2194-9-28**] 06:30AM BLOOD ALT-797* AST-808* LD(LDH)-800*
AlkPhos-220* TotBili-2.6*
[**2194-9-28**] 06:30AM BLOOD Lipase-25
[**2194-9-28**] 06:34AM BLOOD Lactate-1.5
LFT TREND:
[**2194-9-28**] 06:30AM BLOOD ALT-797* AST-808* LD(LDH)-800*
AlkPhos-220* TotBili-2.6*
[**2194-9-29**] 04:49AM BLOOD ALT-397* AST-194* AlkPhos-139*
TotBili-3.9*
[**2194-9-30**] 05:01AM BLOOD ALT-263* AST-83* AlkPhos-128 TotBili-1.2
DirBili-0.7* IndBili-0.5
OTHER PERTINENT LABS:
[**2194-9-30**] 05:01AM BLOOD PT-15.5* PTT-34.0 INR(PT)-1.5*
[**2194-9-29**] 04:49AM BLOOD Calcium-7.4* Phos-2.8 Mg-1.6
[**2194-9-29**] 04:49AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40
[**2194-9-29**] 04:49AM BLOOD IgG-1238
MICROBIOLOGY:
Blood cultures [**2194-9-28**]: KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Urine culture [**2194-9-28**]: negative
Blood cultures [**2194-9-29**]: pending
Blood culture [**2194-9-30**]: pending
IMAGING:
RUQ Ultrasound [**2194-9-28**]:
1. Intra- and extra-hepatic bile duct dilation, similar to prior
MRCP. If
further evaluation is required, MRCP may be helpful.
2. Biliary stent is not visualized on this study. Correlate with
history of removal.
ERCP [**2194-9-28**]: S/P sphincterotomy - this was widely patent. A
single smooth stricture that was 20 mm long was seen at the
lower third of the common bile duct. Given cholangitis, only
minimal injection of contrast was performed. A 5cm by 10FR
Double pig-tail biliary stent was placed. A 7cm by 10FR biliary
stent was placed. Pus and sludge were extracted successfully
using a balloon. (stent placement, stent placement,
stone/sludge extraction) Otherwise normal ercp to third part of
the duodenum.
MRCP
IMPRESSION:
1. New right anterior portal vein thrombosis with secondary
perfusion-related
arterial hyperenhancement in the right lobe of the liver.
2. Mild central peribiliary and extrahepatic bile duct wall
enhancement,
consistent with cholangitis. CBD/CHD stent in situ. Persistent
intrahepatic
duct dilatation which has improved slightly since the previous
MRI.
4. Small bilateral pleural effusions.
Brief Hospital Course:
42M with history of biliary strictures and autoimmune
pancreatitis presenting with abdominal pain, found to have
elevated LFTs and Klebsiella bacteremia in setting of acute
cholangitis, s/p ERCP [**2194-9-28**] with 2 biliary stents placed.
# Acute cholangitis
# Biliary obstruction
# Klebsiella bacteremia
Patient presented with fevers, leukocytosis, tachycardia,
abdominal pain, elevated transaminases, Tbili and AlkPhos,
concerning for acute cholangitis. He was normotensive and did
not require pressor support, but was admitted to ICU given his
tachycardia. RUQ ultrasound showed intra- and extra-hepatic
bile duct dilation. He was started empirically on Zosyn, and
ERCP team consulted. Patient underwent ERCP on [**2194-9-28**], and was
found to have a single smooth stricture 20 mm long at the lower
third of the CBD. Pus and sludge were extracted, and 2 biliary
stents were placed. He tolerated the procedure well, but
remained febrile and tachycardic to the 130s following the
procedure, requiring multiple fluid boluses. Pain was
controlled with dilaudid as needed, and nausea controlled with
zofran as needed.
Blood cultures from [**9-28**] positive for pan-sensitive Klebsiella,
and patient's antibiotics switched to ciprofloxacin on [**9-30**] with
plan to complete 14-day total course of antibiotics. His diet
was advanced as tolerated, to full liquids on [**2194-9-30**]. Per ERCP
team, MRCP ordered [**2194-9-30**] to evaluate for autoimmune
cholangitis/pancreatitis. Also checked IgG (normal), [**Doctor First Name **]
(positive with 1:40 titer), and IgG4 levels (still pending) per
ERCP.
#Autoimmune pancreatitis, newly discovered portal vein
thrombosis - seen by liver consult (Dr. [**Last Name (STitle) 497**] who recommended
anticoagulation. He was started on lovenox 80 mg SQ [**Hospital1 **] and
received one dose of coumadin 5 mg on the day of discharge. On
further discussion with liver, they recommended actually holding
off on starting coumadin until at least 48 hrs after lovenox
initiation. Pt was called on his cell phone within an hour of
discharge, and he expressed understanding of this plan. He will
follow-up with his PCP's office for INR checks. We have tried
to reach his PCP's office today but PCP is [**Name Initial (PRE) **]. Details of this
d/c summary have been faxed to PCP [**Name Initial (PRE) 3726**]. He will f/u with
liver clinic in approximately 1 month, as well as anticipated
repeat MRCP in 12 weeks to re-evaluate the portal v. thrombosis
# Sinus Tachycardia: Was likely multifactorial in etiology in
setting of sepsis, fever, pain, and volume depletion. Improved
with IVF, antibiotics, and pain control. Patient continuing on
IVF until adequate PO intake.
# HTN: Held lisinopril given sepsis physiology on presentation
to ICU. Resumed on regular floor
# OSA: Patient does not use CPAP at home.
Medications on Admission:
-lisinopril 20 mg
-cholecalciferol (vitamin D3) 400 unit
-omeprazole 20 mg
-multivitamin
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
day 1 = [**9-30**] (day 1 of overall antibiotics [**9-28**]), needs 2 week
course
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*22 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 80 mg SQ twice a day Disp #*14
Syringe Refills:*0
7. Warfarin 4 mg PO DAILY
RX *warfarin [Coumadin] 2 mg 2 tablet(s) by mouth at bedtime
Disp #*60 Tablet Refills:*0
Note: On further discussion with liver, they recommended
actually holding off on starting coumadin until at least 48 hrs
after lovenox initiation. Pt was called on his cell phone
within an hour of discharge, and he expressed understanding of
this plan. He will start warfarin on [**2194-10-3**] evening.
8. Outpatient Lab Work
(ICD 9 code: 452 Portal Vein Thrombosis)
Draw INR on [**2194-10-2**], Results to Dr [**Last Name (STitle) **] [**Name (STitle) **]
Phone: [**Telephone/Fax (1) 40236**], Fax: [**Telephone/Fax (1) 85701**]
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Biliary stricture and obstruction
Klebsiella bacteremia
Portal vein thrombosis
Autoimmune pancreatitis
Discharge Condition:
condition: stable
mental status: lucid
ambulatory status: independent
Discharge Instructions:
You were admitted with another episode of cholangitis and
underwent ERCP which showed biliary stricture in the common bile
duct. Two stents were placed. You will need another ERCP in 6
weeks for removal of the stents.
We also obtained an MRI which showed a clot in the portal vein,
which is a liver vein. You were seen by the liver service and
have been started on blood thinner medication. One is an
injection medication (Lovenox/enoxaparin) which is temporary
until your blood reaches the right level. The other
medication(warfarin/coumadin) will be ongoing. It is important
that you have several more lab checks in the coming week to
determine the right coumadin dose. Please contact your PCP
office tomorrow to discuss with Dr. [**Last Name (STitle) **] and to determine which
lab you should have this drawn at. You have been given a
prescription for this lab draw for tomorrow.
Please keep your follow-up appointments as below. You will need
to be seen in the liver clinic in approximately one month, with
a repeat
MRI in 3 months. You will be contact[**Name (NI) **] with an appointment in
the liver clinic.
Please complete your antibiotics as directed. If you develop
severe diarrhea or nausea/vomiting please seek medical
attention. It is important that you not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] of
antibiotics.
Followup Instructions:
Name: [**Doctor Last Name **],[**Doctor Last Name **] [**Doctor Last Name 162**] V.
Location: STEWARD PHYSICIANS
Address: [**Street Address(2) 8727**], [**Apartment Address(1) 19251**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 40236**]
****We have left a message with the office to arrange a follow
up appt for you and call you at home with the appt. If you
don't hear from the office by tomorrow, please contact them
directly to book. Please also call the office to discuss having
your lab (INR) drawn.
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2194-10-15**] at 10:00 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], 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
We are working on a follow up appointment in the Liver Center in
the next month. You will be called at home with the
appointment.If you have not heard or have questions, please call
[**Telephone/Fax (1) 2422**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2194-10-1**]
|
[
"2875",
"42789",
"2859",
"4019",
"53081",
"32723"
] |
Admission Date: [**2166-11-12**] Discharge Date: [**2166-11-18**]
Date of Birth: [**2089-10-2**] Sex: M
Service: NEUROLOGY
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
language difficulty and right weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Per admitting resident:
77 yo RHM with a history of prostate ca, HTN, who went to
bed in his usual state of health at 9 pm, but when he woke up at
6 am, he had right sided weakness and a right facial droop. He
went to work anyway, and according to what the ER stated, his
work place contact[**Name (NI) **] his "son" who brought him to the ER.
Unfortunately, his son was no longer present when I arrived. The
patient is only really able to give "yes" or "no" answers, and
finds it difficult to enunciate words. I contact[**Name (NI) **] his [**Name (NI) 6435**] (Dr
[**Last Name (STitle) 19111**] office on [**Telephone/Fax (1) 12807**], but unfortunately, they did not
have a record of any of his family members names.
At about 3:15 pm, his nephew (not son) arrived, and the history
is as follows, his uncle works with him in his office, and his
uncle arrived at 11:45 am. His nephew, [**Name (NI) **] noted that he could
not speak properly, had a right facial droop, and had right
sided
weakness, thus called the EMS, who brought him to the [**Hospital1 **].
ROS: Patient states "no" to all of the following: vertigo,
headache, nausea, palpitations, dyspnea, chest pain, fevers,
chills, new GI or GU symptoms.
Past Medical History:
Prostate cancer (adenoca) - diagnosed in [**2150**] at [**Hospital1 3278**],
radiotherapy treatment initiated in [**2154**] (as per OMR records)
HTN
sigmoid polyp
Fixation of femur age 16
Social History:
The patient is single and continues to work and
is trained as an interior designer. He exercises regularly and
performs yoga on a regular basis. He previously smoked
cigarettes, stopped 30 years ago and will drink two glasses of
wine occasionally with meals. No use of recreational drugs.
Nephew - [**Name (NI) **] [**Name (NI) 19112**] [**Telephone/Fax (1) 19113**]
Family History:
As per OMR rad-onc records: family history is notable for a
sister who was treated for breast cancer and is alive, well and
another sister who was recently diagnosed with breast cancer.
Physical Exam:
Exam on admission:
T-98 HR-63 (30s) BP-160/64 RR-18 SpO2-99
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, Right
carotid bruit, cannot hear any flow on the left, but no
vertebral
bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, thinks that he is in NEB, and
states
that the date is 18/19. Unable to spell "WORLD" backwards.
Speech is non-fluent with normal comprehension and he has
problems in repeating longer sentences; naming intact.
Dysarthria
noted, and saliva dribbling out of the right corner of his
mouth.
He cannot read a sentence and writing could not be checked.
Registers [**2-25**], recalls [**1-28**] in 5 minutes (but the words are
difficult to understand). No right left confusion. No evidence
of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light (senile arcus
bilaterally), 3 to 2 mm bilaterally. Fundoscopy is normal.
Visual
fields are full to confrontation. Extraocular movements intact
bilaterally, no nystagmus. Sensation intact V1-V3. Right facial
droop noted. Hearing intact to finger rub bilaterally. Palate
elevation symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue appears to be deviated due to the extent of
the facial weakness, but movements are intact.
Motor:
Normal bulk bilaterally. Tone increased in the right arm. No
observed myoclonus or tremor
could not check pronator drift due to R arm weakness
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 3 +4 5 2 2 2 2 +4 +4 5 5 5 5 5
Sensation: Intact to light touch. No extinction to DSS. However,
due to his language deficits, it is difficult to do this
accurately
Reflexes:
B T S P A Pl
R +2 +2 +2 3 2 up
L 2 2 2 2 - down
Coordination: finger-nose-finger normal on the left, could not
do
this on the right, heel to shin normal on the left only, slower
on the right, RAMs normal on the left only.
Gait: not assessed due to his bradyarrhythmia
Exam at time of discharge:
Pertinent Results:
Labs on admission:
[**2166-11-12**] 12:30PM BLOOD WBC-7.2 RBC-5.48 Hgb-17.6 Hct-50.0 MCV-91
MCH-32.2* MCHC-35.3* RDW-14.4 Plt Ct-146*
[**2166-11-12**] 12:30PM BLOOD Neuts-86.2* Lymphs-9.4* Monos-3.7 Eos-0.5
Baso-0.2
[**2166-11-12**] 12:30PM BLOOD PT-13.2 PTT-25.6 INR(PT)-1.1
[**2166-11-12**] 12:30PM BLOOD Glucose-141* UreaN-15 Creat-0.9 Na-139
K-3.7 Cl-101 HCO3-26 AnGap-16
[**2166-11-13**] 03:23AM BLOOD ALT-11 AST-19 AlkPhos-54
[**2166-11-12**] 12:30PM BLOOD CK(CPK)-159
[**2166-11-13**] 03:23AM BLOOD CK-MB-3 cTropnT-<0.01
[**2166-11-12**] 08:25PM BLOOD CK-MB-4 cTropnT-<0.01
[**2166-11-12**] 12:30PM BLOOD cTropnT-<0.01
[**2166-11-12**] 12:30PM BLOOD Calcium-9.4 Phos-2.5* Mg-1.9
[**2166-11-13**] 03:23AM BLOOD Calcium-8.5 Phos-2.0* Mg-2.5 Cholest-200*
[**2166-11-13**] 03:23AM BLOOD Triglyc-94 HDL-66 CHOL/HD-3.0 LDLcalc-115
[**2166-11-13**] 03:23AM BLOOD %HbA1c-5.3
[**2166-11-12**] 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Urine studies:
[**2166-11-12**] 01:15PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG
[**2166-11-12**] 01:15PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2 RenalEp-0-2.
Imaging:
CT head on admission: IMPRESSION: No acute intracranial process.
MRI/A brain/neck:
IMPRESSION:
1. Acute infarct involving the left striatum, with other
punctate foci of
involvement in the left centrum semiovale and possibly left
superior temporal gyrus. Given the lack of involvement of the
more distal portion of the left middle cerebral artery
territory, there is likely collateral flow. However, on the MRA
of the neck images, there is no evidence of enhancement of the
left middle cerebral artery. Dedicated MRA of the head is
recommended.
2. Occlusion of the left internal carotid artery from the
carotid bulb
extending intracranially, although there may be some residual
flow within the distal cavernous and supraclinoid segments.
IMPRESSION:
1. Near-complete occlusion of the left internal carotid artery,
with
propagation since the earlier study and further diminished flow
in the
cavernous and supraclinoid segments.
2. There is also complete occlusion of the left middle cerebral
artery, with no evidence of flow-related enhancement throughout
its visualized extent.
ECHO:
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild (non-obstructive) focal
hypertrophy of the basal septum. The left ventricular cavity
size is normal. Overall left ventricular systolic function is
normal (LVEF>55%). No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Carotid dopplers:
IMPRESSION:
1. No significant right ICA stenosis.
2. Occluded left ICA.
3. Moderate to high-grade left external carotid artery stenosis.
CT head [**11-15**]:
IMPRESSION: Evolution of left MCA infarct with slightly
increased mass effect on the left lateral ventricle without
midline shift. No hemorrhage seen.
XR L shoulder/elbow [**2166-11-16**]:
RIGHT SHOULDER: There is a possible non-displaced fracture of
the lateral
acromion. A well-corticated fragment within the right shoulder
is consistent with calcific tendinopathy of the supraspinatus
tendon and is chronic in nature. There is mild osteoarthritis of
the AC and glenohumeral joints. No dislocations are seen. No
focal lytic or sclerotic lesions identified. No radiopaque
foreign body is seen.
RIGHT ELBOW AND FOREARM: No fracture or dislocation is seen.
There is
osteoarthritis of the ulnar trochlear joint as well as calcific
tendinopathy of the common extensor tendon. No focal lytic or
sclerotic lesions identified. No radiopaque foreign body is
seen.
IMPRESSION:
1. Possible nondisplaced fracture of the lateral acromion.
2. Osteoarthritis of the right shoulder and elbow.
Brief Hospital Course:
77 yo with a history of prostate cancer, HTN, who woke up with a
right facial droop and a right hemiparesis. At work, he was
noted not to speak properly and was brought to [**Hospital1 18**]. On
initial examination he was he had intact comprehension, motor
aphasia, R face/arm weakness >> R leg weakness. CT head showed a
hyperdense MCA sign. ED course was complicated by sinus
bradycardia to 30s. He was admitted to neuromedicine service for
further evaluation.
NEURO. Patient was treated per stroke protocl of HOB < 30, IVF,
SBP autoregulation, ASA, statin and normoglycemia/normothermia
maintenance. MRI head showed a new large LEFT basal ganglia and
left caudate and putamen as well as the anterior limb of the
internal capsule. In additin, there were scattered strokes in
left centrum semiovale, all of this suggesting an embolic
etiology. MRA showed complete occlusion of the L MCA as well as
near complete occlusion of [**Doctor First Name 3098**]. Patient was started on heparin
gtt and carotid US obtained to assess degree of [**Doctor First Name 3098**] stenosis,
which confirmed complete occlusion. ECHO showed no source of
embolism and no afib was noted on Telemetry.
His examination progressed by HD2 to global aphasia and R side
plegia. Given this, no surgical intervention was indicated.
Patient was started on Plavix. He underwent a S&S evaluation
that resulted in requiring ground solids and nectar thick
liquids. He underwent calorie counts showing consumption of
850kCal on [**11-17**]. This will require follow up in skilled nursing
facility setting.
At time of discharge his examination was remarkable for global,
but motor predominant aphasia and R sided hemiplegia.
CV. Patient was noted to have sinus bradycardia while in the
ED. EKG was remarkable only for above finding. He completed
ROMI. Cardiology was consulted and it was felt that this was
due to increased vagal tone. Patient continued to have episodes
of asymptomatic bradycardia while asleep.
He will require adjustment of his medications to a BP goal of
SBP 120-140s. His antihypertensive regimen was held during the
acute post stroke phase. He was restarted at 5mg of Lisinopril
at time of discharge and amlodipine and HCTZ were held.
Medications can be titrated to goal listed above by increasing
Lisinopril first, followed by addition of the either amlodipine
or hydrochlorothiazide.
GU. After disposition from ICU, patient underwent a voiding
trial which he failed with retention of 750cc of urine. This
was felt to be multifactorial, from increased prostatic size and
possible impairment of frontal lobes due to edema from the
stroke. The latter is expected to improve within one to two
months. Foley catheter was replaced. He has follow up with his
urologist, Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2695**], MD Phone:[**Telephone/Fax (1) 22**].
ORTHO: Unfortunately on [**11-16**] patient experience a fall from a
chair, despite being on fall precautions and chair alarm trying
to sit up from a chair. Follow up neurological examination was
unchaned and head CT showed evolution of of the MCA infarction.
Unfortunately patient was c/o of R shoulder pain and was found
to have a R acromion mildly displaced fracture. He was
evaluated by orthopedics and was deemed to be best treated with
a brace, no surgical intervention was recommended. Follow up
was arranged with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name6 (MD) **] orthopedics NP. Patient
is non weight bearing (e.g. Ok for ROM, feeding, combing hair,
glass of water etc., but no heavy weights) and will require OT.
Should you have further questions about limitation, please
contact the orthopedics office.
Code status: DNR/I confirmed with family
Medications on Admission:
AMLODIPINE [NORVASC] - 10mg
HYDROCHLOROTHIAZIDE - 12.5mg daily
LISINOPRIL - 10mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. Insulin Regular Human 100 unit/mL Solution Sig: per SS
Injection ASDIR (AS DIRECTED).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
9. Famotidine 20 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO once a day.
10. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection
every six (6) hours as needed for SBP>160: goal SBP 120-140;.
11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Left MCA infarct and ICA occlusion
Secondary: Hypertension, prostate cancer.
Discharge Condition:
Hemodynamically stable. Neurological exam remarkable for:
Aphasia (global), R hemiplegia in upper and lower extremity
Discharge Instructions:
You were admitted to the hospital with difficulty with speech
and right sided weakness. You were found to have a large
stroke. You underwent an evaluation for this and you were found
to have a blockage in one of your neck arteries that caused your
stroke. You were started on new medications.
You required temporary nasogastric tube placement for feeding,
however, you were able to take over 50% of your calories and
tube was removed.
The following changes were made to your medications:
- Started on Plavix
- Started on Simvastatin
Please make the follow up appointments with your doctors.
You were discharged to a rehabilitation facility.
Should you experience any symptoms concerning to you, please
call your doctor or go to the emergency room.
Followup Instructions:
Please follow up with the following appointments:
Please make a follow up appointment with [**Last Name (LF) **],[**First Name3 (LF) **] M.
[**Telephone/Fax (1) 12807**], your PCP.
NEUROLOGY:
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2166-12-17**] 2:00
In [**Hospital Ward Name 23**] Clinical Center on the [**Location (un) **], [**Hospital1 18**] [**Hospital Ward Name **]
UROLOGY: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2695**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2166-11-27**] 9:30
ORTHOPEDICS:
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2166-12-16**] 9:00
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"5070",
"25000",
"4019",
"42789",
"V5867"
] |
Admission Date: [**2103-1-15**] Discharge Date: [**2103-2-19**]
Date of Birth: [**2032-4-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
70 year old male with one month of increasing jaundice,
pseudocyst of the pancreas on CT scan, in the background of
alcoholism.
Major Surgical or Invasive Procedure:
Puestow procedure, cholecystectomy, feeding jejunostomy tube
placement, central venous line placement.
History of Present Illness:
This 70-year-old gentleman firstpresented one year ago with new
onset diabetes. He is an alcoholic who drinks constantly at home
and lives a sedentary
lifestyle. He has been noncompliant with his treatment of
diabetes for this year. He presented with new onset jaundice
in late [**Month (only) **] to an outside hospital and was transferred
to our facility for endoscopic retrograde
cholangiopancreatography. This was attempted on two
occasions and he was found by CT to have a grossly dilated
pancreatic duct with jaundice. However, he was unable to be
cannulated by ERCP and therefore he was referred to Dr. [**Name (NI) 60612**] care
for a surgical evaluation. I found him to be weak,
malnourished and not suitable for an operation at the point
that he was evaluated. Furthermore, he suffered a GI bleed from
his
attempted sphincterotomy one week afterwards and was
transfused many units of blood to resuscitate him. In the
interim, we provided TPN for nourishment and made him nil per os
through this period of time. His history showed that he had
an elevated alkaline phosphatase as well as significant
elevations of amylase and lipase whenever he ate food.
Past Medical History:
diabetes mellitus type 1, pancreatitis, depression, anxiety,
alcoholism
Social History:
alcoholism, depression
Family History:
noncontributory
Physical Exam:
96.9F, 72, 110/62, 18 98%RA
Alert, cachectic, withdrawn, mildly jaundiced
RRR, no M/R/G
CTAB, no W/R/R
ND, NABS, soft, slight epigastric tenderness, no
hepatosplenomegaly
DP 2+, no peripheral edema
Pertinent Results:
Pertinent admission laboratories
[**2103-1-15**] 08:11PM GLUCOSE-219* UREA N-10 CREAT-0.5 SODIUM-137
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-33* ANION GAP-12
[**2103-1-15**] 08:11PM ALT(SGPT)-162* AST(SGOT)-123* ALK PHOS-937*
AMYLASE-284* TOT BILI-5.5*
[**2103-1-15**] 08:11PM LIPASE-253*
[**2103-1-15**] 08:11PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-1.5*
[**2103-1-15**] 10:00AM ALT(SGPT)-170* AST(SGOT)-144* ALK PHOS-886*
AMYLASE-285* TOT BILI-5.1*
[**2103-1-15**] 10:00AM LIPASE-490*
[**2103-1-15**] 10:00AM WBC-4.4 RBC-3.22* HGB-10.1* HCT-30.7* MCV-95
MCH-31.3 MCHC-32.9 RDW-15.4
[**2103-1-15**] 10:00AM PLT COUNT-250
[**2103-1-15**] 10:00AM PT-12.5 PTT-24.7 INR(PT)-1.0
Brief Hospital Course:
The patient was admitted to the [**Hospital1 1170**] on [**2103-1-15**] for further evaluation of his abdominal pain
and likely pancreatic pseudocyst. The patient was made nil per
os and was started on TPN as at the time of admission the
patient was not physically prepared to withstand the rigors of a
major abdominal procedure. A CTA of the abdomen was also
performed that showed the following:
1) Multiple cystic appearing structures within the pancreatic
head and body, with the dominant one at the pancreatic head,
possibly causing compressive obstruction of the common bile
duct. In addition pancreatic calcifications are seen. The
dindings are more consistent with chronic pancreatitis with
mature pseudocysts rather than cystic pancreatic tumor.
After preparing him with TPN for multiple weeks, the patient was
ready
for an operative intervention for relief of the bile duct.
Furthermore, the hope was to address his pancreatic
pseudocyst through internal drainage and possibly even deal
with the dilated distal pancreatic duct with calcific disease
inside of it. Long and thorough discussions with both
the patient and primarily his daughter regarding his problem
and the need to intervene surgically took place. They understood
the
risks and benefits of this operation and both wished to
proceed and provided informed consent to that effect. It was
made very clear that he was at a heightened risk for
perioperative complications primarily from anesthetic
induction, but also from the operation itself, given his
frail constitution. However, this was socially a situation
where there would be no advantage to continuing with weight
gain over a longer period of time.
The patient was brought to the operating room on the morning of
[**2-6**]
with the intent of performing a biliary bypass through a
choledochojejunostomy as well as a drainage of the pancreatic
pseudocyst. Furthermore, a jejunostomy feeding tube was
placed for postoperative nutritional support. Also, in the
operating room a right sided [**Doctor Last Name 406**] drain was placed that was
later removed in the postoperative period.
In the postoperative period the patient was initially maintained
on TPN until tube feeds were started. The patient also was
noted to have slightly labile blood glucose levels that were
being recorded four times a day. The [**Last Name (un) **] diabetes service
was consulted at this time and adjusted the doses of his insulin
to better control his blood glucose. In the days leading up to
his discharge the patient was also started on a regular diabetic
diet and was tolerating oral intake fairly well.
During his stay patient was also found to have superior rotation
of the acetabular component of his left hip prosthesis, with a
slight superior dislocation of the left femoral head prosthesis.
This limited his mobility though patient was able to work with
physical therapy and was out of bed to chair consistently in the
postoperative period.
In the postoperative period the patient was continued on all of
his home medications and progressed well overall and on [**2103-2-19**]
the patient was deemed fit for discharge to a rehabilitation
facility with instructions to follow up with Dr. [**Last Name (STitle) **] in two
weeks.
Medications on Admission:
colace, multivitamin, ECASA, glipizide, thiamine, folic acid,
vitamin D
Discharge Medications:
1. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4
times a day) as needed for after each loose stool.
5. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO Q2H
(every 2 hours) as needed.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Papain Miscell. for flushing J-tube
9. Insulin Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38**] Landing
Discharge Diagnosis:
pancreatic pseudocyst, diabetes type 1, post Puestow procedure
Discharge Condition:
stable
Discharge Instructions:
Patient to be discharged to rehabilitation facility and to
aware if patient having worsening pain, fevers, chills, nausea,
vomiting, or if there are any questions or concerns.
Followup Instructions:
Patient to follow up with Dr. [**Last Name (STitle) **] in two weeks, appointment
to be scheduled, call [**Telephone/Fax (1) 1231**] to confirm.
|
[
"25000",
"V5867"
] |
Admission Date: [**2187-5-8**] Discharge Date: [**2187-5-20**]
Date of Birth: [**2127-10-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30062**]
Chief Complaint:
DKA, altered mental status
Major Surgical or Invasive Procedure:
endoscopy
Surgical gastric tube placement
History of Present Illness:
61 yo man with a h/o IDDM type I, CAD s/p CABG in [**3-/2187**],
systolic CHF (EF 40-45%) who presented after being found down at
home.
.
Pt was recently admitted for hyperglycemia in the setting of S.
viridans bactermia and pneumonia. He was discharged to rehab on
[**2187-4-18**] to complete a course of IV abx. He returned home last
Wed in his USOH. However, since Sunday, he has had increased
fatigue. His FSG have been in the 400s for the past few days
despite decreased appetite and increase in his Lantus from 10
units to 12-14 units qhs. This AM, he felt unwell while
standing, so sat down on the ground. He was found there by
workers delivering some equipment, and they called EMS. Pt was
reported to be tachycardic to 170s by EMS although BP described
as stable.
.
In the ED, initial vs were: P 170s in irrregular narrow complex
tachycardia, SBP 60s-70s manually, satting 98-100 on 2L. Pt
initially with altered mental status. Only able to palpate
fem/abd pulses on exam. PIV access (18g x 2) placed, and pt
given 2.5 L NS. He remained tachy to 150s, and BPs declined to
a low of 58. Preparations were made to do electrocardioversion,
but but pt self-converted to sinus tachycardia in the 110s with
improvement in his SBP to 70s-80s and clearing of mental status
to AAO x3. He was started on levophed and given empiric
vanc/zosyn. Labs notable for glucose >500, lactate 12, K 7.1
(no peaked T's) for which pt received bicarb, insulin 10 units,
and started on insulin gtt at 10units/h. While attempting to
place CVL for pressors, pt reported his DNR/DNI status on
multiple coversations and refused line and intubation. CT head
and C-spine were negative on prelim read for acute path. On
transfer to MICU, FSG still >500 but lactate trending down to
6.7, K 6.7. Pt initally made only 30cc but after 8 L NS, was
beginning to increase UOP with 90cc within the hour prior to
transfer. On transfer, VS: Afeb, HR 115 (sinus tach), 107/51 on
0.15 mcg/kg levophed, RR 16, O2sat 100% on NRB (placed for
transport to rads).
.
On the floor, pt currently feels at baseline. He denies any
polyuria or polydipsia and reports being asymptomatic from
hyperglycemia in the past. He denies any fevers, chills, cough,
shortness of breath, diarrhea, or dysuria.
.
Review of systems:
(+) Per HPI
(-) 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,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
(1) Recent pansensitive s. viridans bacteremia and pneumonia,
tx'd with ctx and azithromycin via PICC
(2) Diabetes Mellitus Type I - A1c 7.7 in [**3-14**]
(3) CAD: NSTEMI s/p CABG X 3(LIMA>LAD, SVG>OM, SVG>PDA) [**2187-3-16**]
(4) Systolic heart failure post NSTEMI - EF 40%
(5) Orthostatic hypotension, thought autonomic
(6) Gastroesophageal reflux disease (pt denies)
(7) Hx of Melanoma in the LEFT thigh
Social History:
Lives in disabled housing. Retired postal service employee.
- Tobacco: Quit in 2/[**2187**].
- Alcohol: None since 2/[**2187**].
- Illicits: No h/o IVDU. Remote h/o marijuana use.
Family History:
non-contributory
Physical Exam:
Vitals: T 96.4, BP 104/60, P 17, RR 117, O2sat 100% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Mild crackles at bases, no wheezes or rhonchi
CV: Regular rate, mildly tachycardic, normal S1 + S2, no
murmurs, rubs, gallops
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, nonfocal
Pertinent Results:
[**2187-5-8**] 11:04PM LACTATE-2.4*
[**2187-5-8**] 10:51PM GLUCOSE-164* UREA N-61* CREAT-2.6* SODIUM-143
POTASSIUM-3.6 CHLORIDE-113* TOTAL CO2-17* ANION GAP-17
[**2187-5-8**] 10:51PM CALCIUM-7.8* PHOSPHATE-2.5*# MAGNESIUM-1.9
[**2187-5-8**] 03:50PM GLUCOSE-569* UREA N-69* CREAT-2.9* SODIUM-142
POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-5* ANION GAP-37*
[**2187-5-8**] 03:50PM COMMENTS-GREEN TOP
[**2187-5-8**] 03:50PM GLUCOSE->500 LACTATE-6.7* K+-6.7*
[**2187-5-8**] 02:27PM COMMENTS-GREEN TOP
[**2187-5-8**] 02:27PM GLUCOSE-GREATER TH LACTATE-9.4* K+-6.6*
[**2187-5-8**] 02:14PM GLUCOSE-GREATER TH LACTATE-8.0* K+-6.4*
[**2187-5-8**] 01:50PM GLUCOSE-709* UREA N-77* CREAT-3.4*#
SODIUM-139 POTASSIUM-7.1* CHLORIDE-94* TOTAL CO2-7* ANION
GAP-45*
[**2187-5-8**] 01:50PM estGFR-Using this
[**2187-5-8**] 01:50PM ALT(SGPT)-18 AST(SGOT)-28 CK(CPK)-75 ALK
PHOS-93 TOT BILI-0.5
[**2187-5-8**] 01:50PM LIPASE-14
[**2187-5-8**] 01:50PM cTropnT-0.02*
[**2187-5-8**] 01:50PM CALCIUM-9.4 PHOSPHATE-12.8*# MAGNESIUM-2.7*
[**2187-5-8**] 01:50PM WBC-14.5*# RBC-3.73* HGB-11.0* HCT-40.0
MCV-107*# MCH-29.5 MCHC-27.5*# RDW-14.1
[**2187-5-8**] 01:50PM NEUTS-74* BANDS-1 LYMPHS-18 MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2187-5-8**] 01:50PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
BURR-1+ TEARDROP-OCCASIONAL
[**2187-5-8**] 01:50PM PLT SMR-NORMAL PLT COUNT-404#
[**2187-5-8**] 01:50PM PT-12.4 PTT-29.4 INR(PT)-1.0
[**2187-5-8**] 01:30PM PH-6.88*
[**2187-5-8**] 01:30PM GLUCOSE-GREATER TH LACTATE-12.2* NA+-140
K+-7.8* CL--102 TCO2-5*
[**2187-5-8**] 01:30PM HGB-12.2* calcHCT-37
[**2187-5-8**] 01:30PM freeCa-1.18
.
CT Head [**2187-5-8**]:
HISTORY: 59-year-old male with altered mental status, found
down.
COMPARISON: Concurrent CT cervical spine.
TECHNIQUE: Imaging was performed from the foramen magnum to the
cranial
vertex without IV contrast.
HEAD CT WITHOUT IV CONTRAST: There is no fracture, hemorrhage,
edema, mass
effect, shift of midline structures, or evidence of major
vascular territorial infarction. The ventricles and sulci are
normal in size and configuration for the patient's age. The
visualized paranasal sinuses and soft tissues appear
unremarkable.
IMPRESSION: No fracture, hemorrhage, or edema.
.
CT C-Spine ([**2187-5-8**])
HISTORY: 59-year-old male with altered mental status, found
down.
COMPARISON: None available in the [**Hospital1 18**] PACS.
TECHNIQUE: MDCT helical acquisition was performed from the skull
base to the cervicothoracic junction without IV contrast.
Multiplanar reformations were provided.
CT C-SPINE WITHOUT IV CONTRAST: There is no fracture or
malalignment. There is no prevertebral soft tissue swelling.
There is a mild left convex
curvature of the cervical spine, which may be positional.
However, in the
lower cervical spine, most pronounced in C5-C6, there is
degenerative change, with loss of disc height, endplate
sclerosis, and anterior and posterior osteophyte formation. At
this level, there is narrowing of the canal (3:62, 401B:32).
There is a chronic fracture of the left first rib. The
visualized lung apices and soft tissues appear unremarkable.
IMPRESSION:
1. No fracture or malalignment.
.
CXR ([**2187-5-8**])
INDICATION: 59-year-old man found down with altered mental
status and
tachycardia. Study to evaluate for fracture or acute
cardiopulmonary process.
COMPARISON: Chest radiograph from [**2187-4-17**].
CHEST, SINGLE PORTABLE: There is near-complete interval
resolution of a
moderate left pleural effusion since [**2187-4-17**], with
residual tiny
pleural effusion with adjacent atelectasis on the left. The
aerated lungs are clear. The cardiomediastinal silhouette and
hilar contours are normal.
Limited evaluation of osseous structures demonstrates no acute
displaced
fracture. There is no pneumothorax.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Tiny residual left pleural effusion with adjacent
atelectasis, with
significant improvement since [**2187-4-17**].
3. No evidence of displaced fracture. If clinical concern is
high for
osseous injury, dedicated rib series may be obtained.
Brief Hospital Course:
# Shock: The patient was hypotensive with elevated lactate and
creatinine, suggestive of end organ damage upon admission to the
MICU. There was concern for sepsis given an elevated white blood
cell count with left shift and recent S. viridans bacteremia
also with LLL haziness that could represent pneumonia.
Hypovolemia in the setting of osmotic diuresis in the setting of
diabetic ketoacidosis may also have contributed. He was started
on vancomycin, zosyn, and ciprofloxacin. He was given IV fluids
to maintain a CVP of [**9-13**]. He was started on norepinephrine to
maintain a MAP of >65. His hypetensive medication was held. He
was quickly weaned of vasopressor support. Cultures were
unrevealing, the patient eventually was discharged from the MICU
to the floor [**Last Name (un) 5355**] a planned 10d course of abx. Upon arrival to
the floor the patient was found to be unable to swallow. This
innability to swallow likely represents the source of his
pneumonia (aspiration)->PNA->DKA->mixed hypovolemic/septic
shock.
.
# DKA: The precipitant was most likely infection, though there
was concern for infection given the patient's reported
non-compliance with medications and diet. He was aggressively
hydrated with normal saline given his hypotension, which was
then transitioned to D5 1/2NS. He was started on an insulin
drip and his anion gap closed and he achieved normoglycemia. The
[**Last Name (un) **] service was consulted. He was started on broad spectrum
antibiotics to cover for infection. His gap closed and never
reopened on the floor.
.
# Stricture: Patient underwent EGD on the floor revealing a 1cm
stricture. This could not safely be dilated so a G-tube was
placed for the patient to have tube feeds and treatment for his
esophagitis, and return in four weeks for a dilation. Patient
was started on TF, and the TF was at goal rate of 80cc/hr at the
time of discharge.
.
# Pneumonia: The patient was found to have an elevated white
count with left lower lobe infiltrate concerning for pneumonia.
He was treated with vanc/cefepime/cipro for 10 days. He was
afebrile, satting well on room air at the time of discharge.
Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable [**Last Name (un) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule [**Last Name (un) **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Gabapentin 300 mg Capsule [**Last Name (un) **]: One (1) Capsule PO Q12H (every
12 hours).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
[**Last Name (un) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Last Name (un) **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Multivitamin Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily).
7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [**Last Name (un) **]: One (1)
Tablet PO DAILY (Daily).
8. Simvastatin 40 mg Tablet [**Last Name (un) **]: Two (2) Tablet PO DAILY
(Daily).
9. Insulin Glargine 100 unit/mL Solution [**Last Name (un) **]: Ten (10) units
Subcutaneous at bedtime.
10. Insulin Lispro 100 unit/mL Solution [**Last Name (un) **]: As directed
Subcutaneous four times a day: Per insulin sliding scale.
11. Midodrine 5 mg Tablet [**Last Name (un) **]: One (1) Tablet PO TID (3 times a
day).
12. Lisinopril 5 mg Tablet [**Last Name (un) **]: 0.5 Tablet PO DAILY (Daily).
13. Nitrostat 0.4 mg Tablet, Sublingual [**Last Name (un) **]: One (1) tablet
Sublingual as directed as needed for chest pain.
16. Acetaminophen 325 mg Tablet [**Last Name (un) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
17. Senna 8.6 mg Tablet [**Last Name (un) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Polyethylene Glycol 3350 17 gram/dose Powder [**Last Name (un) **]: One (1)
dose PO DAILY (Daily) as needed for constipation.
Discharge Medications:
1. Insulin Glargine 100 unit/mL Cartridge [**Last Name (un) **]: Ten (10) units
Subcutaneous at bedtime.
2. Gabapentin 300 mg Capsule [**Last Name (un) **]: One (1) Capsule PO twice a
day.
3. Multiple Vitamins Tablet [**Last Name (un) **]: One (1) Tablet PO once a
day.
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (un) **]: One (1)
Tablet PO once a day.
5. Simvastatin 40 mg Tablet [**Last Name (un) **]: One (1) Tablet PO once a day.
6. Nitrostat 0.4 mg Tablet, Sublingual [**Last Name (un) **]: One (1) tab
Sublingual q5min: max of 3 doses, call doctor if using.
7. Tylenol 325 mg Tablet [**Last Name (un) **]: 1-2 Tablets PO every six (6) hours
as needed for pain: no more than 4 g per 24 hours.
8. Aspirin 81 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (un) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
10. Oxycodone 5 mg Tablet [**Last Name (un) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times
a day).
13. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
14. Ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
15. Insulin Regular Human 100 unit/mL Cartridge [**Last Name (STitle) **]: sliding
scale Injection four times a day: Please see the attached
sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Aspiration Pneumonia
Espophogeal stricture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a condition known
diabetic ketoacidosis. This was set off by a pneumonia that was
most likely caused by aspiration. In working up your aspiration
we discovered that you had a very tight stricture in your
esophagus. You will eventually need this dilated, but our
gasstroenterologists wanted to treat your esophagitis before we
do this. You had a gastric tube placed, and you are getting
tube feed for nutrition.
.
The following changes were made to your medications:
- Please take oxycodone and lidocaine patch for pain around the
gastric tube site
- Please take Lansoprazole Oral Disintegrating Tab 30 mg daily
for GI protection
- Please note your insulin regimen has been adjusted
Followup Instructions:
Please call [**Last Name (un) **] diabetes center ([**Telephone/Fax (1) 3537**] to make a
follow up appointment.
.
Department: ENDO SUITES
When: FRIDAY [**2187-6-8**] at 9:00 AM
.
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2187-6-8**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
.
Department: CARDIAC SERVICES
When: FRIDAY [**2187-7-27**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2187-5-20**]
|
[
"5070",
"5849",
"4280",
"V4581",
"V5867"
] |
Admission Date: [**2171-12-23**] Discharge Date: [**2171-12-24**]
Date of Birth: [**2121-6-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine / Codeine / Aspirin / Guaifenesin
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
headache/nausea/somnolence this morning
Major Surgical or Invasive Procedure:
none
History of Present Illness:
50 year old female with breast cancer s/p chemotherapy and
nonhealing right lower extremity ulcer who was doing well until
two days ago. She was noted to have cough and rhinorrhea for
past two days thought to be due to viral URI. She was treated
with mucinex. She was noted to have headache/somnolence/nausea
this morning and noted to be cyanotic. She was transferred to
[**Hospital 18654**] hospital where her initial pulse ox was 80% on NRB. She
was noted to have chocolate brown blood and metHgb level of
56.7. She was given methylene blue 150mg (2mg/kg) and had
significant improvement of cyanosis and pulse ox to 100%.
.
She was transferred to [**Hospital1 18**] for further evaluation and
management. In the ED, her initial vitals were 98.3 92 114/84 22
97% 4LNC. VBG showed MetHgb level decreased to 3. She was
admitted to MICU for further observation.
.
On arrival to the MICU, she reports no other complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness. Denies cough, shortness
of breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
-Breast cancer
-Reflex muscular dystrophy
-RLE tibial fracture c/b nonunion, compartment syndrome and
reported osteomyelitis s/p rotational flap approximately 25
years ago.
.
Past Surgical History:
Bilateral mastectomies
TAH-BSO
multiple surgeries to her leg
debridement and skin graft on her left hand following tissue
damage from Adriamycin
Social History:
The patient is married and lives with her husband. She has 4
children. She denies any alcohol, tobacco, or illicit substance
use.
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
General: Pale appearing female in mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses. Right shin with dressing
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE EXAM:
General: Pale appearing female, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses. Right shin with dressing
Pertinent Results:
ADMISSION LABS:
[**2171-12-23**] 05:45PM BLOOD WBC-8.3# RBC-4.23 Hgb-10.9* Hct-32.7*
MCV-77*# MCH-25.7* MCHC-33.3 RDW-16.3* Plt Ct-403#
[**2171-12-23**] 05:45PM BLOOD Neuts-81.3* Lymphs-17.0* Monos-1.6* Eos-0
Baso-0.1
[**2171-12-23**] 05:45PM BLOOD PT-12.0 PTT-28.9 INR(PT)-1.1
[**2171-12-24**] 03:40AM BLOOD Ret Aut-2.1
[**2171-12-23**] 05:45PM BLOOD Glucose-133* UreaN-14 Creat-0.8 Na-143
K-2.8* Cl-113* HCO3-23 AnGap-10
[**2171-12-24**] 03:40AM BLOOD LD(LDH)-121
[**2171-12-24**] 03:40AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.9 Iron-33
[**2171-12-24**] 03:40AM BLOOD calTIBC-293 Ferritn-16 TRF-225
[**2171-12-23**] 05:56PM BLOOD Type-[**Last Name (un) **] pO2-53* pCO2-42 pH-7.35
calTCO2-24 Base XS--2 Comment-GREEN-TOP
[**2171-12-23**] 05:56PM BLOOD O2 Sat-81 MetHgb-3*
DISCHARGE LABS:
[**2171-12-24**] 04:20AM BLOOD Hgb-10.0* calcHCT-30 O2 Sat-97 MetHgb-1
[**2171-12-24**] 03:40AM BLOOD WBC-7.5 RBC-3.88* Hgb-9.6* Hct-29.7*
MCV-77* MCH-24.9* MCHC-32.4 RDW-16.6* Plt Ct-353
[**2171-12-24**] 03:40AM BLOOD Neuts-58.0 Lymphs-37.7 Monos-3.7 Eos-0.3
Baso-0.3
[**2171-12-24**] 03:40AM BLOOD Glucose-96 UreaN-10 Creat-0.7 Na-144
K-3.0* Cl-113* HCO3-24 AnGap-10
Brief Hospital Course:
50 year old female with breast cancer s/p chemotherapy and
nonhealing right lower extremity ulcer admitted with
methhemoglobenemia.
1. Methemoglobenemia: Unsure of the precipitant though suspect
new medication guaifenesin, which was started two days prior to
admission. There are case reports of this in the literature as
well. She had reponded well to methylene blue at the OSH prior
to admission, so on transfer to [**Hospital1 18**] her MetHb was only 3. She
did well clinically overnight and did not receive further
methylene blue at [**Hospital1 18**]. Repeat MetHg the morning after
admission was 1. She was stable so she was discharged back to
rehab.
2. Anxiety/Depression: Held home buproprion, trazodone and
citalopram as methylene blue is a potent reversible MAO
inhibitor and might precipitate serotonin syndrome. She can
plan to restart these on [**12-25**] to ensure time for methylene blue
to be metabolized from system.
3. RSD: Continued Oxycontin 60 mg CR QID which was her rehab
medication; Held off on oxycodone 8 mg po q3 prn because pt was
not asking for it. Continued gabapentin 300 mg po qhs.
4. GERD: Continued omeprazole 40 mg po BID
5. Anemia: Microcyctic with MCV of 77. Checked iron, TIBC,
ferritin (all normal), retic count (normal), LDH (normal) and
hemoglobin electropheresis (pending at the time of discharge) to
evaluate. Unlikely to be G6PD deficient unless she has hemolysis
after methylene blue to hold off on G6PD especially in acute
setting.
Transitional Issues:
1. follow up hemoglobin electropheresis to evaluate microcytic
anemia in setting of normal iron studies.
2. restart psychiatric medications on [**2171-12-25**] to avoid
serotonin syndrome in setting of recent administration of
methylene blue.
Medications on Admission:
Buproprion 100 mg SR po BID
Citalopram 40 mg po qdaily
MVA with minerals po qdaily
Omeprazole 40 mg po BID
Trazodone 50 mg po qhs
Oxycontin 60 mg CR po QID
Valium 10 mg po BID
Dilaudid 12 mg po q3 prn pain
Colace 100 mg po BID
Gabapentin 300 mg po qhs
Heparin 5000 units TID
Mucinex 600 ER po BID
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO once a day.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia: OK to restart on [**2171-12-25**].
4. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Three (3)
Tablet Extended Release 12 hr PO QID (4 times a day).
5. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety.
6. Dilaudid 4 mg Tablet Sig: Three (3) Tablet PO q3h as needed
for pain.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
10. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day: OK to restart on
[**2171-12-25**].
11. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day:
OK to restart on [**2171-12-25**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
Methemoglobinemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for letting us take part in your care at [**Hospital1 771**]. You were transferred to our hospital
for further evaluation after being treated for methemoglobinemia
(a cause of low oxygen levels) in your blood. This condition can
occur as a result of the way your body processes certain
medications. Essentially, the hemoglobin which normally carries
oxygen through your blood was blocked by other molecules
instead. This is treated by giving you a medication (methylene
blue) that knocks those molecules off your hemoglobin and allows
it to carry oxygen again. We think the cause of this was
mucinex (guaifenesin), and you should avoid this medication in
the future. Some of your medications were held while you were
here because they can interact with methylene blue. It will be
safe to restart them tomorrow.
No changes were made to your medications. You can restart
citalopram, bupropion, and trazodone tomorrow on [**2171-12-25**]. Do
not these medications today, as they interact with the methylene
blue that you received for treatment of methhemoglobinemia. Do
not take guaifenesin (mucinex) or any medications that contain
it again.
Followup Instructions:
Please follow up with your PCP in one week.
|
[
"53081",
"311"
] |
Admission Date: [**2160-11-13**] Discharge Date: [**2160-11-18**]
Date of Birth: [**2097-8-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Indocin / Doxycycline
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Off pump Coronary Artery Bypass Graft x4 (Left internal mammary
artery > Left anterior descending, Saphenous vein graft >
Diagonal, Saphenous vein graft > obtuse marginal, Saphenous vein
graft > posterior descending artery) [**2160-11-14**]
History of Present Illness:
63 year old amle with increasing chest pain over the last 2
weeks with worsening dyspnea on exertion. Troponin negative but
cardaic catherization revealed 3 vessel coronary artery disease
with in stent restenosis
Past Medical History:
Coronary artery disease
Hypertension
Diabetes Mellitus type 2
Hyperlipidemia
Depression
Obesity
knee arthritis
Gastroesophegeal reflux disease
Social History:
Retired
ETOH occasional
Tobacco denies
Lives alone
Family History:
None
Physical Exam:
Admission
Skin unremarkable
HEENT unremarkable
Neck Supple Full ROM
Chest Clear to ausculation bilat
Heart RRR
Abdomen soft, NT, ND +BS
Ext warm well perfused +2 edema, pulses palpable
Neuro grossly intact
Discharge
Vitals 98.4, 112/64, 99 SR 18, RA sat 94% wt 130.7
Neuro a/o x3 nonfocal
Pulm CTA decreased bilat bases
Heart RRR no m/r/g
Abd soft, NT, ND + BS BM [**11-17**]
Ext warm, pulses palpable +1 LE edema
Inc sternal CDI sternum stable, Left EVH CDI
Pertinent Results:
[**2160-11-17**] 11:00AM BLOOD Hct-25.1*
[**2160-11-17**] 06:45AM BLOOD WBC-6.3 RBC-2.64* Hgb-8.9* Hct-24.8*
MCV-94 MCH-33.9* MCHC-36.0* RDW-14.6 Plt Ct-174
[**2160-11-13**] 04:44PM BLOOD WBC-5.8 RBC-3.52* Hgb-11.7* Hct-32.0*
MCV-91 MCH-33.1* MCHC-36.5* RDW-14.6 Plt Ct-163
[**2160-11-17**] 06:45AM BLOOD Plt Ct-174
[**2160-11-16**] 12:26AM BLOOD PT-12.3 PTT-33.4 INR(PT)-1.1
[**2160-11-14**] 11:24AM BLOOD PT-14.2* PTT-31.8 INR(PT)-1.3*
[**2160-11-13**] 04:44PM BLOOD Plt Ct-163
[**2160-11-15**] 02:55AM BLOOD Fibrino-490*#
[**2160-11-17**] 06:45AM BLOOD Glucose-163* UreaN-18 Creat-1.0 Na-137
K-4.2 Cl-103 HCO3-27 AnGap-11
[**2160-11-13**] 04:44PM BLOOD Glucose-157* UreaN-19 Creat-1.0 Na-139
K-4.1 Cl-102 HCO3-27 AnGap-14
[**2160-11-13**] 04:44PM BLOOD ALT-21 AST-27 LD(LDH)-309* AlkPhos-63
Amylase-94 TotBili-0.8
[**2160-11-13**] 04:44PM BLOOD Lipase-33
[**2160-11-16**] 04:36PM BLOOD Mg-2.4
[**2160-11-13**] 04:44PM BLOOD %HbA1c-6.4*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2160-11-17**] 2:12 PM
CHEST (PA & LAT)
Reason: evaluate for effusion
[**Hospital 93**] MEDICAL CONDITION:
63 year old man s/p cabg
REASON FOR THIS EXAMINATION:
evaluate for effusion
HISTORY: Evaluate for pleural effusion.
FINDINGS: In comparison with study of [**11-15**], there is again
generalized enlargement of the cardiac silhouette in a patient
with intact sternal sutures. The area behind the heart shows
some increased opacification posteriorly. This could reflect any
combination of pleural effusion, atelectasis, and even
pneumonia.
To assess for the degree of pleural effusion, lateral decubitus
view would be most helpful.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2160-11-18**] 9:48 AM
Cardiology Report ECG Study Date of [**2160-11-14**] 2:44:10 PM
Sinus rhythm. Modest inferior ST-T wave changes which are
non-specific.
Borderline first degree A-V block. Compared to tracing of
[**2160-11-13**]
there is no significant diagnostic change.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 190 98 388/417 46 18 -6
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 56135**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 56136**] (Complete)
Done [**2160-11-14**] at 10:30:36 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2097-8-1**]
Age (years): 63 M Hgt (in): 72
BP (mm Hg): 126/66 Wgt (lb): 280
HR (bpm): 53 BSA (m2): 2.46 m2
Indication: Intraoperative TEE for off-pump CABG
ICD-9 Codes: 440.0, 424.0
Test Information
Date/Time: [**2160-11-14**] at 10:30 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: 0.31 >= 0.29
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.2 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.8 cm <= 2.5 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Simple atheroma in ascending aorta. Complex
(>4mm) atheroma in the aortic arch. Mildly dilated descending
aorta. Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-REVASCULARIZATION:
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is moderate symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 %). There is hypokinesis to akinesis of the apical
segments and inferior wall.
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is mildly dilated. There are simple
atheroma in the ascending aorta. There are complex (>4mm)
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened.
POST-REVASCULARIZATION:
1. During revascularization, and clamping of coronary vessels
there was noted wall motion abnormalities and increase in mitral
regurgitation; wall motion abnormalities and mitral
regurgitation have resolved to pre-revascularization.
2. Biventricular function is maintained. Overal LVEF is 45% with
inferior hypokinesis and apical hypokinesis.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician
Brief Hospital Course:
Transferred in from outside hospital, evaluation for cardiac
surgery. On [**11-14**] he was brought to the operating room where he
underwent an off pump coronary artery bypass graft x 4. Please
see operative report for surgical details. He tolerated the
procedure well and was transferred to the CVICU for invasive
monitoring in stable condition. In the first 24 hours he awoke
neurologically intact and was extubated. On post-op day one he
had short burst of atrial fibrillation that was controlled with
beta blockers. He remained in sinus rhythm. On post operative
day 2 he was transfused for hematocrit 21.3 with post
transfusion hematocrit 25. He was transferred to the floor for
the remained of his care. Physical followed patient during
post-op course for strength and mobility. He continued to make
steady process and was ready for discharge to rehab post-op day
four.
Medications on Admission:
Ativan
Trazadone
Diovan
Propanolol
Aspirin
Prilosec
Plavix
Pravachol
Vicodin
Gemfibrozil
Actos
Metformin
Relafen
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for anxiety.
4. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Pravachol 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days.
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
5 days.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
14. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
16. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
TCU [**Location (un) 1110**]
Discharge Diagnosis:
Coronary Artery Disease s/p offpump CABG
Post Operative Atrial Fibrillation
Hypertension
Diabetes Mellitus
Hyperlipidemia
Depression
Obesity
Knee Arthritis
Gastroesophageal reflux disease
Myocardial infarction [**2157**]
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr [**First Name (STitle) 5936**] after discharge from rehab [**Telephone/Fax (1) 42923**]
Dr [**Last Name (STitle) 20222**] after discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2160-11-18**]
|
[
"41401",
"9971",
"4280",
"4019",
"25000",
"2724",
"53081",
"42731",
"412"
] |
Admission Date: [**2192-3-16**] Discharge Date: [**2192-3-22**]
Date of Birth: [**2149-6-23**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 4373**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
42 year old man with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau disease (with
non-functioning pheo s/p right adrenalectomy, pancreatic tail
tumor, retinal hemangiomas, multiple spine hemangiomas),
metastatic renal cell carcinoma (to lungs, scalp and brain)on
sorafenib trial.
He presented to [**Hospital3 26615**] hospital after his sister found him
napping at home, confused, not wearing clothing. He had not felt
well, had noticed decreased urine and had a fever to 104 1 day
prior to this and had taken cipro at home. His sister denied
that he had complained of vomiting or diarrhea. At [**Hospital3 26615**]
he was found to have a fever, UTI (given levo), had a negative
head CT and a sodium of 112 so was transferred to [**Hospital1 18**]. There
was also a question of right sided weakness which was not
further described.
.
ED course:
vitals T 98.3 88 119/70 16 100%3L FS 211
1L NS then 3%NS at 25cc/hr
responding to voice, speaking non-sensically
CXR showed RUL PNA, UTI positive started on levo
Past Medical History:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau
-cerebellar haemangioblastoma excised [**2159**]
-[**2161**] medulla irradiation
-[**2168**] spinal irradiation
-[**2179**] cervical and thoracic spinal tumours excised... residual
chronic back pain
-[**2174**] phaeochromocytoma...R adrenalectomy; islet cell tumour
excised with spleen and consequent DM
-[**2180**] endolymphatic sac tumour R ear...deaf R ear/balance
problems
-[**2188**] Partial R nephrectomy for removal of renal cyst (benign)
-[**2189-11-7**] metastatic renal cell carcinoma (R ureteral stent
replaced q 4months) assoc with metastatic disease to the brain,
scalp and lung.
Haem-Onc Dr [**Last Name (STitle) **] [**Last Name (STitle) **].
-osteoporosis (prev treated with fosamax)
-GERD
-DM insulin dependent
-Migraines
-HTN last couple months (not on treatment)
-Appendicectomy
-Hernia OT
Social History:
Not employed. Walks inside "furniture surfing" from item to
item; uses wheelchair outside. Non-smoker, no alcohol.
Family History:
Mother CAD and depression; father alzheimer's disease and
depression; sister depression/migraines/2 brothers well
Physical Exam:
vs 97.6, HR 104, BP 137/81, 97%2L, RR 23
gen pale, lying in bed, speaking in non-sensical sentences
CV RRR, no murmurs
Pulm CTAB anteriorly
Abdomen soft, NT
R.nephrostomy tube insertion site-slightly erythematous
Extremities no edema
Lines 2 PIV
Pertinent Results:
[**2192-3-16**] 09:16PM LACTATE-2.0 NA+-116*
[**2192-3-16**] 09:15PM GLUCOSE-148* UREA N-16 CREAT-0.9 SODIUM-115*
POTASSIUM-5.5* CHLORIDE-80* TOTAL CO2-23 ANION GAP-18
[**2192-3-16**] 09:15PM estGFR-Using this
[**2192-3-16**] 09:15PM CORTISOL-46.1*
[**2192-3-16**] 09:15PM URINE HOURS-RANDOM
[**2192-3-16**] 09:15PM URINE GR HOLD-HOLD
[**2192-3-16**] 09:15PM WBC-58.3*# RBC-3.25* HGB-7.3*# HCT-25.6*
MCV-79* MCH-22.6*# MCHC-28.7* RDW-15.5
[**2192-3-16**] 09:15PM NEUTS-82* BANDS-11* LYMPHS-1* MONOS-4 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0 NUC RBCS-1*
[**2192-3-16**] 09:15PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ BURR-OCCASIONAL
TEARDROP-OCCASIONAL ACANTHOCY-OCCASIONAL
[**2192-3-16**] 09:15PM PLT SMR-VERY HIGH PLT COUNT-831*
[**2192-3-16**] 09:15PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.009
[**2192-3-16**] 09:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2192-3-16**] 09:15PM URINE RBC-[**4-11**]* WBC->50 BACTERIA-MANY
YEAST-MANY EPI-0
[**2192-3-18**] 02:05PM BLOOD WBC-50.2* Hct-25.2*
[**2192-3-17**] 01:22AM BLOOD Neuts-67 Bands-20* Lymphs-5* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-2*
[**2192-3-18**] 02:05PM BLOOD Glucose-129* Na-134
[**2192-3-18**] 03:46AM BLOOD ALT-14 AST-24 AlkPhos-290* TotBili-0.3
[**2192-3-18**] 03:46AM BLOOD Albumin-2.1* Calcium-8.6 Phos-2.7 Mg-2.0
[**2192-3-17**] 06:48AM BLOOD TSH-2.9
[**2192-3-17**] 06:48AM BLOOD T4-6.5
[**2192-3-17**] 08:04AM BLOOD Cortsol-42.2*
CXR [**2192-3-17**]:IMPRESSION: Right upper lobe pneumonia. Markedly
limited study due to motion.
Brief Hospital Course:
42 year old man with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau disease (with
non-functioning pheo s/p right adrenalectomy, pancreatic tail
tumor, retinal hemangiomas, multiple spine hemangiomas),
metastatic renal cell carcinoma (to lungs, scalp and brain)on
sorafenib trial who presented with altered mental status,
hyponatremia, and right lobar PNA.
.
HOSPITAL COURSE BY PROBLEM:
.
#Severe Hyponatremia-p/w Na 112 at OSH,trending down since
[**Month (only) 359**] (acute on chronic). Possible causes considered were:
adrenal insufficiency (could be primary as he has h/o pheo, or
secondary as he has had surgery on his pituitary gland, but this
was not evidenced by his presentation or vital signs) as he has
had labile BP recently, especially in the setting of
hyperkalemia, or more likely volume depletion secondary to
infection as his exam was consistent with volume depletion.
Other possible cause was SIADH as he has intracranial processes
as well as pneumonia. Also, hypothyroidism could be a cause, but
his thyroid function tests were all normal. He received 3% NaCl
to correct his sodium and was started on intravenous
antibiotics. His sodium improved with these interventions.
.
#Change in Mental Status-unclear if from hyponatremia or
infection, more worrisome would be intracranial hemorrhage or
stroke as he has history of this, however he improved with
antibiotic therapy.
.
#right middle lobe pneumonia- sputum culture not obtained, but
empirically placed on ceftriaxone and levofloxacin IV. His
oxygenation remained adequate on room air and he was largely
asymptomatic. Blood cx remained negative. Influenza was
negative. He will finish a 2 week course of antibiotics
.
#?[**Name (NI) 12007**] pt has r nephrostomy tube, u/a concerning for UTI and pt
placed on ceftriaxone also for dual coverage of PNA. Cultures
were however inconclusive ("mixed urogenital flora").
.
#VHL-stable, hemangiomas of retina, spine
.
#Renal Cell Ca- on chemotherapy (sorafenib) per Dr. [**Last Name (STitle) **],
currently on hold
.
#DM-continue home dose of lantus 5 qam and sliding scale
.
#Chronic Pain-home doses of Morphine 15 mg po q.8h p.r.n.
.
#Hypothyroidism-continue levothyroxine, held briefly during
hospitalization
.
#GERD-protonix
.
#[**Doctor First Name 30617**] (sister)HCP [**Telephone/Fax (1) 30618**]
Medications on Admission:
1. Ambien CR 12.5 mg at bedtime.
2. Ativan 1 mg one to two tablets q.6h.
3. Fioricet one to two tablets q.4-6h. p.r.n. migraine.
4. Imitrex 20 mg for migraines.
5. Imitrex nasal spray for migraines.
6. Lantus 5 units in the morning.
7. Levothyroxine 25 mcg p.o. once daily.
8. Lexapro 5 mg a day.
9. Lipitor 20 mg a day.
10. Morphine 15 mg q.8h p.r.n.
11. Neurontin 200 mg at bedtime.
12. Nexavar 400 mg twice a day.
13. Normal saline.
14. Novalog 100 units subq.
15. Pangestyme 20,000 units once daily.
16. Ritalin 2 mg day.
17. Zomig p.r.n.
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
2. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous once a day.
3. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed: hold for sedation or rr< 10.
4. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for constipation.
5. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO TID
(3 times a day) for 10 days.
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 10 days.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig:
Two (2) gm Intravenous Q24H (every 24 hours) for 10 days.
11. Insulin Glargine 100 unit/mL Solution Sig: humalog sliding
scale Subcutaneous four times a day.
12. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**]
Discharge Diagnosis:
PRIMARY:
pneumonia
SECONDARY:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau
Metastatic Renal Cell Carcinoma
Chronic Pain
Right nephrostomy tube
Constipation
Discharge Condition:
Good
Afebrile
Normotensive
Discharge Instructions:
You were admitted with altered mental status and were found to
have a right-sided pneumonia. Your sodium was low likely
secondary to infection and returned to [**Location 213**] levels on
discharge. Your white blood cell count was markedly elevated and
is trending down on antibiotics and you are much improved. No
clear urine cultures identified infection and there was no yeast
in your nephrostomy or bladder urine. You were started on
nystatin swishes because of your tendency to develop thrush with
antibiotics. You were placed on an aggressive bowel regimen to
encourage a bowel movement.
.
Your chemotherapy is currently on hold and Dr. [**Last Name (STitle) **] will
discuss future treatment with you once your infection has
improved. Your levothyroxine was held but may now be restarted
as your sodium and blood pressures have all normalized. No
other changes were made in your medications. You will finish a
2-week total course of antibiotics for your pneumonia and
nystatin swishes while you are on antibiotics.
.
You will be going to a rehab facility to help you improve your
strength. All your medications will be administered there.
.
If you develop any concerning symptoms such as increased pain,
persistent fevers, shortness of breath or chest pain, please
call your physician or proceed to the emergency department.
Followup Instructions:
Please call your primary care phsyician Dr. [**Last Name (STitle) 13517**] to schedule
a f/u appointment [**Telephone/Fax (1) 30619**] within the next 1-2 weeks to
discuss your hospitalization.
.
Please call Dr. [**Last Name (STitle) **] to set up an appiontment with him in 2
weeks to discuss your chemotherapy. ([**Telephone/Fax (1) 16668**]
.
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2192-6-4**]
10:35
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2192-6-4**] 11:30
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2192-7-26**] 1:00
|
[
"486",
"2761",
"5990",
"4019",
"2449",
"53081"
] |
Admission Date: [**2162-2-16**] Discharge Date: [**2162-2-25**]
Date of Birth: [**2100-3-16**] Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61yo woman from group home with a hx of mental retardation,
DMII, HTN, nephrolithiasis was brought to [**Hospital1 18**] ED for acute
renal failure. She was brought to [**Hospital1 3494**] ED for failure to
thrive (decreased appetite, malaise) x 1 month. At [**Location 17065**]
(97.2 105 16 110/64 88% RA) she was found to
have multiple lab abnormalities: K+ 7.4, glucose 388, WBC 14.4
with 92.7% polys, HCO3 14, AST 102, ALT 50, U/A with >50
bacteria, 0-2 WBC, -nitrate, -leuk esterase, and ?????? bottles blood
cx aerobic + for Gram+ cocci, ABG 7.296/26/2/90.1 and base
excess ??????12. Received D50/insulin/bicarbonate/calcium
gluconate/kayexelate. Dopamine gtt @ 20 started for SBP
80-90/palp. Abdominal CT: no hydronephrosis. Head CT were
negative. Lab abnormalities from triage assessment: CK 5336 Trop
0.38 CKMB 60 BUN/CR = 130/11.6. Her initial [**Hospital1 18**] ED vitals on
dopamine gtt @ 20 were:
97F 111 123/92 18 92% RA
She was alert, oriented to person and place, answering simple
questions, and denied pain. She had just finished a 10d course
of Bactrim for UTI. In the [**Hospital1 18**], she received 1L NS, 1L D5W +
3amps NaHCO3, CTX 1g IV, kayexylate, and a Foley was placed.
Dopamine gtt weaned to 5. Mixed venous O2 sat: 71%. Admitted to
[**Hospital Unit Name 153**] for hypotension of unknown etiology.
[**Hospital Unit Name 153**] course: Weaned off dopamine. Renal consult: no need for
acute dialysis. Renal U/S showed R kidney stone with mild
hydronephrosis. NS IVF given for CVP goal [**1-19**]. FENA 3.8%
pointed away from pre-renal etiology for ARF. Admission CR was
10.2 CR fell rapidly.
Past Medical History:
1. HTN
2. mental retardation
3. Type II DM
4. Recent UTI and PNA
5. hypercholesterolemia
6. nephrolithiasis - R kidney stone, staghorn calculus - planned
for surgical removal in the next several months. Dr. [**Last Name (STitle) 59213**]
plans to do surgery in 2 months.
7. depression
8. hx cystitis
9. s/p L TKR
10. depression
11. s/p recent hospitalization at [**Hospital3 **] for hitting herself
and attempting to bite others - "psychotic episode" - per
patient brother - started on risperidone and celexa at this time
Social History:
Lives in group home. Used a walker after her knee replacement
several weeks ago. No EtOH. No tobacco or other drug use per
brother.
Family History:
Sister is deaf and has UC. Mother with DM II. Father with [**Name2 (NI) **].
Physical Exam:
Vitals: 97.9 134/78 86 26 96% on 2L
General: 61yo obese [**Known lastname **] male lying in NAD with head deviated
to the L, R IJ central line
Neuro: Alert. Pupils 3-->1 bilaterally. Was able to get her to
say only one word: "hello." Follows simple midline commands like
stick out your tongue and wiggle your toes. Nods to questions
inconsistently. No blink to R visual field confrontation. Blinks
to L visual field confrontation. EOMI. Tongue midline.
Neck: JVP hard to assess. No lymphadenopathy.
CV: RRR. No thrill. Normal S1, S2. JVP difficult to assess
because of obese neck and brisk carotid pulsation.
Lungs: Difficult to assess because could not get patient to sit
up. Listening near the axilla bilaterally, could hear air
movement and did not hear any crackles or wheezes.
Abd: Distended and tympany to percussion. +BS. No scars.
Difficult to assess tenderness as patient would nod
inconsistently. But patient tolerated deep palpation without
obvious distress.
Ext: 2+ pitting edema bilaterally in the LE.
Pertinent Results:
[**2162-2-19**] 09:30AM BLOOD WBC-9.9 RBC-3.24* Hgb-9.8* Hct-29.4*
MCV-91 MCH-30.1 MCHC-33.2 RDW-13.4 Plt Ct-246
[**2162-2-18**] 04:45AM BLOOD WBC-9.1 RBC-3.24* Hgb-9.4* Hct-28.3*
MCV-87 MCH-29.0 MCHC-33.2 RDW-12.7 Plt Ct-265
[**2162-2-17**] 06:01AM BLOOD WBC-10.0 RBC-3.27* Hgb-10.0* Hct-28.8*
MCV-88 MCH-30.5 MCHC-34.7 RDW-13.7 Plt Ct-244
[**2162-2-16**] 11:06PM BLOOD WBC-10.2 RBC-3.24* Hgb-9.3* Hct-28.2*
MCV-87 MCH-28.6 MCHC-32.9 RDW-12.9 Plt Ct-259
[**2162-2-16**] 02:00PM BLOOD WBC-9.7 RBC-3.27* Hgb-9.6* Hct-29.2*
MCV-89 MCH-29.4 MCHC-32.9 RDW-13.7 Plt Ct-252
[**2162-2-16**] 12:39AM BLOOD WBC-16.0* RBC-3.61* Hgb-10.6* Hct-32.2*
MCV-89 MCH-29.2 MCHC-32.7 RDW-13.6 Plt Ct-302
[**2162-2-16**] 11:06PM BLOOD Neuts-80.6* Lymphs-12.1* Monos-5.9
Eos-1.2 Baso-0.2
[**2162-2-16**] 02:00PM BLOOD Neuts-79.3* Lymphs-14.0* Monos-5.9
Eos-0.7 Baso-0.1
[**2162-2-16**] 12:39AM BLOOD Neuts-87.1* Lymphs-9.0* Monos-3.7 Eos-0.1
Baso-0.1
[**2162-2-19**] 09:30AM BLOOD Plt Ct-246
[**2162-2-19**] 09:30AM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1
[**2162-2-18**] 04:45AM BLOOD Plt Ct-265
[**2162-2-18**] 04:45AM BLOOD PT-13.3 PTT-25.0 INR(PT)-1.1
[**2162-2-17**] 06:01AM BLOOD Plt Ct-244
[**2162-2-17**] 06:01AM BLOOD PT-13.9* PTT-24.8 INR(PT)-1.2
[**2162-2-16**] 11:06PM BLOOD Plt Ct-259
[**2162-2-16**] 02:00PM BLOOD Plt Ct-252
[**2162-2-16**] 12:39AM BLOOD Plt Ct-302
[**2162-2-16**] 12:39AM BLOOD PT-13.9* PTT-24.3 INR(PT)-1.2
[**2162-2-19**] 09:30AM BLOOD Glucose-136* UreaN-28* Creat-0.8 Na-145
K-4.6 Cl-112* HCO3-25 AnGap-13
[**2162-2-18**] 04:45AM BLOOD Glucose-136* UreaN-59* Creat-1.6* Na-148*
K-3.9 Cl-114* HCO3-29 AnGap-9
[**2162-2-17**] 05:52PM BLOOD Glucose-119* UreaN-79* Creat-2.5*#
Na-150* K-3.6 Cl-115* HCO3-26 AnGap-13
[**2162-2-17**] 06:01AM BLOOD Glucose-138* UreaN-91* Creat-4.1*#
Na-149* K-3.7 Cl-112* HCO3-27 AnGap-14
[**2162-2-16**] 11:06PM BLOOD Glucose-131* UreaN-98* Creat-5.4*#
Na-148* K-3.8 Cl-111* HCO3-27 AnGap-14
[**2162-2-16**] 02:00PM BLOOD Glucose-226* UreaN-112* Creat-8.0* Na-144
K-4.3 Cl-104 HCO3-25 AnGap-19
[**2162-2-16**] 08:30AM BLOOD Glucose-144* UreaN-113* Creat-8.8* Na-145
K-4.8 Cl-103 HCO3-24 AnGap-23*
[**2162-2-16**] 04:25AM BLOOD Glucose-159* UreaN-113* Creat-9.3* Na-144
K-5.0 Cl-103 HCO3-22 AnGap-24*
[**2162-2-16**] 12:39AM BLOOD Glucose-159* UreaN-123* Creat-10.1*
Na-142 K-6.0* Cl-102 HCO3-18*
[**2162-2-19**] 09:30AM BLOOD ALT-22 AST-23 LD(LDH)-315* CK(CPK)-184*
AlkPhos-51 Amylase-131* TotBili-0.2
[**2162-2-18**] 04:45AM BLOOD ALT-29 AST-31 LD(LDH)-281* CK(CPK)-566*
AlkPhos-49 Amylase-223* TotBili-0.1
[**2162-2-17**] 06:01AM BLOOD CK(CPK)-1553*
[**2162-2-16**] 11:06PM BLOOD ALT-35 AST-49* LD(LDH)-315* CK(CPK)-1888*
AlkPhos-49 Amylase-156* TotBili-0.1
[**2162-2-16**] 02:00PM BLOOD LD(LDH)-342* CK(CPK)-2860* Amylase-116*
[**2162-2-16**] 08:30AM BLOOD CK(CPK)-3454*
[**2162-2-16**] 04:25AM BLOOD ALT-43* AST-75* LD(LDH)-356*
CK(CPK)-3656* AlkPhos-54 TotBili-0.2
[**2162-2-16**] 12:39AM BLOOD CK(CPK)-4468*
[**2162-2-19**] 09:30AM BLOOD Lipase-181*
[**2162-2-18**] 04:45AM BLOOD Lipase-453*
[**2162-2-16**] 11:06PM BLOOD Lipase-368*
[**2162-2-16**] 02:00PM BLOOD Lipase-167*
[**2162-2-18**] 04:45AM BLOOD CK-MB-4 cTropnT-<0.01
[**2162-2-17**] 06:01AM BLOOD CK-MB-11* MB Indx-0.7 cTropnT-0.02*
[**2162-2-16**] 11:06PM BLOOD CK-MB-14* MB Indx-0.7 cTropnT-0.03*
[**2162-2-16**] 02:00PM BLOOD CK-MB-24* MB Indx-0.8 cTropnT-0.06*
[**2162-2-16**] 08:30AM BLOOD CK-MB-31* MB Indx-0.9 cTropnT-0.11*
[**2162-2-16**] 04:25AM BLOOD cTropnT-0.12*
[**2162-2-16**] 12:39AM BLOOD CK-MB-43* MB Indx-1.0
[**2162-2-16**] 12:32AM BLOOD cTropnT-0.13*
[**2162-2-19**] 09:30AM BLOOD Calcium-8.8 Phos-1.2*# Mg-1.4*
[**2162-2-18**] 04:45AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8
[**2162-2-17**] 05:52PM BLOOD Calcium-8.6 Phos-3.9# Mg-2.0
[**2162-2-17**] 06:01AM BLOOD Calcium-8.5 Phos-5.6* Mg-2.1
[**2162-2-16**] 11:06PM BLOOD Calcium-8.4 Phos-6.4*# Mg-2.2
[**2162-2-16**] 02:00PM BLOOD Calcium-8.5 Phos-8.3* Mg-2.2
[**2162-2-16**] 04:25AM BLOOD Albumin-3.2* Calcium-8.5 Phos-8.9* Mg-2.3
[**2162-2-18**] 04:45AM BLOOD Triglyc-127
[**2162-2-16**] 11:06PM BLOOD Triglyc-130
[**2162-2-16**] 04:25AM BLOOD TSH-0.36
[**2162-2-16**] 08:30AM BLOOD C3-138 C4-39
[**2162-2-16**] 02:00PM BLOOD GreenHd-HOLD
[**2162-2-16**] 02:00PM BLOOD Type-MIX
[**2162-2-16**] 11:04AM BLOOD Type-MIX
[**2162-2-16**] 02:00PM BLOOD Lactate-1.6
[**2162-2-16**] 12:38AM BLOOD K-5.7*
[**2162-2-16**] 11:04AM BLOOD O2 Sat-71
[**2162-2-16**] 02:00PM BLOOD O2 Sat-78
CHEST (PORTABLE AP) [**2162-2-18**] 4:48 PM
IMPRESSION:
1) No CHF.
2) Left base atelectasis/consolidation.
3) Hazy opacity at the right base, medially, unchanged.
ECG Study Date of [**2162-2-17**] 10:13:32 AM
Poor quality tracing. Sinus rhythm. Since the previous tracing
of [**2162-2-16**] the
rate has decreased, the axis is more leftward and ST segments
are probably
improved. Clinical correlation is suggested.
TTE/ECHO Study Date of [**2162-2-17**]
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. There is mild pulmonary artery systolic hypertension.
UNILAT UP EXT VEINS US RIGHT PORT [**2162-2-17**] 1:23 PM
IMPRESSION:
Short segment of thrombus within the cephalic vein superior to
the antecubital fossa. The remainder of the upper extremity
veins are widely patent.
ECG Study Date of [**2162-2-16**] 12:14:12 AM
Baseline instability makes identification of P waves difficult.
The rhythm is
likely sinus tachycardia, rate 133. Another possibility (though
less likely) is
atrial flutter, atrial rate 265, with 2:1 A-V block. Possible
old inferior
myocardial infarction. Possible old anterior myocardial
infarction.
Intraventricular conduction delay of right bundle-branch block
type, possibly
rate-related.
CHEST (PORTABLE AP) [**2162-2-16**] 3:34 AM
IMPRESSION: Technically limited, but no overt CHF. Recommmend PA
and lateral to evaluate right base (see above).
RENAL U.S. [**2162-2-16**] 7:05 AM
CONCLUSION:
Normal sized kidneys with mild right hydronephrosis secondary to
a stone or stones in the right renal pelvis. No evidence of left
hydronephrosis.
Brief Hospital Course:
61yo female with mental retardation, DM II, HTN, nephrolithiasis
was brought from the [**Hospital 17065**] hospital ED to the [**Hospital1 18**] ED for
acute renal failure (Cr 11.6) and hypotension on dopamine gtt.
She was admitted to the [**Hospital Unit Name 153**], quickly weaned off dopamine, a
central venous line was placed, and she was aggressively fluid
resuscitated to a goal CVP 8-12. A renal U/S showed R kidney
stone with mild hydronephrosis. Nephrology was consulted and
decided that the patient has no acute need for dialysis despite
a very elevated creatinine. In the ICU she received a 3 day
course of levofloxacin for possible urinary tract infection and
a single dose of vancomycin for a single coag-neg Staph negative
culture bottle from the outside ED from where she was
transferred. Her renal function improved rapidly and she
remained afebrile and hemodynamically stable in the ICU. She
was transferred to the medicine floor with the following vitals:
97.9 134/78 86 26 96% on 2L. CXR showed
questionable opacification at the L and R bases and she was
continued on levofloxacin (for total 10d course) for empiric
coverage of community-acquired pneumonia. Her lipase and
amylase had risen while she was in the ICU but began to decrease
when she came to the floor; she never had clinical signs of
pancreatitis. All blood cultures remained negative. The
patient's kidney function continued to improve on the floor.
She was weaned off oxygen. Her medications for hypertension and
diabetes were reinstituted without complication. Psychiatry
consultation recommened the addition of remeron and seroqual for
depression and and anxiety respectively.
Medications on Admission:
1. lisinopril 20mg PO qd
2. metformin 500mg PO qd
4. trazadone 50mg PO qd
5. colace 100mg PO bid
6. lipitor 10mg PO qd
7. risperdal 0.5mg PO bid - started 10d ago
8. celexa 30mg PO qd - started 10d ago
9. senna 2 tabs qhs
10. iron sulfate 325mg PO qd
11. estrace vaginal cream 1x/week
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
5. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Quetiapine Fumarate 25 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
7. Quetiapine Fumarate 25 mg Tablet Sig: 0.5-1 Tablet PO BID PRN
() as needed for anxiety.
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
1. Acute Prerenal Failure
2. Hypotension
3. Pneumonia/Sepsis
4. Recurrent UTI's, with nephrolithiasis and right sided
nephrolithiasis causing mild hydronephrosis
4. Type II Diabetes
5. Hypertension
6. Mental Retardation
7. Depression and Anxiety
8. Superficial thrombophlebitis
Discharge Condition:
Fair
Discharge Instructions:
Please return to the emergency room should you experience high
fever > 101F and shaking chills, shortness of breath, chest
pain, abdominal pain, or other alarming symptom.
Followup Instructions:
1) Please follow-up with your Urologist Dr. [**Last Name (STitle) 59213**] for
planned treatment for your renal calculi.
2) Please arrange for formal neuropsychological testing to
further evaluate cognitive function and capacity to care for
self.
3) Have Hct re-checked along with an anemia evaluation. You
should also have a colonoscopy to assess for a potential cause
for the anemia
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2162-2-25**]
|
[
"5849",
"51881",
"5180",
"486",
"0389",
"25000",
"2720",
"4168"
] |
Admission Date: [**2113-12-27**] Discharge Date: [**2113-12-30**]
Date of Birth: [**2059-10-8**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Iodine
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
54-year-old female with past medical history of UGIB secondary
[**Known firstname **] duodenal ulcer, on pantoprazole no presents with dark red
vomit and dark red bowel movement starting today.
.
The patient was in her usual state of health until the day of
admission. At that time the patient had emesis x1 which was dark
red in appearance. She also noted a dark red bowel movement. A
few hours later she became lightheaded. This reminded her of her
prior duodenal bleed so she presented [**Known firstname **] [**Hospital1 18**] EW for further
evaluation. The patient denies chest pain, palpitations,
diarrhea, constipation or other symptoms. She notes mild
epigastric discomfort. She has not taken her pantoprazole for
"some time". She denies aspirin or NSAID use.
.
In the EW, initial vitals were: T 98.2, HR 107, BP 85/61, RR 18,
SaO2 100% RA. The SBP nadired in mid 70s but responded without
treatment [**Known firstname **] SBP 100s. She was started on maintanance fluid for
a total of 1L. Guaiac positive with maroon stool. NGL with
coffee grounds that did not clear after 1L. She was started on
pantoprazole gtt. She has 18g x2 for access and was typed and
crossed for 2 units. GI was consulted. The patient was sent [**Known firstname **]
the MICU with vitals: HR 86, SBP 112, RR 13, SaO2 100% RA.
.
Currently, the patient notes discomfort from the NG tube. She
otherwise feels well.
.
ROS: Per HPI. Otherwise negative in 10 other systems.
Past Medical History:
1. Mild asthma
2. h/o anemia
3. h/o duodenal ulcer, s/p UGIB, s/p cauterization, H. Pylori
positive although no treatment (GI felt that treatment was not
warranted)
4. h/o low back pain
5. h/o shingles
6. h/o benign mass in soft palate
7. h/o anxiety
8. h/o gestational diabetes
9. h/o palpitations
Social History:
immunologist. Lifelong nonsmoker. She drinks alcohol about one
drink (glass of wine) per day. She does not use recreational
drugs.
Family History:
HTN, HLD, CVA. 5-healthy siblings.
Physical Exam:
Admission Exam:
VS: Temp: 97.7 BP: 112/71 HR: 98 RR: 13 O2sat: 100% RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, MMM, op without lesions, no supraclavicular or
cervical lymphadenopathy,
RESP: CTA b/l with good air movement throughout
CV: RR, nl rate, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, epigastric tenderness, no masses or
hepatosplenomegaly
EXT: warm, no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. CN II-XII grossly intact
RECTAL: per EW guaiac positive dark red stool
Discharge Exam:
Vitals: 98.7 98/62 60 16 97% RA
General: thin, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear [**Known firstname **] 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
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs
[**2113-12-27**] 02:15PM BLOOD WBC-13.1*# RBC-4.06* Hgb-11.8* Hct-35.7*
MCV-88 MCH-29.0 MCHC-33.0 RDW-13.9 Plt Ct-268
[**2113-12-27**] 02:15PM BLOOD PT-12.5 PTT-27.5 INR(PT)-1.1
[**2113-12-27**] 02:15PM BLOOD Glucose-168* UreaN-40* Creat-0.8 Na-139
K-4.0 Cl-102 HCO3-27 AnGap-14
[**2113-12-27**] 02:15PM BLOOD ALT-16 AST-21 AlkPhos-55 TotBili-0.3
Serial HCTs
[**2113-12-27**] 05:10PM BLOOD Hct-29.5*
[**2113-12-27**] 10:44PM BLOOD Hct-25.6*
[**2113-12-28**] 03:22AM BLOOD Hct-27.9*
[**2113-12-28**] 10:20AM BLOOD Hct-30.7*
[**2113-12-29**] 05:10PM BLOOD Hct-33.9*
[**2113-12-30**] 06:25AM BLOOD WBC-5.7 RBC-3.71* Hgb-11.2* Hct-32.1*
MCV-87 MCH-30.1 MCHC-34.7 RDW-14.3 Plt Ct-196
Imaging:
CXR:
IMPRESSION: No acute cardiopulmonary process. No evidence of
free air
beneath the diaphragms.
EGD:
-Coffee grounds in the stomach
-A single 1cm ulcer was found in the proximal bulb.
-A small clot/pigmental material was present, which is
predictive of the likelihood of rebleeding.
-8 cc of Epinephrine 1/[**Numeric Identifier 961**] was injected circumferentially at
the base of the ulcer.
-A bipolar gold probe was applied [**Known firstname **] the area for coaptive
coagulation of the underlying vessel.
-Otherwise normal EGD [**Known firstname **] 2nd part of duodenum.
Brief Hospital Course:
54-year-old female with past medical history of UGIB secondary
[**Known firstname **] duodenal ulcer, on pantoprazole but not taking it regularly
presented with upper GI bleed.
.
# Upper GI bleed with acute blood loss anemia: Patient had
history of duodenal ulcer and GIB. There were no precipitating
triggers for this bleed, such as NSAID use, but patient had been
not taking pantoprazole consistently. NGL in ED with coffee
ground emesis, melena and increased BUN/Cr ratio. She was
started on PPI gtt and underwent EGD which revealed a 1cm ulcer
in the proximal bulb of the duodenum. This was treated with
epinephrine and coaptive coagulation. She received 2 units pRBCs
for HCT drop from 35 [**Known firstname **] 25 and had subsequent stable HCTs around
30. She was hypotensive overnight on initial evening of
admission with SBPs 80s but this improved with fluids and PRBCs.
The patient was transferred from the MICU [**Known firstname **] the floor and
remained stable. H pylori tested was deferred [**Known firstname **] outpatient. The
patient will followup with GI in two weeks; before this she will
have H.pylori testing with her PCP. [**Name10 (NameIs) **] was discharged with
strict instructions [**Known firstname **] continue taking pantoprazole 40 mg [**Hospital1 **].
.
# Leukocytosis: The patient presented with leukocytosis of
unclear etiology. She had no evidence of infection and CXR
without consolidation. Her WBC resolved [**Known firstname **] 5.7 on discharge.
Medications on Admission:
1. pantoprazole 40 mg PO BID
2. Calcium/Vit D 500/500 mg/iu PO BID
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Outpatient testing
Please perform urease breath test and H.pylori stool antigen.
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcer with upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dr. [**Known lastname **],
You were admitted [**Known firstname **] the hospital for an upper GI bleed that was
found on endoscopy [**Known firstname **] be secondary [**Known firstname **] a duodenal ulcer. The
ulcer was cauterized and injected with epinephrine.
.
Your HCT was stable for two days before discharge. Please make
sure [**Known firstname **] return if you have any recurrent signs of bleeding,
including dark stool. You will need [**Known firstname **] followup with GI in 2
weeks; this appointment is listed below. Before then, you will
need [**Known firstname **] have testing for H.pylori with a urease breath test and
H.pylori stool antigen. We will write you a prescription for
this and notify your PCP. [**Name10 (NameIs) 357**] talk [**Known firstname **] your PCP and make sure
this testing is complete before your GI appointment.
.
You should take the followng medication every day:
Pantoprazole 40 mg by mouth twice daily.
.
We have made no other changes [**Known firstname **] your medications.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2114-1-4**] at 1:40 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ENDO SUITES
When: FRIDAY [**2114-1-5**] at 1:30 PM
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2114-1-5**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: GASTROENTEROLOGY
When: THURSDAY [**2114-1-11**] at 10:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"2851",
"49390"
] |
Admission Date: [**2117-2-10**] Discharge Date: [**2117-2-14**]
Date of Birth: [**2052-12-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64yoM with PAD s/p stents to L CIA/SFA, CAD s/p BMS to D1, DM,
dyslipidemia, idopathic pulmonary fibrosis (unproven biopsy)
presenting with fever, non-productive cough, and chest pain for
the past four days. Pt notes worsening SOB with any exertion,
productive cough of clear-white sputum (more then usual), and
some chest pain that has been getting progressively worse in 4
days. Denies any sudden SOB symptoms, no new pedal edema or calf
tenderness. He has been checking his Temp in the morning daily
and it is 96, but never took it in the PM. Denies any chills,
rigors, sweats. He called pulmonary clinic this AM with
complaints of SOB, fatigue and weakness, bed-ridden for the past
few days. No sick contacts. [**Name (NI) 227**] his prior history, he was
referred to the ED for further evaluation.
.
Of note, per last pulmonary note in [**12/2116**]: He was previously
followed for IPF at [**Hospital1 112**], had initial plans for lung transplant
but decided not to pursue lung transplantation. (although, when
talking to me, pt reports that he did in fact want the
transplant) He is on 2-4L NC O2, on NAC, although he reportedly
stopped taking this in [**Month (only) 1096**]. (however, pt tells me today
that he still takes it). He has undergone pulm rehabilitation.
He is known to feel SOB all the time, even at night. He has a
chronic cough productive of clear white sputum. Known to have a
little blood coming out of his nose when he sneezes a lot. Uses
flonase nasal spray, combivent nebs at night for cough/sob. He
is known to be losing weight.
.
In the ED inital vitals were, Tm 101.2, HR 100 BP 79/47 RR 44
Sat 90% on 100%NRB. DNI but will accept NIV. His labs were
notable for Na 129 (baseline low 130s), K 4.2, Cl 98, HCO3 22,
BUN 13, Cr. 0.7, Gluc 115. Trop-T: <0.01 proBNP: 220 wbc 14.9,
hgb 11.1, hct 34, plt 492 PT: 13.5 PTT: 28.6 INR: 1.3; He
was given Acetaminophen, Vancomycin, and Cefepime. Got 2L NS.
Most recent vitals: temp 101, BP 99/57, rr 30, sat 90% (baseline
90% on 2L at home) on BIPAP.
.
On arrival to the ICU, pts vitals: T 98.4, 95/61 (baseline BP is
70-90s per son), HR 82, RR 40, 95% on 100% non-rebreather. He
says he is currently feeling at his baseline when he lies still.
But when he ambulates, he feels significantly worse. He notes at
home that he uses CPAP at home for OSA and uses 2L NC during the
day all day long. Occasionally he will use 4 L NC. He notes that
he had back surgery performed 2 months ago, denies any clots in
his legs, no calf pain. Does have known mild pedal edema, for
which he uses compression stalkings. He notes that he has not
been drinking very much lately because he is worried about
taking the trip to the bathroom, concerned he will be too SOB.
Thus, drinking only very little daily and mainly coffee.
.
Review of systems:
(+) Per HPI. Known to be losing weight.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies palpitations, no
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Interstitial lung disease-- on 2L home O2, CPAP at night, used
to take NAC daily
CAD s/p angioplasty with BMS to D1, DM
Peripheral vascular disease, s/p stents to L CIA and L SFA
DM x10 yrs, c/b peripheral neuropathy
Hyperlipidemia
GERD
Colitis
Bilateral hearing loss/cholesteatoma
Sleep apnea, on CPAP every night
s/p bilateral ear surgery
s/p right cataract surgery
Prior positive IgG for strongyloides- says he took medications
for this about 10 yrs ago.
Positive [**Doctor First Name **] titer 1:40
Social History:
He is married and lives with his wife.
[**Name (NI) **] is a former three pack a day smoker, quit in [**2107**], 60-90 pk
year smoking hx.
He previously worked in construction doing wiring for fences,
also painting at a body shop.
Originally from [**Male First Name (un) 1056**] but in the United States since [**2073**].
No drugs.
Family History:
Mother died of lung CA, father died of throat CA. Brother died
of gastric CA at age 56. Sister died of lung CA at age 43.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.4, 95/61 (baseline BP is 70-90s per son), HR 82,
RR 40, 95% on 100% non-rebreather
General: Alert, oriented, breathing quickly but looks
comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: velcro fine crackles throughout lung fields bilaterally,
most prominant at the bases.
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 , put out 400 cc
Ext: warm, well perfused, 2+ pulses, clubbing in all fingers
and does, cyanosis or edema
Pertinent Results:
LABS:
On admission:
[**2117-2-10**] 10:50AM BLOOD WBC-14.9* RBC-4.01* Hgb-11.1* Hct-34.1*
MCV-85 MCH-27.6 MCHC-32.5 RDW-13.3 Plt Ct-492*
[**2117-2-10**] 10:50AM BLOOD Neuts-87.0* Lymphs-7.1* Monos-4.3 Eos-1.2
Baso-0.4
[**2117-2-10**] 10:50AM BLOOD PT-13.5* PTT-28.6 INR(PT)-1.3*
[**2117-2-10**] 10:50AM BLOOD Glucose-115* UreaN-13 Creat-0.7 Na-129*
K-4.2 Cl-98 HCO3-22 AnGap-13
[**2117-2-10**] 10:50AM BLOOD cTropnT-<0.01 proBNP-220
[**2117-2-10**] 09:00PM BLOOD Calcium-9.2 Phos-3.4 Mg-2.2 Iron-17*
[**2117-2-10**] 07:33PM BLOOD Type-ART pO2-67* pCO2-37 pH-7.47*
calTCO2-28 Base XS-3
[**2117-2-10**] 10:56AM BLOOD Lactate-1.4
IMAGING:
[**2-10**] CXR:
IMPRESSION: Increased markings bilaterally may be due to the
combination of
underlying pulmonary fibrosis and moderate pulmonary edema,
superimposed
infectious process cannot be excluded.
[**2-11**] Echo:
The left atrium is elongated. 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 leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. Moderate pulmonary artery systolic pressure.
Compared with the prior study (images reviewed) of [**2113-1-23**], the
pulmonary artery systolic pressures can be estimated on the
current study and are moderately elevated. The other findings
are similar.
[**2-11**] CTA chest:
1. Worsened air space disease on a background of emphysema and
chronic
fibrotic changes consistent with reported idiopathic pulmonary
fibrosis.
Differential includes acute exacerbation of IPF, infectious
process, or ARDS.
The pulmonary vasculature is well opacified and without filling
defect to suggest pulmonary embolism.
Brief Hospital Course:
64yoM with PAD s/p stents to L CIA/SFA, CAD s/p BMS to D1, DM,
dyslipidemia, idopathic pulmonary fibrosis (on [**2-20**] L NC at
home), OSA on CPAP, presenting with fever, worsening productive
cough, and chest pain for the past four days, suggestive of
underlying pneumonia vs IPF exacerbation.
.
# Dyspnea, Hypoxia: Etiology pneumonia vs IPF exacerbation,
progression of underlying IPF. Urine legionella, UA, blood
cultures negative. CTA showed extensive GGO, consistent w/
worsening IPF exacerbation, infectious process, or ARDS, but no
filling defects. CTA showed severe progression of disease when
compared to [**2115**] CTA. He was placed on broad spectrum
antibiotics: cefepime, vanco, azithro. Patient was given lasix
for question of pulmonary edema, with good UOP. He was
additionally given methylprednisolone for possible IPF flare.
Bronchoscopy was deferred, as patient has been too hypoxic to
tolerate one. He was been maintained on a non-rebreather,
refusing CPAP machine, and is DNI. A d-dimer was checked and
elevated at 3027, which is a poor prognosis for IPF. He was
started on a lovenox, as one study (see details below in ILD)
showed decreased mortality with anticoagulation in IPF flares.
Patient reports feeling better, however oxygen saturation
remained in the mid 70s to upper 60s. Palliative care was
consulted.
Patient and his Health Care Proxy decided that it would be best
for a focus on comfort given his severe ILD. They wanted a
continuation of antibiotics and his chronic medications.
# ILD: Pt with underlying IPF although never biopsy proven. He
also has history of strongyloides in the past with positive IgG,
but unknown if there is any association. CT chest appears to
show significantly worsened IPF from [**2115**] CT scan. D-dimer,
elevated at 3027, consistent w/ poor prognosis but suggests
anticoagulation may provide benefit based on study in Chest in
[**2110**] (Anticoagulant Therapy for Idiopathic Pulmonary Fibrosis).
Patient was started on methylprednisolone and lovenox.
Palliative care was consulted and patient was transferred to the
floor for further management and observation.
.
# Hyponatremia: Baseline is 133-140, but was 129 on admission.
Improved to 132 with small fluid boluses. Likely hypovolemic
hyponatremia as pt has had poor POs for several days plus
element of SIADH (from pulm disease), suggested on urine
electrolytes.
#Leukocytosis: Since [**10/2116**], pt has had leukocytosis of 15-20.
Diff shows 87% neutrophils. Might be reflective of underlying
infection/pneumonia, although unclear why it has been elevated
since [**15**]/[**2116**]. No recent steroids to explain leukocytosis. Can
also see a leukocytosis in setting of acute inflammatory
processes or physiological stress.
.
# DM2: 10 years of DM2, on metformin at home. Metformin was held
and patient was managed with 5units of glargine and an ISS.
.
# GERD: Continued pantoprazole 40mg daily.
.
# CAD s/p angioplasty and BMS: Continued ASA 81mg, plavix 75mg,
imdur 60mg, simva 20mg, lisinopril 2.5mg, ranolazine 150mg qhs.
.
# Anemia: HCT baseline 32-40. Currently 34. Ferritin 31 (checked
1 mo ago), Iron 27 (checked in [**2112**]). Given his significant
pulmonary disease, would expect an elevated HCT. However, he
possibly has anemia of chronic disease (although would expect to
see elevated Ferritin) vs Iron def anemia, esp since MCV has
been in the low 80s in the past. Iron studies consistent with
iron deficiency anemia. Continued home ferrous sulfate.
.
# OSA: Uses home CPAP at night, however patient was
uncomfortable using it here.
**Patient was transferred to the medical floor on [**2117-2-12**].
During the day of [**2117-2-13**] he was surrounded with close family
and friends. In the early am on [**2117-2-14**] he was seen to have
some respiratory distress, but then he improved. The RN found
that he had passed away. Time of death is 5:44 AM on [**2117-2-14**].
I emailed the PCP and spoke to the family who came to the
hospital to pay their last respects. They have decided against
an autopsy.**
Medications on Admission:
(reviewed with patient. Of note, pt states he does NOT take any
steroids)
ASA 81mg daily
Plavix 75mg daily
Pantoprazole 40mg daily
Imdur 60mg daily
Clonazepam 1.5mg QHS
Simvastatin 20mg daily
Lisinopril 2.5mg daily
NAC 600mg TID
Oxycodone 5 mg TID
Ranolazine [Ranexa] 500 mg ER [**Hospital1 **]
Ranitidine 150mg QHS
Metformin 500mg [**Hospital1 **]
Relafen 750mg daily prn
FERROUS GLUCONATE [FERGON] - 240 mg (27 mg iron) Tablet - 1
Tablet(s) by mouth once a day
NABUMETONE [RELAFEN] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**]) - 750 mg Tablet - 1 Tablet(s) by mouth daily
as
needed for pain
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - 1 tsp by mouth
at bedtime disp 4 hours
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays in each
nostril
once a day
IPRATROPIUM-ALBUTEROL - 0.5 mg-2.5 mg/3 mL Solution for
Nebulization - 1 neb inhaled four times a day as needed for SOB
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puffs inhaled four times a day as
needed
Discharge Medications:
None. Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Interstitial Lung Disease
Pulmonary Edema
Pneumonia
Diabetes
Coronary Artery Disease
Discharge Condition:
Patient deceased.
Discharge Instructions:
Patient deceased.
Followup Instructions:
None
|
[
"486",
"2761",
"41401",
"V4582",
"2724",
"53081",
"32723",
"V1582",
"2859"
] |
Admission Date: [**2140-3-8**] Discharge Date: [**2140-3-18**]
Date of Birth: [**2083-9-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
hypothermia, hyperkalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 56 year old man with hx of schizoaffective
disorder, CKD stage IV, OSA presenting hypothermia. Found by VNA
to have stopped taking psych meds. On arrival, hypothermic to 90
degrees.
In the ED his vitals were 32.7C 64 111/71 20 99%RA. He
transiently dropped his sbp to 92 with responded to NS. Serum
potassium was notable at 6.3. A EKG was unremarkable for peaked
T waves. He received kayexalate, thiamine, bicarb 1amp,
dextrose/insulin. He received vancomycin/ceftazadime. A CXR was
improved from prior. Psychiatry was consulted who recommended
re-introducing risperdal and would continue following.
He denies pain, shortness of breath, chest pain, nausea,
headache, visual changes, abdominal pain, diarrhea, dysuria, or
other symptoms.
Past Medical History:
-Hypertension
-stage V chronic kidney disease
-Schizoaffective disorder
-Morbid obesity
-Gout
-Chronic LE edema
-Dyslipidemia
-Severe OSA (prior Bipap settings [**8-30**] 2L O2)
Social History:
Pt was born and raised in [**State 9512**]. He attended college at
[**University/College **] and reported that he went to medical school for a brief
time at Duke. He later worked at [**University/College 25203**]as a
librarian in the [**Doctor Last Name **] Science Library. Pt currently lives alone
in [**Location (un) 100433**] [**Location (un) 34564**] (which was arranged
through [**University/College **] Housing). Prior to this he had been living in a
[**Last Name (un) **], which he was removed from due to poor hygiene. Pt is
estranged from his family; reported to have a brother who lives
in [**Name (NI) 622**] and rest of family in North or [**Doctor First Name 26692**].
Family History:
Non-contributory
Physical Exam:
VS:
HEENT: NCAT, PERRLl, MMM
NECK: Unable to appreciate JVP 2/2 body habitus
CV: RRR, no m/r/g
PULM: Clear bilaterally, no rales or wheezes
ABD: Obese, soft, NT, NABS
EXT: Edema of bilateral extremities to knees, palpable distal
pulses
NEURO: AAOx3, pleasant and cooperative, follows commands
Brief Hospital Course:
A/P 56 year old man with hx of schizoaffective disorder, CKD,
HTN and morbid obesity who is admitted after being found by his
VNA hypothermic, in acute on chronic renal failure and with
hyperkalemia to 6.3, off his psychiatric meds for 2 weeks.
# Hypothermia: Etiology unclear. [**Name2 (NI) **] clear infection. Thyroid
studies normal, cortisol normal, no evidence of infection.
Rectal temp is always approximately 0.2 degrees higher than
axillary or oral temp. Call medicine consult if trends to less
than 92 for more than two days.
# Acute on chronic kidney disease: Stage V CKD, followed by
renal in hospital. Discussion of HD initiated with guardian and
pt. Guardian agrees with HD if pt. will go along with it (as
his agreement despite lack of capacity is still practical
prerequisite to being able to sucessfully perform HD). Pt.
stated he would do it if he had no other choice (if he would die
without it). No urgent need for HD found during admission.
Plan further outpatient monitoring and arrangement for HD as
needed. Lasix started both for chronic edema and to help keep
potassium down, was successful. Check chemistry 10 panel twice
per week, if K > 5.8 and not hemolyzed specimen, call renal
consult team.
# Hyperkalemia: Patient has chronically elevated K in the
setting of CKD. Acute elevation in the setting of acute on
chronic renal failure. Insulin/dextrose, bicarb, kayexelate
given in ED. He recieved Kayexalate in ICU. Lasix as above
successful at medical management.
# Schizoaffective disorder with psychosis: Patient is on
risperidone and abilify as an outpatient, and it is unclear as
to when he stopped taking these medications. At this time, the
patient reports that the psychotropic medications make him
tired, and since he does not feel psychotic, he does not want to
take them. He has been unable to care for himself at home
despite increased home health care arranged after his prior
admission. Psychiatry was consulted from the ED who recommended
he be started back on Risperdal 1mg qhs - but this did not
control his disordered and delusional thoughts, so IV haldol was
instituted with improvement. Later on medical floor, pt agreed
to risperdal and refused haldol because he claimed it was
causing blurry vision. Risperdal was restarted and increased to
2 mg qhs at recommendation of psychiatry team.
# Obstructive sleep apnea: Patient was found to have sleep
disordered breathing during his last admission. At that time,
he was started on nightly BiPAP, though the patient has not been
using this at home. He was continued on his prior settings for
BiPAP (10/7/2L).
# Hypertension: The patient has a long-standing history of
hypertension and is on a number of medications at home including
toprol XL, clonidine patch and norvasc. He has been
normotensive since on clonidine and norvasc. Toprol was
discontinued given concern that it could worsen hypothermia.
# Dyslipidemia: Continued simvastatin 10mg daily
# Gout: Continued allopurinol, renally dosed.
Pt. has repeately failed to do well in an
unsupervised/unassisted setting, therefore, after lengthy
discussion with guardian and psychiatry and case management,
permanent placement in an assisted setting was pursued. The
general hope is that as pt's psychiatric state improves, he will
consent to initiate hemodialysis. Gaurdian and pt willing at
this point to initiate only if emergent, which renal team feels
it is impending, but not currently urgent.
Medications on Admission:
Simvastatin 10 mg daily
Senna 8.6 mg [**Hospital1 **]
Lisinopril 20 mg daily
Toprol XL 100 mg daily
Toprol XL 50 mg Tablet
Albuterol 90 mcg q6prn
Allopurinol 100 mg qoday
Amlodipine 10 mg daily
Aripiprazole 5 mg
Aspirin 325 mg daily
Sodium Citrate-Citric Acid 500-300 mg/5 mL 60 mL TID
Clonidine 0.1 mg/24 hr Patch qFriday
Ferrous Sulfate 325 mg (65 mg Iron) daily
B Complex-Vitamin C-Folic Acid 1 mg daily
Psyllium 1.7 g [**Hospital1 **]
Risperidone 2 mg qhs
Sevelamer HCl 2400mg TID W/MEALS
Ergocalciferol [**Numeric Identifier 1871**] qweek for 7 weeks
Tums 500 mg TID W/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. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u
Injection TID (3 times a day).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Epoetin Alfa 2,000 unit/mL Solution Sig: [**2131**] ([**2131**]) u
Injection QMOWEFR ([**Year (4 digits) 766**] -Wednesday-Friday).
12. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QWED (every Wednesday).
13. Haloperidol Lactate 5 mg/mL Solution Sig: Two (2) mg
Injection TID (3 times a day) as needed for agitation.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
16. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
18. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
end stage kidney disease
schizoaffective disorder
benign hypertension
Discharge Condition:
stable
Discharge Instructions:
Please be sure to contact your doctor with increased edema in
legs, difficulty breathing, ot other concerning symptoms.
Followup Instructions:
Follow up with your nephrologist within one month.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2140-3-18**]
|
[
"5849",
"40391",
"2767",
"32723",
"2724"
] |
Admission Date: [**2116-12-22**] Discharge Date: [**2116-12-25**]
Service: MEDICINE
Allergies:
Percocet / Lisinopril / Zetia / [**Year/Month/Day **] / Lovastatin / Doxepin /
Boniva / Gleevec
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Chief Complaint: Weakness, dizziness
Reason for MICU Admission: Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 87 yo F with CML recently discontinued from
[**First Name3 (LF) 99026**], DM2, HTN, CKD, CAD, CHF, afib who presents with
increasing fatigue, generalized weakness, and dizziness for the
past 2 weeks. She had a PCP [**Name Initial (PRE) 648**] 2 weeks ago, was noted
to have a HgbA1c of 9.9%, and started on glipizide 2.5 mg daily.
During this time, she also noted a 10 lb weight loss due to
anorexia and some nausea. She denies any fever, chills. She had
a dry cough for one day, which has since resolved. Her DOE is at
baseline. She has [**Name Initial (PRE) **] angina at rest. Her last episode was
in the ambulance, where she described a fleeting substernal
pain, rating [**1-20**] without radiation, and resolved prior to any
intervention. She does not consistently get chest pain with
exertion, usually at rest. She also reports mild dysuria x 2
days.
.
In the ED, initial vs were: T 97.4, P74, BP 121/57, R 16, O2 sat
100% on RA. Labs were sig. for K 5.9, Cr 1.9, BUN 56, glu 543,
Na 130. WBC is [**10-18**] wtih 80% pmns. EKG showed no ischemic
changes or peaked T waves. U/A had tr leuk, neg nitr, neg
ketones. UCx is pending. CXR showed no acute pulmonary process.
Patient was given 5 units of insulin IV and started on insulin
gtt. Pt received 500 cc NS. During her ED stay, she developed
dizziness. EKG was repeated and was sig. for STE in leads III
and AVF. Cardiology said no intervention at this time.
.
On the floor, she denies any chest pain. Only complains of
fatigue.
.
Review of sytems: As above.
Past Medical History:
1. Hypertension / CAD / CHF, [**2094**]
IWMI cardiogenic shock. Cath: LVEF 0.40, INFERIOR AKINESIS, 1+
MR,
LMCA, LAD AND LCX -- NO SIGNIFICANT DISEASE, RCA -- 100% PROX.
[**2110-1-6**] ETT modified [**Doctor Last Name 4001**], 3.5 min, 55% age pred max heart
rate, MIBI LVEF 48%, large inf fixed defect. Echocard [**5-/2113**]:
mild sym LVH, EF only 30%, 2+ MR. s/p mi [**2094**], cath [**2103**] one
vessel dz RCA, LVEF 40%; [**4-13**] ETT fixed defect inf/lat and
apical EF 42%, [**12-17**] new septal moderate, parially reversible
defect
2. Type 2 diabetes, diet controlled.
3. Atrial fib / flutter and wide complex tachycardia, rx
pacemaker / defibrillator [**2108**], anticoag, followed by Dr. [**Last Name (STitle) **].
4. CML, stable on Gleevec despite side effects incl eye
discomfort and occasional gassiness, dry heaves
5. Hyperlipidemia, discontinued pravachol due to myalgias which
then promptly resolved. Had liver problems on [**Name2 (NI) 17339**], zocor so
intolerant to multiple statins.
6. COPD, FEV1 1.13 [**2112**]. Stopped smoking in [**2094**], pulmonary
eval [**2112**]: deconditioning and wt is contributing to dyspnea.
7. Depression,
8. Eczema / psoriasis, pruritis improved with Sarna.
9. GERD, ? asymptomatic.
10. Gout, treated.
11. Hypothyroidism.
12. Mesenteric ischemia, without abdominal sx after eating.
Positive angiogram
13. Osteporosis. stopped Fosamax due to heartburn.
14. Renal insufficiency, creat 1.4.
Social History:
Social History: Pt lives alone in her own apartment. She has a
homemaker and someone who helps buy her groceries. She ambulates
with a walker. She was a previously smoker, 2ppd x 40 years,
quit in [**2094**]. No ETOH or recreational drugs.
Family History:
Family History: Mother, brother, and [**Name2 (NI) 802**] with DM. Sister,
brother with heart disease. Sister with breast cancer, who has
now passed.
Physical Exam:
General: Alert, oriented x3, no acute distress
HEENT: PERRL, EOMI, no nystagmus, sclera anicteric, MM slightly
dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally except for a few
crackles in the LLL
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 CVAT
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2116-12-22**] 12:00PM BLOOD WBC-12.6* RBC-3.96* Hgb-12.7 Hct-39.7
MCV-100* MCH-32.1* MCHC-32.1 RDW-15.4 Plt Ct-154
[**2116-12-22**] 12:00PM BLOOD Neuts-79.6* Lymphs-10.4* Monos-4.1
Eos-5.1* Baso-0.8
[**2116-12-23**] 02:34AM BLOOD WBC-11.3* RBC-3.38* Hgb-11.5* Hct-33.8*
MCV-100* MCH-34.0* MCHC-34.0 RDW-14.9 Plt Ct-133*
[**2116-12-24**] 05:55AM BLOOD WBC-9.9 RBC-3.39* Hgb-11.8* Hct-34.4*
MCV-102* MCH-34.8* MCHC-34.3 RDW-14.6 Plt Ct-135*
[**2116-12-25**] 06:45AM BLOOD WBC-11.6* RBC-3.59* Hgb-11.9* Hct-35.9*
MCV-100* MCH-33.2* MCHC-33.2 RDW-14.8 Plt Ct-162
[**2116-12-22**] 12:00PM BLOOD PT-35.5* PTT-31.6 INR(PT)-3.6*
[**2116-12-23**] 02:34AM BLOOD PT-33.6* PTT-32.9 INR(PT)-3.4*
[**2116-12-24**] 10:45AM BLOOD PT-26.7* PTT-28.8 INR(PT)-2.6*
[**2116-12-25**] 06:45AM BLOOD PT-25.4* PTT-28.5 INR(PT)-2.5*
[**2116-12-22**] 12:00PM BLOOD Glucose-543* UreaN-56* Creat-1.9* Na-130*
K-5.9* Cl-96 HCO3-22 AnGap-18
[**2116-12-23**] 02:34AM BLOOD Glucose-227* UreaN-43* Creat-1.5* Na-140
K-4.7 Cl-107 HCO3-24 AnGap-14
[**2116-12-24**] 05:55AM BLOOD Glucose-242* UreaN-41* Creat-1.5* Na-141
K-4.1 Cl-108 HCO3-23 AnGap-14
[**2116-12-25**] 06:45AM BLOOD Glucose-205* UreaN-44* Creat-1.7* Na-142
K-3.9 Cl-108 HCO3-24 AnGap-14
[**2116-12-22**] 12:00PM BLOOD Calcium-9.8 Phos-3.8 Mg-2.5
[**2116-12-22**] 07:22PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.5
[**2116-12-23**] 02:34AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.3
[**2116-12-24**] 05:55AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.4
[**2116-12-22**] 07:22PM BLOOD ALT-43* AST-31 CK(CPK)-25* AlkPhos-78
Amylase-31 TotBili-0.6
[**2116-12-22**] 07:22PM BLOOD Lipase-76*
[**2116-12-22**] 12:00PM BLOOD CK-MB-3
[**2116-12-22**] 12:00PM BLOOD cTropnT-0.02*
[**2116-12-22**] 07:22PM BLOOD CK-MB-4 cTropnT-0.02*
[**2116-12-23**] 02:34AM BLOOD CK-MB-4 cTropnT-0.02*
[**2116-12-22**] 12:00PM BLOOD CK(CPK)-58
[**2116-12-22**] 04:06PM BLOOD CK(CPK)-26*
[**2116-12-23**] 02:34AM BLOOD CK(CPK)-37
[**2116-12-22**] 07:22PM BLOOD Osmolal-298
[**2116-12-22**] 12:00PM BLOOD Digoxin-1.2
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
PROTEUS SPECIES. 10,000-100,000 ORGANISMS/ML..
FINDINGS: Similar to the prior exam, a left chest wall
pacemaker/AICD with
dual contiguous leads remains stable in position and course. The
lungs are
clear without consolidation or edema. Aortic tortuosity with
calcification of the arch is again noted. The cardiac silhouette
remains enlarged but stable. No effusion or pneumothorax is
noted. A gradual S-shaped scoliosis of the thoracolumbar spine
including prior vertebroplasty in the upper lumbar spine is
again noted and likewise stable.
IMPRESSION: No acute pulmonary process.
Brief Hospital Course:
Assessment and Plan: 87 yo F with h/o DM type 2, CML, HTN, HL,
CAD s/p MI in [**2094**] (treated medically), ventricular tachycardia
s/p AICD, and PAF who presents with hyperglycemia.
hyperglycemia/DM2:
The patient was admitted with a blood sugar of 543 and recent
HbA1c of 9.9% ([**2116-12-9**]), up significantly from a previous value
of 6.2% ([**2116-7-8**]). She had been previously diet-controlled until
two weeks prior to admission, when her PCP started her on
glipizide 2.5 mg for her increased HbA1c. The Ddx for her spike
in blood sugars was natural progression, change in diet,
nonadherence to medication, infection (UTI), or cardiac
ischemia. In the ED, she was treated with 5U insulin IV and
started on insulin drip. EKG showed no ischemic changes or
peaked T waves, and CXR showed no acute pulmonary process.
Troponins were <0.02 x3. One day after admission, she was
transitioned off insulin drip onto insulin sliding scale and
Lantus 10U at bedtime. On [**2116-12-24**], [**First Name8 (NamePattern2) **] [**Last Name (un) **] consult was called,
and her evening Lantus was eventually increased to 22U and her
sliding scale titrated up as well. In
addition, she was started on PO glipizide 2.5 mg [**Hospital1 **]. The
worsening of her glucose control may have been secondary to
discontinuing [**Hospital1 **]. Some evidence exists implying increased
insulin sensitivity with [**Last Name (LF) **], [**First Name3 (LF) **] it is possible that her
discontinuation of [**First Name3 (LF) **] several weeks ago worsened her
glucose control.
Her discharge medications for diabetes were as follows: Lantus
20U qhs, glipizide 5 mg [**Hospital1 **]. She was scheduled for outpatient
f/u at [**Last Name (un) **], as well as with her PCP within the week after
discharge.
##UTI
On admission, the patient complained of dysuria, and her UA
showed many bacteria and [**4-22**] WBC's. Subsequent urine culture
grew Proteus mirabilis, and Klebsiella pneumoniae. On [**12-22**], the
patient was started on a 5 day course of ciprofloxacin 250 qday.
She remained afebrile throughout her hospital admission.
#Coronary artery disease s/p MI [**2094**] (RCA occlusion, managed
medically):
The patient's admission EKG showed mild STE's in the inferior
leads, which resolved on subsequent EKGs throughout the
admission. Troponin levels were <0.02 x3. For her known CAD, we
continued ASA 325 mg daily, as well as atenolol 12.5 mg in am,
25 mg in pm daily. Statin was not initiated because of the
patient's reported prior allergy to atorvastatin and her history
of elevated LFT's.
#Systolic CHF
ECHO in [**8-21**] showed LVEF of 40%. The patient's Lasix was held
until [**12-24**], at which point Lasix 40 mg PO was given. The
patient's remained on room air through her admission, and her
shortness of breath was at baseline.
#Ventricular tachyarrhythmia s/p AICD in [**2107**]
The patient remained on her home dofetilide 500 mcg q12h and
digoxin 0.125 mg po daily. Her digoxin level was 0.7 on [**2116-12-23**].
#Paroxysmal atrial fibrillation:
INR on admission was 3.4, and coumadin was held. On [**12-24**], INR
was 2.6, and coumadin was restarted on the patient's home
regimen (4 mg/day on [**Doctor First Name **], M, W, F, Sa and 5 mg/day on T, Th).
#HTN:
The patient remained stable (100-120s/50-60s) on her home
irbesartan 75 mg daily and atenolol.
#CML:
The patient was previously on [**Doctor First Name 99026**] from [**2110**] until 3 weeks
prior to admission, at which point her oncologist changed her to
dasatinib. On admission, she was not taking any medication for
her CML. She has been scheduled for outpatient f/u with her
oncologist, Dr. [**Last Name (STitle) 2539**].
#CKD:
The patient's baseline Cr was 2.0 and her Cr remained 1.5-1.9
over her admission.
#Hypothyroidism:
The patient was stable on her home levothyroxine 88 mcg/day.
#Gout:
The patient was stable on her home allopurinol.
#Osteoporosis:
The patient was given daily calcium carbonate supplements.
#Nutrition/prophylaxis
The patient was placed on a low sodium, cardiac healthy,
diabetic diet.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth every day
ATENOLOL - 25 mg Tablet - [**11-14**] Tablet(s) by mouth in AM and 1 tab
in PM per Dr.[**Name (NI) 71235**] note - prevent heart attack, blood
pressure
DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1
Tablet(s) by mouth once a day
DOFETILIDE [TIKOSYN] - 500 mcg Capsule - one Capsule(s) by mouth
twice a day
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day -
diuretic
GLIPIZIDE - 2.5 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth once a day before breakfast - diabetes
IRBESARTAN [AVAPRO] - 75 mg Tablet - 1 Tablet(s) by mouth 1 po
qd
LEVOTHYROXINE - 88 mcg Tablet - 1 Tablet(s) by mouth once a day,
take separately from calcium - thyroid
POTASSIUM CHLORIDE [K-DUR] - 20 mEq Tab Sust.Rel.
Particle/Crystal - 1 Tab(s) by mouth twice a day
WARFARIN - 2 mg Tablet - 2 - 3 Tablet(s) by mouth once a day as
directed
ASPIRIN [ENTERIC COATED ASPIRIN] - (OTC) - 81 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day with food -
heart protection
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in
the morning)).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
8. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO daily ().
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ASDIR
([**Doctor First Name **],MO,WE,FR,SA).
12. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO ASDIR(Tues, Thurs).
Tablet(s)
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
14. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO twice a day.
15. Lantus Solostar 300 unit/3 mL Insulin Pen Sig: Twenty (20)
Units Subcutaneous at bedtime.
Disp:*2 Pens* Refills:*2*
16. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
17. Calcium 500 mg Tablet Sig: Two (2) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hyperglycemia from uncontrolled diabetes mellitus type II
UTI
Discharge Condition:
Stable, ambulatory, tolerating oral diet
Discharge Instructions:
Dear Ms. [**Known lastname 1617**],
You were admitted for acutely increased blood sugar levels
(>500) from your diabetes. You were treated with IV insulin, and
we performed multiple finger sticks each day to monitor your
blood glucose. You were also given an oral medication
(glipizide) to help with your diabetes.
Your other [**Known lastname **] medical conditions (coronary heart disease,
hypertension, congestive heart failure, hypothyroidism, gout,
osteoporosis) were treated with your home medications.
Please take all medications as directed. The following changes
were made to your medications:
1) Lantus 20U by injection once before bedtime each day
2) Glipizide 5 mg tablet twice a day (one in morning, one at
night) each day
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2117-1-1**] 9:30
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB)
Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2117-1-1**] 11:00
Dr. [**First Name (STitle) **] [**Name (STitle) 9835**] (endocrinologist) on Tuesday [**12-29**] at 11:30
am: [**Last Name (un) 3911**] [**Location (un) 86**], MA [**Location (un) **]
Completed by:[**2116-12-27**]
|
[
"5990",
"2761",
"4280",
"5859",
"41401",
"42731",
"496",
"2724",
"53081",
"412",
"V5861",
"V1582",
"V5867",
"2449"
] |
Admission Date: [**2106-9-25**] Discharge Date: [**2106-10-11**]
Date of Birth: [**2028-9-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
morphine
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2106-9-25**] emergency repl. ascending and arch aorta
[**2106-9-27**] chest closure
History of Present Illness:
78 year old retired urologist
presented to OSH complaining of 40 minutes of chest pain that
radiated to his back and throat. Per report from OSH, ECG
notable for inferior and lateral ST changes concerning for
ischemia and pt not currently in AFib. CTA done at OSH revealed
type A Aortic dissection. He was medflighted into [**Hospital1 18**]. Dr.[**Last Name (STitle) **]
reviewed the CTA and Mr.[**Known lastname **] was taken emergently to the
operating room.
Past Medical History:
Chronic AFib->on Pradaxa, HTN,
? hx of
cardiac dz per OSH HPI, prostate cancer.
Social History:
has family in vicinity
? girlfriend
Physical Exam:
pt was seen emergently-VS noted
Pulse: 64 Resp: O2 sat:
B/P 104/65
Height: 74" Weight: ? 90 kg
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [] Edema [] _____
Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+ bounding DP pulses(B)
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit Right: Left:
Pertinent Results:
Pe-Bypass:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is severely dilated. The descending thoracic
aorta is mildly dilated. A mobile density is seen in the
ascending and descending aorta, and across the arch, consistent
with an intimal flap/aortic dissection. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild aortic regurgitation is seen. The flap overlies
the aortic valve enough that the short axis window is poor, and
coronary flow cannot be determined. The STJ looks intact.
Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is paced, on no inotropes.
Preserved biventricular systolic fxn.
There is a tube graft in the ascending aorta. 1+ AI.
Descending aorta unchanged. Other parameters as pre-bypass.
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) **] [**2106-10-7**] 13:18
Brief Hospital Course:
Mr.[**Known lastname **] was Medflighted in from [**Hospital3 **] and taken emergently
to OR for Type A dissection repair with Dr. [**Last Name (STitle) **]. He underwent
Resection of ascending aortic dissection with hemi-arch
replacement under circulatory arrest. Cross clamp time: 99
minutes.Pump time:170 minutes.Circulatory arrest time:26
minutes. He had been on Pradaxa at home and had significant
coagulopathy postoperatively requiring his chest to be left
open. On [**2106-9-27**] his bleeding has stopped, and he was brought
back to the operating room for closure of the sternum. Please
refer to operative reports for further surgical details.
Mr.[**Known lastname **] [**Last Name (Titles) 8337**] the operations well and was transferred back
to the CVICU intubated and sedated in stable condition on
titrated phenylephrine and propofol drips. Postoperatively, he
developed renal failure with creatinine peaking at 5.8. Renal
service was consulted. His creatnine trended down during
admission. Chest tubes and pacing wires removed per protocol. He
was gently diuresed toward his preop weight. He awoke
neurologically intact and was extubated on POD #4. He had
intermittent confusion over the next few days. His mental status
cleared and he was transferred to the step down unit on POD # 12
to begin increasing his activity level. Physical Therapy was
consulted for evaluation of strength and mobility. His chronic
atrial fibrillation was not well rate controlled on maximum dose
of Diltiazem and Rhythmol alone. Beta-blocker was added to his
regimen, as previously the patient deferred beta-blocker due to
his feeling lethargic after taking it. A Non-selective
beta-adrenoreceptor was initiated in lieu of Lopressor. His
anticoagulation was resumed with Coumadin. The remainder of his
postoperative course was essentially uneventful. His Creatnine
continued to trend down and he was cleared to [**Hospital1 **] [**Hospital3 **]
rehab on POD#15. All follow up appointments were advised.
(stopped [**10-10**])
Medications on Admission:
Nexium 40(1),lipitor 40 mg 3x/weekly.,
Propafenone HCL 150mg (4), Pradaxa 150 (2), Levitra prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
acute Type A aortic dissection s/p repl. ascending and arch
aorta
acute renal failure
Chronic AFib->was on Pradaxa s/p ablation
hypertension
hx of cardiac dz per OSH HPI
prostate cancer
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal and R axillary - 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 have been scheduled for the following appts:
Surgeon Dr. [**Last Name (STitle) **] Thursday [**11-11**] @ 1:15 pm [**Hospital Ward Name **] [**Hospital Unit Name **]
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiologist) [**Telephone/Fax (1) 19666**] [**10-25**] @ 11:00 AM
Please call to schedule appointments with your
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 4 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw day after discharge
*** please arrange for coumadin/INR f/u with PCP or cardiologist
prior to discharge from rehab***
Completed by:[**2106-10-10**]
|
[
"5845",
"2851",
"4241",
"42731",
"4019",
"2875"
] |
Admission Date: [**2140-4-6**] Discharge Date: [**2140-4-15**]
Date of Birth: [**2140-4-6**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Preterm infant born at 35 5/7
weeks, admitted to the Neonatal Intensive Care Unit for
management of respiratory distress.
Infant born at 35 5/7 weeks to a 27 year old gravida 2, para
1 mother. Prenatal screens: 0 positive, antibody negative,
hepatitis B surface antigen negative, Rubella immune, RPR
nonreactive, Group B Streptococcus unknown. Reported benign
antepartum, admitted to Labor and Delivery in labor.
Cesarean section for breech presentation. Apgars were 8 at
one minute and 9 at five minutes.
Grunting, flaring and retractions noted in the Delivery Room.
[**Hospital **] transferred to Neonatal Intensive Care Unit because of
persisting respiratory symptoms.
PHYSICAL EXAMINATION ON ADMISSION: Birthweight 2590 (50th
percentile), length 44 cm (10th to 25th percentile), and head
circumference 32.5 cm (50th percentile).
Anterior fontanelle soft and flat, normal facies, intact
palate, grunting, mild retractions, fair air entry, no
murmur, present femoral pulses, flat, soft, nontender abdomen
without hepatosplenomegaly, stable hips, normal phallus,
testes in scrotum, normal perfusion, normal tone/activities
for gestational age.
HOSPITAL COURSE: (By systems) Respiratory - Due to
increased respiratory distress, the infant was placed on CPAP
6 cm of water requiring room air to 30%. Infant remained on
CPAP until day of life #4 and was placed on nasal cannula
requiring 25 to 50 cc, 100% FIO2. Infant transitioned to
room air by day of life #7 and has remained in room air with
oxygen saturations greater than 94%, respiratory rate 40s to
60s. The infant has not had any apnea or bradycardia this
hospitalization. A chest x-ray on admission showed streaky
opacification suggestive of pneumonia.
Cardiovascular - The infant has remained hemodynamically
stable this hospitalization with mean blood pressures 50 to
64, no murmur, heart rate 140s to 160.
Fluids, electrolytes and nutrition - Infant was initially
receiving nothing by mouth, on D10/W at 60 cc/kg/day. An
umbilical venous catheter was placed on day of life #2 for
difficulty with peripheral intravenous access. The umbilical
venous catheter was discontinued on day of life #5. Enteral
feedings were started on day of life #3 and the infant was
advanced to full volume feedings by day of life #6. The
infant is currently taking 130 cc/kg/day of Enfamil 20 cal/oz
all p.o. The most recent electrolytes on day of life #2
showed a sodium of 134, potassium 5.5, chloride 101, pCO2 20.
The most recent weight is 2510 grams.
Gastrointestinal - The infant did not receive phototherapy
this hospitalization. The most recent bilirubin level on day
of life #6 was 9.7 with a direct of 0.3.
Hematology - Complete blood count on admission showed a white
blood cell count of 19.3, hematocrit 49.1%, platelets
290,000, 65 neutrophils and 1 band. The infant did not
receive any blood transfusions this hospitalization.
Infectious disease - Complete blood count as noted above, due
to respiratory symptoms, the infant was started on Ampicillin
and Gentamicin, and received a total of seven days of
Ampicillin and Gentamicin for a chest x-ray suggestive of
pneumonia and persisting respiratory symptoms after day of
life #2. A lumbar puncture on day of life #5 showed 27 red
blood cells, 14 white blood cells, 1 neutrophil, 32
lymphocytes, 17 monocytes, glucose 48, protein 77.
Neurology - Normal neurological examination.
Sensory - Hearing screen was performed with automated
auditory brain stem responses, infant passed in both ears.
Ophthalmology, the patient does not meet the criteria for eye
examination.
Psychosocial - Parents involved. [**Hospital6 649**] social worker involved with family, the
contact social worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable on room air.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1182**], phone [**Telephone/Fax (1) 54552**].
CARE/RECOMMENDATIONS:
1. Feedings at discharge - Enfamil 20 cal/oz minimum 130
cc/kg/day, p.o. ad lib.
2. Medications - None.
3. Carseat position screening - Performed and infant passed.
4. State newborn screen - Sent on [**4-9**], no abnormal
results have been reported, infant is due for 14 day newborn
screen on [**4-19**].
5. Immunizations - The infant received hepatitis B vaccine
on [**4-13**].
6. Immunizations recommended - Influenza immunization is
recommended annually in the fall for all infants once this
reach six months of age. Before this age and for the first
24 months of the child's life immunization against influenza
is recommended for household contacts and out of home
caregivers.
FOLLOW UP APPOINTMENT: Primary pediatrician Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1182**].
DISCHARGE DIAGNOSIS:
1. Prematurity.
2. Status post respiratory distress.
3. Status post pneumonia.
4. Breech presentation.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 43219**]
MEDQUIST36
D: [**2140-4-14**] 21:10
T: [**2140-4-14**] 21:14
JOB#: [**Job Number 54553**]
|
[
"486",
"7742",
"V053"
] |
Admission Date: [**2153-12-25**] Discharge Date: [**2153-12-31**]
Date of Birth: [**2133-7-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
RIJ placement and removal
History of Present Illness:
20 yo F w/ PMH of suicide attempt was admitted to MICU for
tylenol PM (150 tablets) OD, and now transferred to the medicine
floor for continued monitoring and management. Pt recently
broke up with her boyfriend (2 days prior to admission).
Another stressor in her life is that patient's father, to whom
patient is very close, is going to be deployed back to
[**Country 84061**]. Patient lives with her mother. She spoke to her
mother at 8:30pm on the day prior to admission and went to bed,
and her mother [**Name (NI) 15598**]'t see her 12 hours later so went to check on
her at 8:30am. Patient was found to be covered with emesis,
unresponsive. Mother found a bottle of tylenol PM which had
contained 150 tabs nearby as well as some Hydroxycut "MAX!".
Patient was was initially taken to OSH where she was started on
NAC w/ a Acetaminophen level of 450. She was transferred to
[**Hospital1 18**] and continued on NAC in the ED and MICU. Acetaminophen
368 on admission. By the time she arrived at the MICU, her
mental status had improved significantly, and she was able to
follow commands.
.
In the MICU, paitent was seen by liver service who recommended
Q4 labs, RUQ U/S and notified the transplant team. Toxicology
and psych are also following. Admission INR 1.4, peaked at 2.6,
2.1 on transfer. ALT/AST/LDH 329, 234, 339 on admission, peaked
at 9120, 6923, 4690 respectively, 6630, 3480, 1622 on transfer
to the floor.
.
On transfer to the floor, patient's mental status was clear.
She denies complaints.
Past Medical History:
Prior episodes of cutting
Social History:
Lives with her mother, parents divorced, father lives in [**Name (NI) 1727**]
No smoking, Etoh or illicit drug use
Family History:
NC
Physical Exam:
Vitals - 99.1, 120/80, 76, 20, 100% on RA, FSBG 99
GENERAL: Pleasant, well appearing, in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP flat.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-26**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS:
[**2153-12-25**] 02:00PM BLOOD WBC-7.0 RBC-4.63 Hgb-14.6 Hct-41.4 MCV-89
MCH-31.5 MCHC-35.3* RDW-13.2 Plt Ct-343
[**2153-12-25**] 02:00PM BLOOD Neuts-84.9* Lymphs-7.8* Monos-6.3 Eos-0.5
Baso-0.6
[**2153-12-25**] 02:00PM BLOOD PT-16.1* PTT-27.5 INR(PT)-1.4*
[**2153-12-25**] 02:00PM BLOOD Glucose-173* UreaN-10 Creat-0.7 Na-137
K-3.7 Cl-105 HCO3-15* AnGap-21*
[**2153-12-25**] 02:00PM BLOOD ALT-329* AST-234* LD(LDH)-339* AlkPhos-42
TotBili-1.1
[**2153-12-25**] 02:00PM BLOOD Lipase-106*
[**2153-12-25**] 09:27PM BLOOD Calcium-9.2 Phos-2.2* Mg-2.4
DISCHARGE LABS:
[**2153-12-31**] 05:50AM BLOOD WBC-3.3* RBC-3.75* Hgb-11.6* Hct-34.6*
MCV-92 MCH-31.1 MCHC-33.6 RDW-14.7 Plt Ct-213
[**2153-12-31**] 05:50AM BLOOD PT-11.1 PTT-26.6 INR(PT)-0.9
[**2153-12-31**] 05:50AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-142 K-4.2
Cl-108 HCO3-27 AnGap-11
[**2153-12-31**] 05:50AM BLOOD ALT-2230* AST-135* LD(LDH)-165 AlkPhos-43
TotBili-0.4
[**2153-12-31**] 05:50AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.2
[**2153-12-28**] 03:25PM BLOOD calTIBC-231* Ferritn-1673* TRF-178*
[**2153-12-29**] 05:30AM BLOOD TSH-0.97
MICROBIOLOGY:
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2153-12-27**]): POSITIVE BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2153-12-27**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2153-12-27**]): NEGATIVE <1:10
BY IFA.
CMV IgG, IgM negative
Rubeolla IgG: pending
RPR: negative
Rubella: IgG/IgM positive
VZV IgG: equivocal
Toxo IgG/IgM: negative
HIV Ab: negative
Blood cx ([**2153-12-26**]): pending
IMAGING STUDIES:
EKG: Sinus tachycardia. QRS 88ms
.
Abdominal Xray ([**2153-12-25**]): No bezoar seen.
.
Abdominal US ([**2153-12-25**]): Starry [**Hospital Ward Name **] appearance of the liver
compatible with acute hepatitis. No focal liver lesions
identified. Patent portal vein.
.
CXR ([**2153-12-26**]): No acute cardiopulmonary findings.
Brief Hospital Course:
20 yo F w/ acetominophen/diphenhydramine OD and anticholinergic
toxidrome admitted to the MICU and transferred to the medical
floor.
# APAP OD: Patient took 150 tylenol PM at home, and on admission
INR was 1.4, peaked at 2.6, 2.1 on transfer to the floor.
Patient was treated with NAC until APAP level was undetectable.
ALT/AST/LDH were 329, 234, 339 on admission, which peaked at
9120, 6923, 4690 respectively, 6630, 3480, 1622 on transfer to
the floor. Her LFTs continued to trend downwards, with
improvement in her LDH and alk phos. On the day of discharge,
her coags, LDH and alk phos were in normal range, ALT was 2230,
and AST was 135. Patient was followed by Liver, Transplant
surgery, toxicology and psychiatry during this hospital stay.
Per discussion with psychiatry team, she would benefit from an
inpatient hospital stay given that this had been a suicide
attempt. Her LFTs are trending down nicely, and LFT check every
2-3 days will be sufficient on the psych floor to ensure
continued down-trend.
.
# Anemia/Leukopenia: This is likely related to bone marrow
suppression in the setting of her acute illness. Her iron
studies revealed elevated ferritin and low/nl iron, consistent
with anemia of chronic inflammation. There was low likelihood
of hemolysis given her lab values. On discharge, patient's
platelets have recovered. She will need a follow up CBC in [**1-26**]
weeks after discharge from the medical floor to ensure that her
hematocrit and WBC count are improving.
# History of depression/cutting: An inpatient psychiatry consult
was obtained given her suicidal attempt to help with further
management and disposition. They recommended an inpatient
psychiatry hospitalization after her medical issues were
stabilized.
.
# PPX: Patient was put on heparin SQ for DVT ppx. She was given
bowel regimen for constipation prn.
.
# CODE: Full (confirmed w/ Mother)
.
# CONTACT: Father and mother
.
# DISPO: inpatient psychiatry.
Medications on Admission:
Nuva ring
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-26**] Sprays Nasal
TID (3 times a day) as needed for Dry nose.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
APAP overdose
Discharge Condition:
Stable, ambulating well, LFTs trending down, afebrile,
tolerating POs well.
Discharge Instructions:
It was a pleasure to be involved in your care, Ms. [**Known lastname 84062**].
You were admitted to [**Hospital1 69**]
because of tylenol PM overdose. You were initially admitted to
intensive care unit where you were observed for 3 days. You
liver function tests have trended down nicely, and we expect
that you will have a full recovery from this overdose. You will
be transferred to an inpatient psychiatry unit for further
treatment for your depression and suicidal ideation.
Your medications have been changed.
Please take colace, senna and miralax as needed for
constipation.
Followup Instructions:
Will need outpatient psych followup. Will also need a PCP after
discharge from inpatient psych unit (patient currently has no
PCP)
|
[
"2762",
"311",
"2859"
] |
Admission Date: [**2140-1-16**] Discharge Date: [**2140-1-23**]
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is an 86 year old female
who has had recent multiple admissions to the hospital for
shortness of breath who was admitted on [**2140-1-16**], from
rehabilitation with listlessness and a blood pressure in the
low range of 100/60. She also had an oxygen saturation of
88% on two liters. The patient's primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 3357**], assessed the patient and she was sent to [**Hospital1 346**] Emergency Department for evaluation
for congestive heart failure. She had some wheezes on
examination and was given Albuterol and Ipratropium
nebulizers and Lasix 40 mg intravenously. Her blood pressure
on admission to Emergency Department triage was approximately
80/60 which was lowered to 74/23. Dopamine drip was started
for blood pressure support and the patient was admitted to
Intensive Care Unit and given two liters of normal saline.
She was noted to be 88% in room air and got antibiotics for
possible pneumonia. She was placed on an eight liter face
mask and had an arterial blood gases of 7.30 with a pCO2 of
47 and a pO2 of 58. She was in the Intensive Care Unit for
three hospital days and was transferred out to the Medicine
floor after it was determined that she was likely dehydrated
and went into renal failure due to dehydration and possible
over diuresis.
PAST MEDICAL HISTORY:
1. Multi-infarct dementia.
2. Coronary artery disease, status post pacer for complete
heart block.
3. Diabetes mellitus.
4. Depression.
5. Congestive heart failure.
6. Status post radial fracture.
7. Bilateral knee arthroplasty.
MEDICATIONS ON ADMISSION:
1. Colace.
2. Vitamin D.
3. Lipitor 10 mg p.o. once daily.
4. Aspirin 81 mg p.o. once daily.
5. Lopressor 50 mg p.o. twice a day.
6. Imdur 90 mg p.o. once daily.
7. Lisinopril 20 mg p.o. once daily.
8. Ultram 50 mg p.o four times a day.
9. Protonix 40 mg p.o. once daily.
10. Lasix 20 mg p.o. once daily.
11. Zyprexa 10 mg p.o. twice a day.
12. Effexor 75 mg p.o. once daily.
13. Effexor XR 150 mg p.o. q.h.s.
14. Neurontin 300 mg p.o. twice a day.
PHYSICAL EXAMINATION: Upon presentation to Medicine,
temperature is 96.9, blood pressure 103/63, heart rate 86,
respiratory rate 27, oxygen saturation 96% in room air. In
general, she is sitting in bed, bright and alert. Head,
eyes, ears, nose and throat examination reveals moist mucous
membranes with a clear oropharynx. The lungs show slight
crackles at the left base and no audible wheezes.
Cardiovascular reveals a regular rate and rhythm with distant
heart sounds. Abdomen is soft, obese, nontender,
nondistended with positive bowel sounds. Extremities show no
pedal edema.
LABORATORY DATA: Upon presentation to Medicine, white blood
cell count was 9.1, hematocrit 35.6, platelet count 326,000.
Creatinine 1.1, blood urea nitrogen 27, potassium 5.2,
glucose 171.
HOSPITAL COURSE:
1. Dyspnea, hypoxia - She was much improved after getting
fluids in the Intensive Care Unit without any diuresis. It
was determined by chest x-ray that she was dry and had
possible infiltrate and was treated with antibiotics,
Levofloxacin, Flagyl, Vancomycin. The Vancomycin was
discontinued, however, she remained on Levofloxacin and
Flagyl for concern of aspiration pneumonia. Intensive Care
Unit team also felt that the patient had reactive airways and
started steroids p.o. along with continuing nebulizers. She
had a negative infectious workup to date. Of note, she has
not had a history of chronic obstructive pulmonary disease or
asthma in the past. Upon transfer to the Medicine floor, she
was found the next day to be in significant respiratory
distress requiring respirator care and nebulizers. She
seemed to do better after this. Chest x-ray was obtained and
showed progressive heart failure over the past four days in
the hospital. She was given 20 mg intravenous Lasix and had
good urine output and was saturating well. She then became
very lethargic and was given intravenous fluids as it is
noted in the past the patient responds very well to
intravenous fluids, becoming more alert and aware of her
environment. Also of note, the patient had a transthoracic
echocardiogram which showed an ejection fraction of 55% and
E:A ratio of 0.82, however, this did not meet criteria for
diastolic dysfunction. She also had a very poor quality
echocardiogram which limited our evaluation of whether she
has systolic dysfunction in addition to diastolic
dysfunction. A heart failure consultation was obtained by Dr.
[**Last Name (STitle) **] and it was determined that it was difficult to tell
whether she had pure diastolic dysfunction. It was
recommended that the patient start Diltiazem for rate control
without using beta blockers to exacerbate any potential
bronchospasm. The patient did well on Diltiazem and was
continued only on Lisinopril 5 mg p.o. once daily. Her
previous Imdur and Lopressor were discontinued.
2. Hypotension - It was unclear whether the patient was
overmedicated with blood pressure medications upon admission
or was over-diuresed. Her previous hospital stay had
actually cut down her previous Lasix dose so it is unclear
whether this had anything to do with her hypotension.
However, while in house, the patient's blood pressure
remained well without Lopressor or Lisinopril at 20 mg. At
the reduced Lisinopril dose as well as the Diltiazem, the
patient did well. She was restarted on her Lasix 20 mg p.o.
Once daily.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To [**Hospital 5412**] Rehabilitation.
DISCHARGE DIAGNOSES:
1. Multi-infarct dementia.
2. Coronary artery disease, status post pacer for complete
heart block.
3. Diabetes mellitus.
4. Depression.
5. Congestive heart failure.
6. Status post radial fracture.
7. Bilateral knee arthroplasty.
MEDICATIONS ON DISCHARGE:
1. Diltiazem XR 120 mg p.o. once daily, hold for systolic
blood pressure of less than 110.
2. Prednisone 40 mg p.o. twice a day on a taper to decrease
by 10 mg twice a day every two days.
3. Metronidazole 500 mg p.o. three times a day.
4. [**2140-1-23**], is her last day of Levofloxacin 250 mg p.o.
once daily.
5. [**2140-1-23**], is her last day of Acetamodic.
6. Gabapentin 300 mg p.o. twice a day.
7. Phenylfaxene SR 75 mg p.o. once daily.
8. Lisinopril 5 mg p.o. once daily.
9. Ipratropium MDI two puffs inhaled four times a day.
10. Albuterol MDI one to two puffs inhaled q4hours p.r.n.
11. Olanzapine 10 mg p.o. twice a day.
12. Vitamin D 400 units p.o. once daily.
13. Docusate 100 mg p.o. twice a day.
14. Aspirin 81 mg p.o. once daily.
15. Atorvastatin 10 mg p.o. once daily.
FOLLOW-UP PLANS: The patient is to follow-up with her
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3357**].
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2140-1-23**] 08:39
T: [**2140-1-23**] 09:13
JOB#: [**Job Number 5413**]
|
[
"5849",
"25000"
] |
Admission Date: [**2173-7-27**] Discharge Date: [**2173-8-6**]
Date of Birth: [**2105-8-12**] Sex: M
Service: MEDICINE
Allergies:
Ephedrine / Penicillins / Plavix / Cipro Cystitis / aspirin
Attending:[**Last Name (un) 11974**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
-Superior and inferior mesenteric arteriography
-Colonoscopy
History of Present Illness:
67M with history of recent a-fib s/p cardioversion x 2 with
second one successful 6 weeks ago at [**Hospital3 **], on Pradaxa
until he stopped taking 6 days ago with onset of symptoms. 6
days ago he had severe [**11-10**] LLQ abdominal pain worsened with
movement, bending over, going over bumps in the car and
palpation but that has since resolved. He has had intermittent
BRBPR over the past week, mostly very light, but since earlier
today with three episodes of large bright red blood. He had a
sigmoidoscopy performed on Friday without cause for bleeding
seen, and is scheduled for colonoscopy tomorrow. He drank Mg
Citrate at 7pm and is scheduled for another dose at 3am and then
NPO past 5 am for the colonoscopy at 9 am. He does not report
LH, CP, SOB, fevers or chills. He is currently pain free. He did
have nausea today associated with drinking the Mg Citrate very
quickly but that has since resolved.
He has a history of many prior polypectomies in the past with
prior colonoscopies
Upon arrival to the floor, the patient continued to have BRBPR
and developed LH with standing. He does not report CP. Pt
trigered for this.
In ER: (Triage Vitals:2 97.6 72 161/107 16 100% ra )
Meds Given: none
Fluids given: none
Radiology Studies:none
consults called: GI
Past Medical History:
-Afib - dx'd two months ago, started pradaxa at that time.
Underwent cardioversion two weeks ago.
-Renal Artery Stenosis S/P R Renal Bypass [**2135**]
-Diverticulitis
-Diverticulosis - has not had a problem in >10yrs since
initiating daily wheat bran
-[**Year (4 digits) **] adenoma
-IR intervention on the mesenteric vasculature after 21u pRBC
transfusion in the [**2131**]
-Transient Ischemic Attack
-Gout
-CAD: [**10-6**] Cath - 90% LAD lesion (s/p DES). 60% RCA lesion. ETT
[**2-5**] neg for ischemia. Followed by Dr. [**First Name (STitle) **] at [**Hospital 2586**].
-S/P Radiofrequency ablation of right greater saphenous vein
(VNUS closure). [**6-/2170**]
-S/P Right leg stab avulsions greater than 20 incisions
(micro phlebectomy)for painful varicose varicosities [**7-/2171**]
-Multiple knee surgeries
-Sinus surgery for sinusitis/polyps
-h/o SCC and BCC removal
Social History:
He lives with his wife of 40 years. He is a retired teacher. He
has never smoked. He drinks socially and has never drank
heavily. He has 2 grand children. He is physically very active
and this weekend he was painting climbing on very tall ladders.
He is independent of IADLs and ADLS.
Family History:
Cousins with [**Name2 (NI) 499**] cancer. His father died of cirrhosis from
ETOH at age 74. His mother died of a brain tumor at age 72.
Physical Exam:
Admission:
VS T = 97.7 P = 70 BP = 146/87 RR = 20 O2Sat on _98% on RA___
General: Alert, oriented, no acute distress. Supine on bedpan
with R leg in brace, intermittently producing bloody diarrhea.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Conjunctivae pale.
Neck: supple, no LAD. JVP <5cm H20.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, hyperactive BS. no organomegaly,
no tenderness to palpation, no rebound or guarding. Healed
transverse scar (renal bypass [**Doctor First Name **])
GU: no foley
Ext: Hands/feet pale and warm without palpable pulses. No
clubbing/cyanosis/edema.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 1+ reflexes in upper extremities,
lower extremity reflexes and gait deferred.
Discharge:
VS: 97.5 112/66 73 16 96% RA
GEN: Alert. Cooperative. In no apparent distress. Appears
comfortable
HEENT: PERRLA. EOMI. MMM. No icterus or pallor
LUNGS: Clear to auscultation B/L. No wheezes or crackles.
CV: S1, S2 Regular rhythm. No murmurs/gallops/rubs. Pulses 2+
throughout. No JVD.
ABDOMEN: BS present. Soft. Nontender. Nondistended. No
organomegaly noted.
SKIN: No rashes or skin changes noted. No jaundice
EXTREMITIES: No gross deformities, clubbing, peripheral edema,
or cyanosis.
Pertinent Results:
Admission Labs:
======================
[**2173-7-27**] 10:27PM PT-11.3 PTT-30.2 INR(PT)-1.0
[**2173-7-27**] 10:10PM GLUCOSE-111* UREA N-21* CREAT-0.9 SODIUM-139
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-27 ANION GAP-19
[**2173-7-27**] 10:10PM estGFR-Using this
[**2173-7-27**] 10:10PM WBC-10.0 RBC-4.82 HGB-15.2 HCT-44.2 MCV-92
MCH-31.5 MCHC-34.4 RDW-13.2
[**2173-7-27**] 10:10PM NEUTS-59.0 LYMPHS-26.9 MONOS-9.5 EOS-3.8
BASOS-0.8
[**2173-7-27**] 10:10PM PLT COUNT-269
.
Discharge Labs:
========================
[**2173-8-5**] 09:15AM BLOOD WBC-7.3 RBC-3.79* Hgb-12.0* Hct-35.5*
MCV-94 MCH-31.7 MCHC-33.8 RDW-14.7 Plt Ct-226
[**2173-8-5**] 09:15AM BLOOD Glucose-115* UreaN-5* Creat-0.6 Na-141
K-3.8 Cl-103 HCO3-27 AnGap-15
.
Imaging
==========
CTA Abd [**2173-7-28**]
1. Acute uncomplicated descending colonic diverticulitis with
acute active extravasation supplied by the first left colic
branch of the inferior mesenteric artery (3A:84).
2. Sigmoid and descending colonic diverticulosis.
3. Small hiatal hernia.
.
Colonoscopies:
=====================
Colonoscopy [**2173-7-30**]
Diverticulosis only in the sigmoid [**Month/Day/Year 499**]. No active bleeding was
noted.
Otherwise normal sigmoidoscopy to cecum
-------------------
Colonoscopy [**2168**]
Diverticulosis of the sigmoid [**Year (4 digits) 499**]
Otherwise normal colonoscopy to cecum
Recommendations: High fiber diet
Follow-up with Dr. [**First Name (STitle) **] as needed
Colonoscopy in [**5-6**] years
Additional notes: The efficiency of colonoscopy in detecting
lesions was discussed with the patient and it was pointed out
that a small percentage of polyps and other lesions can be
missed with the test. Degree of difficulty = 2 (5 most
difficult)
-------
Colonoscopy [**2163**]:
Polyp at distal sigmoid
-------
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
====================================
Mr. [**Known lastname **] is a 67 y/o M with a hx of CAD (s/p DES to LAD in
[**2166**]), atrial fibrillation, diverticulosis, and massive GIB in
the [**2131**], who was admitted with lower GI bleed 2 months after
starting Pradaxa for AFib; likely Diverticular Bleeding
ACTIVE ISSUES:
=======================
# Lower GI bleed: Most likely diverticular bleed in setting of
new dabigatran use. The patient was initially admitted to the
medical floor but was transferred to the ICU because of brisk GI
bleed. A CTA was performed while bleeding on [**7-28**] which showed
descending colonic diverticulitis with active extravasation from
a branch of the inferior mesenteric artery. However, by the time
the patient was taken to the IR suite, bleeding had ceased. He
had no further events but Hct trended down from baseline 44 to
26.4 at lowest and he required transfusion of 5 units of packed
red cells. A colonoscopy was performed on [**2173-7-30**] which showed
only diverticulosis with no source of bleed. After that point he
stabilized without further evidence of bleeding and his HCT
trended up to 35 prior to discharge. Aspirin was held on
admission and was resumed at 325mg daily 2 days prior to
discharge without any evidence of re-bleed. Patient had already
stopped Dabigatran several days prior to admission and it was
not continued.
- Patient will follow-up with his gastroenterologist ~1week
after discharge for a possible repeat colonoscopy. If there is
no evidence of further bleeding then patient may be started on
anticoagulation at follow-up with his cardiologist. He likely
should be on coumadin instead of dabigatran so that his
anticoagulation can be reversed rapidly if he has further GI
bleeding.
# Atrial Fibrillation: The patient had patient had been
diagnosed ~2 months prior to admission and had successful
cardioversion. He had been on sotalol for maintenance of sinus
rhythm. During the admission he went into afib with rapid
ventricular response. He wasn't able to be converted back into
sinus rhythm despite increased doses of sotalol and therefore he
was switched to dofetilide. He converted to sinus rhythm after a
single dose. He was monitored for 3 days and his Qtc never
exceeded 500.
- The patient may be restarted on anticoagulation at follow-up
with cardiology as discussed above pending a careful
risk/benefit discussion.
- Patient discharged on Dofetilide 500mg [**Hospital1 **]
- Patient was counseled extensively on risks of QT prolongation
and to avoid any medications or herbal supplements that could
increase risk of torsade.
# Diverticulitis: Patient had abdominal pain on admission and
CTA showed diverticulitis. Unclear if this is related to bleed
or incidental finding. The patient completed a 7 day course of
Aztreonam/Flagyl
- Patient will follow-up with GI as above
- High fiber diet
# Gout: patient had podagra during admission that improved with
1.8mg of colchicine (1.2mg followed by 0.6mg 1 hour later).
- He will continue colchicine 0.6mg daily after dicharge
CHRONIC ISSUES:
=======================
# CAD (s/p DES to LAD in [**2166**]): no signs of ischemia during this
admission. Aspirin was held initially because of bleed. Due to
aspirin allergy patient had to be de-sensitized again
- discharged on ASA 325mg daily. If he goes back on
anticoagulation then can switch back to ASA 81mg daily
- continued Atorvastatin 40mg
TRANSITIONAL ISSUES:
=============================
# Patient will follow-up with his gastroenterologist ~1week
after discharge for a possible repeat colonoscopy. If there is
no evidence of further bleeding then patient may be re-started
on anticoagulation if benefits are deemed to exceed the risks.
He likely should be on coumadin instead of dabigatran so that
his anticoagulation can be reversed rapidly if he has further GI
bleeding.
# If patient goes back on anticoagulation then can switch back
to ASA 81mg daily
# Code Status: Confirmed Full Code
Medications on Admission:
Confirmed with pt on admission
atorvastatin 80 mg Tablet 0.5 (One half) Tablet(s) by mouth once
a day (Dose colchicine 0.6 mg Tablet 1 (One) Tablet(s) by mouth
once a day [**2172-1-23**]
lisinopril 5 mg Tablet 1 (One) Tablet(s) by mouth once a day
[**2173-2-23**]
soltatlol 80 mg [**Hospital1 **]
aspirin 325 mg Tablet 1 Tablet(s) by mouth once a day - he was
on 81 mg daily when he was started on pradaxa but with d/c of
that 6 days prior to admission he started taking 325 mg ASA
daily
pradaxa - [**Hospital1 **] but self d/c'ed 6 days ago
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Colchicine 0.6 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Dofetilide 500 mcg PO Q12H
check ecg 2 hours after each dose
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. saw [**Location (un) 6485**] *NF* 160 mg Oral daily
9. Vitamin B Complex 1 CAP PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 Tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Lower GI bleed
- Diverticulosis
- Diverticulitis
- Atrial Fibrillation with Rapid Ventricular Response
- Aspirin Allergy
Secondary
- Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **], it was a pleasure taking care of you here at
[**Hospital1 18**]. You were admitted to the hospital because of rectal
bleeding. You lost a large amount of blood and required 5 blood
transfusions. Eventually your bleeding stopped on its own and
your blood counts started to recover. You had no further
bleeding for several days prior to discharge.
During the admission your heart went into an abnormal rhythm
called atrial fibrillation. You were put on a new medication
called Dofetilide to help keep in you in normal (sinus) rhythm.
It is VERY important that you let all your providers know that
you are taking Dofetilide. There is risk of life-threatening
arrythmias if dofetilide is combined with certain other
medications. Please see the list of medications provided. You
will follow-up with Dr. [**Last Name (STitle) **] in about 3 weeks as detailed
below.
After discharge you will follow-up with your gastroenterologist.
If there is no evidence of further bleeding then you may discuss
with your cardiologist about going back on a different blood
thinner to help prevent stroke.
Followup Instructions:
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
When: THURSDAY [**2173-8-12**] at 9:50 AM
With: Dr [**Last Name (STitle) 19701**] [**Name (STitle) 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: GASTROENTEROLOGY
When: FRIDAY [**2173-8-20**] at 12:00 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2173-8-27**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
|
[
"2851",
"42731",
"V4582",
"4019",
"2724"
] |
Admission Date: [**2118-9-27**] Discharge Date: [**2118-10-4**]
Date of Birth: [**2047-1-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Acute renal failure, severe hyperkalemia.
Major Surgical or Invasive Procedure:
Bilateral nephrostomy tubes, [**2118-9-27**].
History of Present Illness:
71yo male with castrate resistant metastatic prostate cancer and
stage III CKD presents after being found to have acute renal
failure and hyperkalemia on routine labs at OSH. Per pt, went
to oncologist yesterday with complaint of general weakness and
increased SOB at rest with resultant labs. The patient states
he had noted no urine output for the last 5 days. He also
admits to a productive cough for the last 8 weeks as well as new
SOB. He is not on any home oxygen. He also reports
intermittent nausea and occasional vomiting. He was sent to
[**Hospital1 6687**] ED where he received kayexelate and lisinopril 40mg
prior to transfer to [**Hospital1 18**].
.
In ER, initial VS: T- 98.5, HR- 72, BP- 143/89, RR- 24, SaO2 89%
on RA. Labs pertinent for BUN/Cr 107/13.7 with potassium of
6.7. UA showed small leukocytes, 56 WBC, large blood and >182
RBCs. CXR demonstrated mild pulmonary edema. EKG with low
voltages but sinus rhythm at a rate of 80, NA/NI, no peaked
T-waves. Bedside u/s revealed a small pericardial effusion with
no tamponade physiology. U/S also demonstrated bilateral
massive hydronephrosis. He was noted to have minimal foley
output. For hyperkalemia, he was given dextrose, insulin,
calcium gluconate, and he received duonebs for SOB. Urology was
consulted and recommended CT to assess for level of ureteral
obstruction and to continue foley decompression of the bladder.
Renal agreed with CT and urgent decompression of obstruction,
with no indication for urgent dialysis but to give kayexelate
for hyperkalemia and expect post-obstructive diuresis. Oncology
was consulted and stated they would follow along. IR agreed to
take patient for urgent bilateral percutaneous nephrostomy
placement. Vital signs on transfer were HR 90, afebrile,
satting 92-94% on 2L NC, 88% on RA, BP 141/78.
.
In the ICU, initial vital signs were T- 97.3, HR- 85, BP 127/70,
RR- 17, SaO2- 91% on NC. Patient reports symptom improvement
after IR procedure. Denies fevers, chills with some shortness
of breath that has also improved.
Past Medical History:
- Metastatic prostate cancer, first diagnosed in [**2110**] s/p
cryotherapy; increasing PSA noted, then put on hormonal therapy,
recently completed 8 cycles of taxotere; has known spinal
metasteses
- Hypertension
- Hyperlipidemia
- Stage III CKD, baseline Cr 1.5 in [**2116**]
Social History:
He lives in [**Hospital1 6687**] with his wife. [**Name (NI) **] is retired, but had
previously worked as a controller of a company.
- Tobacco: less then 10 cigarettes per day
- Alcohol: less than 2 drinks per day
- Illicits: Denies
Family History:
NC
Physical Exam:
Admission Exam:
Vitals: T- 97.3, HR- 85, BP 127/70, RR- 17, SaO2- 91% on NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, NC in place
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles with wheezes, good respiratory effort.
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
GU: bilateral nephrostomy tubes in place, draining well
Ext: warm, well perfused, 2+ pulses, with 1+ edema bilaterally
Pertinent Results:
Admission Labs
.
CBC:
[**2118-9-27**] 05:00PM WBC-8.2 RBC-4.03* HGB-12.6* HCT-37.3* MCV-93
MCH-31.4 MCHC-33.8 RDW-15.7*
[**2118-9-27**] 05:00PM NEUTS-84.9* LYMPHS-10.3* MONOS-3.9 EOS-0.3
BASOS-0.5
[**2118-9-27**] 05:00PM PLT COUNT-311
.
CHEM-7:
[**2118-9-27**] 05:00PM GLUCOSE-98 UREA N-107* CREAT-13.7*#
SODIUM-140 POTASSIUM-6.7* CHLORIDE-102 TOTAL CO2-20* ANION
GAP-25*
[**2118-9-28**] 03:30PM BLOOD Calcium-9.3 Phos-6.8* Mg-2.1
.
Renal function:
[**2118-9-27**] 05:00PM BLOOD UreaN-107* Creat-13.7*#
[**2118-9-28**] 04:24AM BLOOD UreaN-98* Creat-11.5*#
[**2118-9-28**] 03:30PM BLOOD UreaN-83* Creat-8.4*#
.
LFTs:
[**2118-9-28**] 04:24AM BLOOD ALT-14 AST-13 LD(LDH)-184 AlkPhos-68
TotBili-0.2
.
URINE STUDIES:
[**2118-9-27**] 07:30PM URINE Color-Pink Appear-Hazy Sp [**Last Name (un) **]-
[**2118-9-27**] 07:30PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-SM
[**2118-9-27**] 07:30PM URINE RBC->182* WBC-56* Bacteri-FEW Yeast-NONE
Epi-0
.
CXR [**2118-9-27**]: IMPRESSION:
1. Moderate right pleural effusion.
2. Bibasilar opacities at the lung bases, likely atelectasis,
cannot exclude superinfection.
3. Engorgement of the vessels centrally.
4. Enlarged cardiac silhouette.
.
[**2118-9-27**] CT ABD/PELVIS: IMPRESSION:
1. Worsening moderate-to-severe bilateral hydronephrosis and
proximal
hydroureter, with the ureters compressed and/or encased by
extensive
retroperitoneal lymphadenopathy which may be slightly increased
in size compared to prior.
2. Bilateral large pleural effusions, worse on the right with
bibasilar atelectasis.
3. Small amount of free fluid in the pelvis with presacral
edema.
4. T12 and L1 vertebral body sclerotic osseous metastases,
similar to outside CT from [**2118-7-19**]. Mild loss of height
of T12 vertebral body is stable compared to [**2118-7-19**];
however, is new from [**2117-11-11**].
6. Cholelithasis.
7. Diverticulosis.
.
[**2118-9-28**] CXR: IMPRESSION: Worsening of pleural effusions and
pulmonary edema that may be due in part to technical differences
between this and the prior study.
.
[**2118-9-30**] CXR: IMPRESSION:
1. Stable bilateral pleural effusions, moderate on the right and
small on the left. Improved pulmonary edema.
2. Stable mediastinal widening corresponding with known
adenopathy.
.
[**2118-9-30**] ECHO: Mild symmetric left ventricular hypertrophy,
LVEF>55%, mildly dilated RV, ascending aorta is mildly dilated,
at least mild pulmonary artery systolic hypertension.
.
DISCHARGE LABS:
[**2118-10-4**] 07:02AM BLOOD WBC-8.9 RBC-3.79* Hgb-11.8* Hct-35.8*
MCV-94 MCH-31.1 MCHC-32.9 RDW-15.6* Plt Ct-321
[**2118-9-30**] 06:40AM BLOOD PT-12.2 PTT-29.3 INR(PT)-1.0
[**2118-10-4**] 07:02AM BLOOD Glucose-89 UreaN-27* Creat-1.6* Na-143
K-3.6 Cl-107 HCO3-28 AnGap-12
[**2118-10-4**] 07:02AM BLOOD Calcium-9.4 Phos-2.6* Mg-1.9
[**2118-10-4**] 07:02AM BLOOD ALT-25 AST-18 AlkPhos-63 TotBili-0.3
Brief Hospital Course:
71yo man with metastatic prostate CA and stage III CKD who was
transferred from OSH for [**Last Name (un) **] and hyperkalemia due obstructive
uropathy. Bilateral percutaneous nephrostomy tubes were placed
[**2118-9-28**].
.
# Acute kidney injury due to obstruction: Resolved s/p bilateral
nephrostomy tube placement [**2118-9-28**]. Urology and Nephrology
consulted. Post-obstructive diuresis slowing. Aspirin held
because of macroscopic hematuria post-nephrostomy placement.
.
# Hyperkalemia: Resolved s/p Kayexylate, insulin/glucose,
calcium.
.
# Prostate CA: Started abiraterone [**2118-9-26**]. Leuprolide given
last week. XRT started Monday [**2118-10-3**], finishes Friday
[**2118-10-7**]. Continued prednisone, but dose increased for COPD
exacerbation, plant to taper down slowly to baseline 5mg [**Hospital1 **].
Restarted abiraterone (Zytiga) 1000mg PO daily [**2118-10-3**] per
primary oncologist.
.
# Hypoxia and right-sided pleural effusion: CXR with moderate
new right pleural effusion and vascular congestion. Cough
x6wks. Sputum culture grew Moraxella catarrhalis, started
levofloxacin for possible pneumonia. Echo normal. COPD
exacerbation given prominent wheeze, cough, and smoking history.
O2 needs resolved since increase in prednisone. Continued
prednisone taper. Changed nebs to prn and discharged with a
nebulizer. Continued levofloxacin, renally dosed, for Moraxella
pneumonia. Held diuretics while auto-diuresing.
.
# Pulmonary edema: Improved with post-obstructive diuresis.
Held on furosemide while auto-diuresing. Now off O2.
.
# Hypertension: Outpatient furosemide held with post-obstructive
diuresis. PCP to restart next week as needed.
.
# Hyperlipidemia: Continued outpatient statin.
.
# Anemia: Continued vitamin B12 replacement.
.
# Hypernatremia: Due to free water deficit. Resolved.
.
# FEN: Regular low-sodium diet. Hypophosphatemia
post-obstructive diuresis not repleted, but monitored.
.
# GI PPx: PPI and bowel regimen.
.
# DVT PPx: Heparin SC.
.
# Precautions: None.
.
# Lines: Peripheral IV, bilateral nephrostomy tubes.
.
# CODE: FULL.
Medications on Admission:
Abiraterone 1000mg PO daily, started 10/[**2117**].
Atorvastatin 20mg PO daily
Dexamethasone 8mg PO daily
Enalapril 10mg PO daily
Furosemide 20mg PO daily
Leuprolide (Lupron Depot) 7.5mg IM qmo
Prednisone 5mg PO BID
MVI 1 tab PO daily
Aspirin 81mg daily
Vitamin B12
KCl 20meq ER PO daily
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY.
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY.
3. Zytiga 250 mg Tablet Sig: Four (4) Tablet PO DAILY.
4. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY.
5. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H x2
doses.
Disp:*2 Tablet(s)* Refills:*0*
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H PRN wheezing,
shortness of breath.
Disp:*30 neb* Refills:*1*
7. ipratropium bromide 0.02 % Solution Inhalation Q6H PRN
Dyspnea, wheeze.
Disp:*30 neb* Refills:*1*
8. prochlorperazine maleate 10mg PO DAILY: Take 1hr prior to
radiation.
9. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO q6hr
PRN nausea.
Disp:*20 Tablet(s)* Refills:*1*
10. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO q8HR PRN
nausea.
Disp:*20 Tablet(s)* Refills:*1*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
PRN Constipation.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN
Constipation.
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) PO Q24H.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY: Take
40mg daily x3d, then 20mg daily x4d, then return to your
previous dose 5mg [**Hospital1 **].
Disp:*10 Tablet(s)* Refills:*0*
15. Home nebulizer
Home nebulizer
Dx: COPD.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
1. Acute kidney failure.
2. Hyperkalemia (high potassium level).
3. Obstructive uropathy (kidney damage due to obstruction).
4. Metastatic prostate cancer to lymph nodes and bones/spine.
5. Hypoxemia (low oxygen levels).
6. Dyspnea (shortness of breath).
7. Acute COPD exacerbation (chronic obstructive pulmonary
disease, emphysema).
8. Possible pneumonia.
9. Pulmonary edema and pleural effusion (fluid in lungs).
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 for acute kidney failure due
to obstruction from metastatic prostate cancer. Your potassium
level was also dangerously high, a result of the kidney failure.
You were given medications to reduce the potassium level and
catheter drains were placed into both ureters to bypass the
obstruction. You immediately began excreting urine and over
several days the kidneys returned to baseline. Once the
potassium and kidney function began improving, you were
transferred out of the Intensive Care Unit (ICU). Radiation
Oncology decided that to relieve the obstruction and control
cancer growth in the spine you should have radiation therapy,
which started Tuesday [**2118-10-4**]. The nephrostomy tubes will need
to stay in place until after radiation therapy and how long they
are needed will be determined by Urology. Your breathing
remained labored and you began needing oxygen support. Chest
x-ray showed fluid on the lungs (pleural effusion and pulmonary
edema). This fluid began coming off once your kidneys began
working again. While the your urine output increased, your
furosemide (Lasix) was held. In addition, you were started on
an antibiotic for a bacteria that grew in your sputum (possible
pneumonia) and steroids (prednisone) for acute COPD exacerbation
(chronic obstructive pulmonary disease, emphysema). You will
need to complete a course of the antibiotic and a slow taper of
the steroids. Aspirin has been held due to bleeding from the
nephrostomy tubes.
.
MEDICATION CHANGES:
1. Levofloxacin once daily x7 days total.
2. Prednisone as directed.
3. Hold aspirin until further notified.
4. Hold furosemide (Lasix) until directed by your primary care
physician.
5. Stop enalapril and potassium supplements as both elevate
potassium levels and your potassium level had been dangerously
high. Your primary care physician may reinstitute these at a
later date.
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 86355**], MD
Specialty: Internal Medicine
When: Tuesday [**10-11**] at 1:45pm
Address: [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier 54491**]
Phone: [**Telephone/Fax (1) 22442**]
[**Doctor Last Name 2270**] from Dr. [**Last Name (STitle) **] office says that if this is not a
convenient time for you, you can call the office to reschedule.
.
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2118-10-12**] at 3:15 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Specialty: Urology
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"5849",
"2760",
"2762",
"4280",
"2767",
"40390",
"2724",
"3051",
"2859"
] |
Admission Date: [**2154-1-15**] Discharge Date: [**2154-1-19**]
Date of Birth: [**2121-6-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
chest pain, arm pain
Major Surgical or Invasive Procedure:
[**2154-1-15**] - Catheter placement, coronary thrombectomy, coronary
artery infusion of eptifibatide, Intravascular ultrasound,
Coronary Angiography
[**2154-1-18**] Coronary catheterization with placement of 2 bare metal
stents to mid LAD.
History of Present Illness:
This is a 32 year-old with a PMH significant for HTN,
insulin-dependent diabetes mellitus who presents with a 3-day
history of chest and arm pain that developed with exertion with
some exertional dyspnea and fatigue.
.
The patient awoke Sunday ([**2154-1-13**]) feeling well and went to the
laundry mat walking 1-block with bags full of laundry and
developed some exertional dyspnea and left arm pain that
radiated in a pulsatile fashion to his fingers; without frank
chest pain, but with some diaphoresis. When he returned home,
his dyspnea improved with rest. However, his left arm pain
progressed to right arm pain even while resting. This pain
continued through Monday and early Tuesday morning he noted the
left arm pain was [**9-5**] in intensity and was sharp in character,
radiating to the left shoulder and back with some chest
discomfort that was constant. He presented to the BU Student
Health Center Tuesday PM and they gave him Aspirin 325 mg PO x 2
and called EMS. He was BIBA to the [**Hospital1 18**] ED for further
management.
.
In the ED, initial VS 102 114/85 20 99% 2LNC. An EKG showed
sinus tachycardia @ 119, NA/NI, 2-[**Street Address(2) 2051**]-elevations in lead
V2-6, 1-mm ST-elevations in leads aVL, I and inferior lead
reciprocal changes. He received Metoprolol 5 mg IV x 1, Heparin
bolus of 4000 units IV and Ativan 2 mg PO x 1. He was emergently
rushed to the cardiac cath [**Street Address(2) **] where the patient was noted to
have an abrupt cut-off at the mid-LAD with visible vessel
thrombus of the mid-LAD and distal reconstitution with
distal-LAD disease; underwent aspiration and ballooning of LAD
via RFA access (closed with angioseal). In the [**Street Address(2) **], he was given
Plavix 300 mg loading dose. Integrillin gtt was started and
heparin gtt was continued. In the cath [**Street Address(2) **] he was also
diaphoretic with a blood glucose of 390 mg/dL. He remained chest
pain free, but had on-going arm pain following the procedure.
.
On arrival in the CCU, the patient has some on-going left arm
pain while resting flat, but no chest pain, diaphoresis,
palpitations or nausea.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or pre-syncope.
.
ROS: The patient denies a history of prior stroke/TIA, deep
venous thrombosis or pulmonary embolus. They deny bleeding at
the time of prior procedures or surgeries. Denies headaches or
vision changes. No cough or upper respiratory symptoms. Denies
dizziness or lightheadedness; no palpitations. No nausea or
vomiting, denies abdominal pain. No dysuria or hematuria. No
change in bowel movements or bloody stools. Denies muscle
weakness, myalgias or neurologic complaints. No exertional
buttock or calf pain.
Past Medical History:
1. Insulin-dependent diabetes mellitus (diagnosed at age 19
year-old - blood glucose runs in the 150-200 mg/dL range; takes
Lantus and Humalog)
2. Hypertension
Social History:
Patient lives at home with his wife, who is 9-weeks pregnant. He
denies any smoking history. He stopped drinking 8-years ago for
spiritual reasons. He is a BU graduate student who just moved
here from [**Location (un) 58091**], VA/DC for graduate school studying
practical theology. He notes significant stress related to
semester deadlines. He denies recreational substance use.
Family History:
Denies family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death. Strong family history of diabetes,
hypertension and stroke.
Physical Exam:
ADMISSION EXAM
VITALS: 98.6 / 98.6 138/87 112 23 100% 2LNC
GENERAL: Appears in no acute distress. Alert and interactive
African American male.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD difficult to assess
given body habitus.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal. No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Clear to
auscultation bilaterally without adventitious sounds. No
wheezing, rhonchi or crackles. Stable inspiratory effort.
ABD: soft and obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
DERM: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
.
[**2154-1-15**] 11:40AM BLOOD WBC-7.5 RBC-6.16 Hgb-14.6 Hct-46.1
MCV-75* MCH-23.7* MCHC-31.7 RDW-12.9 Plt Ct-244
[**2154-1-15**] 11:40AM BLOOD PT-11.5 PTT-27.3 INR(PT)-1.1
[**2154-1-15**] 11:40AM BLOOD Fibrino-572*
[**2154-1-15**] 08:00PM BLOOD UreaN-10 Creat-0.8 Na-130* K-4.1 Cl-97
[**2154-1-16**] 05:00AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.0
.
PERTINENT LABS AND STUDIES:
[**2154-1-15**] 08:00PM BLOOD CK(CPK)-387*
[**2154-1-16**] 05:00AM BLOOD CK(CPK)-275
[**2154-1-16**] 12:36PM BLOOD CK(CPK)-218
[**2154-1-15**] 08:00PM BLOOD CK-MB-7
[**2154-1-16**] 05:00AM BLOOD CK-MB-6 cTropnT-0.32*
[**2154-1-16**] 12:36PM BLOOD CK-MB-4 cTropnT-0.28*
[**2154-1-15**] 11:40AM BLOOD Lipase-35
[**2154-1-16**] 05:00AM BLOOD %HbA1c-11.5* eAG-283*
[**2154-1-16**] 05:00AM BLOOD Triglyc-180* HDL-35 CHOL/HD-3.4
LDLcalc-48 Cholest-119
.
[**2154-1-15**] CARDIAC CATH - French XBLAD3.5 guide provided good
support. Crossed with Prowater very easily into the distal LAD.
This did not restore flow in the apical LAD and visible
thrombus was seen to occlude
the vessel there. Administered intracoronary Integrilin (180
mcg/kg x 2) and performed catheter based thrombectomy using the
Export catheter with significant clot removal/dissolution.
Administered intracoronary vasodilators. Perfomed intravascular
ultrasound using the Atlantis catheter and this revealed mild
diffuse atherosclerosis throughout the LAD and residual
subocclusive thrombus in the proximal LAD. A ChoICE PT XS [**Name (NI) **]
was redirected into various branches of the distal LAD and an
uninflated 2.0 mm balloon was used to "Dotter" across the apical
vessel clot, but this did not restore flow. It was decided that
we would administer 18 hours of integrilin and IV heparin for at
least 48 hours rather than cause distal embolization with stent,
balloon or rheolytic thrombectomy. Final angiography revealed
normal flow to the apical LAD where there was TIMI 0 flow and
filling via faint collaterals. There was 20-40% residual
thrombus in the proximal LAD. He left the laboratory in stable
condition with no chest pain.
.
[**2154-1-15**] CXR - The cardiomediastinal and hilar contours are
normal. The lungs are essentially clear. There is no pleural
effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary process. [**2154-1-15**]
ECHOCARDIOGRAM The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. IMPRESSION: Suboptimal image
quality. Mild symmetric left ventricular hypertrophy. Normal
global and regional biventricular function. No evidence of
intracardiac shunt with agitated saline administration.
.
[**2154-1-16**] 2D-ECHO - The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. IMPRESSION: Suboptimal image
quality. Mild symmetric left ventricular hypertrophy. Normal
global and regional biventricular function. No evidence of
intracardiac shunt with agitated saline administration.
.
[**2154-1-18**] CARDIAC CATH:
Findings:
ESTIMATED blood loss: <100 cc
Hemodynamics (see above):
Coronary angiography: left dominant
LMCA: No angiographically-apparent CAD.
LAD: Unchanged 60-80% subocclusive thrombus proximal LAD.
Visible thrombus in apical LAD with "train track" appearance
with
some flow in apex.
LCX: No angiographically-apparent CAD.
RCA: Not injected. Known nondominant and free of disease.
.
Interventional details
XB3 guide. Crossed with Prowater wire and performed IVUS
interrogation using the InfraredX catheter. This demonstrated
significant thrombus in the proximal LAD with a RVD of 5.1 cm.
There was very little atheroma. The decision was made to
proceed with direct stenting. A 4.0 x 22 mm Integriti stent was
deployed and postdilated with a 5.0 mm balloon and residual
thrombus was visible distal to this stent and thought to be due
to uncovered (rather than due to prolapse or "toothpasting")
thrombus. A distal overlapping 4.0 x 15 mm Integriti stent was
deployed and postdilated to 5.0 mm. Final angiography revealed
normal flow, no dissection and 0% residual stenosis in the
stent,
no thrombus in the LAD up to the apex and no change in the
apical
LAD appearance.
.
Assessment & Recommendations
1. Secondary prevention CAD, CHF.
2. Plavix (clopidogrel) 75 mg daily X 12 months.
3. Heparin at 1700 U/hr as bridge to therapeutic warfarin.
4. Suggest warfarin INR [**3-1**].
5. ASA 81 mg QD.
6. Consider Cardiac MRI.
.
[**2154-1-19**] 2D-ECHO - The left atrium is mildly dilated. 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. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of three days ago, [**2154-1-16**], the findings are
similar.
Brief Hospital Course:
32M with a PMH significant for HTN, insulin-dependent diabetes
mellitus who presents with a 3-day history of chest and arm pain
that developed with exertion with some exertional dyspnea and
fatigue found to have an anterolateral STEMI.
.
# ACUTE CORONARY SYNDROME, ST-SEGMENT ELEVATION MYOCARDIAL
INFARCTION - patient presented with acute coronary syndrome; no
prior history of chronic, stable angina but he has notable risk
factors including obesity, HTN, diabetes history and family
history. No prior cardiac catheterizations or known coronary
disease. EKG consistent with anterolateral ST-elevations with
cardiac catheterization showing abrupt cut-off at the mid-LAD
with visible vessel thrombus of the mid-LAD and distal
reconstitution with some distal-LAD disease; underwent
aspiration and balloon dottering of LAD via RFA access but given
the need to avoid distal embolization, anti-platelet therapy was
planned for 48-hours with a re-look planned. Received Aspirin
325 mg, Plavix 300 mg load, heparin IV 4000 unit bolus prior to
cath [**Year (4 digits) **] transfer. Integrillin and heparin gtt continued
following cardiac cath. Some on-going left arm pain and
persistent ST-elevations and TWI in the inferior leads following
the procedure resulted in starting Nitroglycerin gtt (evening of
[**1-15**]), which was discontinued. His re-look cardiac
catheterization procedure was performed on [**2154-1-18**] and showed
unchanged 60-80% sub-occlusive thrombus in the proximal LAD.
Visible thrombus in the apical LAD with "train track" appearance
with some flow in the apex was also noted. A 4.0 x 22 mm
Integrity stent was deployed and post-dilated with a 5.0 mm
balloon and residual thrombus was visible distal to this stent
and thought to be due to uncovered (rather than due to prolapse
or "toothpasting") thrombus. A distal overlapping 4.0 x 15 mm
Integrity stent was deployed and post-dilated to 5.0 mm. Final
angiography revealed normal flow, no dissection and 0% residual
stenosis in the stent, no thrombus in the LAD up to the apex and
no change in the apical
LAD appearance. Heparin gtt was continued until Lovenox was
utilized and then the patient was bridged to Coumadin. He was
continued on Plavix (for 12-months), Aspirin, Metoprolol,
Atorvastatin for medical management of his coronary disease, as
an outpatient. He was also treated with Ibuprofen for suspected
pericarditis, given a pleuritic component of his chest pain.
.
# DIASTOLIC HEART DYSFUNCTION - No historical evidence of
systolic or diastolic dysfunction; no prior 2D-Echo reports and
no physical evidence of heart failure noted. Remains on an ACEI
given diabetes for renal protection as an outpatient. His
echocardiogram demonstrated no PFO or atrial septal defects and
his left ventricular function was read as normal with no global
systolic dysfunction (LVEF 55%). He did have evidence of
diastolic dysfunction (grade 2) and for this we continued his
ACEI therapy and he was maintained on a beta-blocker. A repeat
2D-Echo on [**1-19**] was unchanged. He had no indication for
diuresis and his weight was stable this admission.
.
# INSULIN-DEPENDENT DIABETES MELLITUS - He has a history of
insulin-dependent diabetes mellitus diagnosed at age 19-years
when he presented unresponsive and was hospitalized. Has been on
insulin since and has blood glucose levels in the 150-200 mg/dL
range at home, per patient. No history HbA1c, but found to be an
HbA1c of 11.5% here. The patient required aggressive uptitration
of insulin given persistent hyperglycemia in the 400 mg/dL
range. At time of discharge, his blood glucose had improved
control with use of 18U Lantus and 20U short-acting insulin
prior to meals, resulting in blood glucoses of 150-170 mg/dL. He
will follow-up with [**Hospital **] [**Hospital 982**] clinic as an outpatient.
.
# HYPERTENSION - patient's home regimen included HCTZ and ACEI
therapy given his diabetes. We resumed his ACEI during this
hospitalization.
.
TRANSITION OF CARE ISSUES:
1. At the time of discharge, the following laboratory data,
microbiologic data and radiologic studies were pending.
2. Scheduled follow-up with his primary care physician and with
[**Name9 (PRE) **] [**Hospital 982**] clinic regarding the management of his
insulin-dependent diabetes.
3. Will require cardiac MR imaging and follow-up
echocardiography as an outpatient.
4. Will continue Lovenox bridge to Coumadin as an outpatient.
5. We started iron supplementation given his anemia.
Medications on Admission:
1. Lantus 16 units SC at nighttime
2. Humalog 20 units SC prior to meals
3. Metformin 1000 mg PO BID
4. HCTZ 12.5 mg PO daily
5. Lisinopril 10 mg PO daily
Discharge Medications:
1. insulin glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
2. insulin lispro 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous three times a day, prior to meals.
3. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
4. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
5. 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*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Outpatient Physical Therapy
Outpatient physical therapy for mechanical left shoulder pain.
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may repeat every 5 minutes for a maximmum of 3 doses (15 minutes
of treatment).
Disp:*30 Tablet, Sublingual(s)* Refills:*1*
10. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
You labs will have to be drawn while on this medication.
Disp:*30 Tablet(s)* Refills:*0*
11. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): Continue until Dr. [**Last Name (STitle) 4427**]
tells you to stop.
Disp:*14 syringe* Refills:*0*
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Radiology
Cardiac MRI one month from discharge.
16. Outpatient Radiology
Outpatient Echo within the next month.
17. Outpatient [**Name (NI) **] Work
PT/INR on Wednesday [**2154-1-23**]. Please fax results to Dr. [**Last Name (STitle) 4427**]
at [**Hospital 18**] [**Hospital6 733**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Acute anterolateral ST-segment elevation myocardial
infarction
2. Grade II, diastolic heart dysfunction
.
Secndary Diagnoses:
1. Insulin-dependent diabetes mellitus
2. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Coronary Care Unit (CCU) at [**Hospital1 771**] on [**Hospital Ward Name 121**] 6 regarding management of your
chest pain and shortness of breath. You were found to have an
anterolateral ST-segment elevation myocardial infarction (heart
attack) and went to the cardiac catheterization [**Hospital Ward Name **] urgently
where we attempted to remove the thrombus or clot in your heart
artery. You were medically managed with anti-platelet therapy
and anticoagulants following your first procedure and a second
catheterization was planned. This showed persistent clot in your
heart artery and required 2 bare metal stents be placed in that
artery. You chest pain resolved and you were monitored without
any additional events.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
Aspirin 325mg by mouth daily for one month. Following this, you
should take 81mg by mouth daily.
Plavix (Clopidogrel) 75mg by mouth daily for 1 year
Metoprolol extended release 200mg by mouth daily
Nitroglycerin sublingually 0.4 as needed for chest pain
Atorvastatin 80mg by mouth daily
Lovenox 120mg injection twice daily until our primary care
doctor tells you to stop.
Warfarin 7.5mg by mouth daily at 4pm
Iron 300mg by mouth twice daily.
.
* The following medications were CHANGED on admission:
TAKE Lisinopril 20mg daily (you were previously on 10mg daily)
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
You will need a follow up Cardiac MRI and echo.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) **] office to schedule a follow up
cardiology appointment. You should be seen by Dr. [**Last Name (STitle) 911**] in the
next 7-10days. His office can be reached at: ([**Telephone/Fax (1) 7283**].
Name: He, [**Name8 (MD) 91372**] MD
Location: [**Last Name (un) **] Diabetes Center
Address: [**Last Name (un) 3911**] [**Location (un) 86**], [**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 2384**]
Appointment: Wednesday [**2154-1-23**] 2:00pm
*Your appointment will be about 2-3 hours long. You will be
meeting with an educator as well as the doctor.
.
Primary Care:
Department: [**Hospital3 249**]
When: THURSDAY [**2154-1-24**] at 8:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15398**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Cardiology:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2154-2-20**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"4019",
"V5867",
"41401"
] |
Admission Date: [**2148-5-29**] Discharge Date: [**2148-6-27**]
Date of Birth: [**2103-7-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
ESLD secondary to Hepatitis C/ETOH cirrhosis and small hepatoma
with h/o radiofrequency ablation.
Major Surgical or Invasive Procedure:
Orthotopic liver transplant [**2148-5-30**]
Revision of portal vein [**2148-6-15**]
portal vein stenting [**2148-6-17**]
Transjugular liver biopsy [**2148-6-25**]
History of Present Illness:
Felt well, no fevers, chills, nausea/vomiting, diarrhea. Denies
chest pain
Past Medical History:
1. Cirrhosis (Hep C/etOH)
2. hepatoma -s/p ablation now on transplant list/evaluation
3. Esophageal varices
4. s/p femur/tibia/fib fx
5. h/o polysubstance abuse
Social History:
44 yo man, currently unemployed who lives with girlfriend.
h/o alcohol use remission for 5 years
tobacco-1ppd X22 yrs
h/o cocaine, heroine, amphetamine abuse - none since [**2138**]
Family History:
mother died of MI at 65 yo
Physical Exam:
97.5-67-20 144/64, 99%
gen: NAD
Neck: supples, no lad
Heent: eomi, perrla,
Cor:RRR, no MRG
Chest; CTA B
ABD: s/nt/nd
ext: no c/c/e
skin: no lesions, no ulcers
labs: ast 339, alt 317, alk phos 116, t.bili 1.8, Hct 38.3,
creat 0.7
Brief Hospital Course:
Taken to OR [**2148-5-30**] for OLT. See operative report. Induction
immunosuppression (Simulect 20mg, solumedrol 500mg, cellcept 1g)
was administered. He was admitted to the SICU intubated. He was
coagulopathic. This was corrected with FFP, plts and 4 units of
PRBC for hct of 26.7. Post op duplex demonstrated small clot in
left portal vein. IV Heparin was started. He was extubated on
POD 1. Solumedrol taper was initiated on a daily basis.
On POD 2, a tube cholangiogram demonstrated "Successful tube
cholangiogram demonstrating normal filling of the common bile
duct and bilateral the intrahepatic bile ducts." U/S
demonstrated no perihepatic fluid. The main, left portal, and
anterior and posterior right portal branches showed normal color
Doppler flow and waveform. The right, middle and hepatic veins
appeared patent. The arterial waveforms in the right and left
hepatic arteries appeared essentially unchanged, although the
resistive indices were not fully assessed on that "limited
examination."
A CTA was obtained. This demonstrated "A small right pleural
effusion is present. Bibasilar atelectasis is also noted. Two
perihepatic drains are present. A biliary drainage catheter is
also in place. The liver contains several cysts versus
hemangiomas. Periportal edema is present. The hepatic artery,
hepatic veins, and portal veins are patent. No left portal vein
thrombosis is seen. There is a small amount of perihepatic
fluid. The pancreas, adrenal glands, and kidneys are
unremarkable. Splenomegaly is present, with the spleen measuring
up to 14.9 cm in the craniocaudal dimension. There is no
abnormal bowel wall thickening or bowel loop dilatation. There
are multiple small celiac and paraaortic nodes that do not meet
the strict criteria for pathologic enlargement."
He was transferred to the transplant unit where diet was
advanced and immunosuppresion consisted of tapering solumedrol,
cellcept, and prograf. Hparin IV continued. BP was 170's/110.
Lopressor was started with improvement of bp. Glucoses were
elevated. [**Last Name (un) **] was consulted. Sliding scale and glargine
insulin were given with improvement of glucose control.
On POD 4,he received IV simulect once. A t-tube cholangiogram
was done on [**6-4**] as lfts were slightly increased (ast 360, alt
442, alk phos 112, t.bili 3.9). This demonstrated normal filling
of the common bile duct and bilateral the intrahepatic bile
ducts. Lfts continued to increase. Repeat cholangiogram on [**6-4**]
revealed "minimal intrahepatic biliary ductal dilatation. Mild
narrowing of the common bile duct at the T-tube insertion site.
No high-grade stricture or anastomotic leak." T tube was capped
on POD 5. Platelets decreased to 62. HIT antibody was negative.
Platelets returned to [**Location 213**] at end of discharge.
POD 6, lasix was increased for persistent fluid overload. This
improved daily with decreased weight and edema. A this time he
developed diarrhea and abdominal discomfort. Cellcept was
decreased. Stool was positive for c.diff and flagyl was started.
Them edial jp was removed on pod 7. The lateral jp was removed
on pod 8. Diarrhea decreased. LFTs improved although, alk phos
was persistently elevated at 192. Alk phos increased to 392 on
POD 9. The T-tube was opened. On [**6-9**], a repeat cholangiogram
was done. This demonstrated "Minimal intrahepatic biliary ductal
dilatation. Mild narrowing of the common bile duct at the T-tube
insertion site. " No leak was noted. Solumedrol 500mg was
administered on [**6-11**], but liver biopsy was indeterminant for
rejection. Solumedrol was discontinued. Obstruction was
suspected.
On ERCP on [**6-13**] demonstrated normal papilla, no stricture. There
was slight narrowing and irregularity of the mid-duct at the
site of the anastomosis with apparent T-tube site. Ballon
inflated to 6-7 mm pulled through without [**Doctor First Name **] resistance. Free
flow was observed into the ducts.
On [**6-13**], a liver biopsy under u/s was performed for elevated
lfts. This was negative for rejection. HCV viral load was
>700,000. LFts decreased slightly. On [**6-17**] " 1) Percutaneous
transhepatic portal venography was performed, revealing a tight
stricture at the portal venous anastomosis.
2) Successful placement of a 14-mm diameter x 6-cm long Cordis
nitinol Smart stent across the portal venous anastomotic
stricture, followed by dilation of the anastomotic stricture
using a 12-mm balloon with good angiographic success and
reduction in the portal venous pressure gradient from 6 mmHg to
2 mmHg." He was started on aspirin and plavix. " LFTs trended
down slowly.
Repeat duplex on [**6-20**] and [**6-22**] demonstrated normal findings. A
transjugular liver biopsy was done on [**6-25**] as he was on aspirin
and plavix. Preliminary results revealed evidence of recurrent
Hep C and no rejection. Hepatology was consulted. He will follow
up in one week at which time, treatment of Hep C will be
determined.
He was discharged home on prograf, cellcept, and prednisone. He
will complete a 2 week course of po vanco for persistent GI
upset an diarrhea despite 3 negative stools for c.diff and
adjustment of cellcept. Protonix was increased to [**Hospital1 **].
He will be followed by VNA for medication and insulin management
as well as the t. tube that was left to gravity drainage. He was
able to empty and record output. Creatinine trended up. Lasix
was discontinued on day of discharge as his weight decreased
17kg and bun was elevated. Vital signs were stable, he was
ambulatory and tolerating a regular diet.
Labs on discharge were as follows: Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2148-6-27**] 06:12AM 6.7 3.64* 12.3* 35.6* 98 33.8* 34.5 17.4*
128*
BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct
[**2148-6-27**] 06:12AM 128*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2148-6-27**] 06:12AM 96 54* 2.1* 138 4.9 108 18* 17
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2148-6-27**] 06:12AM 350* 102* 557* 1.8*
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2148-6-27**] 06:12AM 4.0
TOXICOLOGY, SERUM AND OTHER DRUGS FK506
[**2148-6-27**] 06:12AM 12.11
1 TARGET 12-HR TROUGH (EARLY POST-TX): [**5-31**] [24-HR TROUGH 33-50%
LOWER
Medications on Admission:
nadolol 60mg qd, lactulose 30ml [**Hospital1 **], carafate 1 qid
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*42 Tablet(s)* Refills:*0*
3. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale instructions Injection every six (6) hours.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
9. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QOD ().
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Orthotopic liver transplant [**2148-5-30**]
Hepatitis C cirrhosis
Hepatocellular carcinoma s/p radio frequency ablation
h/o etoh/substance abuse
PUD
Steroid induced DM, insulin requiring
portal vein stenosis, s/p stenting
recurrent Hepatitis C
C.diff,rx'd with flagyl/vanco
Discharge Condition:
stable
Discharge Instructions:
Call if fevers, chills, nausea, vomiting, inability to take
medications, jaundice, bleeding from incision, redness of
incision, increased diarrhea, abdominal pain.
Labs every Monday & Thursday for cbc, chem 10, ast, alt, alk
phos, t.bili, albumin and trough prograf level. Results to be
fax'd to transplant office [**Telephone/Fax (1) 697**]
No driving while taking pain medication
[**Month (only) 116**] shower
Empty bile (PTC)drain when [**1-14**] full. record amount/color. Bring
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-7-4**] 10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-7-11**] 10:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-7-18**] 11:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2148-6-27**]
|
[
"4019"
] |
Admission Date: [**2181-12-29**] Discharge Date: [**2182-1-17**]
Date of Birth: [**2129-9-1**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
suspected overdose
Major Surgical or Invasive Procedure:
Intramedullary nailing with cephalomedullary
device, gamma nail of right femur fracture.
History of Present Illness:
52 yo M with a history of paraplegia secondary ot HTLV-1
infection, sacral decubiti, COPD, and substance abuse who was
admitted [**12-13**] for menal status changes and respiratory
distress, intubated with pneumonia, sucessfully extubated, then
discharged to his NH on [**12-21**], who re-presents today with a
suspected methadone/benzo overdose responding to narcan in the
ED. He is on chronic methadone/oxycodone at his nursing home for
pain and was found unresponsive w/ a respiratory rate of 4 and
bp of 72/64, satting 88%, EMS was called and gave 4 mg narcan to
which he responded well, however he required two additional
doses for decreased respirations in the ED. Recieved 3 L of NS
for blood pressure support. Toxicology was consulted and
recommended against a narcan gtt. In the ED he desatted to
89-90% on 2L NC and was placed on NRB, subsequently desatted to
75-80% on NRB, lung exam ronchorous, gas at that time 7.37/48/54
and was intubated of hypoxic respiratory failure. CXR on
admission showed resolving pneumonia, shortly prior to
intubation, showing worsened bibasilar infiltrates, possibly c/w
aspiration.
Past Medical History:
1. PNA: resulted in [**2-20**] week ICU stay at [**Hospital3 **]??????s w/trach
intubation and PEG
2. Sacral decubitus ulcers w/ chronic pain
3. Paraplegia secondary to HTLV-1 infection
4. Polysubstance abuse: heroin/cocaine
5. COPD
Social History:
EtOH: occasional. Tobacco: 17 p-y hx. Drugs: The patient has
been a cocaine and heroin abuser since age 20 but has not used
either for the past year. He smokes 1 cigarette of marijuana a
week but has not done so for the past month. The patient has
been living at the [**Hospital 33092**] Nursing Home for several years in
[**Location 1268**].
Family History:
The patient??????s father has h/o CAD.
Physical Exam:
VS: T 94.0 ax, HR 94, BP 97/58, RR 18, SaO2 100% on vent
settings: AC 500X14/5/1.0, with observed tv of 485 cc-500cc,
breathing at 14 (no overbreathing), peak pressure of 21, plateau
of 15
Gen: lying in bed, intubated and sedated, hands restrained,
grimaces to pain
HEENT: PERRL, sluggish, 3mm, anicteric, scar from previous trach
site
CV: PMI in MCL, regular S1 andn S2, no m/r/g
Lung: broncial/ventilator breath sounds, ronchi bilaterally at
bases
Abd: scar from peg, suprapubic catheter in place, S/ND/no
masses;
Back: examination deferred [**2-19**] restraints, known sacral stage IV
decub
Extr: no edema, palpable dp
Pertinent Results:
pH 7.37/pCO2 48/pO2 54/HCO3 29/BaseXS 1
Comments: Verified
Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art; Not Intubated; Non-Rebreathing Mask
Other Blood Gas:
Temp: 37.0
O2-Flow: 15
[**2181-12-29**]
2:20p
PT: 12.9 PTT: 28.8 INR: 1.1
[**2181-12-29**]
1:10p
141 107 19 / AGap=9
---|---|---- 85
3.4 28 0.4 \
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Urine Benzos Pos
Urine Mthdne Pos
Urine Barbs, Opiates, Cocaine, Amphet Negative
[**2181-12-29**] 1:10P
Test Result Reference
Range/Units
CTA URINE DRUGS DETECTED:
SALICYLATES AND
THC METABOLITES
AND METHADONE AND
METABOLITE AND
RANITIDINE AND
OXCARBAZEPINE AND
METABOLITES AND
OXYCODONE AND
CLOZAPINE AND
METABOLITES
INCLUDES TESTS FOR: ALCOHOLS, ANALGESICS, ANTICONVULSANTS,
ANTIDEPRESSANTS, ANTIHISTAMINES, BARBITURATES AND RELATED
COMPOUNDS, HALLUCINOGENS, STIMULANTS (AMPHETAMINES, COCAINE
ETC.), TRANQUILIZERS (BENZODIAZEPINES, PHENOTHIAZINES,
ETC.), MARIJUANA METABOLITE (IN URINE ONLY).
8.9
6.8 >---< 159 MCV: 86
27.3
N:73.4 L:20.8 M:3.9 E:1.7 Bas:0.2
Hypochr: 1+ Anisocy: 1+ Poiklo: 1+
HEPARIN DEPENDENT ANTIBODIES POSITIVE
COMMENT: POSITIVE FOR HEPARIN PF 4 ANTIBODY BY [**Doctor First Name **]
CXR #1: bullous emphysema with superimposed resolving pneumonia
CXR #2: acute worsening of RLL and LLL infiltrates
CXR #3: post intubation, ET tube in place, R IJ cath tip in the
SVC
Hip XR: Right subtrochanteric fracture
Micro:
buttock:
GRAM STAIN (Final [**2181-12-30**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2181-12-31**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
YEAST. MODERATE GROWTH.
URINE CULTURE (Final [**2182-1-1**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 2 S
MEROPENEM------------- 0.5 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
blood cultures showed no growth
Brief Hospital Course:
A: 52 yo gentleman with h/o paraplegia [**2-19**] HTLV-1, multiple
sacral decubiti, COPD, and polysubstance abuse recently admitted
with pneumonia who p/w mental status changes likely socondary to
oversedation with methadone and acute hypoxic respiratory
distress likely secondary to aspiration event. During
hospitalization the following problems were addressed:
1. mental status changes: The patient responded well to narcan
and was found to have methadone and benzo's in his utox which
suggests a medication overdose. The [**Hospital1 33092**] staff was
suspicious that the patient was buying drugs on the street and
reported that there were no prescribed benzo's in their
medication list. Toxicology was consulted in the ED and
recommended not starting a narcan gtt as patient was on high
doses (30mg QID). He was intubated and sedated initially with
propofol, then versed and fentanyl. When sedation was lifted he
was treated with low dose methadone at 15mg [**Hospital1 **] and prn morphine
prior to dressing changes. It is recommended that he follow-up
with a pain specialist to develop a more appropriate dosing
regimen. As his mental status responded to narcan, and the
patient had had a thorough work-up just two weeks prior during
his prior hospitalization, it was not felt his presentation
warrented head CT or LP. B12 and folate levels were normal
during prior hospitalization earlier this month. Psychiatry
consulted to determine whether this overdose was intentional.
From their assessment, it was an accidental overdose, and may
have been secondary to a medication error. The complete tox
screen revealed Trileptal and Clozaril in his system, which were
confirmed by his nursing home to be ordered for another patient
on the same floor. Once his mental status improved to baseline,
methadone was titrated up to a dose that ensured adequate pain
control and put the patient at less risk for oversedation.
2. hypoxic respiratory failure: this was thought to be due to an
aspiration event that occurred in the ED. The patient became
acutely agitated when receiving narcan. He was treated
initially with levofloxacin and clindamycin for a possible
aspiration pneumonia. On day two, vancomycin was added to the
regimen to cover for possible MRSA pneumonia given his previous
hospitalization history. He was extubated on day #3, but
required supplemental oxygen by face mask and continued to
produce copious secretions/sputum. CXR showed bilateral
consolidation and pulmonary edema. The patient autodiuresed and
his respiratory function improved. On day 3 his urine showed
psueudomonas so his antibiotic regiment was changed to
Vancomycin and Meorpenam. His oxygen requirements weaned. The
Vancomycin discontinued after his MRSA screen was negative. He
completed a 10 day course of meropenem.
3. COPD: the patient has severe COPD as evidenced by the
significant bullous disease seen on CXR. He was treated for a
COPD flare during his last hospitalization earlier this month.
At this time he was continued on combivent MDI for secondary
prphylaxis and treatment.
4. Right subtrochanteric fracture-he complained of R hip pain
during the admission. A bilateral hip film was done and revealed
the above fracture. He underwent an ORIF repair, with
intramedullary nailing with cephalomedullary device, gamma nail
of right femur fracture. He is post op day # 8 on the day of
discharge. His course was complicated by 500cc intraop blood
loss, and postoperatively, by acute blood loss anemia and
hypotension. He was briefly on neosynephrine while in PACU. A
CT of the abdomen and pelvis was done to rule out a
retroperitoneal bleed. This CT revealed two tiny hematomas, in
right gluteus medius 3x2 cm and Ant Prox R thigh 3.4x 2.8cm.
These were felt to not be large enough to account for his HCT
drop. He was guaiac negative and the bleeding was likely
postoperative bleeding into his thigh. He received 4 units of
blood and his hematocrit subsequently stabilized. He will need
to follow up with orthopedics in the week after discharge. His
pain in his right leg is well controlled on his current regimen
of methadone, morphine elixir during dressing changes, RTC
tylenol, and neurontin.
5. CHF-He developed worsening shortness of breath two days after
receiving 4 units of blood for his acute blood loss anemia. A
chest xray done at that time revealed bilateral new pleural
effusions, worsening opacities and stable large bullae. This
was thought to be consistent with CHF. He was diuresed
successfully with Lasix and his shortness of breath resolved.
He was able to breath at 97% on Room air, although his
respiratory efforts are diminished and he still therefore
appears to have an oxygen requirement.
6. polysubstance abuse: psychiatry was consulted, and methadone
resumed at a low dose. The patient would also benefit from a
social work addictions consult given his two recent admissions
and continued risk for overdose and aspiration. It is still
unclear whether this overdose was intentional or not.
7. Paraplegia: due to remote HTLV infection. He was continued
on his bowel regimen and baclofen for muscle spasm.
8. Pain control: methadone resumed at lower dose. Patient was
also given prn morphine during dressing changes. Tyelenol and
Neurontin were also added to his regimen. He would likely
benefit from a pain management consult.
9. Decubitus ulcers: wet to dry dressing changes were
continued. The patient is supposed to follow up with Dr. [**First Name (STitle) **] in
plastic surgery for a possible skin graft to those areas. Gram
stain of the ulcers showed 1+PMN, 1+GPC, 1+GNR.
10. UTI: Urine culture was positive for pseudomonas. His
suprapubic catheter was changed and he completed a ten day
course of meropenem.
11. Heparin induced thrombocytopenia-He has HIT which was
discovered during this admission. He was put on argatroban
during his perioperative period. Currently he is on
fondaparinux for prophylaxis as he is at significant.
Medications on Admission:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs IH Q4-6H
PRN
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H as
needed.
5. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID
6. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q3H as needed.
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet [**Hospital1 **]
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
9. Methadone HCl 10 mg Tablet Sig: Three (3) Tablet PO QID
10. Methylphenidate HCl 5 mg Tablet Sig: One (1) Tablet PO BID
11. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia.
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
13. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO QHS
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY
15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID
16. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*2 MDI units* Refills:*0*
2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
Disp:*240 Tablet(s)* Refills:*0*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
Disp:*2 MDI units* Refills:*0*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Trazodone HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*20 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever or pain.
11. Fondaparinux Sodium 2.5 mg/0.5 mL Syringe Sig: One (1)
Syringe Subcutaneous DAILY (Daily) for 20 days.
Disp:*20 Syringe* Refills:*0*
12. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QD ().
Disp:*30 Capsule(s)* Refills:*0*
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
15. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for breakthrough pain.
Disp:*100 Tablet(s)* Refills:*0*
16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours) as needed for constipation.
17. Methadone HCl 10 mg Tablet Sig: Four (4) Tablet PO TID (3
times a day).
Disp:*360 Tablet(s)* Refills:*0*
18. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
19. Sodium Chloride 0.9% Flush 10 ml IV Q SHIFT
flush TLC w/ 10 cc normal saline Q shift; NO HEPARIN (pt has
HIT)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 33092**] - [**Location 1268**]
Discharge Diagnosis:
Primary:
1. Methadone Overdose.
2. Aspiration Pneumonia.
3. Pseudomonas Urinary Tract Infection.
4. Heparin Induced Thrombocytopenia - Positive Antibody.
5. Stage III/IV Sacral Decubitus Ulcer.
6. Right subtrochanteric comminuted femur fracture.
7. Right Thigh Hematoma.
8. Blood Loss Anemia.
9. Congestive Heart Failure.
10. Possible medication error: pt found to have trileptal and
clozaril in his urine
Seconary:
1. Paraplegia secondary to HTLV-1.
2. Anemia of Chronic Disease.
3. Substance abuse - opiate dependence.
4. Chronic Pain Syndrome.
Discharge Condition:
1. Stable.2. 95% on room air, with deep inspiration.
Discharge Instructions:
Please keep your follow up appointments, currently scheduled for
[**1-28**] (see below.)
Followup Instructions:
1. Patient will need to complete a 30 day course of Fondaparinux
for both Heparin Induced Thrombocytopenia and Hip Fracture.
2. Patient is now HEPARIN ALLERGIC and should never recieve
heparin in any form, included subcutaneous and flushes.
3. Follow-up with Dr. [**Last Name (STitle) 1005**] from Orthopedics for
post-operative follow-up.
4. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
[**Apartment Address(1) 98572**]
[**Location (un) **], [**Numeric Identifier 98573**]
([**Telephone/Fax (1) 30799**]
Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 5499**]
Date/Time:[**2182-1-29**] 8:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2182-1-29**] 9:00
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"51881",
"5070",
"496",
"5990",
"4280",
"2851",
"2859"
] |
Admission Date: [**2144-3-3**] Discharge Date: [**2144-3-6**]
Date of Birth: [**2088-7-27**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Intoxication
Major Surgical or Invasive Procedure:
Inubation/extubation
History of Present Illness:
(from ED signout and records).
50 y.o. woman w/ pmh of suicide attempts, reportedly told her
husband she was going to kill herself. She then proceeded to
take a bottle of benadryl and sertraline, along with alcohol.
Her husband reportedly called EMS, who found the patient
delirious and combative. She was also vomiting.
.
On presentation to the ED her vitals were 96.4, 126 155/106, 22
88%RA. On physical exam, no signs of trauma were apparent, and
her pupils were 2mm and reactive. She had pink pills crushed on
her face, and EMS reported pills throughout her room. She was
intubated in the ED for hypoxia and airway protection, started
initially on propofol, however she remained agitated and was
switched to fentanyl and versed. Toxicology was consulted. Her
ekg's showed QTc of 450. CXR showed possible infiltrate, and she
was started on levofloxacin and flagyl for aspiraiton pneumonia.
She was also bolused 2L of NS. Vitals prior to transfer were
133/86, 88 100% FiO2 100%
Past Medical History:
alcoholism
attempted suicide
section 12 in past
threatened violence towards husband.
Social History:
alcoholic
no tobacco
no other drugs.
Family History:
noncontributory
Physical Exam:
Vitals: HR 113, BP 119/65, O2 99on 2L NC
GEN: NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA. MMM.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: soft rhonchi bilaterally. good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/
SKIN: No rashes/lesions, ecchymoses.
NEURO: not responding to voice or sternal rub.
Pertinent Results:
Labs on admission:
[**2144-3-3**] 10:45AM BLOOD WBC-5.2# RBC-4.63 Hgb-14.1# Hct-40.9
MCV-88 MCH-30.5 MCHC-34.5 RDW-13.4 Plt Ct-359#
[**2144-3-3**] 10:11AM BLOOD PT-21.6* PTT-48.5* INR(PT)-2.1*
[**2144-3-3**] 10:45AM BLOOD Glucose-110* UreaN-13 Creat-0.6 Na-142
K-3.6 Cl-107 HCO3-20* AnGap-19
[**2144-3-3**] 03:01PM BLOOD ALT-17 AST-25 LD(LDH)-292* CK(CPK)-87
AlkPhos-59 TotBili-0.2
[**2144-3-3**] 10:11AM BLOOD Lipase-56
[**2144-3-3**] 10:45AM BLOOD cTropnT-<0.01
[**2144-3-3**] 10:45AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.8
[**2144-3-3**] 03:01PM BLOOD Osmolal-318*
[**2144-3-4**] 04:00AM BLOOD TSH-0.89
[**2144-3-3**] 10:45AM BLOOD ASA-NEG Ethanol-214* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2144-3-3**] 04:27PM BLOOD Type-ART PEEP-5 FiO2-50 pO2-113* pCO2-48*
pH-7.28* calTCO2-24 Base XS--4 Intubat-INTUBATED
[**2144-3-3**] 10:29AM BLOOD Glucose-46* Lactate-1.2 Na-146 K-1.2*
Cl-133* calHCO3-10*
.
Labs on discharge:
[**2144-3-6**] 06:56AM BLOOD WBC-4.5 RBC-3.80* Hgb-11.3* Hct-33.4*
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.4 Plt Ct-253
[**2144-3-6**] 06:56AM BLOOD Glucose-104 UreaN-7 Creat-0.5 Na-138
K-3.6 Cl-104 HCO3-26 AnGap-12
[**2144-3-6**] 06:56AM BLOOD Calcium-8.8 Phos-2.2* Mg-1.8
.
[**2144-3-3**] MRSA screen - pending
[**2144-3-3**], [**2144-3-4**] blood culture - no growth to date
[**2144-3-3**] urine culture - negative
[**2144-3-3**] Sputum culture - contaminate with oropharyngeal flora
.
Imaging:
[**2144-3-3**] CXR:
IMPRESSION:
1. Right main stem bronchus intubation with distal tip of the ET
tube
approximately 4 cm from the inferior border of the clavicles.
2. Increased density at the left lung base may be related to
right main stem bronchus intubation associated poor aeration of
the left lung and atelectatic changes. However, consolidation
cannot be excluded. Recommend repeat chest radiograph to assess
ETT repositioning and left lung base.
Brief Hospital Course:
Patient is a 50 year old woman with past history of suicide
attempts, presenting with delirium and agitation after ingestion
of EtOH, benadryl, and sertraline, admitted to ICU after being
intubated for hypoxia and airway protection.
.
1.) Toxic Ingestion/suicide attempt: As above, the patient
presented with toxic ingestion of EtOH, benadryl, and
sertraline. Given concern for QTC or QRS prolongation with
anticholinergic toxicity, and concern for serotonin syndrome
with sertraline ingestion, patient was closely monitered in the
intensive care unit on monitering, with twice daily EKGs. She
remained stable with resolution of the medication effects, and
was extubated without complication and transferred the regular
medical floor.
Due to her psychiatric presentation with suicide attempt,
psychiatry was involved throughout her hospital course and she
was discharged with section 12 to an inpatient pyschiatric
facility.
.
2.) Aspiration pneumonia/hypoxic respiratory failure: Patient
had vomited on admission with subsequent hypoxia and inability
to protect airway due to above. She was intubated in this
setting, and treated with levofloxacin, discharged to complete a
7 day course. She was successfully extubated and oxygen was
weaned off by time of transfer to psychiatry. Of note, she was
having intermittent hemoptysis with stable hematocrit, felt
likely to be due to airway irritation from her recent
intubation/extubation.
.
3.) Alcohol use/abuse: The patient was monitered for signs of
withdrawl by the CIWA scale throughout her hospital course, but
did not experience withdrawl. She was maintained on thiamine,
folate, and multivitamin. These can likely be discontinued on
discharge if patient maintains good nutrition.
.
Her other medical issues remained stable throughout her hospital
course.
Medications on Admission:
sertraline
claspral
estrogen patch
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for fever or pain.
9. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Suicide attempt with toxic ingestion
Aspiration pneumonia
Secondary:
Alcohol abuse
Depression
Discharge Condition:
Stable. Oxygenating well, in no acute distress.
Discharge Instructions:
You were admitted to the hospital after toxic ingestion. You
were initially in the intensive care unit. You were followed by
psychiatry and transferred to inpatient psychiatry upon
resolution of your medical issues.
Please take medications as directed.
Please follow up with appointments as directed.
Please contact physician if develop shortness of breath,
fevers/chills, any other questions or concerns
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 15957**] within 1-2 weeks from discharge from the
inpatient psychiatric facility.
Please follow up with psychiatry as directed.
|
[
"5070",
"51881"
] |
Admission Date: [**2133-6-30**] Discharge Date: [**2133-7-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
shaking chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 year old man with coronary artery disease s/p CABG [**2120**],
congestive heart failure with [**Hospital1 **]-ventricular systolic
dysfunction (ef 35%), atrial fibrillation, BPH s/p TURP,
requiring 3x daily intermittent catheterization on chronic
keflex with multiple UTI's who presents with one day of acute
onset shaking chill.
.
Patient reports tripping over step while carrying groceries
about a week ago, fell and hit bridge of his nose and right
ribs. Went to [**Hospital **] hospital, negative CT and no rib
fractures, has had some continued nose bleeding since that time,
now minimal. (Coumadin held for past few days.)
.
Then today, reports developing shaking chills while lying next
to his wife. Says otherwise, only mild intermittent non
productive cough with eating (peanuts). Says has been
catheterizing himself about three times a day, no change
recently and has not noted change in color or odor of urine.
Also developed possible small volume hemoptysis x 1 today, says
small amount in mucous today. No other specific complaints,
generally feeling malaise since recent fall.
.
Denies chest pain, orthopnea, pnd, doe. At baseline, goes
golfing, help with care as his wife is demented and requires 24
hour assistance but he can perform all his ADL's.
.
No hematochezia, melena, other bleeding besides nose.
.
In the ED low grade fever to 99.4, hypotensive to sbp's in the
80's and initially 88% on room air. To 95% on 3 liters and bp
improved to 100's with 3 liters NS. Initially tachy to 110's in
er, now in 70's. WBC was 21 with 93% neutrophils, he received
ceftriaxone 1g IV, azithromycin 500mg IV, aspirin 325mg po, and
acetominophen 1g po.
Past Medical History:
1. Coronary artery disease status post CABG in [**2120**], no cath
since then.
2. Atrial fibrillation on coumadin.
3. Biventricular heart failure with an EF of 35%.
4. Mild AS, MR [**First Name (Titles) **] [**Last Name (Titles) **]
5. Benign Prostatic hypertrophy status post TURP x 2, now 3x
daily catheterizations and keflex chronic suppression.
6. Anemia for which he receives darbepoetin every 2 weeks.
7. Macular degeneration in left eye.
8. Multiple UTIs last culture [**2132-6-26**] showed E.coli and
corynebacterium (diphtheroid) resistant to
cipro/levo/bactrim/amp, but sensitive to ceftriaxone; UTI in
[**2130**] grew bactrim, ticarcillin and fq resistant bacteria; UTI in
[**2129**] grew pan sensitive enterobacter cloacae
9. Parkinson's disease
Social History:
Former smoker - quit 40 years ago. He drank EtOH regularly until
25 years ago, and now only drinks rarely. Lives at home with
wife. Wife with dementia-has 24 hour caretaker. Active, walks
independently and independent of ADLs plays golf. Family very
involved with his care. HCP = [**Name (NI) 17**] [**Name (NI) 1182**] cell [**Telephone/Fax (1) 97770**],
and daughter [**Name (NI) **] [**Telephone/Fax (1) 97771**] is second HCP. [**Name (NI) **] used to be in
the navy, then worked in a creamery, and then owned two
restaurants and was in catering before he retired.
Family History:
Non-contributory
Physical Exam:
VS - Temp 99.4, BP 92/40, HR 75, RR 16, O2Sat 93% rm airL
I/O: 3liters/500cc
GENERAL: Elderly male laying in bed, NAD, pleasant
HEENT: right pupil round and reactive to light; surgical left
pupil; EOMI, no scleral icterus; OP clear; moist mucous dry, dry
blood over bridge of nose, no active nasal/oral bleeding, no JVD
NECK: supple, no LAD, JVD - 8cm
LUNGS: crackles [**2-10**] way up bilaterally
CARD: irregular rhythm; III/VI systolic murmur--previously noted
ABD: +b/s, soft, NT/ND,
EXT: no edema; weak dorsalis pedis pulses
SKIN: multiple ecchymoses
NEURO: alert, oriented x 3; CN III-XII intact; mild left facial
droop, which the patient says he's had for a long time; speaks
slowly, but attentive; jokes and tells stories
Pertinent Results:
[**2133-6-30**] 08:20AM WBC-21.2*# RBC-3.30* HGB-11.9* HCT-35.1*
MCV-106* MCH-36.0* MCHC-33.9 RDW-22.1*
[**2133-6-30**] 08:20AM NEUTS-93.1* BANDS-0 LYMPHS-3.0* MONOS-2.7
EOS-0.7 BASOS-0.5
[**2133-6-30**] 08:20AM PLT COUNT-243
.
[**2133-6-30**] 01:36PM VIT B12-1338* FOLATE-GREATER THAN 20
.
[**2133-6-30**] 08:20AM PT-16.3* PTT-21.8* INR(PT)-1.5*
.
[**2133-6-30**] 08:00AM GLUCOSE-167* UREA N-22* CREAT-1.1 SODIUM-138
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
ALT 11, AST 28, ALK PHOS 57, T BILI 1.5, LDH 194, ALB 3.3
.
CORTISOL 29.5
.
[**2133-6-30**] 08:10AM LACTATE-1.9
.
[**2133-6-30**] 01:36PM DIGOXIN-0.7*
.
[**2133-6-30**] 08:20AM CK-MB-NotDone
[**2133-6-30**] 08:20AM cTropnT-0.03*
[**2133-6-30**] 01:36PM CK-MB-7 cTropnT-0.16*
[**2133-6-30**] 08:28PM CK-MB-7 cTropnT-0.13*
.
SPEP: WNL
UPEP: ONLY ALBUMIN
.
[**2133-6-30**] 09:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2133-6-30**] 09:00AM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-5.0
LEUK-NEG
[**2133-6-30**] 09:00AM URINE RBC-[**4-13**]* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-[**4-13**]
.
BLOOD CX: NO GROWTH
.
[**2133-6-30**] 9:00 am URINE Site: CATHETER
**FINAL REPORT [**2133-7-2**]**
URINE CULTURE (Final [**2133-7-2**]):
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
URINE CX [**2133-7-1**]: NO GROWTH
.
[**2133-6-30**] 8:56 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2133-7-3**]**
GRAM STAIN (Final [**2133-7-1**]):
[**12-3**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2133-7-3**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). RARE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
.
EKG:
Atrial fibrillation with rapid ventricular response
Leftward axis
Left bundle branch block
Since previous tracing of [**2132-10-1**], intraventricular conduction
delay is new
.
CHEST (PORTABLE AP) [**2133-6-30**] 7:38 AM
FINDINGS: Compared with [**2132-10-2**], the moderate left ventricular
cardiomegaly appears essentially unchanged. Status post CABG.
There is engorgement of the pulmonary vessels suggesting an
element of CHF.
Additionally, there is more confluent airspace opacity overlying
the right mid lung field, consistent with pneumonia.
.
ECHO [**2133-7-1**]:
The left atrium is markedly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is
11-15mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. There is mild to
moderate global left ventricular hypokinesis. Right ventricular
chamber size and free wall motion are normal. The aortic root
is mildly dilated at the sinus level. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2130-2-15**], the
ascending aorta is larger. Otherwise, the findings are similar.
.
CT HEAD W/O CONTRAST [**2133-7-3**] 9:07 AM
FINDINGS: The study is somewhat limited by motion artifact.
However, there is no evidence of hemorrhage. There is no mass
effect. The ventricles and sulci are mildly prominent. There is
a focal lacune in the right caudate head. These findings have
not changed since the prior study. The right maxillary sinus
appears small and there may be a surgical defect in its medial
wall. There is partial opacification of the ethmoid air cells
and mucosal thickening in the maxillary air cells bilaterally
and in the sphenoid sinus. There are no fluid levels within the
sinuses.
Incidentally noted are hypodensities in the cerebellar
hemispheres bilaterally that presumably represent lacunar
infarctions.
CONCLUSION: No evidence of hemorrhage or other acute
abnormality. Old lacunes in the right caudate head and in the
cerebellar hemispheres bilaterally. These findings are unchanged
since [**2132-6-24**].
.
VIDEO OROPHARYNGEAL SWALLOW [**2133-7-3**] 9:03 AM
FINDINGS: The oral phase demonstrated difficulty bolus
formation. Transition from oral to laryngeal phase was mildly
delayed. No epiglottic deflection was identified. Penetration
aspiration were noted with thin liquid and nectar. Chin tuck
improved aspiration with thin liquids with no effect on
aspiration with nectar. Moderate retention within the valleculae
was noted throughout the exam. Cough reflex was initiated
induced by aspiration.
IMPRESSION: Relatively unchanged aspiration with thin liquid and
nectar that is partially responsive to chin-tuck. Please refer
to the speech pathologist note in CCC for further details.
Brief Hospital Course:
# Urosepsis: Patient was initially admitted to the ICU for care
and started on meropenem and azithromycin -> imipenem/vancomycin
for broad antibiotic coverage. Blood pressure stabilized with
IVF boluses. [**Last Name (un) **] stim was appropriate. Following
hemodynamically stability and the results of his urine culture,
antibiotics were scaled back to levofloxacin (for the UTI) with
the addition of flagyl (given concern for concurrent aspiration
pneumonia). Blood cultures were negative. Patient will
complete a total of 10 days of antibiotics. Case discussed with
Dr. [**Last Name (STitle) 770**] who was comfortable with discontinuation of
indwelling foley placed on admission and resumption of patient's
regimen of regular straight catheterization. Emphasis with
compliance with his tid regimen was made prior to discharge
given his recent urinary tract infection.
.
# Troponin leak with new LBBB: Patient's cardiologist followed
along while the patient was in the unit. CKMB remained flat and
ECHO was essentially unchanged. The patient was thought to most
likely have had demand ischemia in the setting of his
hypotension. He was continued on his ASA and ACEI. No beta
blocker, reportedly due to severe bradycardia. LDL 52 off any
statin.
.
# Atrial fibrillation: Coumadin was initially held on admission
but restarted prior to discharge. He is on digoxin for rate
control and had no rate issues.
.
# Aspiration pneumonia: Patient has a history of aspiration
pneumonia. He has been permitted thin liquids in the past but
video eval concerning and given recurrent episodes, speech
recommends nectar thick liquids with soft solids to be continued
at home as well. Patient is completing a 10 day course of
levo/flagyl for his current aspiration pneumonia. He is stable
on room air at the time of discharge, including with ambulation.
.
# S/p fall: Patient had a mechanical fall 1 week prior to
admission. He complained of right rib pain but CXR without
overt fracture. No evidence of hematoma/overlying bruising. He
did undergo a CT while in house given complaints of a mild
headache. This showed no evidence of intracranial bleeding.
.
# Orthostatic hypotension: Noted on PT evaluation. SPEP, UPEP,
folate, B12, and lytes all normal. Patient given a fluid bolus
to improve his volume status and will follow-up with his primary
for continued monitoring. Likely the digoxin is contributing to
a blunted heart rate response. Patient warned to be slow and
deliberate with positional changes to minimize his risk of
falling.
.
# [**Hospital1 **]-ventricular heart failure (EF 35%): Patient was restarted
on his home lasix and ACEI prior to discharge.
.
# Parkinson's: Stable on carbidopa//levodopa
.
# FEN: nectar thick liquids and soft solids with aspiration
precautions, ensure pudding tid given low albumin
.
# Code: Full
.
# Communication: HCP = [**Name (NI) 17**] [**Name (NI) 1182**] cell [**Telephone/Fax (1) 97770**], and
daughter [**Name (NI) **] [**Telephone/Fax (1) 97771**] is second HCP.
.
# Dispo: patient was discharged home with services for vitals
check, home PT, and medication assistance
Medications on Admission:
1. Lisinopril 5 mg daily
2. Omeprazole 20 mg daily.
3. Aspirin 81 mg daily.
4. Digoxin 125 mcg daily
5. Carbidopa/levodopa 25/100 tid
6. Colace 100 [**Hospital1 **]
7. Lasix 20 mg daily
8. Warfarin--being held
9. MVI
10. keflex 500mg daily
Discharge Medications:
1. Coumadin 5 mg Tablet Sig: 1-2 Tablets PO once a day: please
resume your regular coumadin regimen.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY DAY
EXCEPT FRIDAY ().
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
primary:
urosepsis
aspiration pneumonia
s/p mechanical fall
orthostatic hypotension
secondary:
atrial fibrillation
CAD s/p CABG
biventricular heart failure
Parkinson's disease
Discharge Condition:
good: ambulating with PT, stable on room air, blood pressure
normal
Discharge Instructions:
Please call your doctor or go to the emergency room if you
experience temperature > 101, chills, chest pain, worsening
cough, or other concerning symptoms.
Because you have a diagnosis of heart failure, you should:
# Weigh yourself every morning, call your doctor if your weight
increases by 3 lbs or more
# Limit yourself to 2 gm of sodium per day
# Adhere to a 1.5 liter Fluid Restriction per day
Because right now, there is evidence that you are aspirating
thin liquids, you MUST thicken all of your liquids until you
have a repeat swallow test that shows you are no longer
aspirating.
To maintain your nutrition, please take 3 ensure puddings per
day.
Given your current urinary tract infection, you MUST straight
cath at least 3 times per day.
Be sure to follow-up with Dr. [**Last Name (STitle) 1270**] to discuss:
# the results of tests sent to work-up the decrease in your
blood pressure when you stand and to discuss if further testing
is needed
# to schedule a follow-up swallow study in 1 month
# to continue adjustment of your coumadin, as needed
Please follow the speech/swallow recommendations to decrease
your risk of aspirating:
1. you must add thickener to all liquids to create nectar
thickened consistency
2. any solid food you eat should be of a soft consistency
3. always do a chin tuck, as you were instructed, when you
swallow to decrease your risk of aspirating
4. Crush all your pills and put them in puree.
Followup Instructions:
Dr.[**Name (NI) 15895**] office will contact you with an appointment to
see him within 2 weeks. Please call tomorrow to confirm the
time/date of your appointment. Phone: [**Telephone/Fax (1) 5027**]
Please call to schedule follow-up with Dr. [**Last Name (STitle) 770**] within 2
weeks. Phone: [**Telephone/Fax (1) 5727**]
|
[
"0389",
"5070",
"5990",
"4280",
"42731",
"V4581"
] |
Admission Date: [**2114-6-16**] Discharge Date: [**2114-6-25**]
Date of Birth: [**2047-10-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Pollen Extracts
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
MVR (tissue), Maze, LAA ligation
History of Present Illness:
known MR, AFib, increasing symptoms of SOB
Past Medical History:
[**First Name3 (LF) **]
[**First Name3 (LF) **]
varicose veins
deviated septum
hemmorhoidectomy
hernia repair
Social History:
married, lives w/wife
Family History:
non-contributory
Physical Exam:
unremarkable upon admission
Pertinent Results:
[**2114-6-25**] 07:40AM BLOOD WBC-12.4* RBC-4.01* Hgb-11.9* Hct-34.6*
MCV-86 MCH-29.7 MCHC-34.5 RDW-14.0 Plt Ct-420
[**2114-6-25**] 07:40AM BLOOD PT-15.2* PTT-27.4 INR(PT)-1.4*
[**2114-6-24**] 05:45AM BLOOD PT-14.7* INR(PT)-1.3*
[**2114-6-25**] 07:40AM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-134
K-4.6 Cl-99 HCO3-28 AnGap-12
PATIENT/TEST INFORMATION:
Indication: Mitral valve disease. Shortness of breath.
Status: Inpatient
Date/Time: [**2114-6-18**] at 09:10
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Four Chamber Length: *7.2 cm (nl <= 5.2 cm)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aorta - Arch: *3.4 cm (nl <= 3.0 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: Marked LA enlargement. Mild spontaneous echo
contrast in the LAA.
No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is
seen in the RA and extending into the RV. No thrombus in the
RAA. No ASD by 2D
or color Doppler.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Normal LV wall
thickness. Normal LV cavity size. Low normal LVEF. [Intrinsic LV
systolic
function likely depressed given the severity of valvular
regurgitation.]
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Mildly dilated aortic sinus. Normal ascending aorta
diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. Trace AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Myxomatous
mitral valve leaflets. Partial mitral leaflet flail. No mass or
vegetation on
mitral valve. Mild mitral annular calcification. Moderate
thickening of mitral
valve chordae. No MS. Eccentric MR jet. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient received antibiotic prophylaxis. The
TEE probe was
passed with assistance from the anesthesioology staff using a
laryngoscope.
The patient was under general anesthesia throughout the
procedure.
Conclusions:
PRE-CPB: 1. The left atrium is markedly dilated. Mild
spontaneous echo
contrast is present in the left atrial appendage. No thrombus is
seen in the
left atrial appendage.
2. No thrombus is seen in the right atrial appendage No atrial
septal defect
is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses and cavity size are normal.
Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF
50-55%). [Intrinsic left ventricular systolic function is likely
more
depressed given the severity of valvular regurgitation.]
4. Right ventricular systolic function is borderline normal.
5. The aortic root is mildly dilated at the sinus level. There
are simple
atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is
seen.
7. The mitral valve leaflets are severely thickened/deformed.
The mitral valve
leaflets are myxomatous. There is partial mitral leaflet flail.
There is
severe prolapse of the anterior leaflet and prolapse of the
posterior
leaflet.No mass or vegetation is seen on the mitral valve. There
is moderate
thickening of the mitral valve chordae. An eccentric jet of
Severe (4+) mitral
regurgitation is seen. The mitral regurgitant jet is die\rected
posteriorly.
POST-CPB: On infusions of epinephrine, milrinone and
phenylephrine.
Well-seated bioprosthetic valve in the mitral position. Trivial
MR with small
perivalvular jet consistent with suture hole, not seen after
protamine
administration. LV systolic function is preserved on inotropic
support. LVEF
is 55%. RV Systolic function was depressed prior to milrinone
administration.
Trace AI. Aortic contour is normal post decannulation.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2114-6-18**] 10:40.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mr. [**Known lastname **] was transferred from MWMC s/p catheterization on
[**2114-6-16**], for mitral valve replacement. He was taken to the OR on
[**2114-6-18**] for MVR (porcine), Maze, and LAA ligation. Please see
operative report for complete details of procedure.
Post-operatively, he was taken to the CSRU in stable condition.
He was weaned off mechanical ventilation and extubated on the
day of surgery. He was started on Amiodarone and Lopressor (for
the maze procedure), but was soon noted to have AV dissociation
with a rapid junctional escape rhythm. The EPS service was
consulted, Amiodarone and lopressor were stopped, and he
returned to NSR. He has since been back on and again off
Lopressor due to continued episodes of this same AV
dissociation. He is being anticoagulated for the rhythm issues
(pre-op AFib, post-op heart block, s/p maze). He has remained
hemodynamically stable throughout, and is ready to be discharged
home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitior. His coumadin will again be
followed by Dr.[**Name (NI) 42421**] office.
Medications on Admission:
Diovan 80', ASA 162', Magox, Coumadin
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
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:*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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
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. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day for
2 days: then INR to be drawn and called to Dr. [**Last Name (STitle) 656**];s office
for continued dosing ([**Telephone/Fax (1) 73217**].
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
MR
[**First Name (Titles) **]
[**Last Name (Titles) **]
AFib
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no driving for 1 month
no lifting > 10# for 10 weeks
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (STitle) 656**] in [**2-3**] weeks
with Dr. [**Last Name (Prefixes) **] in [**4-5**]- weeks
Completed by:[**2114-6-25**]
|
[
"4240",
"42731",
"4280",
"32723",
"4019",
"V5861"
] |
Admission Date: [**2199-10-24**] Discharge Date: [**2199-10-29**]
Date of Birth: [**2116-1-12**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
Pelvic mass
Major Surgical or Invasive Procedure:
Exploratory laparotomy, supracervical hysterectomy, bilateral
salpingo-oophorectomy, pelvic and para-aortic lymph node
dissection, omentectomy, appendectomy, repair of cystotomy.
History of Present Illness:
Ms. [**Known lastname 29257**] is an 83-year-old woman who initially presented to
the emergency room at [**Hospital1 18**] [**Location (un) 620**] with one day of abdominal
pain, nausea, and vomiting. She was found to have pre-renal
acute renal failure and was admitted to the medical service for
hydration. During this admission, a pelvic mass was found. A
pelvic ultrasound and an abdominal CT revealed massive ascites
and a 12-cm pelvic mass. A pelvic MRI revealed a heterogeneous
pelvic mass suspicious for a neoplasm, thought to be arising
from the uterus, or less likely from the ovary or from the
rectum. There was a small-to-moderate amount of ascites with
proteinaceous debris in the procedure cul-de-sac. Her CEA level
was 212 and her CA-125 level was only elevated to 71.
Ms. [**Known lastname 29257**] was transferred to [**Hospital1 1170**] on [**2199-9-13**], and discharged from the hospital after
resoluation of her renal failure. She does have lower pelvic
discomfort, but has been tolerating a regular diet since then.
She has no gastrointestinal symptoms.
Past Medical History:
Past Medical History:
- Osteoporosis.
- DVT of the right leg in [**2190**], s/p Coumadin.
- Frequent UTIs
Past Surgical History: None.
OB/GYN History:
- Gravida 0
- Denies any history of pelvic infections or abnormal Pap
smears.
Social History:
30 pack year smoker. No ETOH or drugs. Widowed since [**2190**].
Lives alone in [**Location (un) 745**]. Retired factory worker.
Family History:
She denies any family history of breast, ovarian, or uterine
cancer.
Physical Exam:
She appears her stated age, in no apparent distress.
Lymphatics: Lymph node survey, negative cervical,
supraclavicular, axillary, or inguinal adenopathy.
Chest: Lungs clear bilaterally.
Heart: Regular rate and rhythm. I appreciate no murmurs.
Back: No spinal or CVA tenderness.
Abdomen: Slightly distended without a dominant palpable mass.
Extremities: There is no clubbing, cyanosis, or edema.
Pelvic: Normal external genitalia. The inner labia minora is
normal. The urethral meatus is normal. Speculum was placed.
The cervix is normal in appearance. There is no cervical motion
tenderness. Bimanual exam reveals a mobile uterus with mass
without any posterior cul-de-sac nodularity.
Rectal: Reveals no mass or lesion. There is good sphincter
tone.
Pertinent Results:
[**2199-10-23**] 08:30AM BLOOD WBC-7.3 RBC-3.55* Hgb-10.4* Hct-31.8*
MCV-90 MCH-29.4 MCHC-32.7 RDW-13.1 Plt Ct-252
[**2199-10-28**] 06:00AM BLOOD WBC-9.8 RBC-3.23* Hgb-9.9* Hct-29.1*
MCV-90 MCH-30.7 MCHC-34.0 RDW-13.9 Plt Ct-251
[**2199-10-23**] 08:30AM BLOOD UreaN-15 Creat-0.9 Na-139 K-4.4 Cl-103
HCO3-30 AnGap-10
[**2199-10-25**] 03:29AM BLOOD Glucose-134* UreaN-19 Creat-1.1 Na-140
K-5.7* Cl-108 HCO3-23 AnGap-15
[**2199-10-29**] 05:55AM BLOOD K-4.5
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2199-10-29**]):
REPORTED BY PHONE TO S. [**Doctor Last Name **], R.N. ON [**2199-10-29**] AT 0540.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2199-10-24**]
10:36 PM
FINDINGS: No previous images. The cardiac silhouette is at the
upper limits of normal in size and there is mild tortuosity of
the aorta. Specifically, no evidence of pulmonary edema, pleural
effusion, or acute pneumonia. There may be minimal bibasilar
atelectatic change.
.
Radiology Report RENAL U.S. Study Date of [**2199-10-25**] 10:04 AM
IMPRESSION:
1. No evidence of hydronephrosis to explain low urine output.
Decompressed
bladder with Foley catheter in place.
2. Small amount of free intraperitoneal fluid.
.
PORTABLE CHEST, [**2199-10-25**]
FINDINGS: The cardiac silhouette is mildly enlarged, but
pulmonary
vascularity is normal, and there is no evidence of pulmonary
edema. The aorta remains tortuous. Minor areas of atelectasis
are present, with linear opacities in the right infrahilar and
left retrocardiac region. Possible very small left pleural
effusion.
.
CT CHEST W/CONTRAST [**10-28**]:
IMPRESSIONS:
1. No evidence of mediastinal or hilar adenopathy. Previously
seen right hilar opacity likely corresponds to vascular
structures.
2. Subpleural 2-3 mm lung nodules. For patient at high risk for
intrathoracic malignancy, follow-up CT is recommended in 12
months to document stability. Otherwise, no follow up is
necessary.
3. Dependent atelectatic changes.
4. Moderate ascites. Anasarca
Brief Hospital Course:
Pt is an 83 yo female admitted s/p ex-lap, SCH-BSO, pelvic and
para-aortic LN dissection, omentectomy, appendectomy, repair of
cystotomy for 15 cm right adnexal mass, likely mucinous ovarian
ca on frozen. Intraoperative course was complicated only by
cystotomy which was primarily repaired. Please see operative
report for full details.
.
The patient's post operative course was complicated by the
following issues:
.
*) Hypotension:
- Initially low BPs immediately post op, improved with hydration
and was normotensive upon discharge.
.
*) Hyperkalemia:
- Post operatively had elevated K up to 5.7, which was not
treated and improved spontaneously. K was normal upon
discharge.
.
*) Cystotomy:
- A cystotomy was primarily repaired intra-op. Plan was made to
keep a foley catheter in until POD 10. Patient was discharged
home with foley and VNA care.
.
*) Low urine output:
- This was an isssue on POD 1 and 2. Thought to be due to third
spacing of fluid and intravascular hypovolemia. Improved with
fluid boluses.
.
*) Post op anemia:
- Patient's pre-op hct was 32. Due to EBL of 1000 cc, she
received 2U PRBC intra-operatively and 2U PRBC in the PACU. Her
hematocrit had a nadir of 28 and remained stable at 29.1 on day
of discharge.
.
*) Pulmonary nodules:
- A post-op CXR showed possible hilar LAD. This was further
evaluated with a chest CT which revealed no lymphadenopathy, but
did show 2-3 mm subpleural nodules. F/u chest CT in 12 months
was recommended.
.
*) C. Diff:
- Patient had one day of loose stools on POD#5, and her stool
tested positive for C. Diff. She was started on a 10 day course
of Flagyl 500mg PO TID. Her diarrhea was not severe. She had
no fever or dehydration or electrolyte abnormalities.
.
*) Disposition
- Pt was discharged POD #6 in stable condition. VNA was
arranged for foley care. She was asked to f/u in the office for
staple removal and foley catheter removal.
Medications on Admission:
Boniva
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Adnexal mass
Discharge Condition:
Good
Discharge Instructions:
No heavy lifting or strenuous activity for 6 weeks.
Take pain medications as needed.
No driving while taking the Percocet.
Call if you have any fevers or chills, increasing pain, nausea
or vomiting, increase in your diarrhea, redness or drainage from
your incision, or any other problems.
Followup Instructions:
Please call Dr.[**Name (NI) 2989**] office ([**Telephone/Fax (1) 26840**] to nake an
appointment early next week to have your staples and your foley
removed.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2199-11-28**]
10:15
Completed by:[**2199-10-31**]
|
[
"2851",
"2767"
] |
Admission Date: [**2200-2-14**] Discharge Date: [**2200-2-19**]
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
consulted for SDH found on head CT
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 male sent to [**Hospital1 18**] ER with mental status changes from the
nursing home. There is no report of a fall or any other trauma.
The patient is unable to provide a history at this time and his
health care proxies are unavailable. He had a head CT which
revealed a SDH and small SAH. Neurosurgery was consulted for
evaluation.
Past Medical History:
prostate cancer
Social History:
lives at nursing home with wife
Family History:
non-contributory
Physical Exam:
Upon admission:
T:98.6 BP:119/76 HR:117 RR:18 O2Sats:100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:Pupils surgical bilaterally. EOMs-intact
Ears: Patient is nearly deaf.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person.
Language: + dysarthria, speech is not fluent
Cranial Nerves:
I: Not tested
II: Pupils surgical bilaterally. Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-20**] in the uppers and [**4-20**] in the
lowers. He did not participate with all muscle groups in the
lowers. Did not participate with pronator drift testing.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Upon discharge:
Patient is oriented x 1 upon discharge. His pupils are surgical
bilaterally.
He is following commands. He appears to have some neglect on the
right side but does move the right side somewhat. His left side
is strong, purposeful. He has a foley catheter in place.
Pertinent Results:
CT head [**2200-2-17**]:
FINDINGS: The study is compared with the initial NECT of [**2-14**]
and the
interval unenhanced and enhanced MR examinations of [**2200-2-15**].
Over the three-day interval, there has been little change in the
overall appearance of the heterogeneous but predominantly
hyperattenuating lobulated process centered in the extra-axial
space of the left parietovertex. This appears to "mold" to the
contour of the subjacent convexity, where there is focal
low-attenuation in the immediate subcortical white matter,
corresponding to the FLAIR-signal abnormality in this region,
which may represent edema secondary to venous congestion,
gliosis, or both. The overall appearance is most suggestive of a
partially calcified en plaque meningioma, though there is no
specific evidence of "reactive change" in the suprajacent inner
table of the skull. There has been no other short-interval
change.
IMPRESSION: No short-interval change in the overall appearance,
with the
lobulated, predominantly hyperdense, process, in the extra-axial
space at the left parietovertex, given its stability and MR
[**Date Range **] more likely an en plaque meningioma, partially
calcified, accounting for the MR [**First Name (Titles) 16313**] [**Last Name (Titles) **].
Moreover, the findings on both this exam and the recent enhanced
MR study
raise the serious possibility of at least partial invasion of
the immediately subjacent superior sagittal sinus, without
definite thrombosis, and possible venous obstruction-related
edema in local white matter. If this will affect therapeutic
decision, dedicated MR [**First Name (Titles) **] [**Last Name (Titles) **] venography might be considered.
MRI Brain [**2200-2-15**]:
FINDINGS:
The study is significantly limited due to patient motion
artifacts. There is enhancement noted in the area of known
hemorrhage in the left parieto-
occipital region, compared to the pre-contrast sequences done on
the prior
study. However, the etiology of enhancement is not clear as
there is
significant amount of hemorrhage in this location, as seen on
the prior CT and MR studies. Mildly dilated ventricles are
visualized, not adequately assessed.
IMPRESSION:
1. Study significantly limited due to motion artifacts.
Enhancement noted in the left parieto-occipital region, partly
extending along the dura, the
etiology of which is uncertain, as this is in the region of the
known
hemorrhage. Repeat evaluation, after resolution of the
hemorrhage can be
considered, to evaluate for any underlying vascular or
space-occupying lesion. Close followup with CT scan can also be
considered as clinically indicated.
Brief Hospital Course:
The patient was admitted on [**2200-2-14**] to the neurosurgery service
after a mental status change at the nursing home. He was
admitted with a presumed SDH on the CT scan. However, the
patient had an MRI which revealed a mass resembling a
meningioma. There was no hemorrhage there. The patient was
transferred out of the ICU on [**2200-2-18**].
He was evaluated by PT and a speech/swallowing therapist. PT
felt that he was safe to be discharged back the his nursing home
on [**2200-2-19**]. On [**2-19**] he was also able to take in thin liquids and
pureed solids without difficulty.
He had his foley catheter removed on [**2-18**] but had urinary
retention. A Coud?????? catheter was placed that night and he was
discharged with it in place. Flomax was started as well and
bladder training was begun. He may be able to have it removed in
a day or so at the nursing home. The patient should follow up
with a urologist.
The patient was made DNR/DNI in the hospital by his health care
proxy as well as for the ambulance ride. Palliative care and
medical consults were obtained to assist in management of the
patient. His medications were optimized due to his mental status
changes. Additionally a family meeting with all 3 teams
occurred. It was felt that surgery would not benefit the patient
and that quality of life was important. We all agreed that being
at the nursing home with his wife would be the best for him at
this time. The nursing home staff may want to consider a "Do not
hospitalize" policy with this patient and his health care proxy.
Medications on Admission:
Lisinopril 10 mg PO DAILY
Atenolol 25 mg PO DAILY
Omeprazole 10 mg PO DAILY
Hydrochlorothiazide 12.5 mg PO DAILY
Vesicare 5 mg Oral daily
Ferrous Sulfate 325 mg PO DAILY
Meclizine 25 mg PO QID
Mirtazapine 7.5 mg PO HS
Cholestyramine 4 gm PO DAILY
Trazadone 25 mg PO HS
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Docusate Sodium 100 mg PO BID
Senna 1 TAB PO BID
Bisacodyl 10 mg PO/PR DAILY
Discharge Medications:
1. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
DAILY (Daily) for 3 days.
3. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Oxycodone 5 mg Tablet Sig: 0.5-1.0 Tablet PO Q4H (every 4
hours) as needed: pain.
*****The PO vitamin B12 should begin after the injections are
completed.
Discharge Disposition:
Extended Care
Facility:
Academy Manor of [**Location (un) 7658**] - [**Location (un) 7658**]
Discharge Diagnosis:
meningioma
Discharge Condition:
neurologically improved compared to admission
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
No follow up with Dr. [**First Name (STitle) **] needed. Call [**Telephone/Fax (1) 1669**] with
questions.
Your medications were adjusted while in the hospital. Please
take as directed in the following pages.
You had a foley catheter placed on [**2-18**] due to urinary retention.
Follow up with a urologist at the nursing home or at [**Hospital1 18**] -
Call
[**Telephone/Fax (1) 164**] for an appointment in the urology office on the
[**Hospital Ward Name 516**].
Completed by:[**2200-2-19**]
|
[
"2724",
"2859",
"53081"
] |
Admission Date: [**2170-10-24**] Discharge Date: [**2170-10-26**]
Date of Birth: [**2150-12-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 19 year-old male with no significant past medical
history who presented today with UGI bleed. Patient reported
that on monday he felt like he was getting a cold as he felt
fatigued and complained of sinus congestion. He took tylenol
sinus that day. He also noticed a dark stool on the mornings of
mon, tues and wed. He called his school clinic and went in for
an appointment and was found to be guaic pos on tuesday. He was
advised to go home on tuesday and came back to his parent's
house in Mass. He had a GI appt today and after the appointment
felt weak upon standing, syncopized and had large projectile
coffee ground emesis witnessed by his mother. [**Name (NI) **] was brought to
the ED. Prior to this event pt denies use of any nsaids. He
drinks etoh weekly and usually binges. Last drink was friday
where he drank approx 12 etoh beverages. No otc supplements,
steroids, etc. No previous episodes of melena or hematochezia.
No family history of GI bleeds. No recent travel. No fever or
chills. No recent weight loss.
.
In the ED, his initial vs were: T 98.2, P 96, BP 118/75, R 18 ,
O2 sat 100 RA. He was given 40 mg IV protonix. He went for egd
which showed multiple erosions and blood in the stomach but no
active bleeding. No intervention was done.
.
In the ICU, his initial vs were: P 71, BP 107/59, R 16, O2 sat
100% RA. Patient felt well. Only complained of feeling "gassy".
Denied dizziness, ha, chest pain, sob, palp, nausea, vomiting,
diarrhea, constipation, le edema, etc.
Past Medical History:
Acne
Social History:
Patient is a college student at [**Company 80401**] [**Location (un) **]. He does not
smoke tobacco, but occasionally smokes flavored tobacco and pot.
No other drug use. Binge drinks weekly but is not a daily
drinker. Studying computer science. Eats a normal diet. No
recent travel or sick contacts.
Family History:
no family history of GI bleeds
Physical Exam:
Vitals: T: afebrile BP: 107/59 HR: 71 RR: 16 O2Sat: 100% RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: NCAT, EOMI, PERRL, sclera anicteric, dried blood in right
nares, MMM, OP Clear without blood in OP
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
Pertinent Results:
[**2170-10-25**] 05:31AM BLOOD WBC-4.9 RBC-2.89* Hgb-9.4* Hct-24.9*
MCV-86 MCH-32.7* MCHC-37.9* RDW-13.3 Plt Ct-124*
[**2170-10-24**] 12:00PM BLOOD Neuts-48.0* Lymphs-46.9* Monos-4.3
Eos-0.8 Baso-0
[**2170-10-25**] 05:31AM BLOOD PT-14.4* PTT-33.9 INR(PT)-1.3*
[**2170-10-25**] 05:31AM BLOOD Glucose-79 UreaN-16 Creat-0.8 Na-138
K-4.2 Cl-108 HCO3-26 AnGap-8
[**2170-10-24**] 12:00PM BLOOD ALT-16 AST-18 AlkPhos-40 TotBili-0.3
[**2170-10-25**] 05:31AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.8
[**2170-10-25**] 05:31AM BLOOD GASTRIN-PND
[**2170-10-25**] 10:56AM BLOOD Hct-PND
EGD: [**2170-10-25**]
Multiple erosions in the stomach with stigmata of bleeding.
(biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Protonix 40 IV bid
[**Hospital **] transfer to monitor for futher bleeding overnight.
Serial Hct q 6-8 hours
Follow up H. Pylori biospies
Discontinue amoxicillin
Consider re-scope in AM if further bleeding.
Brief Hospital Course:
UGIB/BLOOD LOSS ANEMIA:
He was resuscitated with crystalloid and 2 units of PRBC's. EGD
showed erosions with stigmata of recent bleeding. Biopsies were
obtained, and cultures sent for H.pylori, and a gastrin level
was sent. Based on the EGD findings and subsequent history, it
is believed that this is related to alcohol binging in the
setting of amoxacillin induced gastric irritation. He is
scheduled to return for repeat endoscopy and review of lab
results.
Medications on Admission:
amoxicillin 250 mg tid
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI Bleed
Acute Blood Loss Anemia
Discharge Condition:
Good
Discharge Instructions:
If you develop nausea, vomiting of blood, blood in stool,
lightheadedness, return to the emergency room.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2170-12-11**] 9:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2170-12-11**] 9:00
- Please do not eat any food or water starting at midnight on
[**2170-12-10**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"2851"
] |
Admission Date: [**2165-5-7**] Discharge Date: [**2165-5-20**]
Date of Birth: [**2097-3-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
Somnolence and hyponatremia.
Major Surgical or Invasive Procedure:
PICC placement on [**5-12**].
T9-T12 spinal fusion and L1 Laminectomy
History of Present Illness:
Ms [**Known firstname 1743**] [**Initial (NamePattern1) **] [**Known lastname **] is a 68 year-old female with hypertension
on HCTZ, hyothyroidism, s/p left BKA with back pain who was
admitted for elective s/p T9-l2 fusion and L1 laminectomy on
[**5-7**] who was found to have altered mental status and sodium of
115. She was in her prior state of health with chronic back
pain, s/p Kyphoplasty L1 a year ago without any significant
improvement in her symptoms, so she was brought 5 days ago for
elective s/p T9-l2 fusion and L1 laminectomy on [**5-7**]. During her
postoperative course she has been either NPO of with very poor
PO. Her net fluid balance has been -5.5 L aproximately. She has
not received any IVF and has been having good UOP. Furthrmore,
she has had severe post-operative pain that required dilaudid
PCA, oxycodone, morphine SR and IV dilaudid. Her mental status
was noted by her sister to be altered, specially in the terms of
memory and not recognizing friends. Initially it was thought
that her symptoms were secondarily to narcotics, which were
progressively decreased without improvement in her symptoms.
Yesterday the primary team checked a sodium of 116 (on repeat
was 115) with osm 244, K 2.1, urine 21 and urine osm 457 and
urine specific gravity of 1.016. She was started on 1000 mL NS
Continuous at 150 ml/hr for 1000 ml. Medicine and nephrology
consults were called who recommended transfer for ICU for
administration of 3% saline. She has been on HCTZ for at least 3
years (per patient's report) and it has been continued in house.
.
Of note, she has developped new thrombocytopenia up to 56 with
baseline of 161. There is no record of any form of heparin
administration. Pt has been on CefazoLIN 1 g (3 doses), but no
vancomycin. She has been continued in her home-dose HCTZ as
well.
.
She was transfused 3 units of PRBC on [**5-7**] and 1 units of RBC on
[**5-8**]. She has not received any PLTs.
.
She has been very constipated as well.
Past Medical History:
1. Status post left BKA in [**2150**] due to osteomyelitis (performed
at [**Hospital1 2025**])
2. Hypertension
3. Hypothyroidism
4. Hyperlipidemia
5. Lung nodules
6. Osteoporosis
7. Hx of Squamous and basal cell carcinomas
8. Chronic low back pain secondary to L5-S1 disc bulge
9. Status post left thumb CMC arthroplasty as well as left MP
joint volar plate advancement.
10. s/p hysterectomy
11. s/p L5-S1 ant/post fusion laminectomy
12. s/p kyphoplasty
13. s/p right ORIF patella
Social History:
The patient worked as a nurse practitioner until [**2159**] when she
developed back pain. She is single and lives with her sister.
She has never been pregnant. She smokes half a pack of
cigarettes a day. She has tried to quit. Has smoked for "many"
years and was unable to quantify. She does not drink alcohol.
She exercises regularly with a personal trainer.
Family History:
Sister with osteoarthritis of the back and hips.
Physical Exam:
VITAL SIGNS - Temp F, BP 123/59 mmHg, HR 72 BPM, RR 11 X',
O2-sat 94% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
not jaundiced (skin, mouth, conjuntiva), complaining of back
pain and headache
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). Pt had a L AKA.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEUROLOGIC:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation. Non
papilledema on fundoscopic exam. Extraocular movements intact
bilaterally, no nystagmus. Sensation intact V1- V3. Facial
movement symmetric. Hearing decreased to finger rub bilaterally,
L=R.
Palate elevation symmetrical. Sternocleidomastoid and trapezius
normal bilaterally. Tongue midline, movements intact.
.
[**Last Name (un) **]-Hallpike:
Defered.
.
Cerebellum: Normal hands up & down; normal finger-nose. Did not
walk patient.
.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. No pronator drift.
D [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5
.
Sensation: Intact to light touch, throughout. No extinction to
DSS
.
Reflexes:
Trace and symmetric throughout.
Toes downgoing bilaterally.
Reflexes: B T Br Pa Pl
Right 3 3 3 3 3
Left 3 3 3 3 3
Pertinent Results:
LABORATORY RESULTS ON DISCHARGE:
[**2165-5-20**] 05:31AM BLOOD WBC-13.6* RBC-3.13* Hgb-9.4* Hct-28.2*
MCV-90 MCH-30.2 MCHC-33.5 RDW-13.6 Plt Ct-238
[**2165-5-20**] 05:31AM BLOOD PT-12.3 PTT-45.0* INR(PT)-1.0
[**2165-5-20**] 05:31AM BLOOD Glucose-102* UreaN-10 Creat-0.4 Na-129*
K-3.9 Cl-97 HCO3-26 AnGap-10
[**2165-5-20**] 05:31AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.9
.
IMAGING/STUDIES:
CXR [**2165-5-12**]: No focal masses are appreciated. There is no
evidence of consolidation or effusion. A skin fold is
prominently visualized over the lateral aspect of the right lung
field. [**Location (un) 931**] rods project over the thoracolumbar spine.
Cardiac silhouette and mediastinal contours are normal.
IMPRESSION: No acute cardiopulmonary disease and no lung masses
detected.
.
KUB [**2165-5-15**]: The patient is status post fixation of the lower
thoracic and lower lumbar spines. No acute fracture or
dislocation is detected.
Mildly dilated loops of small bowel are seen. The cecum is
moderately
dilated. Findings may be compatible with ileus in the setting of
recent
surgery. No free air is seen.
IMPRESSION: Moderately dilated cecum, with mildly dilated loops
of small
bowel, compatible with postoperative ileus.
Brief Hospital Course:
Ms [**Known firstname 1743**] [**Initial (NamePattern1) **] [**Known lastname **] is a 68 year-old female with hypertension
on HCTZ, hyothyroidism, s/p left BKA with back pain who was
admitted for elective s/p T9-l2 fusion and L1 laminectomy on
[**5-7**] who was found to have altered mental status and sodium of
115.
.
#. Hyponatremia - Pt was transfered to the ICU with altered
mental status per the family members that know her well and
nurses in the floor. Her sodium was found to be 115 with serum
osm of 244 and calculated osm of 240, urine osm of 457 and
sodium of 21. Her TTKG was 2.8. She looked euvolemic on physical
exam, but her I/O balance has been very negative secondarily to
poor PO, no IVF and high UOP. She had severe back after her back
surgery. Initially it was not clear how much it was dehydration,
poor PO intake only taking free water and HCTZ in the post-op
setting vs. SIADH, most likely secondarily to pain. Nephrology
was consulted who recommended 3% saline. Initially we tried free
water restriction and follow up Na, but pt did now improve
within 6-8 hours. PICC was placed and 3% NaCl was started. Her
sodium was 120 upon the next lab check, and 3% was stopped. Her
pain was controlled (see below). She was then placed on 1500cc
free water restriction with minimal improvement. Salt tablets,
2 gm three times daily were started on [**5-15**] and her Na improved
with this measure and fluid restriction. She should continue on
1500cc fluid restriction daily, and 2 gram salt tabs TID on
discharge. Please check electrolytes every other day to ensure
that sodium continues to normalize. On discharge, sodium was
129, and should continue to be monitored until it stabilizes
above 130 for several days.
# Ileus - Patient with constipation noted post-operatively. Had
minimal improvement to soap suds enemas. On [**5-15**] her abdomen
was noted to be markedly distended. Abdominal x-ray revealed
very distended colonic loops upwards of 10 cm. She was made
NPO, a rectal tube was placed, her narcotics were decreased and
she was started on oral narcan for opiod contributions. With
further enemas, her abdominal distension improved markedly by
[**5-16**]. She was started on a clear diet and the rectal tube was
removed. After resolution of her ileus, the patient was changed
back to her home dose of oxycodone, but pain was not
well-controlled. Consequently, her pain medications were
increased. She should continue bowel regimen with colace, senna
and bisacodyl while on narcotics, and bowel movements monitored
closely to avoid recurrence of her ileus.
.
#. Thrombocytopenia - Pt with new thrombocytopenia; her initial
WBC were in the 150s and dropped up to 105 on day 5. She also
had a high PTT of 44. This strongly suggested heparin side
effect, however there was no documentation in the chart of
administration of either heparin or LMWH. Heparin was briefly
held while discussing the possibility of HIT. She was restarted
on heparin [**5-15**]. The exact cause of her thrombocytopenia was
unclear but she did have Cefazolin perioperatively.
Thrombocytopenia resolved over the course of her
hospitalization, and platelets were 238 on the day of discharge.
.
#. Hypochloremic metabolic alkalosis - with urine chloride of
69. Pt has been with very poor PO, constipated, no vomit. Most
likely is contraction alkalosis in the setting of poor PO and
HCTZ. Her sodium was corrected and she was encouraged to have
better PO (free water restriction only).
.
#. Isolated PTT elevation - Unclear etiology, no evidence of
heparin or coumadin or lovenox, but matches well, specially
given thrombocytopenia on day 5. Pt received 5 mg of PO vitamin
K and her PTT remained unchanged. Patient did recall a prior
extensive workup for this abnormality in the past, but could not
recall her diagnosis. She should follow-up with her PCP [**Name Initial (PRE) **]/or
hematologist as an outpatient to follow this lab abnormality.
.
#. T9-l2 fusion and L1 laminectomy - pt was admitted for
elective back surgery. She had good post-op evolution. DVT
prophylaxis was initially not started given increase risk of
bleeding and recommendation of our orthopaedic colleagues.
However, during her stay in the MICU, DVT prophylaxis was
started and should be continued until patient is appropriately
ambulatory. Patient had significant post-operative pain
requiring significant narcotics, as noted above. At the time of
discharge, the patient's narcotics regimen was oxycontin 10 mg
[**Hospital1 **], with oxycodone 5 mg PO q3h prn.
.
#. Hypokalemia - Pt with poor PO, no diarrhea or vomit on HCTZ.
Pt good blood pressure, but also low sodium. TTKG was 2.8.
Cortisol was 27. She was corrected and her K remained normal.
.
#. Hypertension - Pt was having sinus bradycardia to 40s. normal
renal function. Atenolol was initially held, and restarted with
good blood pressure effect. As HCTZ was discontinued, patient
was slightly hypertensive on atenolol alone, and was started on
amlodipine with improved BP control.
.
#. Hypothyroidism - Continued on home levothyroxane. Her TSH was
6.3.
.
#. Hyperlipidemia - Continued home-dose statin.
Medications on Admission:
ASA
atenolol
HCTZ
neurontin 900mg TID
Oxycontin
Fluoxetine
Simvastatin
Synthroid
Trazadone
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Fever / pain.
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
5. Calcium Citrate-Vitamin D3 315-200 mg-unit Tablet Sig: Two
(2) Tablet PO twice a day.
6. Ocuvite Tablet Sig: Two (2) Tablet PO once a day.
7. Fish Oil 1,200-144-216 mg Capsule Sig: Two (2) Capsule PO
once a day.
8. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day).
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please discontinue when patient
appropriately ambulatory.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary Diagnoses:
Hyponatremia
Delerium
Post-operative Ileus
.
Secondary Diagnoses:
Hypothyroidism
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for an elective spinal
surgery. Your post-operative course was complicated by severe
pain, electrolyte abnormalities and an ileus. We decreased your
pain medication and treated your ileus with a rectal tube and
enemas, with good effect. You were also in the ICU for
treatment of your electrolyte abnormalities, which are slowly
resolving with restriction of your fluid intake and salt tabs.
.
We made the following changes to your medications:
-Stop HCTZ - we think this may have contributed to your
electrolyte abnormalities
-Start Amlodipine - this is a new blood pressure medication to
replace HCTZ
-Start Sodium chloride tabs, 2 grams three times daily
-Start bowel regimen, including colace, senna and bisacodyl
-Start Oxycontin 10 mg twice daily, and with oxycodone decreased
to 5 mg every three hours as needed for breakthrough pain
Followup Instructions:
Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 **] [**Hospital **] MEDICAL CENTER
Address: [**Location (un) **], [**Hospital Ward Name 23**] Building [**Location (un) 551**],
[**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3573**]
Appointment: Thursday [**2165-5-23**] 11:00am
Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 **] [**Hospital **] MEDICAL CENTER
Address: [**Location (un) **], [**Hospital Ward Name 23**] Building [**Location (un) 551**],
[**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3573**]
Appointment: Friday [**2165-6-21**] 9:30am
Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 **] [**Hospital **] MEDICAL CENTER
Address: [**Location (un) **], [**Hospital Ward Name 23**] Building [**Location (un) 551**],
[**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3573**]
Appointment: Thursday [**2165-8-1**] 9:30am
|
[
"5180",
"2851",
"4019",
"2449",
"2875",
"2724",
"3051"
] |
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